CHAPTER
17
Endoscopic Dacryocystorhinostomy
INTRODUCTION
n  ndoscopic dacryocystorhinostomy (DCR) is a well-
E along the frontal process of the maxilla and adjacent
established treatment for epiphora caused by ana-
tomic or functional obstruction of the nasolacrimal
apparatus.
n A thorough understanding of the endonasal anato-
my, wide marsupialization of the lacrimal sac, and
meticulous care of the mucosa are critical for suc-
cess.
ANATOMY
n  he lacrimal sac extends approximately 10 mm
T
above the axilla of the middle turbinate.
n The common canaliculus opens high up on the later-
al wall of the sac. This area must be exposed during
a DCR for best results.
n The lacrimal bone extends from the frontal process
of the maxilla anteriorly to the attachment of the un-
cinate process posteriorly.
n This retrolacrimal region of the lamina papyracea is
extremely thin; inadvertent disturbance of the unci-
nate at this point can lead to orbital penetration.
n It is important to recognize that the lacrimal bone
and sac lie anterior to the orbit; therefore, the orbit
is not at risk unless the surgeon is inadvertently pos-
terior to these landmarks (Fig. 17.1).
PREOPERATIVE CONSIDERATIONS
n S urgery is performed under general anesthesia.
n The nose is prepared with local injections and vaso-
constrictive neurosurgical cottonoids.
n With a dental syringe, 2 mL of 1% lidocaine with
1:100,000 epinephrine is infiltrated into the axilla of
the middle turbinate and frontal process of the max-
illa (Fig. 17.2).
Raymond Sacks and Yuresh Naidoo
 hree neurosurgical cottonoids soaked in 1:3000
T
n
epinephrine are then placed in the middle meatus,
to the septum.
n A septoplasty is performed if a septal deflection is
preventing access to the middle meatus and lateral
nasal wall. The septal incision is ideally placed on
the side contralateral to the DCR, because this pre-
vents inadvertent trauma to the septal flap when the
endoscope is inserted into the nasal cavity. It also
minimizes clouding of the endoscope with blood
from the septal incision as well as the potential for
the development of postoperative synechiae between
the septum and lateral nasal wall.
Radiographic Considerations
n  dacryocystogram and lacrimal scintigraphy can be
A
of some use preoperatively. They often provide some
idea as to the level of obstruction and whether a tight
common canaliculus is contributing to epiphora.
n For patients with concomitant sinus disease, the

relevant computed tomographic scans should be re-
viewed in the usual fashion. The sinuses can be ad-
dressed at the same time as the DCR in most cases.
INSTRUMENTATION
n  -degree and 30-degree endoscopes
0
n Scalpel with a No. 11 blade or Beaver blade
n Hajek-Koffler punch or 2-mm upbiting Kerrison

rongeur
n DCR spear knife
n Bellucci micro ear scissors (from micro ear tray)
n Round knife (from micro ear tray)
n Punctum dilators
n Bowman lacrimal probes (sizes 00 and 000)
n DCR sickle knife
n Lusk pediatric through-biting forceps
143
144 PART 4 Orbital Surgery

n  he Hajek-Koffler punch and/or Kerrison rongeurs

T
Common are faster at removing bone than the DCR bur. Per-
canaliculus form as much of the removal of the hard bone of
Lacrimal the frontal process of the maxilla with the hand in-
sac struments and move to the DCR bur only when the
punch is unable to grip the bone adequately.
Septum n When using the Hajek-Koffler punch, release the

jaws after each bite. If a small amount of lacrimal
Lacrimal sac has been caught inadvertently between the jaws
bone
Ethmoid of the punch, it can be released and only the bone
bulla Uncinate removed. This will prevent inadvertent trauma to the
process sac.
Middle
n Use the DCR bur on the bone–sac interface to expose
turbinate the sac in its entirety but never between the sac and the
bone, because this can potentially traumatize the sac.
n Remove all of the lacrimal bone up to the insertion
of the uncinate, but do not disturb the uncinate itself.
This retrolacrimal region where the uncinate inserts
into the lamina papyracea is extremely thin, and in-
Fig. 17.1. Artist’s depiction of an endoscopic view of the advertent orbital injury might result.
left middle turbinate, frontal process of the maxilla, lacri- n When probing the lacrimal system, do so delicately
mal bone, and insertion of the uncinate. The lacrimal sac so that a false passage is not created. The upper and
extends above the axilla of the middle turbinate and the
lower canaliculi have an angulated course that must
opening of the common canaliculus is high up on the lateral
be carefully navigated to avoid creating a false pas-
wall of the sac.
sage. Working on a team with an oculoplastic sur-
geon will enable the ear, nose, and throat surgeon to
Infiltration obtain the requisite skills in probing and examining
site the lacrimal system.
n Make an incision into the sac only when the lacrimal
probe can be clearly seen through the sac wall.

MT
Uncinate
process
Fig. 17.2. Endoscopic view showing site of infiltration with a
local anesthetic and vasoconstrictor. MT, Middle turbinate.
n DCR bur
n Crawford silicone elastomer (Silastic) tubes
PEARLS AND POTENTIAL PITFALLS
n  ave a low threshold for performing a septoplasty.
H Step 2: Raise the Mucosal Flap
Limited access restricts the surgeon in making the
precise surgical cuts required for the mucosal flaps.
n Use a 30-degree endoscope to perform the DCR.
 the surgical plane in the transition from the hard
This will provide a better view of the lateral nasal
wall than a 0-degree endoscope.
SURGICAL PROCEDURE
Step 1: Create a Posteriorly Based Mucosal Flap
to Expose the Lacrimal Bone and Frontal Process
of the Maxilla
n Make a superior incision that runs horizontally 10
mm above the axilla of the middle turbinate. Extend
the incision from 2 to 3 mm posterior to the axilla
and run it forward for approximately 10 mm onto
the frontal process of the maxilla.
n Now, turn the blade vertically and make a cut on
the frontal process of the maxilla from the superior
incision to just above the insertion of the inferior tur-
binate.
n Next, turn the blade horizontally and make the infe-
rior mucosal incision from the insertion of the unci-
nate to join the vertical incision (Fig. 17.3).
n Use a suction Freer elevator to elevate the flap

(Fig. 17.4). Stay directly on bone to avoid losing
bone of the frontal process of the maxilla to the
soft lacrimal bone.
 CHAPTER 17
MT
Incision
Fig. 17.3. Endoscopic view showing incision to create a
posteriorly based mucosal flap to expose the lacrimal bone
and frontal process of the maxilla. MT, Middle turbinate.
Fig. 17.4. Endoscopic view of the raising of the mucosal flap.
Step 3: Remove Overlying Bone
n Use a round knife from the ear tray to flake off the
lacrimal bone overlying the anterior-inferior portion
of the lacrimal sac.
Step 4: Use a Hajek-Koffler Punch to Remove the
Hard Bone of the Frontal Process of the Maxilla
Overlying the Anterior-Inferior Aspect of the
Lacrimal Sac
n When the punch can no longer grip the frontal pro-
cess, change over to the DCR bur. Fully expose the
sac by further removing bone up to the mucosal inci-
sions. The sac should form a prominent bulge into
the nasal cavity (Fig. 17.5).
Step 5: Expose the Agger Nasi Cell
n Expose the agger nasi cell (Fig. 17.6). This will al-
low the mucosa of the lacrimal sac to lie against the
Endoscopic Dacryocystorhinostomy 145
Lacrimal
sac
Fig. 17.5. Endoscopic view of the completely exposed sac.
The lacrimal sac is seen bulging into the nasal cavity.
Agger cell
Fig. 17.6. Endoscopic view of exposure of the agger nasi
cell.
mucosa of the agger nasi cell, which allows healing
by primary intention.
Step 6: Marsupialize the Lacrimal Sac
n Use a lacrimal probe to tent the lacrimal sac. Make
sure that the probe is clearly visible through the mu-
cosa of the sac before incising the sac to prevent in-
advertent trauma to the common canaliculus. Use a
DCR spear knife to incise the sac as far posteriorly
as possible to create the largest possible anterior flap
(Fig. 17.7).
n Use Bellucci micro ear scissors to create upper and
lower releasing incisions in the posterior flap and use
a DCR sickle knife to create the corresponding inci-
sions in the anterior flap.
n The sac should now be completely marsupialized

and lying flat on the lateral nasal wall (Figs. 17.8
and 17.9).
146 PART 4 Orbital Surgery
Lacrimal
probe
Fig. 17.7. Endoscopic view of lacrimal probe tenting of the
medial sac wall. The probe should be seen clearly through
the mucosa of the sac before incision to avoid inadvertent
injury to the common canaliculus. A vertical incision into
the sac is made using a dacryocystorhinostomy spear knife
and a gentle rotating movement.
Lacrimal
probe
Vertical incision
into sac
Fig. 17.8. Endoscopic view of the vertical incisions made
superiorly and inferiorly into the lacrimal sac to fully marsu-
pialize the sac.
Step 7: Trim the Mucosal Flap to Appose the
Lacrimal Sac Mucosa
n Trim the mucosal flap so that only a superior and
inferior limb remain, which can be positioned to ap-
proximate the corresponding superior and inferior
borders of the marsupialized sac (Fig. 17.10).
n Confirm that the agger nasi cell is open and that its
mucosa is opposing the posterior-superior aspect of
the sac.
Step 8: Pass Crawford Silastic Tubes
n Pass Silastic lacrimal tubes into the nasal cavity via
the superior and inferior puncta (Fig. 17.11). Slide a
small piece of absorbable gelatin sponge (Gelfoam)
AN
Mucosal
apposition
Lacrimal
sac
Fig. 17.9. Endoscopic view of the lacrimal sac fully mar-
supialized and lying flat against the lateral nasal wall. AN,
Agger nasi.
up the Crawford tubes to hold the flaps in place
(Fig. 17.12). Secure the tubes either by placing a
ligating clip or by simply tying the tube ends to-
gether.
POSTOPERATIVE CONSIDERATIONS
n efore the procedure is completed, all flaps are
B
checked to ensure that they are sitting perfectly to
allow healing to occur by primary intention.
n Some surgeons use Crawford tubes routinely in their
surgery for three reasons:
1. They dilate the common canaliculus, the narrow-
ing of which contributes to epiphora in a signifi-
cant number of patients. This condition can only
be diagnosed intraoperatively, but a negative re-
sult on dacryocystography with penetration of
the sac on scintigraphy is highly suggestive of this
problem.
2. It facilitates the positioning of the flaps by allow-
ing a piece of Gelfoam to be slid up along the
Crawford tubes onto the mucosal edges.
3.  The tubes promote tear drainage through the
canalicular system by capillary action along the
tubes.
n The patient is discharged with instructions to use a
saline spray, complete a 5-day course of oral anti-
biotics, and apply antibiotic eye drops for 2 weeks.
The patient is examined at 2 weeks, and crusting is
removed.
n The Crawford tubes are removed after 4 weeks, and
the patency of the lacrimal system is checked using the
fluorescein dye disappearance test and the Valsalva
bubble test.
 CHAPTER 17 Endoscopic Dacryocystorhinostomy 147

Mucosa of
lacrimal sac

Mucosa to
be excised

Lower limb
A B

Fig. 17.10. (A) Before: area of mucosal flap to be trimmed to allow for precise apposition to mucosa of lacrima sac.
(B) After trimming of mucosal flap.

Gelfoam

AN
Common
canaliculus

Stent Lower limb of

mucosal flap

Fig. 17.12. Endoscopic view of the Gelfoam slid up the

Fig. 17.11. Endoscopic view of Crawford tubes passing Silastic stents. The mucosal flaps are carefully positioned
through the common canaliculus. AN, Agger nasi. to ensure mucosa-to-mucosa apposition.

SPECIAL CONSIDERATIONS n  pplication of mitomycin C has been shown to be of

A
some benefit in revision endoscopic DCR.1–3
Revision Surgery n Crawford stents should remain in situ for 4 to 6
n  ake mucosal cuts onto the remaining bone. DCR
M weeks postoperatively.
surgery usually fails because of inadequate exposure n The patient should use topical steroid drops for 1
of the common canaliculus and lacrimal sac. Palpate week postoperatively.
the bone above the axilla of the middle turbinate and
frontal process of the maxilla to assess the size of the
previous osteotomy and make the new mucosal cuts REFERENCES
directly onto the bone.
n Sharply dissect a mucosal flap from the underlying Access the reference list online at ExpertConsult.com.
prelacrimal sac.
n A free mucosal graft harvested from the agger nasi
cell can be used to prevent secondary fibrosis and
formation of granulation tissue.
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REFERENCES 3. Camara JG, Bengzon AU, Henson RD. The safety and ef-
ficacy of mitomycin C in endonasal endoscopic laser-assisted
1. Kao SC, Liao CL, Tseng JH, et al. Dacryocystorhinostomy with dacryocystorhinostomy. Ophthal Plast Reconstr Surg. 2000;16:
intraoperative mitomycin C. Ophthalmology. 1997;104:86–91. 114–118.
2. Zilelioglu G, Ururbas SH, Anadolu Y, et al. Adjunctive use of
mitomycin C on endoscopic lacrimal surgery. Br J Ophthalmol.
1998;82:63–66.

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