Return to: Paranasal Sinus Surgery Protocols

GENERAL CONSIDERATIONS

1. Indications: 
   1. Epiphora/lacrimal duct obstruction
2. Contraindications:
   1. Watery eyes are not due to ductal obstruction. It is important to note that not all watery eyes are epiphora.

PREOPERATIVE PREPARATIONS

1. Evaluation
   1. Physical exam
      1. Palpation over lacrimal sac to determine the presence of reflux.
      2. Fluorescein dye test (place dye in both eyes; there should be symmetric disappearance of the dye within 5 minutes).
      3. Jones I test - cotton swab placed in the inferior meatus will pick up fluorescein (positive Jones I test).
      4. Jones II test - placement of lacrimal probe into the superior or inferior canaliculus. A soft stop suggests an obstruction. A hard stop occurs when the probe hits the medial wall of the lacrimal sac.
   2. Imaging
      1. Scintilligraphy 
      2. Dacryocystogram
2. Consent/Risks
   1. Hemorrhage/epistaxis
   2. Orbital fat exposure
   3. Orbital hematoma
   4. Scarring of the ostium
   5. Torn lacrimal puncta

NURSING CONSIDERATIONS

1. Room Setup
   1. Rotate 90 degrees if bilateral. If only unilateral, it is sometimes possible to pull the table away from anesthesiology unit without rotating the bed.
   2. An endoscopy tower can be placed at the head of the bed opposite the side that is being worked on.
2. Instrumentation and Equipment
   1. Nasal Prep Tray
   2. Sinoscopy Instrument Tray
   3. Sinus Tray (available only)
   4. Minor Instrument Tray, Otolaryngology (available only)
   5. Sinoscopy Telescope Instrument Basket
   6. Sinoscopy Instrument Basket
   7. Neuro patties, ½ x ½, ½ x 1½, ½ x 3
   8. Storz fiberoptic light cable, 3.5 mm x 230 cm
   9. Lacrimal duct probes
   10. Light pipe
   11. Crawford stent
3. Medications
   1. 1% lidocaine with 1:100,000 epinephrine. Alternatively, 4% cocaine (no more than 4 ml) may be used for pre-surgical vasoconstriction and to assist with hemostasis (see below).
   2. Oxymetazoline HCL nasal spray, 0.05%
   3. Hydrogen peroxide solution, topical, 3%
   4. FRED (fog reduction elimination device)
4. Prep and Drape
   1. No prep
   2. Drape:
      1. Head drape.
      2. Square off with towels at neck and forehead.
      3. Split sheet.
      4. The patient's eyes should be left accessible  for assessment during the case in the event of orbital injury or concern for intraorbital bleeding - no tape or tegaderm; ointment only.
5. Drains and Dressing
   1. A "drip dressing" may be fashioned using a 2x2 cm gauze or oval eye pad.

ANESTHESIA CONSIDERATIONS

1. Head of the table oriented to position anesthesia equipment at the patient's side opposite the surgeon.
2. Television monitor offset from the head of the patient.
3. Instrument trays positioned so that instruments can be placed in the surgeon's hand away from the uncovered eyes of the patient.
4. Head of the bed elevated.
5. The oral endotracheal tube is traditionally secured to the corner of the mouth on the patient's LEFT side to allow ample access to the airway by the anesthesia provider and to prevent interference with the operative surgeon's hands during instrumentation.

OPERATIVE PROCEDURE

1. Position the patient with the head slightly extended and raise the head of the bed 20-30 degrees (this helps with hemostasis).
2. Inject 1% lidocaine with 1:100,000 epinephrine in the axilla of the middle turbinate and also slightly anterior.
3. Place oxymetazoline-soaked pledgets in the middle meatus and along the lateral wall of the nose over the lacrimal duct.
4. Dilate the superior canaliculus with a 0 or 00 Bowman lacrimal probe. Then cannulate the superior canaliculus with a 25G light pipe into the nasolacrimal duct sac (this step should be performed with the assistance of ophthalmology colleagues).
5. Use a 0-degree rigid telescope to identify the light pipe in the lacrimal sac. The light should be visible just superior and anterior to the axilla of the middle turbinate.
6. The bone and mucosa overlying the lacrimal sac can be drilled away with a guarded 4-diamond drill on a suction irrigator.
7. Use a sickle knife to open the sac vertically, superior to inferior.
8. Thread a Crawford stent through the superior and inferior canaliculus.
9. Tie the Crawford stent intranasally with care not to pull the stent too tightly as it can cheese-wire through the lacrimal puncta. Secure the loop to the lateral wall.

POSTOPERATIVE CARE

1. Amoxicillin 1000mg PO BID x 1 week.
2. Tobradex or Neomycin/Polymyxin/Dexamethasone eye drops BID x 5 days. 

SAMPLE DICTATION

Informed consent was reviewed with the patient in the preoperative evaluation area. The patient was then taken to the operating suite where IV access and cardiac monitoring devices were placed. The patient was transorally intubated. The nose was examined with a 0-degree telescope and the axilla of the middle turbinate, as well as the lateral wall of the nasal cavity overlying the lacrimal duct, was infiltrated with 1% lidocaine with 1:100,000 epinephrine. The nose was then packed with oxymetazoline-soaked cottonoid pledgets. The patient was prepped and draped in the usual fashion. A punctal dilator was then used to dilate the left upper lid puncta. A light pipe was then passed through the puncta and canaliculus of the left upper lid to a bony stop of the nose. Using a protected 4-diamond bur, the mucosa and bone overlying the sac was removed. The sac was then opened with a sickle knife. A set of Crawford tubes was then placed through the left upper and lower puncta and canaliculus through the ostium and retrieved in the nose. The Crawford stent was then secured to the left vestibule with a Prolene suture. The patient tolerated the procedure well with no complications.

REFERENCES

An endoscopic endonasal approach to dacryocystectomy. Shams PN, Selva D. Orbit. 2013 Apr;32(2):134-6.

Endoscopic dacryocystorhinostomy for acquired nasolacrimal duct obstruction: creating a window with a drill without use of mucosal flaps. Saratziotis A, Emanuelli E, Gouveris H, Babighian G. Acta Otolaryngol. 2009 Sep;129(9):992-5.

Endoscopic dacryocystorhinostomy in functional lacrimal obstruction. Brewis C, Yung M, Merkonidis C, Hardman-Lea S. J Laryngol Otol. 2008 Sep;122(9):921-3. Epub 2007 Nov 27.

Clinical results of endoscopic dacryocystorhinostomy using a microdebrider. Yoon SW, Yoon YS, Lee SH. Korean J Ophthalmol. 2006 Mar;20(1):1-6.

Functional endoscopic transnasal dacryocystorhinostomy. Whittet HB, Shun-Shin GA, Awdry P. Eye (Lond). 1993;7 ( Pt 4):545-9.