How is a standard external dacryocystorhinostomy performed for the treatment of dacryocystitis?

Updated: Oct 08, 2019
  • Author: Grant D Gilliland, MD; Chief Editor: Edsel Ing, MD, MPH, FRCSC  more...
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Answer

A standard external dacryocystorhinostomy operation that is used in the treatment of dacryocystitis is discussed below. Instrumentation may vary, but the author prefers the following:

  • After the patient is prepared and draped in the usual sterile fashion, the skin is incised 11 mm medial to the medial commissure, beginning at the level of the inferior margin of the medial palpebral tendon.
  • The skin is incised, avoiding the angular vessels, which are found 8-9 mm medial to the medial commissure. It is made parallel to the angle of the nose and is approximately 1.5-2.5 cm long.
  • A self-retaining, spring-type retractor (eg, Agrikola) is placed in the wound.
  • Steven tenotomy scissors, mosquito forceps, or periosteal elevators are used to bluntly dissect through the levator labii superioris alaeque nasi muscle down to the periosteum.
  • Hemostasis is maintained throughout with bipolar or handheld cautery.
  • Then, the periosteum is incised sharply with a periosteal elevator along the course of the skin wound and elevated off the anterior lacrimal crest and lacrimal bone, both anteriorly and posteriorly.
  • Some practitioners remove the self-retaining retractor and place a Goldstein retractor in the wound, retracting the periosteal flaps.
  • The lacrimal sac is injected with 2% Xylocaine with epinephrine, and a small 0.25 X 0.25-inch cottonoid soaked in cocaine is placed in the lacrimal fossa medial to the lacrimal sac.
  • With adequate irrigation and suction, a drill can be used to burr the nasal bone just medial to the lacrimal sac. The drilling is continued in a circular pattern until the nasal mucoperiosteum becomes barely visible. Blood is seen oozing from the site of the osteotomy. (Osteotomy can also be performed without a mechanical burr.)
  • The nasal mucoperiosteum is then injected with 2% Xylocaine with epinephrine until blanching is noted.
  • A dental burnisher is used to separate the nasal mucoperiosteum from the overlying nasal bone.
  • The anterior lacrimal crest and the wall of the lacrimal fossa are removed with a forward biting rongeur (eg, Kerrison rongeur). Frequently, a Lempert rongeur is used to remove the medial wall of the lacrimal fossa and any ethmoidal air cells in the vicinity of the lacrimal fossa.
  • The osteotomy is enlarged superiorly to a level just under the inferior border of the medial canthal tendon and inferiorly to the portion of the medial wall of the nasolacrimal canal.
  • If needed, cottonoid sponges soaked in thrombin are inserted into the wound for hemostasis.

A punctal dilator is used to dilate the upper and lower puncta. In some cases, Steven tenotomy scissors are used to perform a 1-snip procedure on each puncta. Steps are as follows:

  • A number 0 Bowman probe is inserted into the lower punctum and advanced medially, thereby tenting the lacrimal sac.
  • A number 11 Bard-Parker blade is used to incise the medial wall of the lacrimal sac parallel to the skin wound.
  • Sharp Steven tenotomy scissors are used to create an H-shaped incision in the medial wall of the lacrimal sac. Steven tenotomy scissors and Bishop-Harmon forceps are used to excise the posterior flap of the lacrimal sac.
  • Biopsy of the lacrimal sac is performed if abnormal pathology is suspected based on the preoperative clinical presentation or if the appearance of the lacrimal sac is abnormal at the time of surgery. [16]
  • A periosteal elevator is inserted into the nose and used to tent the nasal mucoperiosteum laterally, while a number 11 Bard-Parker blade is used to incise the nasal mucoperiosteum horizontally.
  • Steven tenotomy scissors are then used to create another H-shaped flap in the nasal mucoperiosteum. Again, the posterior flap is excised. Bicanalicular silicone stents are inserted through the puncta and canaliculi and grasped in the nose under direct visualization with a straight hemostat or retrieved with a grooved director.
  • A piece of absorbable collagen (Instat) or Gelfoam soaked in thrombin is rolled and inserted posterior to the silicone in the region of the lacrimal sac. [17, 18]
  • Two sutures (eg, 5-0 chromic or finer) are used to approximate the anterior flap of the lacrimal sac and the anterior flap of the nasal mucoperiosteum; the needle is carried through the orbicularis to tent the flaps anteriorly.
  • The periosteum of the nasal bone is then approximated with several interrupted 5-0 Vicryl sutures. The skin is closed with a running subcuticular 6-0 Vicryl and a running 6-0 plain, fast-absorbable suture.
  • The silicone stents can be tied with 2-3 square knots and allowed to retract under the inferior turbinate.
  • Antibiotic ointment is placed on the wound, and an adhesive bandage or dental roll is used to dress the wound.

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