Dacryocystorhinostomy

A type of nasal surgery that helps correct long-term tears. Chronic dacryocystitis is a common and frequently-occurring disease in ophthalmology, which is more common in women and the elderly. Due to the ineffectiveness of drug treatment, the effect of exploration and intubation is not ideal, and the effect of laser treatment is difficult to be affirmed. At present, surgical treatment is still the main. As a classic surgical procedure, the dacryocystorhinostomy is aimed at directly matching the lacrimal sac with the nasal mucosa, so that the secretions and tears directly enter the middle nasal passage from the lacrimal sac to eliminate the purulent septic lesion and relieve the phenomenon of tears. Treatment of diseases: dacryocystitis, chronic dacryocystitis Indication Suitable for all chronic dacryocystitis: Chronic dacryocystitis nasal obstruction. If the lacrimal sac has been significantly reduced or there is atrophic rhinitis, the effect will be affected, and the effect is difficult to be sure. Contraindications 1. Acute inflammation of the lacrimal sac. 2. Dacryocystography shows that the lacrimal sac is very small. 3. Accompanied by nasal polyps, severe nasal septum deviation, severe suppurative sinusitis, severe atrophic rhinitis, nasal tumors and other nasal diseases. 4. Occupying lesions in the lacrimal sac, lacrimal sac tuberculosis, syphilis. Preoperative preparation All patients are required to undergo a detailed assessment by an ophthalmologist before surgery to rule out other diseases that cause excessive tears. Surgical procedure 1. Anesthesia: general anesthesia or local anesthesia. 2, mucosal flap incision: the first horizontal incision is 8-10 mm above the anterior humerus of the middle turbinate, the incision is located in the middle turbinate anterior condyle about 3 mm backward, the incision is about 10 mm forward, cut to the maxillary amount Protrusion, then the blade is turned into a longitudinal direction, making a vertical incision to 2/3 of the vertical height of the middle turbinate, the incision is terminated above the lower turbinate inserted into the outer side wall of the nasal cavity, the blade is turned to the lateral direction, and the lower incision begins at the attachment of the uncinate process, The front is connected to the vertical slit. The mucosal flap is lifted with a stripper, and the stripper is placed against the bone surface and slides along the protrusion of the maxillary frontal projection. Touching the bone at this site identifies the connection between the soft lacrimal bone and the hard maxillary frontal process. In this way, a mucosal flap that is pedicled in the uncinate process is formed. The mucosal flap can be trimmed to cover the exposed bone surface when the lacrimal sac is completed. The mucosal flap can also be directly removed. 3, the method of excision of bone: thinner tear bone in front of the hook protrusion, about 2-5 mm wide, the surgical area with the uncinate process as the posterior boundary. The soft teardrops are removed from the posterior margin of the lacrimal sac with a round knife. If difficulties are encountered, the maxillary frontal protrusions need to be removed before the teardrops are removed. The maxillary sinus bite was used to bite the lower part of the maxillary forehead, and the tip of the rongeur was pushed outward on the lacrimal sac that had removed the tear bone. When the rongeur is close to the lacrimal sac to remove bone, be careful not to pinch the wall. After the maxillary frontal process was removed, the anterior and posterior portions of the lacrimal sac were exposed. The rongeur continues to remove the bone as much as possible until the bone is thick enough that the rongeur cannot be operated. In this position, a coarse gold steel drill is used to remove bone below the upper labial margin. The light gold steel drill lightly contacts the lacrimal sac wall without damaging the lacrimal sac, but the bit is obviously pressed against the lacrimal sac and can cause damage. The bone is removed until the entire lacrimal sac is completely exposed. The lacrimal sac should be located on the convex part of the outer side wall of the nasal cavity. When the lacrimal sac is cut open and the mucosal flap is turned over, it can be laid flat on the outer side wall of the nasal cavity. The larger the lacrimal sac mucosal flap, the easier it is to lie flat on the outer side wall of the nasal cavity, so the lacrimal sac is on the outer side wall of the nasal cavity to create a bag rather than just opening a window on the wall of the capsule. 4, lacrimal sac treatment: use the punctum dilator to expand the small tears, and then the lacrimal sac probe into the lacrimal sac, when the probe moves up and down in the lacrimal sac, you can see its tip moving behind the lacrimal sac wall Confirm that the probe is indeed in the lacrimal sac. If the probe end does not move behind the thin wall of the lacrimal sac, it indicates that the probe may still be at the junction of the common tear duct and the lacrimal sac. The outer wall of the lacrimal sac can be pushed onto the inner side wall, so the inner side wall can move, but can not see Probe head. After seeing the probe head through the wall of the capsule, the tip of the probe is pressed into the wall of the ascending capsule at the lower edge of the probe, and the lacrimal sac is cut from the top to the bottom to form two longitudinal mucosal flaps before and after the flap. The upper and lower transverse incisions are made so that the mucosal flaps are better attached to the outer side wall of the nasal cavity. The lacrimal sac should be opened to the end to prevent the formation of the bottom water tank, causing the mucus to accumulate and block the orifice. The tip of the lacrimal sac should be open upwards to allow easy access to the opening of the lacrimal canal into the lacrimal sac. Some authors have argued that when the lacrimal sac is cut longitudinally, the lacrimal sac can be made into a large anterior mucosal flap or posterior mucosal flap, which is then attached to the wound surface of the lateral wall of the nasal cavity. It is usually easier to do the posterior mucosal flap. 5, dilatation tube: If the lacrimal sac is large, and the surface of the lacrimal sac mucosa has no obvious edema or polyps, the lacrimal sac mucosal flap can be well spread on the outer side wall of the nasal cavity to stop the blood stasis, ear gel or silver clip to the mucosal flap After the fixation is completed, it is not necessary to place the expansion tube. However, in patients with small lacrimal sac or undergoing corrective surgery, it is necessary to insert a dilatation tube through the canaliculus as a dilatation of the lacrimal sac opening. 6. Stuffing: assessing the bare bone around the lacrimal sac, restoring the mucosal flap of the outer wall of the nasal cavity to the open lacrimal sac, trimming the mucosal flap to cover the bone surface, and making the mucosal flap and the lacrimal sac mucosa and nasal mucosa It is good for healing to reduce the formation of granulation and scars. Gently fill the nasal cavity with hemostasis. complication When excising the bone, it may damage the cardboard to expose the fat. Be careful not to excessively disturb the exposed fat, so as to prevent the intra-orbital complications. As long as it is operated in front of the hook, it is not easy to enter the sputum. The incidence of postoperative adhesions is relatively high, mainly the adhesion of the lateral wall of the nasal cavity to the middle turbinate or nasal septum. The nasal septum should be corrected positively. In some cases, the front end of the middle turbinate can be removed to prevent the opening of the lacrimal sac from being too close. Reduce adhesions. For patients with small lacrimal sac, it is sometimes difficult to locate the lacrimal sac, which may damage the soft tissue of the face too far. The lacrimal probe can play a better role at this time.