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ARTICLE
Year : 1969  |  Volume : 17  |  Issue : 6  |  Page : 263-265

Dacryocystorhinostomy with intubation


Kanpur Eye Hospital, Kanpur, India

Date of Web Publication11-Jan-2008

Correspondence Address:
L K Trivedi
Kanpur Eye Hospital, Kanpur
India
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Source of Support: None, Conflict of Interest: None


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How to cite this article:
Trivedi L K, Massey L B, Rohatgi R. Dacryocystorhinostomy with intubation. Indian J Ophthalmol 1969;17:263-5

How to cite this URL:
Trivedi L K, Massey L B, Rohatgi R. Dacryocystorhinostomy with intubation. Indian J Ophthalmol [serial online] 1969 [cited 2020 Dec 3];17:263-5. Available from: https://www.ijo.in/text.asp?1969/17/6/263/38552

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There have been several modifica­tions of the original procedure for dacryocystorhinostomy of Toti and Mosher. [6] 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 [5] 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 [5] 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, [6] Dupuy-Dutemps [2] and Gill. [3] 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 Top


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 Top


Anaesthesia:

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. [4]

Mucosal Flaps

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. [3] 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 Top


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 Top


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 Top

1.
Bonaccolto. G.: Dacryocystorhinostomy with polyethylene tubing (Simplified technique) J. Internal. Coll. Surg. 1957.  Back to cited text no. 1
    
2.
Dupuy-Dutemps: Ann. d'ocul, 157: 445, 1920.  Back to cited text no. 2
    
3.
Gill, W. D.: Dacryocystorhinostomy (A simplified technique) Amer. J. Ophth. 30: 198 (1947).  Back to cited text no. 3
    
4.
Stallard, H. B.: Eye Surgery Bristol, 1958 ed. 3. pp. 321.  Back to cited text no. 4
    
5.
Summerskill, W. H.: Dacryocystorhino­tomy by Intubation, Brit. J. Ophthal. 36: 240 (1952).  Back to cited text no. 5
    
6.
Toti-Mosher, H. P.: Laryngoscope, 31: 392-521, 1921.  Back to cited text no. 6
    



 
 
    Tables

  [Table - 1], [Table - 2], [Table - 3]



 

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Material and Method
Operative Technique
Discussion
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