Surgical Correction of Injuries of the Nasolacrimal System

Armamentarium

  • Appropriate sutures

  • Balanced sterile saline solution and fluorescein dye

  • Bard-Parker knife handle and blades (#15, #11, #12)

  • Bowman lacrimal probes

  • Corneal shield protectors

  • Cotton tip applicators and neuro cotton pads

  • Electrocautery (bipolar forceps)

  • Eye cannula with 3-cc syringe for irrigation

  • Fine directing hook

  • Kerrison bone rongeurs

  • Lacrimal punctal dilators

  • Local anesthetic with vasoconstrictor

  • Magnifying loupe glasses

  • Mitomycin C 0.5% solution and

  • Nasal speculum

  • Ophthalmic Betadine 5% sterile solution

  • Oxymetazoline nasal spray (Affrin or 4% cocaine)

  • Periosteal elevators (Molt #9 and curved Freer)

  • Rotary instruments (round burs, Sonopet ultrasonic aspirator)

  • Senn retractors

  • Silicone tubing with stainless steel probes (i.e., Quickert-Dryden or Crawford tubes)

  • Stevens tenotomy scissors

  • Westcott scissors

History of the Procedure

The correction of disorders of the nasolacrimal system dates back to the first century, when Cornelius Celsus (25 BC to AD 50) and Claudius Galenus (AD 130 to 200) described their original work on dacryocystorhinostomy (DCR). It was not until 1904 that Addeo Toti, an Italian rhinologist, described the formal technique of external dacryocystorhinostomy. This surgical technique was subsequently modified and popularized by Dutemps, Bourguet, Ohm, and Iliff, making this procedure the gold standard for treatment of obstruction of the nasolacrimal duct system. In 1893, Caldwell first described the endonasal approach to the lacrimal sac; however, difficult access limited the use of this approach until recent advances in endoscopic surgical techniques. In 1989, McDonough and Meiring documented the first clinical series of studies on the intranasal endoscopic approach for dacryocystorhinostomy. The instruments, stents, and tubes used to maintain patency of the nasolacrimal (NL) duct system also have evolved. Henderson initially described the use of 1-mm polyethylene tubes for management of lacrimal canaliculi strictures. Later, Gibbs introduced silicone tubes to maintain patency of the nasolacrimal drainage system. Crawford subsequently added the stainless steel probe attachment to the silicone tubing, which is the most common design used currently. More recently, the neurosurgical ultrasound device (Sonopet OMNI; Stryker, Kalamazoo, Michigan), which uses both longitudinal and torsional motion of the tip, has been used for bone removal.

History of the Procedure

The correction of disorders of the nasolacrimal system dates back to the first century, when Cornelius Celsus (25 BC to AD 50) and Claudius Galenus (AD 130 to 200) described their original work on dacryocystorhinostomy (DCR). It was not until 1904 that Addeo Toti, an Italian rhinologist, described the formal technique of external dacryocystorhinostomy. This surgical technique was subsequently modified and popularized by Dutemps, Bourguet, Ohm, and Iliff, making this procedure the gold standard for treatment of obstruction of the nasolacrimal duct system. In 1893, Caldwell first described the endonasal approach to the lacrimal sac; however, difficult access limited the use of this approach until recent advances in endoscopic surgical techniques. In 1989, McDonough and Meiring documented the first clinical series of studies on the intranasal endoscopic approach for dacryocystorhinostomy. The instruments, stents, and tubes used to maintain patency of the nasolacrimal (NL) duct system also have evolved. Henderson initially described the use of 1-mm polyethylene tubes for management of lacrimal canaliculi strictures. Later, Gibbs introduced silicone tubes to maintain patency of the nasolacrimal drainage system. Crawford subsequently added the stainless steel probe attachment to the silicone tubing, which is the most common design used currently. More recently, the neurosurgical ultrasound device (Sonopet OMNI; Stryker, Kalamazoo, Michigan), which uses both longitudinal and torsional motion of the tip, has been used for bone removal.

Indications for the Use of the Procedure

The NL duct system, or the excretory component of the lacrimal apparatus, is composed of (1) the superior and inferior lacrimal puncta; (2) the superior and inferior canaliculi, with or without the common canaliculus; (3) the nasolacrimal sac; and (4) the nasolacrimal duct ( Figure 60-1 ). The symptom of epiphora due to inadequate tear drainage is the most common indication for interrogation and/or surgical correction of the nasolacrimal duct system. Pain, swelling, and mucopurulent discharge from the lacrimal puncta are other symptoms and signs that may indicate a need for these procedures. The timing of intervention and the choice of procedure to correct disorders of the NL duct system depend on several factors, such as the cause of the obstruction, the anatomic site of obstruction, and the duration of symptoms ( Box 60-1 ). Common causes of obstruction of the NL duct system include aging, naso-orbito-ethmoid (NOE) fractures, facial soft tissue lacerations involving the eyelids, and periorbital or paranasal sinus infections ( Figure 60-2 ). Occasionally, the obstruction may be a consequence of reconstructive craniofacial surgery (e.g., frontal/midface osteotomies) or ablative surgery for midface tumor resection (e.g., maxillectomy). Other infrequent causes of obstruction include develop­mental malformations at birth, lacrimal sac tumors, and stenosis due to radiation therapy or thermal or chemical injury.

Figure 60-1
A, The lacrimal fluid or tears secreted by the lacrimal gland and accessory glands flow to the medial angle of the eye and enter the lacrimal canaliculi through the puncta. The canaliculi discharge into the lacrimal sac, which transmits the fluid into the nose through the nasolacrimal duct, which opens in the inferior meatus. The nasolacrimal duct runs inferiorly encased in the maxillary bone for about 12 mm and then traverses as a membranous duct in a lateral and posterior direction before it exits beneath the bony horizontal ridge of the inferior meatus. B, Several membranous folds within the sac and nasolacrimal duct function as valves to prevent retrograde tear movement. The valves can be points of stenosis or obstruction. The most superior valve of Rosen­müeller joins the sac with the common canaliculus. The inferior mucosal fold forms the valve of Hasner. The medial canthal tendon lies anterior to the canaliculi and attaches to the anterior lacrimal crest. The canaliculi are surrounded by fibers of the par lacrimalis (Horner’s muscle) of the orbicularis occuli, which compress the common canaliculus when the eyelid closes to facilitate tear drainage into the nasolacrimal (NL) duct.

Box 60-1
Causes of Obstruction of Nasolacrimal Duct System

  • Aging

  • Trauma

    • Blunt midfacial injuries: medial orbital wall, naso-orbito-ethmoid, and Le Fort II and III fractures

    • Thermal or chemical injury resulting in scarring

    • Facial soft tissue or lid lacerations (e.g., dog bites in children)

  • Infection

    • Paranasal sinus or periorbital infections, dacryoliths

  • Neoplasm

    • Lacrimal sac tumors

  • Iatrogenic/surgery

    • Midfacial tumor resection (e.g., maxillectomy)

    • Craniofacial reconstructive surgery

  • Idiopathic

    • Females more likely to develop obstruction of nasolacrimal duct

  • Congenital or neonatal dacryocystitis

Figure 60-2
A, The medial canthal tendon and the inferior canaliculi may be disrupted in comminuted naso-orbito-ethmoid (NOE) fractures or lower lid lacerations, as shown here. In these injuries, the function of the pars lacrimalis of the orbicularis oculi, which facilitates the drainage of tears into the nasolacrimal (NL) duct may be disrupted. B1, B2 The axial and coronal images, respectively, of this CT scan show periorbital cellulitis. The nasolacrimal sac housed in the lacrimal fossa is enlarged and swollen. When unaffected, the NL sac is about 12 to 15 mm long and 6 mm wide, with a fundus portion superior to the entry of the common canaliculus. The CT image shows the lacrimal fossa, which is formed by the lacrimal bone and frontal process of the maxilla. The medial wall of the lacrimal sac is adjacent to the most anterior part of the middle meatus of the nose and just below the middle concha. This relationship is important for cannulation of the sac with the endoscopic intranasal approach of dacryocystorhinostomy (DCR).

The most common site of obstruction is the canaliculus, followed by the NL duct itself. The inferior canalicular system is more commonly affected than the superior canaliculus, particularly in blunt force traumatic injuries of the midface. Timely treatment of fractures of the naso-orbito-ethmoid complex can prevent scarring and bony interference of the nasolacrimal drainage pathway. Swelling and edema of midfacial soft tissues can cause transient obstruction of the nasolacrimal duct system, which can be managed by close follow-up and may resolve with time. Intraoperative nasolacrimal intubation during management of NOE fractures has been reported and may be valuable in select cases. Surgical intervention is indicated when there is obvious canalicular laceration, often seen in children with eyelid injuries due to dog bites. Nasolacrimal duct system interrogation and ultimately DCR, with or without intubation, may be considered if symptoms of obstruction do not completely resolve with time after close follow-up.

Evaluation and Diagnostic Investigations

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Jun 3, 2016 | Posted by in Oral and Maxillofacial Surgery | Comments Off on Surgical Correction of Injuries of the Nasolacrimal System
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