Middle meatal obstruction following endoscopic dacryocystorhinostomy. (Rhinoscopic Clinic).

Dacryocystorhinostomy (DCR) is the surgical method of bypassing the distal lacrimal drainage system. An obstructed lacrimal system causes epiphora and can lead to acute or chronic dacryocystitis. Obstruction of the lacrimal system usually occurs in the distal portion of the lacrimal sac or in the nasolacrimal duct. With DCR, a new drainage duct can be created that traverses from the proximal lacrimal sac, through the medial wall, and into the nasal cavity. The new ostium is usually created via an external approach into the lacrimal sac, and flaps are created from the nasal mucosa to the lacrimal sac. Long-term patency rates have been reported to be well over 90%. (1) As an alternative, many authors advocate transnasal approaches to opening the lacrimal sac, and they have reported similar success rates. (1,2)

The preferred location for the ostium created by DCR is through the lacrimal bone in the anterosuperior part of the lateral nasal wall. The medial wall of the lacrimal sac is located at the most anterior portion of the middle meatus. After the ostium is created, the area is generally stented with Silastic tubing for several weeks or months.

We evaluated a 50-year-old woman who had developed chronic frontoethmoid sinusitis the left. Prior to this encounter, she had no history on sinusitis. The patient had undergone a DCR on the left 5 years earlier. She now complained of pain and pressure medial to the left eye, epiphora, and intermittent purulent lacrimal drainage. She was prescribed medical treatment but failed to respond. Computed tomography (CT) revealed the presence of persistent left frontoeffimoid sinusitis as a result of an obstruction of the ostiomeatal complex (figure, A). The patient was taken to the operating room for endoscopic sinus surgery.

Although the DCR ostium remained wide and patent, the patient had a marked obstruction of the middle meatus on the ipsilateral side (figure, B). Scarring and lateralization of the middle turbinate were also noted. A concha bullosa was present, which contributed to the obstruction. In order to enlarge the middle meatus, an excision of the lateral wall of the concha bullosa (middle turbinate contour) (figure, C) and removal of the diseased uncinate process (figure, D) were required. This was accomplished with a microdebrider. Seven months postoperatively, this patient was completely asymptomatic. The middle meatus and the opening of the DCR were wide, patent, and functioning.

This patient had developed chronic sinusitis with scarring of the middle meatus following a previous DCR. Although the ostium created by the DCR remained wide and patent, the patient became symptomatic with epiphora as her sinus disease developed. The literature on DCR describes the importance of maintaining the ostium with appropriate stenting and debridement. This case also highlights the potential complications that are related to alteration and scarring of the middle meatus; these complications were a factor in the development of chronic sinusitis and the recurrence of epiphora. A nontraumatic surgical technique in the area of the middle meatus is essential when the surgeon is performing a DCR. (1,2)

References

(1.) Mercandetti M, Mirante JP. Endoscopic dacryocystorhinostomy. Facial Plast Surg Clin North Am l997;5:195-202.

(2.) Metson R. Dacryocystorhinostomy. In: Kennedy DW, Bolger WE, Zinreich SJ, eds. Diseases of the Sinuses: Diagnosis and Management. Hamilton, Ont.: B.C. Decker, 2001.

From the Department of Otolaryngology, University of South Florida College of Medicine, Tampa, and the Halifax Medical Center, Daytona Beach, Fla. (Dr. Christmas and Dr. Mirante); and the Southern New England Ear, Nose, Throat, and Facial Plastic Surgery Group, New Haven, Conn., and the Section of Otolaryngology, Yale University School of Medicine, New Haven (Dr. Yanagisawa).