Systematic unciformectomy for a standardized endonasal dacryocystorhinostomy

Abstract

Purpose: To describe a standardized osteotomy method for endonasal dacryocystorhinostomy (en-DCR) and the results obtained.

Design: Prospective nonrandomized, noncomparative, interventional case series study.

Participants: One hundred consecutive adult patients (81 females, 19 males) underwent en-DCR performed by the same team of oculoplastic and rhinologic surgeons.

Methods: A standardized procedure was used in all cases. This included endoscopic assessment of the surgical site from the nasal aspect, diaphanoscopy of the common canaliculus, and endonasal osteotomy. Anterior unciformectomy was followed by resection of the lacrimal bone and protected drilling of the maxillary bone of the lacrimal fossa to expose the entire medial aspect of the lacrimal sac. The middle turbinate was preserved whenever atraumatic dissection of the nasal mucosa was possible or when it was resected partially before osteotomy.

Main outcome measures: Rate of direct localization of the lacrimal fossa, rate of turbinectomy/septoplasty, rate of residual postoperative tearing, rate and nature of complications

Results: Transillumination of the common canaliculus was obtained directly in 94% of cases; transillumination, required the opening of an ethmoidal cell in 2%, partial resection of the middle turbinate in 3%, and unciformectomy in 1%. Access to the surgical site required partial resection of the middle turbinate in 21% of cases, but no septoplasty. Osteotomy was initiated in 90% of cases by cleavage of the anterior insertion of the uncinate process, and in 5% by cleavage of the first, overdeveloped ethmoidal cell. The cleavage opened directly to the medial aspect of the lacrimal fossa in these 95 cases. Osteotomy was achieved by drilling alone in only five cases. Perioperative complications were limited to significant bleeding in six cases. Postoperative complications included one case of resolved frontal sinusitis on day 3, and one case of inferior lid hematoma with emphysema.

Conclusions: The authors suggest that anterior resection of the uncinate process is the most important surgical step to expose the medial aspect of the lacrimal fossa during endonasal DCR, whereas partial resection of the middle turbinate can be considered optional.