Endoscopic and Radiologic Findings in Failed Dacryocystorhinostomy: Teaching Pearls for Success

Abstract

Background Although several studies have commented on causes of dacryocystorhinostomy (DCR) failure, detailed description of anatomical findings in such cases remains insufficient. Objective Our objective was primarily to analyze radiologic, endoscopic, and intraoperative findings in patients presenting with failed DCR and secondarily to assess the outcome of revision endoscopic DCR (endo-DCR) carried out at our institution. Methods Twenty-four failed DCRs presenting to our tertiary care center were retrospectively analyzed. Data collection included patients’ history, diagnostic, and management data, as well as thorough analysis of sinonasal CT scans, along with endoscopic and intraoperative findings. Outcome was also assessed in 21 cases with revision endo-DCR performed. Results The anterior part of uncinate process was not previously removed in 15 sides (62.5%), with unopened agger nasi in 13 sides (54.2%). The lacrimal bone was detected covering the posterior sac despite removal of the anterior ascending process of maxilla in 9 sides (37.5%). Rhinostoma was anterior to lacrimal sac in 2 sides (8.3%) and was below the sac in 7 sides (29.2%). Fibrous membrane covered the rhinostoma despite removal of all sac-overlying bones in 6 sides (25%). Other findings included intranasal adhesions, septal deviation, lateralized middle turbinate, granulation tissue, foreign body reaction, and chronic sinusitis. Nineteen of the 21 revision endo-DCRs were successful (90.5%). Conclusion This study provides a precise anatomical description of findings in cases of failed DCR. Such information is paramount in helping surgeons enhance their learning curve, refine the surgical technique, and improve patients’ outcome.

Endoscopic dacryocystorhinostomy with mucosal anastomosing in chronic dacryocystitis with three categories of ethmoid sinuses

“…We found that 12.0% (179/1489) of the affected eyes have C1 ethmoid, 59.0% (878/1489) have C2, and 29.0% (432/1489) have C3. Our findings were in accordance with other published reports [7][8][9]17,[20][21] . During routine En-DCR, osteotomy is initiated at the lacrimomaxillary suture and then carried forward into the nasal fossa until the lacrimal sac is exposed [1][2]11,15] .…”

“…These sinuses often project past the ethmoid bone suture and into the lacrimal and maxillary bones of the lacrimal sac fossa. Therefore, understanding the physical interaction between the anterior ethmoid air cells and the lacrimal sac fossa is essential for DCR [7][8][9]11] . Unfortunately, an ethmoid-cell entry may present a blind cul-de-sac and can lead to surgical failure.…”

“…Therefore, its close proximity to the lacrimal sac fossa is an essential factor in lacrimal surgery. The ethmoidal bone stems from the posterior of the lacrimal sac and often extends anterior to the posterior lacrimal crest and, at times, even reaches the anterior lacrimal crest [6][7] . The categories of ethmoid sinuses were intricately classified in 1990 by Blaylock et al [8] , who divided them into three categories, depending on their anatomic relationship between the ethmoid sinus and the dacryocyst.…”

Surgical and Anatomic Consideration in Endoscopic Dacryocystorhinostomy of a Patient with Damaged Sinonasal Anatomy Post–Caldwell-Luc Surgery: A Case Report

“…The light reflex that was observed intranasally determines the target of the lacrimal sac. Either a 20-/23-gauge vitreoretinal fiberoptic endoilluminator or a lighted lacrimal stent could be inserted and this procedure could be conducted at the beginning of endo-DCR before the mucosa is incised [21][22][23]. However, in our experience, the light could be insufficient in the case of a very thick frontal process of the maxilla or hypertrophied nasal mucosa.…”

Editorial

“…Wise surgeons realize that we learn much more from our failures than our successes. Herzallah and colleagues 4 reported a detailed analysis of their series of 24 patients who had previously failed dacryocystorhinostomy. Radiographic analysis demonstrated the most common findings being an incompletely removed uncinate process leading to retained lacrimal bone over the sac as well as limited removal of the ascending process of the maxilla and agger nasi leading to a poorly placed or suboptimaly sized rhinostoma.…”