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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: jean.anderson.eloy@gmail.com

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.

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Fig. 1

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Fig. 2