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Nine-Millimeter Endoscopic Balloon Dacryocystorhinostomy: A New, Less-Invasive Procedure for Tearing in Adults
David I. Silbert
Toti introduced incisional dacryocystorhinostomy (DCR) in 1904, and modifi cations resulted in successful outcomes by the 1920s. Aside from variations in the size and location of the incision, silicon tube intubation, and antibiotics, the basics of the procedure have changed little.
Most lacrimal surgeons are familiar with the external approach and its advantages, including a high success rate and excellent visualization of the common canaliculus. In addition, many surgeons believe the external approach affords a better view of the lacrimal sac, which is important in suspected cases of neoplasia, and allows for easier access to tissue for biopsy.
Disadvantages to the external approach are numerous. Recovery can be quite prolonged because of swelling and healing of the external incision. The incision sight often interferes with the nose pads of spec- tacles, and hypertrophic scarring can occur. Blood loss from inadver- tent damage to the angular vessels or infraorbital artery, or from excessive manipulation of the nasal mucosa, which is poorly visual- ized, can complicate and prolong the procedure. Nasal packing is sometimes required because of excessive bleeding and may be uncom- fortable. Bleeding may recur when the packing is removed.
Advantages of the endoscopic balloon (eb)-DCR include the absence of a skin incision and no need for power instrumentation in most cases.
When performed properly, there is minimal bleeding and cautery is rarely necessary. Once the surgeon becomes facile with the endoscope, the procedure time decreases signifi cantly compared with the external approach and no fl aps or incisions need to be closed. Recovery times are reduced, with less postoperative sequelae. In the author’s hands, the success rate is comparable to the external approach.
Indications for eb-DCR include complete or functional (partial) naso- lacrimal duct obstruction. In cases of partial obstruction, the patient
often provides consent for a 3-mm balloon dacryoplasty (DCP) with the understanding that the surgeon may convert to an eb-DCR.
Frequently, in adults, it is impossible to intraoperatively pass probes down the nasolacrimal system, necessitating conversion from DCP to eb-DCR. From the patient’s standpoint, the main difference between DCP and eb-DCR is the presence of stenting tubes in the latter procedure.
Suspicion of a lacrimal sac tumor is a contraindication to eb-DCR.
However, imaging studies in select cases can help rule out neoplasia.
Relative contraindications to the endoscopic approach include severe nasal septal deviation and canalicular obstruction. It was once thought that dacryocystitis was a contraindication to the endoscopic approach;
however, this is not the case. Approaching an infected sac and draining it endonasally without creating a skin incision is particularly effective and markedly minimizes the risk of a cellulitis by contamination of the incision site through the external approach.
Anesthesia is either monitored anesthesia care with sedation or general endotracheal or laryngeal mask anesthesia. General anesthesia with a laryngeal mask is a good choice in selected cases. Less patient bucking is encountered when coming out of anesthesia, which decreases postoperative bleeding. A throat pack can be used, but is rarely neces- sary, in the author’s experience.
Local anesthetic is used with both monitored anesthesia care and general anesthesia. Lidocaine 2% with epinephrine mixed 10 : 1 with bicarbonate is injected submucosally using a 25-gauge spinal needle.
This is usually done by using a headlight and nasal speculum imme- diately after the patient is brought into the operating room and sedated or placed under general anesthesia. Approximately 3 cc of anesthetic is injected into the anterior middle turbinate, and just anterior and infe- rior to the insertion of the turbinate. Alternatively, the anesthetic can be injected under endoscopic control.
After the endonasal injections are given, the nose is packed with 1/2-inch cottonoids soaked in 4% cocaine mixed 1 : 1 with oxymetazo- line hydrochloride 0.05% nasal spray. The cottonoids are placed beneath the middle turbinate and in the area anterior to the insertion of the turbinate. This is usually done by using bayonet forceps, a nasal specu- lum, and a headlight.
After the packing of the nose, the patient is prepped and draped and the endoscope is set up. Generally, a right-handed surgeon stands to the patient’s right hand side using the left hand to hold the endoscope and the right hand to hold other instrumentation. The monitor is placed 2 feet in front of the head of the bed, leaving room for a Mayo stand with the instrumentation. A 4-mm, straight (0-degree) endoscope is used for the procedure. The patient is placed on a surgical bed with the right arm tucked tightly against the patient to provide ample space for the surgeon.
Equipment on the Mayo stand should include the following:
Punctal dilators
Reinforced Bowman’s probe (Quest Medical Inc., Allen, TX) Dandy nerve hook
Blakesley and Truecut forceps, straight, up-biting, back-biting Freer elevator
Turbinate scissors Nasal speculum
4-mm, straight (0-degree) sinuscope
LacriCATH® 9-mm balloon catheter (Quest Medical) LacriCATH® 5-mm balloon catheter (Quest Medical) Infl ation device (Quest Medical)
STENTubes (Quest Medical) Frazier suction
Irrigating cannulas Retinal-style light pipe
Optional equipment:
Essential shaver Suction Bovie cautery
Procedure
The punctum is fi rst dilated with a punctal dilator. It needs to be dilated enough to allow passage of the number 3 or 4 reinforced Bow- man’s probe. A retinal-type light pipe may be used to demonstrate the area of the proposed ostium endonasally. The light pipe is introduced through the superior (or inferior) punctum and directed into the sac.
The packing is removed from the nose, and the endoscope is intro- duced. The endoscope is held with the left hand and the light pipe is manipulated, moving it superiorly, inferiorly, anteriorly, and posteri- orly. Performing this maneuver with the light pipe allows visualization of the lacrimal sac location by transillumination. This permits the surgeon to anticipate the location of the ostium. Generally, the ostium will be just inferior to the anterior insertion of the middle turbinate and the uncinate process, although there is considerable variability.
The light pipe maneuver also helps determine whether any debulking of the turbinate is necessary.
The middle turbinate is infractured with a Freer elevator. Care should be taken to avoid overmanipulation, because the middle turbi- nate originates from the cribriform plate. Disruption of the cribriform plate could result in cerebrospinal fl uid leaks and meningitis. If the turbinate interferes with the planned site of the ostium, the anterior portion of the turbinate can be debulked by anterior turbinectomy with turbinate scissors. It is preferable not to debulk the turbinate unless absolutely necessary because excess manipulation can result in bleed- ing and scarring.
The reinforced Bowman’s probe is introduced through the superior punctum and passed into the sac. It is directed toward the inferior and posterior aspect of the lacrimal fossa where the thinnest bone is present.
It is fi rmly advanced and “popped” through the thin posterior lacrimal bone. At this point, the endoscope is inserted and the location of the probe noted (Figure 19.1). If it is advanced too far, it can penetrate the turbinate. If this occurs, it is repositioned until it rests beneath or ante-
rior to the turbinate. The probe is then pulled back under endoscopic control and passed through the thin lacrimal bone as inferiorly as pos- sible. The probe is then pivoted, pushing the external portion of the probe inferiorly, which moves the endonasal portion superiorly, thus
“fi lleting open” the lacrimal sac. Small, up-biting Blakesly forceps are introduced into the nose under endoscopic control. They are placed into the ostium created by the reinforced Bowman’s probe. The assis- tant removes the probe, and the Blakesly forceps are opened and then pulled back into the nose in the open position, thus enlarging the ostium (Figure 19.2).
The surgeon infl ates the device halfway with fl uorescein-stained saline and removes all air. The 9-mm endonasal balloon is attached to the infl ation device. The Bowman’s probe is again passed through the ostium and visualized in the nose endoscopically. The probe will be used as a guide when introducing the 9-mm balloon. The balloon probe is then placed into the nose with the balloon portion facing cephalad. It is passed halfway into the ostium and the Bowman’s probe is removed (Figure 19.3). The balloon is infl ated to 8 atmospheres of pressure and left in place for 1 minute and then pulled into the nose while still infl ated. This serves to dramatically enlarge the ostium (Figure 19.4). The probe is then defl ated and removed from the nose.
If it is impossible to pull the probe out of the ostium infl ated, it has likely been inserted too far. It should be defl ated, pulled slightly back into the nose, and reinfl ated.
In many cases, the ostium is now of adequate size. Any fragments of bone and mucosa can be pushed into the nose with the Bowman’s probe and removed with Blakesly forceps. At the surgeon’s discretion, the ostium may be further enlarged using Blakesly forceps, truecut forceps, or back-biting forceps.
FIGURE 19.1. The reinforced Bowman’s probe is introduced through the superior punctum and passed into the sac. It is fi rmly advanced through the thin posterior lacrimal bone.
Bleeding is generally minimal during the procedure but if hemor- rhaging interferes with visualization, Frazier-tipped suctioning or suction cautery can be used. The surgeon may need to repack the nose with the cocaine and oxymetazoline hydrochloride 0.05% soaked cot- tonoids until bleeding stops.
If the endoscope fogs during the procedure, special solution (“FRED”) can be used to prevent fogging.
Once the ostium is found to be of adequate size, the canaliculus is irrigated with an antibiotic–steroid mixture and intubated with
FIGURE 19.2. The ostium is enlarged with Blakesly forceps.
FIGURE 19.3. The balloon probe is then placed into the nose with the balloon portion facing cephalad. It is passed halfway into the ostium and the Bowman’s probe is removed.
stenting tubes. The stent tubes are typically 0.86 mm wide at the cana- licular portion, and widen to 1.3 mm where they pass through the ostium. The olive-tipped probes are passed through the canaliculus and the ostium, and recovered in the nose with a Crawford hook under endoscopic control. It is important to make sure that the thinner portion of the tubes rests in the canaliculi. The tubes are tied to themselves using two silk ties, cut, and allowed to retract into the nose (Figure 19.5).
FIGURE 19.4. The balloon is infl ated to 8 atmospheres of pressure, left in place for 1 minute, and then pulled into the nose while still infl ated. This serves to dramatically enlarge the ostium.
FIGURE 19.5. The olive-tipped probes are passed through the canaliculus and the ostium, and recovered in the nose. It is important to make sure that the thinner portion of the tubes rests in the canaliculi. The tubes are tied to themselves, cut, and allowed to retract into the nose.
It is useful to use a muscle hook to hold the tubes at the punctum while tying the silk sutures, because the tubes are stretched when tied. The muscle hook prevents damage to the canaliculi and puncta while tying the tubes together. A drip pad is placed beneath the nose if necessary. Generally, nasal packing is not required but can be used if warranted.
Intravenous steroids, usually 8 mg of dexamethasone, are given intraoperatively to suppress infl ammation. In cases of dacryocystitis, an intravenous antibiotic such as 1 g of cephalexin is also administered.
Postoperatively, efforts are made to suppress edema, infection, and fi brosis to prevent stenosis of the ostium. The patient is placed on oral antibiotics for 10 days, topical antibiotic/steroid drops for 2 weeks, and a tapering steroid dose of dexamethasone (Medrol Dosepak®; Pharma- cia & Upjohn Co., Kalamazoo, MI) for 6 days if not medically contra- indicated. Saline nasal spray is used four times daily for 1 month, and intranasal steroids are used once daily for a month. The patient is asked to refrain from nose-blowing for a few weeks.
The STENTubes are left in place for up to 3 months and irrigation is performed postoperatively at approximately 1 month. If an endoscope is available in the offi ce, intranasal cleaning of the ostium can be per- formed monthly until the tubes are removed. The patients are placed on antibiotic–steroid drops for 1–2 weeks after removal of the stent tubes. Occasionally, oral steroids and antibiotics are given if there are signs of infection or infl ammation.
The success rate of the procedure in experienced hands is com- parable to that of external DCR. Failures can be reoperated on using the 5-mm balloon via a canalicular approach with or without reintuba- tion with stent tubes.
