How To: Modified Endoscopic Dacryocystorhinostomy Nasal Mucoperiosteal Flap Technique

INTRODUCTION

With the combination of the endoscope, illumination, and a powered instrument, along with the use of a nasal mucoperiosteum flap, the ostium patency rate of endoscopic dacryocystorhinostomy (eDCR) is currently comparable to that of an external approach. Meanwhile, due to its avoidance of a facial scar, better accuracy in the location of the lacrimal sac, and decreased blood loss, eDCR has become much more popular. A nasal mucoperiosteal flap is often designed to prevent stenosis and atresia of the newly created ostium in an eDCR. Here we report a superiorly hinged clubhead-shaped nasal flap that showed satisfactory results for ostium preservation and scar reduction.

METHOD

Surgical Technique

All procedures were performed under general anesthesia. To provide sufficient mucosal decongestion and surface anesthesia, the nasal common cavity and middle meatus were packed with cotton pledgets soaked in 1% tetracaine and 4‰ adrenaline for several minutes. Almost all the procedures were performed with the 0° endoscope except for the examination of the surgical field with a 45° endoscope at the end of the operation. Surgical procedures were as described below (also see the supporting video).

Clubhead-shaped nasal mucoperiosteal flap: Using an insulated needle-tip electrocautery bent at a 45° angle, we started the first mucosal incision above the axilla of the middle turbinate and 2 mm below the roof of the nasal cavity. It was extended 8 mm anterior to the axilla of the middle turbinate and then turned downward and 1.5 cm anterior to the attachment of the uncinate process to an area of insertion of the inferior turbinate.

The second incision was started from the axilla of the middle turbinate and coursed downward 2 mm anterior to the attachment of the uncinate process. When the second incision reached where the insertion of the inferior turbinate was, it turned anteriorly to connect with the first incision. A Cottle septum elevator was then used to elevate the mucoperiosteal flap in a subperiosteal plane. After that, the flap, which looked like the head of a golf club, was tucked into the olfactory cleft to keep it out of the operating field. Mucoperiosteum posterior to the second incision was elevated 2 mm posteriorly to facilitate apposition with the following lacrimal flap.

Bone window (Figure 1): The frontal process of the maxilla, axilla of the middle turbinate, and maxillary line were identified. A curved 15° diamond burr was used to thin the frontal process of the maxilla around the region of the maxillary line. The axilla of the middle turbinate and the lacrimal bone were then partially drilled away to fully expose the medial wall of the lacrimal sac. Note that the bone 4 mm above the axilla of the middle turbinate was drilled away to extend the bone window to facilitate further exposure of the fundus of the lacrimal sac. The uncinate process should be reserved as a bony holder of the following lacrimal flap, even if the attachment of the uncinate process was drilled away and the infundibulum or the agger nasi cell was accidentally entered. For the identification of the anterior-most margin of the lacrimal sac, a small patch of periosteum anterior to and continuous with the reddish lacrimal fascia was inevitably exposed.