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ARTICLE |
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Year : 1958 | Volume
: 6
| Issue : 4 | Page : 80-82 |
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Dacryocystorhinostomy - Analysis of 105 operations
SP Mathur
Victoria Hospital, Bharatpur, Rajasthan, India
Date of Web Publication | 8-May-2008 |
Correspondence Address: S P Mathur Victoria Hospital, Bharatpur, Rajasthan India
Source of Support: None, Conflict of Interest: None | Check |
How to cite this article: Mathur S P. Dacryocystorhinostomy - Analysis of 105 operations. Indian J Ophthalmol 1958;6:80-2 |
This paper gives an analysis of 105 operations of dacryocystorhinostomy performed by various techniques on cases of chronic dacryocystitis with regurgitation in different age groups of patients. It also stresses various points to be kept in mind so as to make the operation a. success even in the hands of comparatively inexperienced surgeons provided with little special equipment. Many surgeons, even today, do not feel encouraged to undertake this simple and effective operation probably because they think it difficult and time-consuming, working in. a small field particularly regarding stitching of the flaps.
Technique of the Operation | | |
The technique is practically the same as described by Jain et al (1955). We would like to lay stress on perfect haemostasis, a straight and well forward skin incision, proper separation of periosteum, a big bony window, bigger flaps of the nasal mucous membrane and securing them with those of the sac with at least two stitches in each of the flaps. The operation does not need special instruments and is quite simple.
Post-operative treatment consists of a pain powder as and when indicated and sulphadiazine 1.5 gm. for 3 days. Syringing is done after 48 hours with Penicillin solution and skin stitches are removed on the seventh day when patients are instructed to report in case epiphora recurs.
Results | | |
[Table - 1] shows results of operating by various techniques and causes of failure, where it occurred.
Comments | | |
Cases of chronic dacryocystitis with regurgitation on pressure were subjected to this operation, care being taken to exclude any malignancy or tuberculosis of the sac (Lyle et. at. 1946) and pathology of the nose e.g. atrophic rhinitis, or large recurrent polypi. Cases below 3 years of age responded well to probing and those above 6o years of age usually had some nasal pathology and therefore treated by excision. Patients between 15 to 35 years with normal health are the best subjects for dacryocystorhinostomy.
It is essential to pack the nose tightly to support the nasal mucous membrane while the bony window is being chiselled out. Two operations performed by the Toti technique in this series were done because the nasal mucous membrane got very much lacerated during excision of the bone due to a defective nasal pack and, therefore flaps could not be made.
It is desirable to make a straight skin incision well forward because by doing so, whole of the dissection is brought more anteriorly and easy to manipulate in a small field in which one has to work. The angular vein is always protected. A curved incision frequently damages the angular vein and gives an unsightly scar (Hogan 1948). Perfect haemostasis must always be kept by pressure with adrenaline packs. Annoying oozing mars the thrill a surgeon gets on making a clean dissection. It is important to properly incise and separate the periosteum from the underlying bone laterally together with the sac. Three cases of failure with new bone formation after two weeks were the result of early attempts when the importance of proper separation of periosteum was not fully realised.
The bony window should be fairly large to make bigger flaps of the nasal mucous membrane. This makes stitching easier with minimum of traction over them.
Prcplaced sutures in the nasal mucous membrane before incision, suggested by Jain et. al. (1955) do not give an additional advantage over stitches applied after making flaps. On the contrary it unnecessarily introduces another time consuming step. Factors which make anastamosis of the flaps easier arc a large anterior skin incision, a larger bony window, and bigger flaps of the nasal mucous membrane (size of the sac is always uncertain and so also its flaps). If all these factors are achieved it should not be difficult to put in two or three or even four stitches in each of the flaps to secure them well in position, and chances of closure of the rhinostomy thus become remote. In three cases operated early in this series, flaps were stitched with catgut. Two of them developed marked fibrosis blocking the new passage, which could not be relieved even after excision of the fibrous tissue.
The importance of putting some antiseptic powder has to be stressed because of danger of the infection spreading, after cutting a sac which is loaded with pus.
While closing the skin care should be taken to give minimum of scar by carefully applying cuticular sutures. Bad stitching frequently gives rise to an unsightly painful scar.
It is advisable to hospitalise the patients for at least two days for observation. Three of the cases reported in this series developed secondary haemorrhage after 36 hours. They were brought to the theatre, the nose was cleaned of blood clots and packed with gauze soaked with adrenaline. Coagulants and antibiotics were given in suitable doses.
The first syringing should always be done early, say after 48 hours. This will wash out any lurking infection or a blood clot in the area, both of which promote fibrosis.
We are not in agreement with Jain et. al. (1955) in advocating cortisone suspension as drops or for irrigation in cases of post-operative fibrosis after repeated probing as it gives only a temporary relief. In such cases it is advisable to take another chance to open up and excise all the fibrous tissue but even after this it is doubtful whether the patency, will be maintained.
It is felt that after stitching both the flaps results were better and surer than if the flaps were left unstitched. It is in agreement with Jain et al. (1955) The percentage of success claimed by various workers is as follows :
Dupuy-Dutcmps (1920) - 94%
Martin and Cordes (1929)
Hogan (1948) - 85% to 95%
Lyle et al. (1946) - 78%
Jain et al. (1955) - 93.1%
Present series - 94.3%
Summary | | |
An analysis is presented of 105 dacryocystorhinostomy operations performed with slight modifications of the technique described by Jain et al.[5]
References | | |
1. | Dupuy-Dutemps, (1920) - Ann. D'Ocul., 157, 415. |
2. | Hogan, M. J. (1948) - Trans. Am. Ac. of Oph. and Otol., 52, 600-612. |
3. | Jain, N. S., Sethi, D. V., and Om Prakash - J. A11-India Ophth. Soc. (1955) 3, 37 - 44 |
4. | Lyle, T. K., Cross, A. G., Simpson, J. F., Fraser, G. A., (1946), Brit. J. Ophth. 30, 102-119. |
5. | Martin, R. C. and Cordes, F. C., (1929) - Califor and West, med. 31, 1-7. |
[Table - 1]
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