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ARTICLE
Year : 1967  |  Volume : 15  |  Issue : 3  |  Page : 94-97

Dacryocystorhinostomy and the superior-inferior flap technique


Ophthalmic Dept., Patna Medical College Hospital, Patna, India

Date of Web Publication21-Jan-2008

Correspondence Address:
R Pandey
Ophthalmic Dept., Patna Medical College Hospital, Patna
India
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Source of Support: None, Conflict of Interest: None


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How to cite this article:
Pandey R. Dacryocystorhinostomy and the superior-inferior flap technique. Indian J Ophthalmol 1967;15:94-7

How to cite this URL:
Pandey R. Dacryocystorhinostomy and the superior-inferior flap technique. Indian J Ophthalmol [serial online] 1967 [cited 2020 Oct 22];15:94-7. Available from: https://www.ijo.in/text.asp?1967/15/3/94/38692

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Flap suturing in the technique of dacryocystorhinostomy has improved the results of this operation consider­ably because it prevents the bony pro­liferation and the over-growth of gra­nulations.

The Summerskill (1949) technique in which a plastic tube is introduced through the rhinostomy opening is well known. The technique of dacryocystor­hinostomy is not simple because the surgeon has to work in a limited space, and proper preservation of flaps and suturing is still more difficult. This had led ophthalmic surgeons to modify the technique in their own way and ex­cellent results are claimed by the sur­geons with their particular technique.


  Introduction Top


The present series of cases include thirty five cases of chronic dacryo­cystitis and epiphora which were ope­rated by the author in the ophthalmic department of Patna Medical College Hospital between the period Septem­ber, 1959 to August, 1965. In these cases of chronic dacryocystitis, the age, sex, side of affection and the type of disease have been recorded. In all such cases dacryocystorhinostomy was per­formed. The technique of this opera­tion in most of the cases was the clas­sical double flap with the anterior and porterior flap suturing (Dupuy­-Dutemps), but in some cases a new technique of preparing and suturing superior and inferior flaps was evolved and followed, while in still fewer cases a single flap was made and sutured.


  Surgical Anatomy Top


In describing the passage between the lacrimal sac and the nose, we pre­fer to use the term lacrimonasal duct instead of the nasolacrimal duct be­cause the usual passage of fluid is from the lacrimal sac to the nose and not vice versa.

It is necessary to keep in mind some of the finer points in the anatomy of the lacrimal sac for this operation.

On the medial side, the upper half of the lacrimal fossa is related to the anterior ethmoidal cells and the lower half with the middle meatus of the nose. These medial relations are very variable. Sometimes the whole or part of the medial wall is related to the anterior ethmoidal cells, whereas at other times these cells form no relation at all, being small and absent. Hence when making the fenestra, it is always better to confine oneself to the lower portion of the bony lacrimal fossa. (Vide diagram 1).

The outer wall of the lacrimal sac is formed by the lacrimal fascia, which is formed by the splitting of the orbital periosteum which is firmly attached at the anterior and posterior lacrimal crests. Hence the importance of sepa­rating the sac along with this orbital periosteum.

Observations on the etiological aspect of Dacryocystitis :­

The above table shows that the ma­ximum incidence seems to occur in the middle age group and the young per­sons and the aged suffer almost equal­ly. This age incidence compares fav­ourably with those of Keith-Lyle, Simpson and Fraser (1960).

In our series female sufferers were 82.8% whereas the males were only upto 17.1%. According to Duke Elder also the incidence of dacryocystitis in females is 75 to 80% whereas in males it is only 20 to 25%.

In our series 18 (51.4%) had the right side affected, whereas in 14 (400%) the left side was involved which does not show any significant difference. Bilaterality is rare-2 cases (5%). One such bilateral case was operated on both sides thus bringing the total to thirty five cases.

80% of the cases were of chronic dacryocystitis whereas the cases of mucocele, lacrimal fistula and obsti­nate epiphora were very few.

As mentioned before most of the cases were operated by the Dupuy­-Dutemps technique of making and su­turing anterior and posterior flaps and in ten cases a new method of making superior and inferior flaps was evolved and followed. The table below shows the different methods adopted in 35 cases.

THE SUPERIOR-INFERIOR FLAPS TECHNIQUE

The age of the patients varied from 15 to 70 years. Morphia 1/4 gr. was injected intramuscularly half an hour before the operation and the nostril on the side of operation was properly sprayed and packed with anethaine 1%, and a few drops of liq. adrena­line. After preparing the skin in the usual manner, a crescentic incision with concavity towards the inner canthus is made midway between the anterior border of the nose and the inner canthus. This incision goes right upto the bone so that the lacri­mal sac can be separated along with the periosteum clearly by means of a rugine. A large hole is made in the frontal process of maxilla and the lacrimal bone on the affected side with hammer, gouge and bone nibbler. This hole is extended upto the lower­most portion of the lacrimal fossa. The mucoperichondreum of the nose is carefully separated from the bone by means of Traquair's elevator. The size of the hole made is usually 1" long and 1/2" wide.

A H-shaped incision is made into the medial wall of the lacrimal sac. Roughy the anterior and the posterior vertical limbs of the H correspond with the anterior and the posterior borders of the lacrimal sac. The horizontal in­cision is made at the middle of these incisions so that one superior and an­other inferior flaps are made. The same type of flaps are made in the corresponding nasal mucosa. Thus in the nasal mucosa as well as in the wall of the lacrimal sac two corresponding superior and inferior flaps are made. The two superior flaps i.e. one of the sac and another of the nasal mucosa are sutured by two sutures and so also the two inferior flaps. The skin inci­sion is closed with thread sutures after putting penicillin powder in the wound. An antibiotic eye ointment sterile dressings and bandage are ap­plied. Systemic antibiotic in the form of Dicrysticin one vial intramuscularly is injected every day for five days.

Post Operative Management:

The bandage is opened on the fifth and seventh day when the lacrimal sac is syringed with sterile normal saline at the same time. The stitches are re­moved on the seventh day. Thereafter the patient is prescribed an antibiotic application for the eyes and the lacrimal sac is finally syringed on the tenth post-operative day with normal saline, and the patient is discharged. The pa­tient is advised to report again after three months for final assessment of the result of operation.

The wound was invariably dressed and the sac was syringed on the fifth day of operation with the idea to mini­mise sac infection as by that time granulations would be forming.

Special indication of Superior-Inferior flap method:

This superior-inferior flap technique is useful for cases in which the width of the nasal mucosa is limited due to the appearance of anterior ethmoidal cells or encroachment of the anterior end of the middle turbinate.

Complications of operation:

The table below shows the various complications met with in dacryocy­storhinostomy operation:

The above table shows the compli­cations met with in this series of da­cryocystorhinostomy cases. The cause of bleeding mostly was due to the in­jury to the nasal mucous membrane. It was observed that if the field of operation extended more forward, backward, above or below bleeding was troublesome.

Avoidance of injury to the mucous membrane while fenestrating the bone is of utmost importance, as it mini­mises the bleeding and the time of ope­ration. It was seen that blunt gouges instead of cutting, fractured the bone and at times injured the nasal mucous membrane and so were the cause of troublesome bleeding. This type of bleeding is difficult to control as the bleeding occurs away from the fenes­tration.

Only in one case the periostitis was encountered and the cause could be as­signed to the purulent infected sac and blunt gouges.

Other complications are unavoidable and does not require elucidation.


  Results Top


Eighteen dacryocystorhinostomy operations have been performed by the standard anterior and posterior flap making and suturing. Only one case out of these eighteen cases ended in failure, the failure being due to fibrotic sac of trachomatous origin.

The number of operations performed by superior inferior flap technique were ten, out of which the two failures were due to an interior canaliculus block. The remaining eight cases were successful in the sense that no epiphora or discharge persisted.

The dacryocytorhinostomy opera­tions performed with making and suturing of a single flap in seven cases, were surprisingly successful.

The percentage of success as a whole comes to about 91.4%, which com­pares well with that of Scott's (1910) figure of 90%. Three cases out of this series of thirty five were suffering from lacrimal fistula and they also were operated successfully. One case of this series had chronic trachoma with fibro­tic lacrimal sac and this ended in fai­lure.

Distended lacrimal sacs, mucoceles and even frankly suppurating cases ended successfully after operation. Aged patients did not give trouble in operation and the operation was equal­ly successful.


  Summary Top


In all, thirty five cases have been in­cluded in this series out of which ten cases were operated by the superior­inferior flaps technique, eighteen by the anterior-posterior flaps technique (Dupuy-Dutemps) and seven with single flap suture.

The two unsuccessful cases in the superior-inferior flap technique were due to a block of the inferior canali­culus. This technique is particularly indicated when there is encroachment on the operation field by an anterior ethmoidal cell or the anterior end of the middle turbinate.

The one failure in the anterior­posterior flap technique was due to a fibrotic sac, a result of old trachoma.

All the seven cases in which only a single flap was made and sutured were successful.[5]

 
  References Top

1.
Arruga (1956), Ocular Surgery 2nd Ed. 248-277.  Back to cited text no. 1
    
2.
Summerskill, W. H. (1949), Trans. Ophth. Soc. U.K. 69, 494.  Back to cited text no. 2
    
3.
Summerskill, W. H. (1952), Brit, J. Ophth. 36, 240.  Back to cited text no. 3
    
4.
Spaeth. E. B. (1949), Principles and Practice of Ophth. Surgery 4th Ed. p. 110-130.  Back to cited text no. 4
    
5.
Stallard, H. B. (1958), Eye Surgery, 3rd Ed. p. 227-336.  Back to cited text no. 5
    


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    Tables

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Surgical Anatomy
Results
Summary
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