|Year : 1962 | Volume
| Issue : 3 | Page : 64-67
Kailash Nath, Suresh Kumar, BR Shukla
Muslim University, Institute of Ophthalmology, Gandhi Eye Hospital, Aligarh, India
|Date of Web Publication||18-Mar-2008|
Muslim University, Institute of Ophthalmology, Gandhi Eye Hospital, Aligarh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Nath K, Kumar S, Shukla B R. Dacryofistulorhinostomy. Indian J Ophthalmol 1962;10:64-7
A Preliminary Report
A lacrimal abscess, commonly the result of superimposition of an acute dacryocystitis upon an already blocked nasal duct, may resolve itself in several ways. If untreated, it may track posteriorly leading to orbital cellulitis or it may track towards the face and discharge spontaneously below the medial palpebral ligament in the region of the medial canthus. Very rarely the products of inflammation are discharged into the nasal cavity. Such naturally occurring dacryocystorhinostomies though rare are well known to ophthalmologists. After subsidence of inflammation permanent tracks communicating with the cavity of the sac may form causing either a lacrimal fistula on the face or into the nose, thereby relieving the old obstruction of the sac and leading to self cure of the disease. If treatment with antibiotics is instituted early, or even otherwise, the fistula may either not form at all and the abscess may resolve without the disease running its full course; or an acute dacryocystitis may result in a small fistula with a very narrow track which will completely close. It would be mischievous to count on a re-establishment of the natural passageways, once a fistula has formed, although it is known to have taken place, very rarely.
At the Gandhi Eye Hospital, Aligarh we come across a fair number of patients suffering from external lacrimal fistula. Dacryocystectomy, the classical treatment for these cases is of limited value because it fails to check the subsequent epiphora. After excision of the fistula a nasal drainage operation can be performed in some cases. But, this is determined by the local altered anatomical conditions found at the time of the operation. Pericystic inflammation, excessive cicatrisation leading to firosis and shrinkage of the sac, or disease of the neighbouring bones and paransal sinuses, all greatly minimise the chances of success of a nasal drainage operation. Dacryofistulorhinostomy, by providing the benefit of a nasal drainage operation in every case, presents a new approach in the surgical treatment of lacrimal fistula. The mouth of the fistula is transplanted into the nasal cavity without much disturbing of the sac itself however distorted or shrunken it may be. This procedure thus imitates the rare naturally occurring fistula which accidentally establishes communication with the nose resulting in sell cure of the disease. Dacryofistulorhinostomy establishes communication between the sac and the nasal cavity via the fistulous track. It transmits satisfactorily the lacrimal secretions from the conjunctival culde-sac to the nasal cavity by means of gravity and blinking mechanism and thus prevents epiphora.
| Operative Technique|| |
A. Presurgical Evaluation
After subsidence of inflammation atleast three weeks must elapse before dacryofistulorhinostomy is attempted. During this period a broad-spectrum antibiotic is administered systemically for one week. Potency of the lower canaliculus and the fistulous track is established by syringing through the inferior punctum. With a view to enlarge the lumen of the fistulous tract a few probings through the cutaneous opening are performed preoperatively with the help of Bowman's lacrimal probes. [Figure - 1].
Incision and Exposure :- Under general endotracheal anaesthesia an incision similar to that for dacryocystectomy is made along with the orbital margin. This encircles the fistula leaving a collar of healthy skin 5mm. wide all round the fistula opening [Figure - 2]. The lips of the wound are undermined, orbicularis fascia and muscle incised and veiw of the operating field enlarged with the help of claw retractors [Figure - 3].
Dissection : A lacrimal probe is introduced into the fistula and the track is carefully dissected from the surrounding tissue with the help of a blunt lacrimal dissector and fine cutting scissors [Figure - 4] All fibrous adhesions are incised and the whole length of the fistulous tract completely freed from its surrounds. Every care is taken to prevent injury to the tract for the continuity of its lumen and thin epithelial wall is essential for the success of the operation.
Bone Resection : The lacrimal fossa and the bone anterior to this is clearly exposed. Using mallet and the chisel the posterior half of the frontal process of maxilla is removed and the nasal mucous membrane exposed. Citelli's punch is then employed to enlarge the bony opening posteriorly by nibbling away the anterior lacrimal crest and front portion of the lacrimal bone. The window of bone removed is roughly oval with its long axis vertical and measures about 12 by 10 mm. [Figure - 5]. The edges of the window are trimmed and made smooth.
Anastamoses :- A vertical incision 10 mm. long is now made in the exposed nasal mucosa. The fistula surrounded by its collar of healthy skin is approximated to this opening and its medial margin is united with the posterior lip of the mucosal opening with three interrupted sutures of 6/0 chromic catgut. A polythene tube of the widest bore possible is introduced into the nasal cavity and brought out at the nostril where it is anchored to the skin. The anastamoses is completed by uniting the lateral margin of the skin surrounding the fistula with the anterior lip of the mucosal opening with three more interrupted 6/0 chromic catgut sutures [Figure - 6].
Closure of Incision : The wound is now dusted with penicillin powder and the incision in the orbicularis muscle is closed with two or three interrupted sutures of 4/0 black silk sutures placed at three millimeter intervals. The eye is irrigated, terramycin ointment instilled and a firm pressure bandage applied.
C Post-Operative Care
A broad spectrum antibiotic is administered for one week. The skin sutures are removed on the seventh day. Syringing is started from the eight day and continued with gradually decreasing frequency upto the sixth week. The polythene tube is removed by the end of the second week.
| Comment|| |
In evolving a nasal drainage operation for lacrimal fistula two techniques were considered. The first wherein the mouth of the fistula is transplanted into the nasal cavity has been termed Dacryofistulorhinostomy, and the details of this operation have been described above. The second technique consists of indirectly communicating the fistula with the nasal cavity via the maxillary sinus (antrum of Highmore). This operation has been named Dacryofistuloantrostomy and will form the subject of a subsequent report.
Dacryofistulorhinostomy is a gravity drainage operation which utilises the fistulous tract for the conduction of tear fluid to the nasal cavity. For its success therefore, it is essential to maintain the potency and continuity of this tract. This is achieved by (i) pre-operative probings, (ii) introduction of polythene tube into the tract during operation and (iii) daily syringing through the lower punctum from the eighth post-operative day, the frequency of this last procedure is gradually reduced and finally abandoned after six weeks. Kinking of the tract is prevented by the polythene tube and if indicated by rotating the sac medially and anchoring its anterior surface to the periosteum of the neighbouring bone. The tube is removed on or about the 15th day after operation by which time the newly formed fibrous tissue has consolidated the direction of the fistulous tract.
Dacryofistulorhinostomy is easy to perform. It is followed by minimum post-operative reaction and immediate cessation of epiphora. The operation has been successfully carried out on one patient whose three month followup has been uneventful. However, the true evaluation of this technique in cases of lacrimal fistula awaits further trial.
| Case History|| |
T. V.: a female patient aged 28 years [Figure - 7] was admitted at Gandhi Eye Hospital in early September for treatment of a discharging sinus situated just below the inner canthus of her right eye. The history was that a couple of months earlier, she had developed a tender swelling in the region of the right medial canthus, which subsided in about ton days time by discharging its contents through the skin leaving behind a permanent opening. On examination this was found to measure about 3 mm. in diameter. Its communication with the sac was confirmed by probing. Obstruction of the nasolacrimal duct was revealed by syringing through the lower punctum which resulted in discharge of fluid from the external opening. Culture taken from the discharging fistula showed presence of pneumococci. It was decided to perform dacryofistulorhinostomy upon the lines already described in the foregoing text. Preoperatively the patient was administered intramuscular injections of dicristicin 1 gm, and Lederkyn one tablet orally daily for one week. At operation, the sac was found to be small and fibrosed. Convalescence was uneventful. The postoperative treatment was as described under the operation.
| Conclusion|| |
Dacryofistulorhinostomy presents a new approach in the treatment of lacrimal fistula. The operation has been devised with an aim of providing the benefit of nasal drainage in every case. Tear fluid is conducted satisfactorily from the conjunctival cul-de-sac to the nasal cavity via the fistulous tract irrespective of anatomical condition of the lacrimal sac. It is a gravity drainage mechanism which also utilises the blinking process for the successful transmission of tear fluid. The operation is easy to perform and is followed by minimum postoperative reaction. Dacryofistulorhinostomy has been carried out successfully in one patient whose three month follow up has been uneventful.
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7]