Figure 8 The bicanalicular silicone tubing is knotted in continuous loop fashion through the surgically created nasolacrimal fistula. (Color version of figure is available online.)

charged to home the same day. Prophylaxis with systemic antibiotics is continued for approximately 1 week after surgery. The use of ophthalmic antibiotic steroid drops is continued for 1 to 2 weeks after surgery. Intranasal saline and topical steroid sprays are used if the age of the patient allows ease of administration.

The subsequent postoperative removal of the nasolacrimal silicone tubing can usually be completed in an outpatient office setting in cooperative older children; general anesthesia may be required in young children. Both an endoscopic examination of the nares and an assessment of nasolacrimal patency should be performed concurrently at that time.

The principal advantages of endoscopic DCR over external DCR include the absence of a facial incision, the preservation of the integrity of the orbicularis oculi muscle and the medial palpebral ligaments that constitute the functional pump mechanism of tearing, and comparatively reduced morbidity during the immediate postoperative course. The endoscopic approach also allows for a detailed examination of the nasal anatomy, with potential correction of any intranasal pathologic conditions that may contribute to DCR failure.29 There are some relative disadvantages of endoscopic DCR in children, including anatomical limitations in small children, the need for appropriate instrumentation, and requisite meticulous intraoperative hemostasis.

Acknowledgments

The author thanks Robert J. Galla for his anatomical drawing expertise.

References

1.Sevel D: Development and congenital abnormalities of the naso-lacrimal apparatus. J Pediatr Ophthalmol Strabismus 18:1319, 1981

2.Hepler KM, Woodson GE, Kearns DB: Respiratory distress in the neonate: Sequela of a congenital dacryocystocele. Arch Otolaryngol Head and Neck Surg 121:1423-1425, 1995

3.Calcaterra EE, Annino DJ, Carter BL, et al: Congenital naso-lacrimal duct cysts with nasal obstruction. Otolaryngol Head and Neck Surg 113:481-484, 1995

4.Boynton JR, Drucker DN: Distention of the lacrimal sac in neo-nates. Ophthalmic Surg 20:103-107, 1989

5.Campolattaro BN, Lueder GT, Tychsen L: Spectrum of pediatric dacryocystitis: Medical and surgical management of 54 cases. J Pediatr Ophthalmol Strabismus 34:143-153, 1997

6.Shashy RG, Durairaj VD, Holmes JM, et al: Congenital dacryocystocele associated with intranasal cysts: Diagnosis and management. Laryngoscope 113:37-40, 2005

7.Levin AV, Wygnanski-Jaffe T, Forte V, et al: Nasal endoscopy in the treatment of congenital lacrimal sac muco-celes. Int J Pediatr Otorhinolaryngol 67:255-261, 2003

8.Mazzara CA, Respler DS, Jahn AF: Neonatal respiratory distress: Sequela of bilateral nasolacrimal duct obstruction. Inter J Pediatr Otorhinolaryngol 25:209-216, 1993

9.Berkowitz RG, Grundfast KM, Fitz C: Nasal obstruction of the newborn revisited: Clinical and subclinical manifestations of congenital nasolacrimal duct obstruction presenting as a nasal mass. Otolaryngol Head Neck Surg 103:468-471, 1990

10.Holzberg N, Ward RF: Bilateral congenital dacryocystoceles. Otolaryngol Head Neck Surg 109:1074-1077, 1993

11.Yee SW, Seibert RW, Bower CM, et al: Congenital naso-lacrimal duct mucocele: A cause of respiratory distress. Inter J Pediatr Otorhinolaryngol 29:151-158, 1994

12.John PR, Boldt D: Bilateral congenital lacrimal sac mucoceles with nasal extension. Pediatr Radiol 20:285-286, 1990

13.Rand PK, Ball WS, Kulwin DR: Congenital nasolacrimal mucoceles: CT evaluation. Radiol 173:691-694, 1989

14.MacEwen CJ, Young JDH: Epiphora during the first year of life. Eye 5:596-600, 1991

15.Wong JF, Woog JJ, Cunningham MJ, et al: A multidisciplinary approach to atypical lacrimal obstruction in childhood. Ophthal Plast Reconstr Surg 15:293-298, 1999

16.Petersen RA, Robb RM: The natural course of congenital obstruction of the nasolacrimal duct. J Pediatr Ophthalmol Strabismus 15:246-250, 1998

17.Paul TO, Shepherd R: Congenital nasolacrimal duct obstruction: Natural history and the timing of optimal intervention. J Pediatr Ophthalmol Strabismus 31:362-367, 1994

18.Yeatts RP: Current concepts in lacrimal drainage surgery. Curr Op Ophthalmol 7:43-47, 1996

19.Hakin KN, Sullivan TJ, Sharma A, et al: Pediatric dacryocystorhinostomy. Australian/New Zealand J Ophthalmol 22:231-235, 1994

20.Welham RAM, Hughes SM: Lacrimal surgery in children. Am J Ophthalmol 103:1226-1228, 1985

21.Nowinski TS, Flanagan JC, Mauriello J. Pediatric dacryo-cystorhinos- tomy. Arch Ophthalmol 103:1226-1228, 1985

22.Cunningham MJ, Woog JJ: Endonasal endoscopic dacryocysto-rhinos- tomy in children. Arch Otolaryngol Head Neck Surg 124:328-333, 1998

23.Vandrveen DK, Jones DT, Tan H, et al: Endoscopic dacryocystorhinostomy in children. JAAPOS 5:143-147, 2001

24.Berlucchi M, Staurenghi G, Brunori PS, et al: Transnasal endoscopic dacryocystorhinostomy for treatment of lacrimal pathway stenoses in pediatric patients. Int J Pediatr Otorhinolaryngol 67: 1069-1074, 2003

25.Kominek P, Cervenka S: Pediatric endonasal dacryocystorhinostomy: A report of 34 cases. Laryngoscope 115:1800-1803, 2005

26.Chastain JB, Cooper MH, Sindwani R: The maxillary line: an anatomic characterization and clinical utility of an important surgical landmark. Laryngoscope 115:990-992, 2005

27.Tsirbas A, Wormald PJ: Endonasal dacryocystorhinostomy with mucosal flaps. Am J Ophthalmol 136:579-580, 2003

28.Tsirbas A, Wormald PJ: Mechanical endonasal dacryocysto-rhinos- tomy with mucosal flaps. BR J Ophthalmol 87:43-47, 2003

29.Nussbaumer M, Schreiber S, Yung MW: Concomitant nasal procedures for endoscopic dacryocystorhinostomy. J Laryngol Otol 118: 267-269, 2004

Conjunctivodacryocystorhinostomy (CDCR) with Jones tube placement is a procedure primarily performed for severe stenosis or obstruction of both upper and lower canaliculi. CDCR may also be indicated after an unsuccessful dacryocystorhinostomy (DCR) or for severe lacrimal pump obstruction.1 By creating a conduit using a Pyrex glass tube (known as a Jones tube) from the medial tear lake at the caruncle into the middle meatus just anterior to the middle turbinate, tears can be redirected into the nasal cavity, effectively decreasing epiphora.1,2 Essentially, Jones tube placement allows for a bypass of the lacrimal system and creates a new outflow pathway for tears to enter the nose.1,3

Traditionally, CDCR with Jones tube placement has been performed through an external incision at the medial canthus through which a bony osteotomy is fashioned and the Pyrex tube is positioned.1,3 Similarly, an external skin incision has been the conventional approach to DCR for treatment of nasolacrimal duct obstruction.1 With the advent of functional endoscopic sinus surgery in otolaryngology, rigid and semirigid endoscopes began to be used with increased regularity.3 This increased interest in endoscopic surgery during the last decade has translated into new innovations in the treatment of lacrimal obstruction. Citing advantages such as enhanced visualization, lack of a cutaneous scar, less intraoperative bleeding, and the ability to address intranasal pathology at the time of the procedure,

Address reprint requests and correspondence: Rhonda Barrett, MD, Ophthalmic Plastic Surgery, PLLC, 1220 New Scotland Road, Suite 302, Slingerlands, NY 12159.

E-mail address: barretr@mail.amc.edu.

1043-1810/$ -see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.otot.2008.10.001

ophthalmologists and oculoplastic surgeons routinely are using nasal endoscopy for Jones tube placement.1,3,4 This

article describes our endoscopic approach to Jones tube placement, which we have found to be safe, reliable, and well tolerated by the patient.

Indications

CDCR with Jones tube placement is indicated for patients with symptomatic epiphora and complete obstruction of the proximal lacrimal duct apparatus.1 Specifically, canalicular obstruction proximal to the common canaliculus with closure of 2 or more millimeters of the nasal ends of the canaliculi are typically best treated with Jones tube placement.5,6 Preoperatively, lacrimal probing and irrigation are performed to confirm complete obstruction or insufficient tissue to perform a canalicular reconstruction.1,6 In addition, nasal inspection should be performed to rule out a deviated septum, an enlarged anterior end of a middle turbinate, or another abnormality such as a polyp6 that could preclude adequate visualization and working room within the nose. Because Jones tubes can require long-term maintenance and may be associated with postoperative complications, including spontaneous tube extrusion, obstruction, and infection,7 other methods of mucosal reconstruction of the lacrimal drainage pathway should be attempted first if possible.8 When other measures fail and placement of a bypass tube is the only means of improving epiphora, then a CDCR is indicated.8

Figure 1 A 16-gauge needle is passed from the medial fornix through the lacrimal bone into the middle meatus and visualized under direct endoscopic visualization.

As proposed by Jones,6 CDCR may also be indicated after a DCR in which the canaliculi are patent, but are nonfunctioning. Permanent paralysis of the lacrimal pump as occurs in facial nerve paresis also has been identified as an indication for Jones tube placement.2,6 Because the tube possesses capillary attraction and the nasal end of the Jones tube has a negative pressure, thus drawing tears into the tube, the Jones tube apparatus can function as a substitute for the deficient lacrimal pump.6

Endoscopic placement of Jones tubes with direct visualization may be beneficial in cases of failed DCRs, allowing for assessment of the intranasal anatomy at the rhinostomy site.1,3 In addition, because precise positioning of the tube is necessary to enhance the success of a primary or revision CDCR procedure, the endoscopic approach provides a distinct advantage with superior intranasal visualization over the external route.3

Additional benefits afforded by the endoscopic approach include absence of a cutaneous scar, faster operative times, and less blood loss.1 Therefore, in patients who are not willing to risk developing a cutaneous scar, or in patients in which longer operative times or increased blood loss may preclude clearance for the surgical procedure, an endoscopic CDCR would be indicated.

Technique

The procedure is performed in the operating room, typically with the patient under general anesthesia, although a minimally invasive technique performed under local anesthesia with intravenous sedation has recently been described.9 Patients are given preoperative 0.05% oxymetazoline nasal spray in addition to nasal packing with 4% lidocaine-soaked pledgets in the middle meatus to decongest the nasal mucosa and to maximize mucosal shrinkage before endoscopic examination.1 Alternatively, intranasal cocaine may be used, although the combination of oxymetazoline and lidocaine has been shown to be as effective as cocaine in

providing nasal mucosal anesthesia and vasoconstriction while eliminating the significant cardiovascular risks associated with cocaine.10 In addition, injection of 2% lidocaine with 1:100,000 units of epinephrine is performed in the lateral nasal wall and middle turbinate using a tuberculin syringe or 27-gauge needle under direct endoscopic visualization.1

Once adequate anesthesia is achieved, the procedure is begun by passing a 16-gauge needle from the medial fornix at the medial canthal angle through the thin lacrimal bone into the middle meatus (Figure 1). Under direct endoscopic visualization, the nasal mucosa is then incised with a curved blade, elevated with a sharp Freer elevator, and removed exposing the underlying lacrimal bone. Alternative approaches may involve laser-assisted removal of the mucosa. An 8-mm osteotomy within the thin lacrimal bone and the thicker frontal process of the maxilla is then created with the Kerrison punch and small cup forceps (Figure 2).

Next, the lacrimal sac is opened with the curved blade. With the previously placed 16-gauge needle serving as a guide, the track is enlarged with sharp iris scissors and the Jones tube is placed into position. Endoscopic visualization is used to ensure that the tube is in proper position without contact with the nasal septum or middle turbinate (Figure 3). If necessary, adjustments in tube length are made at this time. Partial middle turbinate resection can be considered if necessary. To confirm patency, irrigation is performed with fluorescein solution.1 The tube is secured into position by placing a double-armed 6-0 Vicryl suture in a slip-knot loop fashion around the flange of the tube. The tube is then positioned such that the proximal tip is just lateral to the conjunctival edge. Each arm of the suture is then passed through the medial upper and lower lid margins, respectively and tied at the medial commissure, stabilizing the tube.2

Postoperatively, the patient is given a topical antibioticsteroid ophthalmic drop to be used for 14 days.2 Oral antibiotics may be used if frank infection is noted perioperatively. Patients are also asked to refrain from blowing their noses for at least 6 weeks, after which they may maintain gentle pressure over the tube at the medial canthus when blowing their nose or sneezing.2

Figure 2 With the needle placed through the lacrimal bone acting as a guide, the Kerrison punch is used to create an osteotomy. (Color version of figure is available online.)