OPEN ACCESS ATLAS OF OTOLARYNGOLOGY, HEAD &

NECK OPERATIVE SURGERY

ENDOSCOPIC DACRYOCYSTORHINOSTOMY (DCR) SURGICAL TECHNIQUE

Hisham Wasl, Darlene Lubbe

Endoscopic dacryocystorhinostomy (DCR)

is a surgical intervention for epiphora
caused by obstruction of the nasolacrimal
duct. Understanding endonasal anatomy,
wide endoscopic marsupialisation of the
lacrimal sac, and meticulous care of the
nasal mucosa are important to achieve good
results.

Patients develop symptoms of tearing when

there is an imbalance between tear produc-
tion and drainage function of lacrimal sys-
tem. Tearing can therefore be caused by
• Hypersecretion
• Epiphora
• Combinations of the above
Figure 1: Ocular and nasolacrimal duct
Hypersecretion (lacrimation) is excessive anatomy
tearing caused by reflex hypersecretion due
to irritation of the cornea or conjunctiva e.g. Frontoethmoidal suture
trigeminal nerve stimulation in corneal Ethmoidal bone
disease.
Maxillary–lacrimal
suture
Epiphora occurs with poor lacrimal drain-
Posterior lacrimal crest
age due to (lacrimal bone)
• Mechanical obstruction of the lacrimal
Anterior lacrimal crest
drainage system related to trauma, dac- (maxillary bone)
ryocystolithiasis, sinusitis, and congeni-
Nasolacrimal duct
tal nasolacrimal duct obstruction in
children Figure 2a: Anterior and posterior lacrimal
• Lacrimal pump failure (functional epi- crests are formed by the frontal process of
phora) may be caused by eyelid laxity maxillary bone and lacrimal bones
(as in facial nerve palsy), eyelid mal-
position, and punctum eversion

Relevant anatomy

The lacrimal puncta open at the medial ends

of the upper and lower eyelids and drain
into the lacrimal sac via the upper and lower
canaliculi (Figure 1). The lacrimal sac is
located in the lacrimal fossa and drains into
the nasolacrimal duct (Figures 2, 3). The
nasolacrimal duct runs within a bony canal
Figure 2b: Area of bone to be removed
created by the maxillary and lacrimal bones
and opens into the inferior meatus of the
nose (Figures 1-3).
The lacrimal bone extends between the
frontal process of the maxilla anteriorly
(Figure 2), to the attachment of the uncinate
posteriorly. It is important to note that the
lacrimal bone and sac are located just ante-
rior to the orbit. The retrolacrimal region
of the lamina papyracea is thin and
careless surgery to the uncinate at this
point may lead to penetration of the orbit. Figure 3c: Axial CT scan demonstrates
The lacrimal sac extends approximately anatomical relations between lacrimal
9mm above the axilla of the middle turbi- fossa and agger nasi cell
nate (Figure 4). The common canaliculus
opens high on the lateral wall of the sac; this
area should be exposed, and all bone *
removed during endoscopic DCR for a
better result.

Figure 4: Endoscopic view of the axilla of

the right middle turbinate (*) with mucosal
flap raised to expose bone covering the
Figure 3a: Coronal CT scan through the lacrimal sac (arrow)
lacrimal sac
Evaluation of patients with epiphora

Clinical History and Examination

A detailed history and clinical examination

help to
• Differentiate between hypersecretion,
lacrimation and epiphora
• Define the pathological process
• Distinguish whether tearing is due to a
functional or anatomical disorder
• Identify the site of the blockage
Figure 3b: Coronal CT scan through the • Define a surgical approach (if required)
lacrimal sac and agger nasi cell

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Examination includes Syringing
• Eyelids: Lower lid laxity, ectropion,
entropion, punctum eversion, trichiasis, This is generally done by ophthalmologists
blepharitis in an outpatient clinic under local anaesthe-
• Medial canthus: Lacrimal sac enlarge- sia
ment below the medial canthal tendon • Apply topical anaesthesia by applying
• Palpation of lacrimal sac: Reflux of 1-2 drops of Oxybuprocaine or Benoxi-
mucopurulent material from the punc- nate HCl 0.4% (Novesin Wander ® by
tum; pressure over sac in acute dacryo- Novartis) onto the puncta
cystitis causes pain • Dilate the puncta with a punctum dila-
tor if the puncta are small (Figure 5,6)
Special Investigations • Insert a 24G (yellow) intravenous can-
nula into the inferior canaliculus, first
Diagnostic tests are used to identify the aiming vertically and then horizontally
cause of an obstruction and to choose ap- (Figures 5, 7)
propriate treatment 1. Diagnostic tests can • Straighten the lower canaliculus by
be classified as follows: pulling the lower eyelid downwards and
• Anatomical tests to locate the site of laterally (Figure 7)
obstruction • Advance the tip of the cannula 3-6mm
o Diagnostic probing into the canaliculus
o Syringing (irrigation) • Irrigate the lacrimal drainage system
o Dacryocystography with sterile water
o Nasal examination
o CT, MRI
• Physiological/Functional tests
o Fluorescein dye disappearance
o Scintigraphy
o Saccharine test
• Secretion tests
o Schirmer’s test
o Bengal rose test
o Tear-film breakup
o Tear lysozyme

Diagnostic probing & lacrimal syringing

(irrigation)

Diagnostic probing and irrigation of the lac-

Figure 5: Dilator, probing and syringing
rimal system are important anatomical tests.
instrumentation
They provide information about the site of
obstruction but are unable to give infor-
How to interpret syringing tests
mation about functional insufficiency.
Teaming up with ophthalmologists help • Reflux through the opposite punctum
ENT surgeons to obtain the required skills suggests obstruction in the common
of probing and syringing the lacrimal canaliculus or distal to it
system. The required instrumentation is • Fluid coming directly back through the
shown in Figure 5. same punctum indicates a canalicular

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 obstruction; repeat syringing through Diagnostic Probing
the other canaliculus
• Distention of the lacrimal sac indicates Probing is indicated only if syringing
obstruction of the nasolacrimal duct demonstrates obstruction and the site and
• Irrigation into the nose indicates an extent of the obstruction need to be deter-
anatomically patent system, but not mined. If fluid refluxes through the oppo-
necessarily a functional system site punctum, it suggests obstruction of the
common canaliculus or more distally; this
distinction should be made with diagnostic
probing

• Apply topical anaesthesia by using 1- 2

drops of Oxybuprocaine or Benoxinate
HCl 0.4% Novesin Wander ® by No-
vartis) onto the puncta and wait 20
seconds
• Dilate the puncta with a punctum dilator
• Advance an appropriately sized lacri-
mal probe into the canaliculus (Figures
5, 8)
• First pass the probe vertically through
the punctum, and then horizontally until
it encounters the lacrimal bone or meets
the canalicular obstruction
Figure 6: Punctum dilated with a punctum
dilator

Figure 8: Diagnostic probing

How to interpret a diagnostic probing test

• A hard stop is when the probe is advan-
Figure 7: Syringing via lower canaliculus ced along the canaliculus and encoun-
ters the lacrimal bone. This means that
the probe has passed into the sac and

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 touched its bony medial wall, and that required 2, 3. Both dacryocystography and
the common canaliculus is patent scintigraphy provide some idea of the level
(Figure 9a) of obstruction and whether a tight common
• A soft stop is a spongy feeling encoun- canaliculus is contributing to the epiphora.
tered when there is an obstruction
proximal to the lacrimal sac and the Dacryocystography is indicated when there
probe cannot be passed into the sac. In is obstruction in the lacrimal system with
such cases the obstruction is at the com- syringing. It can assist with understanding
mon canaliculus and the lacrimal probe the internal anatomy of the lacrimal system.
presses the common canaliculus and the Indications for dacryocystography include
lateral wall against the medial wall of • Complete obstruction: size of sac, deter-
the sac (Figure 9b). There will also be a mining exact site of obstruction (com-
medial shift of the inner canthus when mon canaliculus or sac)
advancing the probe toward the lacrimal • Incomplete obstruction and intermit-
bone due to the probe displacing the tent tearing: site of stenosis, diverticu-
common canaliculus medially la, stones, and absence of anatomical
• Reflux through the opposite punctum pathology (functional disorders)
when syringing a hard stop suggests • Failed lacrimal surgery: size of the sac
obstruction of the sac or the naso- • Suspicion of sac tumors
lacrimal duct
Nuclear lacrimal scintigraphy is a func-
It is important to note the presence of a tional test, and is useful to assess the site of
hard stop or a soft stop, because the delayed tear transit. It is especially helpful
treatment of an obstruction at the lacrimal in difficult cases with an incompletely ob-
sac or duct vs. at the common canaliculus structed system e.g. questionable eyelid
requires different surgical interventions. laxity, and questionable epiphora.

Computed tomography (CT) is used with

tumours, rhinosinusitis, facial trauma, and
following facial surgery. With concomitant
sinus disease, CT assists a surgeon to ad-
dress the sinuses at the same time as the
DCR.

Magnetic resonance imaging (MRI) is

rarely used to investigate tearing patients.
a b
Nasal endoscopic examination
Figure 9a: “Hard stop” when probe is
passed into lacrimal sac and hits medial
Endoscopic examination of the nasal cavi-
bony wall; b: “Soft stop” when probe dis-
ty is obligatory. It provides very important
places common canaliculus towards medial
information about e.g. nasal polyps, nasal
wall of sac…is associated visible medial
masses, rhinosinusitis, tumours, anatomical
shift of inner canthus
variations, and nasal septal deviation.
Radiological investigations

Radiological investigations are done if

doubt exists about the surgery that is
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Endoscopic DCR surgery technique o Kerrison punch (Figure 11a)
o 2.75mm Cataract knife (Figure 11b)
Anaesthesia and preparation of surgical o Small Blakesley forceps
field o Punctum dilator and probes
o DCR intubation set
• Surgery is performed under general an-
aesthesia with the endotracheal tube out It is quicker to remove bone with a
of the way of the endoscope and Kerrison’s punch than with a DCR burr.
instruments The DCR bur is only used when the punch
• The patient is placed supine, either flat is unable to engage the bone adequately.
or slightly flexed to 15 degrees, and
slightly rotated towards the surgeon
• Using a dental syringe, inject 2ml of 1%
lidocaine with 1:100,000 adrenaline
into the axilla of the middle turbinate
and the frontal process of maxilla
(Figure 10)
• Insert ribbon gauze or neurosurgical
patties soaked in 2ml of 1:1000 adrena-
line between the inferior turbinate and Figure 11a: Kerrison punch
the nasal septum and in the middle
meatus to achieve topical decongestion
• A dose of co-amoxiclav or cefazolin is
given at induction of anaesthesia

+ *
+
BE
+ UP
MT Septum

Figure 11b: 2.75mm Cataract knife

Surgical steps
Figure 10: Injection points of lidocaine 1. Septoplasty
with 1:100,000 adrenaline into axilla of
middle turbinate (*) and frontal process of
• Have a low threshold for performing a
maxilla (+)
septoplasty if a septal deviation ham-
pers access to the middle meatus and
Surgical instruments
lateral nasal wall
• Ideally place the septal incision on the
• Surgical instruments required:
side contralateral to the DCR
o Dental syringe
o No 15-scalpel blade
o Suction Freer elevator
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2. Create a posteriorly based mucosal
flap to expose the lacrimal bone

• Use a no 15 scalpel blade to make a

superior incision that runs horizontally
8-9 mm above the axilla of the middle
turbinate (Figure 12)

Figure 13: Suction diathermy can be to

cauterize the incision sites for haemostasis

Figure 12: Superior and inferior incisions

and the area where the local anaesthetic is
injected

• One can use suction diathermy to cau-

terise the incision line before making
the cut (Figure 13)
• Extend the incision anteriorly for appro-
ximately 10 mm onto the frontal process Figure 14: Vertical incision
of the maxilla
• Turn the blade vertically and make a cut 4. Remove bone to expose lacrimal sac
onto the frontal process of the maxilla
from the superior incision to just above • Use a Kerrison’s punch to remove the
the insertion of the inferior turbinate bone of the frontal process of the maxil-
(Figure 14) la overlying the lacrimal sac (Figure 16)
• Turn the blade horizontally and make • It is quicker to remove bone with a
the inferior incision from the insertion Kerrison’s punch than with a DCR bur
of the uncinate to join the vertical inci- • Only use a DCR bur when the punch is
sion (Figures 12, 14) unable to adequately engage the bone
• Expose the sac by removing bone up to
3. Raise a mucosal flap the mucosal incisions superiorly, infe-
riorly, and anteriorly, so the sac forms a
• Use a suction Freer dissector to raise a prominent bulge into the nasal cavity
mucosal flap and to expose the under- (Figure 16)
lying bone (Figure 15) • Remove all the lacrimal bone up to the
• It is important to stay on bone to avoid insertion of the uncinate, but do not
losing the surgical plane disturb the uncinate itself
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• The lacrimal probe should be passed 5. Expose agger nasi cell
from the puncta through to the nasal
cavity without feeling any bone obstruc- • The agger nasi cell is situated medially,
ting the pathway of the probe. If this is superiorly and more posteriorly to the
not so, then more bone should be lacrimal fossa (Figure 3b)
removed superiorly • Open the agger nasi cell using a Kerri-
• This retrolacrimal region where the son’s punch
uncinate inserts into the lamina papyra- • This allows better exposure of the lacri-
cea is extremely thin, so take care not to mal sac and allows the mucosa of the
cause an accidental orbital injury sac to lie against the agger nasi mucosa
• The common canaliculus opens high on (Figures 17, 18)
the lateral wall of the sac; this area
should be exposed during endoscopic
DCR for a better result

Figure 17: Exposure of agger nasi (arrow);

2 silastic tubes visible

Figure 15: Raising the mucosal flap

Figure 18: Agger nasi (arrow) has been

opened (compare to Figure 3b)

Figure 16: Removal of bone of the frontal 6. Marsupialise the lacrimal sac
process of the maxilla exposes the lacrimal
sac • Cannulate the superior or inferior cana-
liculus with a probe, taking great care
not to make a false passage in the
delicate lacrimal system
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• Both the upper and lower canaliculi • Return the remainder of the flap onto
have an angulated course that needs to the lateral wall and ensure that the
be carefully followed to avoid creating exposed bone is covered
such a false passage
• Tent the lacrimal sac with the lacrimal 8. Inserting silastic stents
probe under endoscopic vision (Figure
19) • The authors prefer to stent the DCR
• Incise the medial wall of the sac only neo-ostium (not all surgeons do so)
when the lacrimal probe can be clearly • Two silastic lacrimal tubes are used to
seen tenting the sac wall stent the lacrimal system (Figures 17,
19)
• Dilate the puncta with a punctum dilator
if the puncta are small (Figure 6)
• Pass the silastic lacrimal tubes through
the superior and inferior puncta into the
nasal cavity (Figure 20)
• Secure the tubes by tying the ends toge-
ther, using 4-6 knots, on the nasal side
• It is important not to tie the tubes too
tightly as this can cause adhesions be-
tween the puncta at the medial canthus;
this is avoided by passing the tip of an
artery clip through the loop at the
medial canthus while knotting the tubes

Figure 19: Tenting the wall of the sac with

a probe before incising the lacrimal sac

• Use a DCR knife or cataract knife to

vertically incise the sac
• Cut releasing incisions in the posterior
and the anterior flaps of the sac
• Either Bellucci micro ear scissors or a
sickle knife can be used for the release
incisions
• The sac must be widely marsupialised,
and be widely open and lying flat on the
lateral nasal wall (Figure 17)

7. Trimming the nasal mucosal flap

Figure 20: Pass the lacrimal tubes through
the inferior and superior puncta into the
• Preserve the mucosal flap until the end
nose
of the procedure to protect the nasal
septum during the surgery
• Use a Tilley’s nasal forceps to advance
• Trim the mucosal flap so that only small
the knot, which is tied outside the nasal
superior and inferior rims remain, and
cavity, down the nasal cavity (Figure
the lacrimal sac remains wide open
21)

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• The first knot should be about 5mm and may require difficult oculoplastic
below the opened sac to avoid the knots corrective surgery
getting stuck within the sac itself • If the tubes are tied too tightly in the
• Check that there is no tension on the nasal cavity the knots can cause granu-
tubes at the medial canthus or in the lation tissue at the neo-ostium
nose • Epistaxis is unusual unless there has
been significant trauma to the nasal
mucosa or turbinates

Late
• Restenosis
• Failed surgery

Revision surgery

Revision surgery is occasionally indicated.

It is imperative that the reason for failure is
ascertained, which may include:
• Not enough bone removed superiorly
• Not enough bone removed inferiorly
Figure 21: Endoscopic view of tied ends of causing a sump effect with tears collec-
silastic tubes passing through the common ting in the sac
canaliculus into the nasal cavity • Sac not marsupialised widely enough
• Missed foreign body or stones within
Postoperative Care the sac
• Stenosis of the superior or inferior cana-
• Patients are generally discharged with- liculi
in a few hours • Stenting that caused excessive granula-
• Prescribe a 5-day course of deconges- tions
tant nasal drops
• Apply antibiotic eye drops for 2 weeks
• Irrigate the nose with saline References
• Patients are again seen at 2 weeks to
clean the nose, remove crusts and to 1. Hurwitz JJ. The Lacrimal System.
remove early adhesions Lippincott-Raven Publishers, Philadel--
• Silastic tubes are removed in the office phia (1996).
after 4 - 6 weeks 2. Hurwitz JJ, Welham RAN. Radiogra-
phy in functional lacrimal testing. Br J
Complications Ophthalmol 1975; 59:323–31
3. Hurwitz JJ, Molgat Y. Radiological test
Early of lacrimal drainage. Diagnostic value
• Adhesions can form if care is not taken versus cost-effectiveness. Lacrimal sys-
to preserve the mucosa of the nasal tem. Symposium on the Lacrimal Sys-
septum and middle turbinate tem, Brussels, 23–24 May 1992, pp 15–
• If the tubes are tied too tightly, an 26
adhesion can form at the medial canthus
between the upper and lower puncta,

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Authors

Hisham Wasl MD, FCORL

University of Cape Town Karl Storz
Rhinology Fellow
Division of Otolaryngology
University of Cape Town
Cape Town, South Africa
[email protected]

Darlene Lubbe MBChB, FCORL

Associate Professor
Division of Otolaryngology
University of Cape Town
Cape Town, South Africa
[email protected]

Editor

Johan Fagan MBChB, FCS (ORL), MMed

Professor and Chairman
Division of Otolaryngology
University of Cape Town
Cape Town, South Africa
[email protected]

OPEN ACCESS ATLAS OF

OTOLARYNGOLOGY, HEAD &
NECK OPERATIVE SURGERY
www.entdev.uct.ac.za

The Open Access Atlas of Otolaryngology, Head & Neck

Operative Surgery by Johan Fagan (Editor)
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