Table 57.1
Indications for surgery
| Symptomatic epiphora from nasolacrimal duct obstruction |
| Primary dacryocystorhinostomy (DCR) failure |
Table 57.2
Preoperative evaluation
Endonasal examination to identify cause of DCR failure:
|
| Lacrimal probing and irrigation |
Introduction
Suturing of the nasal mucosal and lacrimal sac flaps is routinely performed during external dacryocystorhinostomy (DCR). The open approach afforded by the external skin incision and direct visualization allows meticulous suturing of these flaps. However, within the narrow field provided by the endoscopic approach, flap suturing is particularly challenging owing to poor surgical access. In this chapter, flap suturing during endonasal DCR is presented. While this may be considered as an optional adjunct during primary endonasal DCR, flap suturing may be more appropriately applied for cases of failed external or endonasal DCR.
Surgical Technique
Endonasal anatomy and surgical planning
Achieving maximal nasal decongestion is crucial to successful endoscopic DCR with nasal flap suturing (refer to Chapter 53 for full discussion). The nasal mucosa is packed preoperatively with pledgets soaked with 1 : 10,000 epinephrine. Intranasal flap suturing is considered in this case as the nasal septum is deviated towards the surgical side ( Figures 57.1A and 57.1B ). Anatomically, the course of the lacrimal sac is observed to run anterior to the middle turbinate as highlighted in blue and this is where the initial osteotomy will be performed to expose the lacrimal sac ( Figure 57.1C ). The maxillary line is the mucosal projection that represents the maxillary–lacrimal suture line that unites the anterior and posterior lacrimal crest ( Figure 57.1D ). This important landmark is where the initial osteotomy is performed.
