Romanian Journal of Ophthalmology, Volume 61, Issue 3 , July-September 2017 . pp:188- 191 [608228]

Romanian Journal of Ophthalmology, Volume 61, Issue 3 , July-September 2017 . pp:188- 191

GENERAL ARTICLE

188 Romanian Society of Ophthalmology
© 2017
doi:10.22336/rjo.2017.34

Transnasal endoscopic assisted
dacryocystorhinostomy

Hainăroșie R ăzvan * **, Ioni ță Irina* **, Pietroșanu Cătălina* **, Pi țuru Silviu*,
Hainăroșie Mura* **, Zainea Viorel* **
*”Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
**“Prof. Dr. Dorin Hociotă” Institute of Phonoaudiology and Functional ENT surgery, Bucharest, Romania

Correspondence to : Silviu Pi țuru,
”Carol Davila” University of Medicine and P harmacy, Bucharest,
8 Eroii Sanitari Blvd., Code 050474, District 5, Bucharest, Romania,
Mobile phone: +40722 488 675, E -mail: [anonimizat]

Accepted: September 6th, 2017

Abstract
Transnasal endoscopic dacryocystorhinostomy is a good alternative for external DCR. It
is considered a safe and efficient technique with successful results, comparable or even
better than the external technique. Advanced knowledge of the endoscopic anatomy and
the lacrimal system is necessary to pe rform the procedure safely, and to obtain good
surgical outcomes.
The aim of the paper is to analyze the changes of the endoscopic technique and to
improve it. The transnasal endoscopic dacryocystorhinostomy surgical technique is
described in a “step by st ep” manner. Also the surgical technologies that can be used for
this intervention are presented, focusing on the cold instruments.
Keywords: endoscopic, transnasal, dacryocystorhinostomy

Introduction
In the last 20 years, an avalanche of
developments, mainly in the endoscopic field,
has taken place in ENT. Endoscopic sinus surgery
developments were outstanding. Optical
technologies and video chip advancements
offered a perfect view of the endoscopic surgical
field. Surgeons can perform more complex
operations, safely and minimally invasive.
Dacryocystorhinostomy (DCR) is the
procedure that aims to create a direct drainage
of the tears, opening the lacrimal sac directly
into the nasal cavity in cases of nasolacrimal duct
(NLD) blockage.
The procedure is over 100 years old, and it
was described in the first century by Celsus. He
created a new passage for the tears using a cautery at the level of the lacrimal bone. In the
second century, Galen described th e same
procedure.
In the eighteenth century, Woolhouse
imagined a technique to open the lacrimal sac
into the maxillary sinus. That method is
somehow similar to the modern DCR. He
removed the lacrimal sac and placed a stent of
gold or silver. Some of the authors reported
success in almost 70 -85% of the cases.
The first modern description of an external
DCR was published in 1904, while the modified
version of Dupuy -Dutemps and Bourguet remain
the gold standard for the treatment of NLD
obstruction [ 1].
In 1893, Caldwell described for the first
time the endonasal approach of an endoscopic
DCR [ 2]. In 1989, Meiring and Mc Donogh

Romanian Journal of Ophthalmology 2017; 61( 3): 188-191

189 Romanian Society of Ophthalmology
© 2017 described the modern DCR. In our days,
transnasal endoscopic DCR is the primary
treatment for lacrimal o bstruction or revision
surgery before external DCR.
Indications of transnasal endoscopic DCR
include patients with NLD demonstrated
obstruction in cases of facial trauma, failed
external DCR, adolescents with anatomical
variations or congenital disorders o f the lacrimal
pathway. The scar or adhesions can be removed
in cases of previous failure of the endoscopic
DCR.
Relative contraindications of endoscopic
DCR are acute dacryocystitis and anticoagulant
treatment that cannot be stopped.
Absolute contraindica tions are tumors of
the lacrimal sac.
The aim of the paper was to analyze the
modifications of the endoscopic technique and to
improve it.
Material and method
The transnasal endoscopic
dacryocystorhinostomy was performed under
general anesthesia with trans oral intubation.
Cotton pads moisturized in adrenalin
solution were placed at the level of the medial
meatus and inferior turbinate, under endoscopic
control.
Septoplasty is performed if a septal
deviation blocks the access to the medial meatus.
The middl e meatus was localized by using a
0-degree rigid endoscope. Moreover, the middle
turbinate was gently medialized.
The following endoscopic landmarks have
to be identified: middle turbinate, lacrimal crest,
uncinate process, bulla ethmoidalis.
Some authors recommend the head of the
middle turbinate as a landmark, but, in our
opinion, it is not a safe landmark due to the high
variability of this structure.
The uncinate process was located to
identify the lacrimal sac region and the anterior
of the lacrimal cr est was defined.
Many techniques were described by using
multiple mucoperichondrial flaps from the nasal
mucosa. After multiple tryouts, only one flap is
currently used.

A vertical incision was performed at the
level of the anterior limit of the lacrimal crest,
starting at the level of the middle turbinate
insertion and downwards to the superior part of
the inferi or turbinate.

Fig. 1 Endoscopic landmarks; MT – middle
turbinate; UP – uncinate process; LC -lacrimal
crest; IT – inferior turbinate

Fig. 2 Incision on the lacrimal crest and anterior
flap design; MT – middle turbinate; UP – uncinate
process; LC – lacrimal crest

Romanian Journal of Ophthalmology 2017 ; 61(3): 188-191

190 Romanian Society of Ophthalmology
© 2017 Two parallel horizontal incisions were
made at the extremities of the vertical incisions
from the ant erior up to the posterior part of the
lacrimal crest.
The mucoperiosteal flap was elevated
anteriorly and the lacrimal bone was exposed.
The bone removed was represented by the
maxillary branch and lacrimal bone. In cases of
agger nasi rich pneumatization, some anterior
ethmoidal cells can be removed as well.

A high -speed drill was used to remove the
bone. Some authors recommend the use of
piezotome, a device that removes only bone and
does not harm the soft tissue, with minimal
thermal effect.
We removed as much bone as we could
vertically.
A Bowman cannula was inserted into the
inferior canaliculus to identify the medial wall of
the lacrimal sac.

The medial wall of the lacrimal sac was
incised with the endoscopic knife in an “H”
shape.
The two vertical flaps from the lacrimal sac
were exposed until the posterior flap came in
close contact with the nasal mucosa located at
the posterior limit of the lacrimal crest.

The nasal mucosal anterior flap was
shorte ned with the shaver until it reached the
anterior flap from the lacrimal sac.
A piece of Gelaspone was placed to stabilize
the flaps.
No stenting was performed.
No nasal packing was necessary.
Postoperative care was done by using
saline solution and oil drops to clean the nose.
The first visit was at 14 days, then at one
month and two months.
Results and discussions
Our success rate in 37 patients was 91.89%
after the first surgery and 97.3% after the second
surgery. No external DCR was performed.
First, it was believed that the external DCR
would obtain better results than the endoscopic
DCR, but recent studies showed that the results
are comparable, maybe better in endoscopic DCR
[3].
The advantages in endoscopic DCR include
the fact that it does not di sturb the lacrimal
pump system [ 4]. Also, all surrounding
structures were visualized.
Fig. 3 Drilling the lacrimal bone

Fig. 4 Bowman cannula insertion will better
identify the projection of the lacrimal sac. An
incision can be performed safely
Fig. 5 Wide opening of the lacrimal sac, no
stenting required

Romanian Journal of Ophthalmology 2017; 61( 3): 188-191

191 Romanian Society of Ophthalmology
© 2017 Better esthetic results are obtained without
a skin incision.
Less operative bleeding was reported
together with no scar to the external canthus
area and orbicularis musc le.
A disadvantage of the endoscopic DCRS is
that a lacrimal neoplasia cannot be excluded; if a
suspicion is raised, a biopsy must be performed
[5].
LASER or radiofrequency assisted DCR was
described, but we do not recommend that
technique because of the t hermal damage
produced to the tissue and the additional cost of
the procedure. We recommend using “cold”
instruments.
Taking into account that endoscopic and
external DCR have comparable results, from an
ethical point of view, the surgeon has to present
both options (with advantages, disadvantages,
risks, benefits, possible complications) to the
patient. The esthetic result of the procedure
must be addressed, and the patient can choose
the most convenient procedure. The informed
consent is obtained before s urgery.
Also, the surgeon has to be aware of the
limits imposed by his/ her medical specialty, and
always have in mind an improvement of the
patients’ health as a result of the treatment.
Conclusion
Transnasal endoscopic
dacryocystorhinostomy is a safe an d efficient
technique with a success result comparable or
even better than external DCR.
Advanced knowledge of endoscopic
anatomy and lacrimal system is necessary to
perform the procedure safely. In case of failure,
the procedures can be repeated, or external DCR
can be conducted.
In our opinion, “cold” instruments are the
best choice to perform the surgery.
Further studies must be made concerning
the use of piezoelectric surgery in lacrimal bone
removal. That technology offers a “cold” removal
of the bone without damaging the soft tissue,
reducing scar formation, but the operation will
take longer since the speed is low with that type
of technology. Acknowledgement
All the authors have contributed equally to
this paper.
References
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Improve The Results. Indian Journal of Otolaryngology
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Endoscopic dacryocystorhinostomy: personal
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