|Year : 1969 | Volume
| Issue : 6 | Page : 263-265
Dacryocystorhinostomy with intubation
LK Trivedi, LB Massey, R Rohatgi
Kanpur Eye Hospital, Kanpur, India
|Date of Web Publication||11-Jan-2008|
L K Trivedi
Kanpur Eye Hospital, Kanpur
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Trivedi L K, Massey L B, Rohatgi R. Dacryocystorhinostomy with intubation. Indian J Ophthalmol 1969;17:263-5
There have been several modifications of the original procedure for dacryocystorhinostomy of Toti and Mosher.  This necessitated slight difference in technique and instruments, but the main aim was to make an alternative exit for the lacrimal passage into the middle meatus by making an opening through the lacrimal bone.
The work of Summerskill  has demonstrated clearly that excellent drainage can be achieved by intubation. Gill' reports his technique of using a rubber catheter sutured to the sac and left for 6-8 days. Bonaccolto  describes his method by using polyethylene tubing.
The purpose of this paper is to compare and contrast the results of dacryocystorhinostomy using three accepted procedures, viz., those of (1) TotiMosher,  Dupuy-Dutemps  and Gill.  Briefly the Toli-Mosher method, is to make an opening in the lacrimal bone and the nasal mucosa and another opening into the sac and leave them without suturing. The Dupuy-Dutemps technique employed by most surgeons is to suture the nasal and lacrimal mucosa together anteriorly and posteriorly. In Gill's method which is described below, a rubber tube is left in the anastomosis and brought out through the nasal cavity.
| Material and Method|| |
The cases selected were according to the condition of sac whether normal in size or atonic, enlarged or fibrosed.
It was necessary to divide the cases in the above categories for proper assessment of surgical results as it depends partly on the type of sac met with during the operation.
| Operative Technique|| |
Premedication sequil 10-20 mgm intramuscular 15 minutes before operation. Xylocain 2% supra-trochlear block by infiltration, Nasal pack soaked in Adrenalin 1:1000 and 1% anethane solution.
Exposure of Sac:
The usual curvilinear incision is made for exposure of the sac. Medial palebral ligament is divided and preserved for further resuturing. The sac is retracted towards the lateral side.
Opening in Bone
A dental drilling machine or a chisel and hammer are used to make an opening in the lacrimal bone. We use a blunt sac dissector to break the nasal bone. Further removal of bone is completed by Citellis' forceps. The removal of bone extends down to the beginning of lacrimal duct. Unless this is done a cul-de-sac for the retention of muco-pus may be left and patient's symptom may not be relieved. It is limited posteriorly to the posterior lacrimal crest, and anteriorly beyond the anterior lacrimal crest. It extends upwards to the level of medial palpebral ligament.
The edges are made regular and thus a rectangular wide space for nasal mucous membrane is available, this makes the suturing of two mucous memranes quite simple, Stallard. 
The lower punctum is dilated and a probe is put in. The lower portion of the sac at the junction of the nasolacrimal duct is dissected, its adjoining lateral border is separated avoiding injury to the lower canaliculus. The sac is cut at the junction of nasolacrimal duct, its opening is extended by two opposite cuts.
A similar `H' shared cut is made in the nasal mucosa. The nasal pack is removed. The lower flaps of mucosa are sutured by chromic catgut holding the needle by an artery fohrceps which provides ample space for turning the needle. We usually give three sutures. A rubber tube with an inner diameter of 3 mm, and an outer one of 5 mm and 20 cm long with bevelled end is passed from the external nostril through the opening in the nasal mucosa and is drawn into the cavity of the sac. This rubber tube is transfixed at its middle with a double armed suture of 00 to 000 plain cat gut. Both the anterior flaps are now sutured over the tube end, Gill.  Spongoston is placed in superior and inferior spaces.
The medial palpebral ligament is sutured in place. Subcutaneous continuous silk stitches are placed to close the wound. The rubber tubing is given one silk stitch at the ala of nose to keep it in position. The whole operation is facilitated by keeping the field dry with a suction apparatus. Time consumed on an average is 45 minutes.
Post Operative Care
The first dressing is done on the 4th day, the tube is removed on 8th day and the stitches on the 10th day. No probing and syringing are needed. The patient is discharged with Visine drops for the eye and nose three times a day.
| Discussion|| |
Dacryocystorhinostomy is being done as a routine, but the results are not uniform, as there is a certain percentage of cases in which it fails. The reasons for this may be several; improper technique, closing down of the passage by clot and discharge, too redundant a flap which falls forward, blocking the passage. Reoperation is a tedious procedure hence usually surgeons prefer to do a total excision of the sac for the relief of the symptoms, rather than re-explore the wound and try to find out the cause of failure. For this purpose we attempted the three well known techniques to compare and contrast their results.
It was our observation that using a rubber catheter and leaving it for the first week in the post operative period gave satisfactory results and necessitated fewer re-operations and total excision of sac later on. This method may take a few minutes longer but is worth the trouble. It was specially useful in cases with mucocele when it was laree and atonic and there was no need to excise any portion of it. The tube sutured to it was adequate to keep the opening patent. In fibrosed sac it was also useful to keep the two flaps apart during healing. The tube is removed on the 8th day to avoid foreign body reaction and excessive fibrous tissue formation.
| Summary|| |
Method of dacryocystorhinostomy with routine intubation of the opening by rubber catheter is described. Results in relation to Toti and DupuyDutemps and Gill's technique are compared.
| References|| |
Bonaccolto. G.: Dacryocystorhinostomy with polyethylene tubing (Simplified technique) J. Internal. Coll. Surg. 1957.
Dupuy-Dutemps: Ann. d'ocul, 157: 445, 1920.
Gill, W. D.: Dacryocystorhinostomy (A simplified technique) Amer. J. Ophth. 30: 198 (1947).
Stallard, H. B.: Eye Surgery Bristol, 1958 ed. 3. pp. 321.
Summerskill, W. H.: Dacryocystorhinotomy by Intubation, Brit. J. Ophthal. 36: 240 (1952).
Toti-Mosher, H. P.: Laryngoscope, 31: 392-521, 1921.
[Table - 1], [Table - 2], [Table - 3]