Dacryocystorhinostomy
Tear sac surgery, or dacryocystorhinostomy, is a surgical procedure to open the tear sac in the nose to allow tears to flow out. The operation is performed under general anesthetic by an ENT surgeon, and generally requires a one-day hospital stay. The special feature of this 30-year-old ENT technique is that there are no scars on the face, as the entire opening procedure is performed in the nose. The dacryocystorhinostomy is then said to be endonasal, as opposed to a dacryocystorhinostomy performed externally, which is just as effective but leaves a scar on the face.
Find out more about endonasal dacryocystorhinostomy from Dr. Delagranda, ENT and cervico-facial surgeon in La Roche sur Yon, France.
Tear ducts
Tears are produced by the lacrimal gland, located above the eyeball on the outer side of the eye. They then clean and keep the cornea moist to prevent ulceration, forming a film that is regularly deposited by eyelid movements. Once past the cornea, they accumulate temporarily in the inner corner of the eye at the level of the lacrimal lake, then leave the eye via the upper and lower lacrimal canaliculi (beginning at the orifices or lacrimal points), which join to form a common canal. The common canal joins the lacrimal sac, which is located in both the internal angle of the eye and the nose, protected by the lacrimal bone or unguis medially. The lacrimal sac continues vertically through the nasal lacrimal duct, which terminates in the nose beneath the canopy of the inferior turbinate, where the tears are evacuated. This explains why we sniff when we cry, as the excess tears produced are not eliminated quickly enough and flow into the nasal cavity. Infection or inflammation of the lacrimal ducts can prevent tears from flowing through the natural channels, causing them to run down the cheek.
Who is concerned by the opening of the lacrimal sac or dacryocystorhinostomy?
- Adults with chronic lacrimation, dacryocystitis, mucocele (swelling in the inner corner of the eye, with or without redness, with or without pain).
- Children over 5 years of age, as the endonasal technique is not feasible for anatomical and material size reasons.
Indications for dacryocystorhinostomy are mainly complete stenoses of the nasolacrimal duct that appear without known cause, due to repeated infections, or after direct trauma. Incomplete nasolacrimal duct stenoses may benefit from bicaniluculonasal catheterization prior to dacryocystorhinostomy. Canaliculus stenosis is a rarer indication.
Particular to infants and young children under 3: congenital imperforation (present from birth) of the nasal lacrimal duct is the most frequent lacrimal pathology at this age. This can lead to unilateral or bilateral clear lacrimation, conjunctivitis or even acute dacryocystitis, with a red, swollen and painful inner corner of the eye. Congenital imperforation of the nasolacrimal duct usually heals within the first year of life. This imperforation does not require dacryocystorhinostomy, but probing of the lacrimal duct, usually in consultation with an ophthalmologist between 3 and 6 months, and under general anaesthetic in the operating room after 6 months. A monoKA probe is then frequently added. If the problem is accompanied by significant and persistent dilatation of the lacrimal sac, re-evaluation at an older age with possible dacryocystorhinostomy is recommended.
When should an endonasal dacryocystorhinostomy be done?
Endonasal dacryocystorhinostomy is to be performed in case of:
- Repeated acute dacryocystitis or acute infections of the lacrimal sac: round, red, hot and painful swelling located in the inner corner of the eye with tearing (epiphora). If an abscess forms, the swelling becomes white and softer in its center.
- Chronic dacryocystitis: round, firm, persistent swelling for more than a month in the inner corner of the eye with tearing (epiphora) whose pressure causes mucus to come out through the 2 orifices or tear points (not to be confused with an exceptional tumor at this location). This is called mucocele in the lacrimal sac.
- Persistent epiphora (chronic lacrimation)
Objectives of endonasal dacryocystorhinostomy
- Stop chronic tearing.
- Limit and then eliminate acute or chronic dacryocystitis.
- Avoid a scar on the face.
The different stages of the intervention
The surgery
Under general anesthesia in the operating room, it consists of opening the lacrimal sac in its nasal surface after removing the nasal mucosa and milling a little bone of the lacrimal bump in the nose. The 2 tear canalicles must be catheterized and a bicanalicular tube must be left, which starts from the eye and goes into the nose. This probe will remain in place for 3 months and will serve as a tear guide and healing stake. It is easily removed through the nose during an ENT consultation. Opening the tear sac makes it possible to deflect the flow of blocked tears that is still in the nose but higher than the natural orifice, upstream of the stenotic area of the nasal tear duct.
Post-operative convalescence period
The return home is usually the same day in the case of an outpatient hospitalization.
After hospitalization, it is necessary to stay 8-10 days at home at rest, and watch that there is no bleeding through the nose or throat.
A work stoppage of 8-10 days will be given to you by the surgeon if necessary.
It is not recommended to do sports the first 15 days and the recovery should be gradual.
The pain is average. It is controlled by class I analgesics.
Postoperative care at home: saline nose washes for 21 days, analgesics, artificial tears, endonasal spray after the initial healing phase. Antibiotics in some cases.
Scar: no visible scar
Precautions: the bicanalicular probe is mobile, and is located both in the nose and in the corner of the eye. It may come out of the canaliculi with certain extreme eye movements, in which case you need to gently push it back into the nose with your finger in the inner corner of the eye.
Complications of endonasal dacryocystorhinostomy
In addition to the risks inherent in any surgery involving general anaesthesia, endonasal dacryocystorhinostomy presents rare complications:
- Nasal haemorrhage (epistaxis) after the procedure: very slight, it rapidly subsides with nose-blowing and nose-washing.
- Periorbital hematoma due to effraction of the orbital wall close to the lacrimal bone.
- Swelling of the eyelids due to breakthrough of the orbital wall near the lacrimal bone, with air passing from the nose to the eyelids, most often after sneezing or blowing the nose.
To avoid this, it is advisable not to blow your nose by blocking the nostril, but to wash your nose instead. When sneezing, do not block the nose, but rather keep the mouth open to avoid excessive air pressure in the operated area.
Please consult the ENT College’s explanatory sheet on endonasal dacryocystorhinostomy for further explanations and exceptional complications:
Frequently asked questions
Here is a selection of questions frequently asked by Dr Delagranda’s patients during consultations for endonasal dacryocystorhinostomy in La Roche-sur-Yon.
Is the operation compulsory?
- In case of chronic lacrimation: No, this is a comfort operation. The surgeon advises and the patient decides.
- In case of repeated or chronic infections of the lacrimal sac (dacryocystitis): Yes, this is strongly recommended, as it creates an infectious focus that can spread locally, with the risk of facial phlebitis, or disseminate further afield, particularly in the case of diabetes or heart valve pathologies. However, the patient remains the decision-maker.
Fees and coverage of the procedure
Endonasal dacryocystorhinostomy is covered by health insurance. Contact your mutual insurance company to find out whether any extra fees will be covered.
Do you have a question? Need more information?
Dr Antoine Delagranda is available to answer any questions you may have about endonasal dacryocystorhinostomy. Dr Delagranda is a specialist in ENT surgery at the Clinique St-Charles in La Roche sur Yon, France.
ENT consultation for endonasal dacryocystorhinostomy in Vendée
Dr Antoine Delagranda will be happy to answer any questions you may have about dacryocystorhinostomy. Dr Delagranda is a specialist in ENT surgery at the Clinique Saint Charles in La Roche-sur-Yon in the Vendée.