|Year : 1967 | Volume
| Issue : 3 | Page : 94-97
Dacryocystorhinostomy and the superior-inferior flap technique
Ophthalmic Dept., Patna Medical College Hospital, Patna, India
|Date of Web Publication||21-Jan-2008|
Ophthalmic Dept., Patna Medical College Hospital, Patna
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Pandey R. Dacryocystorhinostomy and the superior-inferior flap technique. Indian J Ophthalmol 1967;15:94-7
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|| |
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|| |
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|| |
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|| |
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.
| References|| |
Arruga (1956), Ocular Surgery 2nd Ed. 248-277.
Summerskill, W. H. (1949), Trans. Ophth. Soc. U.K. 69, 494.
Summerskill, W. H. (1952), Brit, J. Ophth. 36, 240.
Spaeth. E. B. (1949), Principles and Practice of Ophth. Surgery 4th Ed. p. 110-130.
Stallard, H. B.
(1958), Eye Surgery, 3rd Ed. p. 227-336.
[Figure - 1]
[Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5]