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Transillumination-guided endoscopic endonasal dacryocystorhinostomy:approach to revision cases and challenging anatomy
Alejandro Vazquez MD, Danielle M. Blake BA, Vivek V. KanumuriBA, Paul D. Langer MD, FACS, Jean Anderson Eloy MD, FACS
PII: S0196-0709(14)00104-5DOI: doi: 10.1016/j.amjoto.2014.04.010Reference: YAJOT 1385
To appear in: American Journal of Otolaryngology–Head and Neck Medicine and Surgery
Received date: 27 February 2014Revised date: 23 April 2014Accepted date: 24 April 2014
Please cite this article as: Vazquez Alejandro, Blake Danielle M., Kanumuri VivekV., Langer Paul D., Eloy Jean Anderson, Transillumination-guided endoscopic en-donasal dacryocystorhinostomy: approach to revision cases and challenging anatomy,American Journal of Otolaryngology–Head and Neck Medicine and Surgery (2014), doi:10.1016/j.amjoto.2014.04.010
This is a PDF file of an unedited manuscript that has been accepted for publication.As a service to our customers we are providing this early version of the manuscript.The manuscript will undergo copyediting, typesetting, and review of the resulting proofbefore it is published in its final form. Please note that during the production processerrors may be discovered which could affect the content, and all legal disclaimers thatapply to the journal pertain.
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Transillumination-Guided Endoscopic Endonasal
Dacryocystorhinostomy: Approach to Revision Cases and
Challenging Anatomy
Alejandro Vazquez, MD1
Danielle M. Blake, BA1
Vivek V. Kanumuri, BA1
Paul D. Langer, MD, FACS2
Jean Anderson Eloy, MD, FACS1,3,4
1Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School,
Newark, NJ 2Department of Ophthalmology and Visual Science, Rutgers New Jersey Medical School,
Newark, NJ 3Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New
Jersey Medical School, Newark, NJ 4Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, NJ
Running Title: Transillumination-Guided DCR
Keywords: Dacryocystorhinostomy, DCR, light pipe, endoscopic DCR, lacrimal duct
obstruction, lacrimal sac disease, lacrimal duct, lacrimal transillumination, lacrimal system,
canalicular stenosis.
Financial Disclosures: None
Conflicts of Interest: None
Word Count: 1016
Corresponding Author:
Jean Anderson Eloy, MD, FACS
Associate Professor and Vice Chairman
Director, Rhinology and Sinus Surgery
Co-Director, Endoscopic Skull Base Surgery Program
Department of Otolaryngology – Head and Neck Surgery
Rutgers New Jersey Medical School
90 Bergen St., Suite 8100
Newark, NJ 07103
Phone: (973) 972-4588
FAX: (973) 972-3767
E-mail: [email protected]
Presented in Part at the 117th
Annual Meeting of the American Academy of
Otolaryngology – Head and Neck Surgery, Vancouver, B.C., October 1, 2013.
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ABSTRACT
Dacryocystorhinostomy (DCR) is a surgical procedure in which a connection is
established between the lacrimal sac and the nasal cavity in an effort to bypass an obstruction of
the distal lacrimal apparatus. Endoscopic endonasal DCR (EEDCR) is a minimally invasive
technique used to achieve this goal. In patients with altered anatomy, EEDCR can be
challenging. Here, we describe the use of canalicular transillumination with EEDCR in three
cases, and discuss the benefits of this technique.
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INTRODUCTION
Dacryocystorhinostomy (DCR) is a surgical procedure whereby a connection is
established between the lacrimal sac and nasal cavity in an effort to bypass distal lacrimal
apparatus obstruction. Endoscopic endonasal DCR (EEDCR) is a minimally-invasive technique
introduced in the 1980s. In patients with altered anatomy, EEDCR can be challenging. Here, we
describe the use of canalicular transillumination with EEDCR in three cases, and discuss the
benefits of this technique compared to standard EEDCR.
ILLUSTRATIVE CASES
Subjects
Three female patients with nasolacrimal duct obstruction in the setting of distorted
sinonasal or lacrimal system anatomy were reviewed retrospectively. The first, a 33-year old
woman, had previously sustained an iatrogenic skull base injury while undergoing right-sided
EEDCR, necessitating intraoperative rhinologic consultation and emergent endoscopic repair of
the defect. Grossly abnormal endoscopic and radiographic anatomy were noted, and a diagnosis
of ozena was ultimately established.1 Two years later, the patient developed nasolacrimal duct
obstruction. Given her history of previous skull base defect and abnormal endoscopic and
radiographic anatomy, a transillumination-guided EEDCR (TG-EEDCR) technique was
performed successfully (Figure 1). The second patient was a 71-year-old woman who developed
recurrent epiphora after previously undergoing right-sided open DCR. Attempts at recanalizing
the fistula under endoscopic visualization were challenging due to excessive scarring and
anatomic distortion. TG-EEDCR served to delineate a path through the dense scar present within
the nasal aspect of the surgical site leading to a successful procedure. The third patient was a 26-
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year old woman who had previously undergone right-sided endoscopic modified medial
maxillectomy for resection of a poorly differentiated neuroendocrine carcinoma of the maxillary
sinus. She received postoperative chemoradiation and subsequently developed canalicular
stenosis as well as stenosis of the nasolacrimal duct. Attempts to stent the obstruction failed to
improve her symptoms, and a TG-EEDCR was successfully performed. Institutional Review
Board approval was obtained at Rutgers New Jersey Medical School.
Surgical Technique
The patient is positioned supine with the neck in a neutral position. The face is prepped
and draped in a sterile fashion using half-strength povidone-iodine solution. Topical
oxymetazoline hydrochloride 0.05% is applied intranasally. The nasal cavity is examined with a
rigid 30-degree endoscope. Submucosal infiltration of 1% lidocaine hydrochloride with
1:100,000 epinephrine solution is carried out at the lateral nasal wall, middle turbinate and
uncinate process. In order to pinpoint the lacrimal sac and outline the lacrimal system, a 20-
gauge vitreoretinal surgery light pipe (Alcon Laboratories, Fort Worth, TX; Figure 2A) is passed
through the lacrimal canaliculi (Figure 2B). Under direct endoscopic visualization with a 30-
degree endoscope (Karl Storz and Co., Tuttlingen, Germany), the location of the nasolacrimal
sac is localized (Figure 2C).The light intensity on the endoscopic tower unit is dimmed to
minimal endoscopic light intensity (Figure 2D), allowing for better visualization of
transilluminated lacrimal system. A flap is elevated over the region of greatest light intensity; the
underlying bone is removed with forceps or drilled. Once sufficiently open, the lacrimal sac is
marsupialized, and egress of tears into the nasal cavity confirmed. A Crawford tube is then
inserted to stent the canaliculi.
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RESULTS
All three patients had anatomic distortion of either the sinonasal tract or lacrimal system
which made conventional open DCR or EEDCR difficult. In two of these cases, the decision to
carry out TG-EEDCR was made preoperatively; in our second case, standard EEDCR was
converted to TG-EEDCR when efforts to recannulate a stenosed fistula proved difficult. All
patients underwent successful TG-EEDCR without major or minor intraoperative complications.
At follow-up, all patients experienced resolution of epiphora. Patency of the
dacryocystorhinostomy was confirmed endoscopically in the office. No postoperative
complications were noted.
DISCUSSION
EEDCR is a safe and effective approach associated with improved cosmesis, decreased
postoperative discomfort, and shorter operative times when compared to open DCR.2 The use of
canalicular transillumination has been described previously in the ophthalmologic literature;3
however, this technique is limited among otolaryngologists.
A cadaveric study using canalicular transillumination noted significant variability in the
endoscopic anatomy of the lacrimal system. The most frequent position of the lacrimal sac was
posterior to the middle turbinate head and anteroinferior to its insertion; however, this was only
noted in 45% of cases.4 Such variability argues against the reliability of lateral nasal wall
structures as landmarks. Moreover, the rates of secondary procedures required for surgical access
(i.e., uncinectomy [35%] and septoplasty [12.5%]) suggests that a one-size-fits-all approach to
EEDCR may be inadequate.4
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Although attempts have been made to standardize EEDCR, to date no such approach
exists. Nevertheless, EEDCR remains a common and safe procedure.5 While it may be difficult
to agree on strict, universally-applicable anatomic rules and references, this may not make much
difference in practical terms. However, as illustrated by our first patient, sometimes nasal vault
anatomy may be altered so dramatically that customary landmarks become unusable. Canalicular
transillumination represents a minimally-invasive low-risk method for adequate localization of
the lacrimal sac. To our knowledge, only one report in the English-language otolaryngologic
literature discusses a similar technique. In a small series, Cunningham, et al., describe canalicular
transillumination for pediatric EEDCR, where reduced dimensions and subtle differences relative
to the more commonly-encountered adult anatomy make surgery difficult.6
Although the results of this report rationalize a place for TG-EEDCR in the
armamentarium of otolaryngologists performing EEDCR, limitations to this series should be
noted. This report is limited by the small sample size and all limitations inherent to any
retrospective study. Additionally, one can make an argument that most experienced rhinologists
that routinely perform EEDCR may not require canalicular transillumination because of the
relative consistency of the position of the lacrimal sac. Nonetheless, in revision cases and other
cases with altered anatomy, the TG-EEDCR may be an efficient and quick way to determine the
exact location of the lacrimal sac.
CONCLUSIONS
Whether the variability inherent to lacrimal system anatomy in normal individuals
justifies routine use of transillumination is beyond the scope of this report. Although its
systematic use could represent a step toward standardization, other factors might hinder this
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practice. Nevertheless, we believe that TG-EEDCR is a feasible technique in the setting of
grossly abnormal lacrimal system or sinonasal tract anatomy resulting from trauma, prior
surgery, or other disease process.
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REFERENCES
1. Friedel ME, Earley MA, Eloy JA. Skull base defect in a patient with ozena undergoing
dacryocystorhinostomy. Allergy Rhinol (Providence). 2011; 2:36-39.
2. Korkut AY, Teker AM, Yazici MZ, Kahya V, Gedikli O, Kayhan FT. Surgical outcomes
of primary and revision endoscopic dacryocystorhinostomy. J Craniofac Surg. 2010;
21:1706-1708.
3. Pelegrinis E, Morphopoulos A, Georgoulopoulos G, Kapogiannis K, Papaspyrou S. Four-
year experience with intranasal transilluminating dacryocystorhinostomy using
ultrasound. Can J Ophthalmol. 2005; 40:627-633.
4. Ricardo LA, Nakanishi M, Fava AS. Transillumination-guided study of the endoscopic
anatomy of the lacrimal fossa. Braz J Otorhinolaryngol. 2010; 76:34-39.
5. Ben Simon GJ, Joseph J, Lee S, Schwarcz RM, McCann JD, Goldberg RA. External
versus endoscopic dacryocystorhinostomy for acquired nasolacrimal duct obstruction in a
tertiary referral center. Ophthalmology. 2005; 112:1463-1468.
6. Cunningham MJ, Woog JJ. Endonasal endoscopic dacryocystorhinostomy in children.
Arch Otolaryngol Head Neck Surg. 1998; 124:328-333.
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FIGURE LEGENDS
Figure 1. (A,B) Coronal computed tomography views of anterior skull base defect in patient 1.
(C) Endoscopic endonasal view of same patient showing site of previous skull base defect and
(D) endoscopic postoperative view of the Crawford tube after a transillumination-guided
endoscopic endonasal dacryocystorhinostomy.
Figure 2. (A) Vitreoretinal light pipe (Alcon Laboratories). (B) Vitreoretinal light pipe inserted
in right nasolacrimal system for canalicular transillumination. (C) Endoscopic endonasal view of
right nasal cavity showing transillumination of the nasolacrimal system lateral to the right middle
turbinate (D) Endoscopic endonasal view with minimal endoscopic light intensity showing
transillumination of the nasolacrimal sac and site of dacryocystorhinostomy.