Armamentarium
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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.
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Aging
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Trauma
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Blunt midfacial injuries: medial orbital wall, naso-orbito-ethmoid, and Le Fort II and III fractures
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Thermal or chemical injury resulting in scarring
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Facial soft tissue or lid lacerations (e.g., dog bites in children)
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Infection
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Paranasal sinus or periorbital infections, dacryoliths
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Neoplasm
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Lacrimal sac tumors
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Iatrogenic/surgery
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Midfacial tumor resection (e.g., maxillectomy)
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Craniofacial reconstructive surgery
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Idiopathic
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Females more likely to develop obstruction of nasolacrimal duct
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Congenital or neonatal dacryocystitis
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.