• ENDOSCOPIC INTRANASALDACRYOCYSTORHINOSTOMY

DALE H. RICE, MD

Dacryocystorhinostomy is a procedure to eliminate na­solacrimal obstruction by connecting the lacrimal sac di­rectly to the nasal cavity. In the early 20th century, trans­nasal procedures were described by West1 and Haller'However, direct visualization was difficult. Later, a trans­nasal/transseptal approach was developed.v" Visualiza­tion was somewhat improved, but the procedure did notacquire wide popularity. The first external approach wasdescribed by Toti.5

The recent wide availability of endonasal rigid endo­scopes with their superior optics has provided the otolar­yngologist-head and neck surgeon with an unprece­dented view of the intranasal cavity.608 A previous ca­daver study has been reported."

TECHNIQUE

After the introduction of general anesthesia, the patient isprepared and draped in the usual manner for endoscopicsinus surgery. Using either a 250 or 300 wide angle en­doscope, the area of the nasolacrimal fossa can be easilyvisualized (Fig 1). The mucosa anterior to the anteriorattachment of the middle turbinate is infiltrated with 1%Xylocaine with 1:100,000 epinephrine and 5 minutes al­lowed to pass. Following this, the mucosa is incised in agenerous circle down to bone and removed. The bone isremoved with either a curette or a drill. Once the bone isremoved the medial wall of the lacrimal sac is in view (Fig2). This wall is incised to open the sac and a generousportion of the medial wall is removed (Fig 3). A polyeth­ylene tube is passed through the inferior and superiorpunctum and the ends tied intranasaIIy to serve as astent. This is removed in 2 weeks.

CONCLUSION

Endoscopic intranasal dacryocystorhinostomy is an effec­tive treatment for nasolacrimal obstruction involving the

From the Department of Otolaryngology-Head and Neck Surgery,School of Medicine, University of Southern California, Los Ange­les, CA.

Address reprint requests to Dale H. Rice, MD, Department of Oto­laryngology-Head and Neck Surgery, School of Medicine, Universityof Southern California, 1200 N State St, Box 795, Los Angeles, CA90033.

© 1990 by W.B. Saunders Company.1043-1810/9010102-0012$05.0010

FIGURE 1. View of laterallasal wall. Lacrimal fossa islocated immediately anterior to anterior end of middleturbinate.

FIGURE 2. Bone has been removed, showing medialbulging of lacrimal sac.

OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY-HEAD AND NECK SURGERY, VOL 1, NO 2 (JUNE), 1990: PP 131-132 131

FIGURE 3. Interior of lacrimal sac can be seen.

nasolacrimal sac or duct. It is technically challenging toremove the bone with the currently available instru­ments. A new drill is being developed for this purpose.

132

It offers the advantage of no external incision and no riskto the canalicular system or medial canthal ligaments.This procedure would also seem to be ideally suited torevision dacryocystorhinostomy.

REFERENCES1. West J: Eine neve method zur operation des Tranersakes von der

arise GUS. Arch Laryngol Rhinol 24:62-64, 19112. Halle M: Zur intranasolen operation am Tranersack. Arch Laryngol

Rhinol 28:256-206. 19143. Kotler K: Beziehungen der Tranersackleiber zur Nase und ihre Be­

handling. Z Hals Nasen Ohrenheikd 27:543-548, 19304. Kofler K: Meine transseptale Tranersackoperation, Monatsschr

Obrenheilkd Laryngo-Rhino 74:603-625, 19405. Toti A: Zum prinzip, zur technik und zer Deschichte de Dakryo­

cystorhinostomie. Z Angerheilkd 23:232-239. 19106. Stammberger H: Endoscopic surgery for mycotic and chronic recur­

ring sinusitis. Ann Otol Rhinol Laryngol94:1-11, 1985 (SuppI1l9)7. Kennedy DW:Functional endoscopic sinus surgery technique. Arch

OtolaryngoI11l:643-649, 19858. Rice DH: Endoscopic sinus surgery-Instrumentation and diagno­

sis. Presented at the Western Section of the Triological Society.Santa Barbara. CA. Jan 12, 1987

9. RiceDH: Endoscopic intranasal dacryocystorhinostomy-A cadaverstudy. Am J RhinoI2:127-128, 1988

DACRYOCYSTORHINOSTOMY