Nasolacrimal Probing and Intubation Chapter 4 53 Nasolacrimal Probing and Intubation 4 Lisa Pierroth, D.A

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Chapter 4Nasolacrimal Probing and Intubation Chapter 4 53 Nasolacrimal Probing and Intubation 4 Lisa Pierroth, D.A. Della Rocca and R.C. Della Rocca

Core Messages! 4.1 Introduction and Background of the Technique Q We perform the probing first through the upper canaliculus and then through the Congenital nasolacrimal duct obstruction is the most inferior canaliculus. common cause for epiphora in the newborn. The most common location of obstruction is at the opening of Q It is important to not rotate the punctual the nasolacrimal system due to an imperforate valve dilator horizontally before 2 mm of vertical of Hasner [1]. Other causes of obstruction may be dilation, so as to avoid damage to the vertical atypical in the nasolacrimal duct to end, within the part of the canaliculus. bony nasal lacrimal canal, in the wall of the maxillary sinus, or below the inferior turbinate. The nasolacri- Q The probe is advanced medially until a hard mal canal may end as a tube of mucosa lateral to the stop is felt. The lid is pulled laterally to ensure inferior turbinate. that the horizontal canaliculus is not kinked, Embryologically, the lacrimal system proceeds as false passageways must be avoided. from proximal to distal and 30% of full-term newborns present with an imperforate valve of Hasner [2]. Q The probe is passed 18–20 mm in children Most infants undergo spontaneous valve opening by before entering the nose through the ob- age 6 weeks, but the remaining 10% may require prob- structed site typically at the valve of Hasner. ing of the nasolacrimal system. The length of the nasolacrimal excretory system is 22–24 mm in the Q The Crawford retrieval hook is placed 1-year-old child. perpendicular to the operating room table Chronic epiphora must be carefully evaluated to towards the inferior turbinate while hugging rule out other causes of lacrimation such as conjunc- the lateral wall. Be sure you know where the tivitis, punctual occlusion, canalicular stenosis, am- open face of the hook is facing. niotocele, dacryoocystocele, epiblepharon, entropion, or ectropion. Congenital glaucoma is usually associ- ated with photophobia and excess lacrimation. An amniotocele, which is uncommon, is caused by Contents amniotic fluid and conjunctival fluid trapped be- 4.1 Introduction and Background of the Technique .... 53 tween the common internal punctae (valve of Rosen- 4.2 Indications and Contraindications ...... 54 müller) and the valve of Hasner, and it presents as a 4.3 Instrumentation ...... 54 bluish fluctuant mass in the medial canthal region 4.4 Anesthesia ...... 54 and should be differentiated from a meningo(ence- 4.5 Operative Technique ...... 54 phaolo)cele or a capillary hemangioma. 4.6 Postoperative Care and Complications ...... 58 4.7 Tube Removal ...... 59 Reference ...... 59 54 L. Pierroth, D.A. Della Rocca, R.C. Della Rocca

Fig. 4.1. Crawford tubes (JedMed) and preferred retrieval hook: set 28-0185

4.2 Indications and Contraindications our experience it is likely that silastic intubation is required initially at 15 months of age or older. Persistent Gentle inferior massage over the area of the nasolacri- tearing and/or dacryocystitis, despite multiple prob- mal sac and lacrimal crest for infants with chronic ings and intubation, is an indication for dacryocysto- and persistent tearing and or mild to moderate muco- rhinostomy at 2 years or older (see Chap. 5). purulent discharge due to nasolacrimal obstruction. Nasolacrimal massage may help to treat the obstruction in the infant and reduce the risk of subsequent 4.3 Instrumentation dacryocystitis. Concurrently, we recommend a 10- day cause of topical antibiotic drops. Obtain a culture Lacrimal probing instruments include a punctual di- and sensitivity of the discharge if possible to define lator, Bowman probes, lacrimal irrigation cannula, the antibiotic sensitivity. Systemic antibiotics are re- irrigation tip, BSS-filled syringe, lacrimal intubation quired if signs of subacute or acute dacryocystitis ex- system (Crawford silicone stent set 28-0185, JedMed ists. Instrument Company, St. Louis, Mo.) and a retrieval If conservative treatment does not relieve symp- hook to Silastic intubation tube (supplied with the toms of tearing due to nasolacrimal obstruction, lacrimal intubation set; Fig. 4.1). probing may be indicated between 6 and 13 months of age [3]. The failure rate of initial probing significantly increases after 13 months of age, as does the number 4.4 Anesthesia and complexity of subsequent procedures that may be required to repair the problem. With persistent mu- We recommend general endotracheal anesthesia for copurulent discharge, probing is done earlier, perhaps children during nasolacrimal probing. Mask anesthe- at age 6 months or before depending on the severity of sia can be used when the silastic tube is removed. dacryocystitis. Newborns presenting with an amniotocele usually require probing within 10 days of diagnosis. 4.5 Operative Technique If probing fails (as it does in approximately 10% of cases), the insertion of a silastic intubation tube is ad- After induction of general anesthesia, neurosurgical vised with subsequent probing. Likewise, a silastic cottonoids moistened with oxymetazoline hydrochlo- intubation tube is used if probing is not achieved eas- ride 0.05% (Afrin spray) are placed medial and lateral ily because of a tightened nasolacrimal pathway. In to the inferior turbinate for vasoconstriction to im- Nasolacrimal Probing and Intubation Chapter 4 55

Fig. 4.2. The punctal dilator is used to dilate the inferior punc- Fig. 4.5. The upper canaliculus is kinked by the lacrimal probe. tum, and then the superior punctum Avoid this by placing the upper lid on lateral traction as the probe is advanced

prove visualization as well as decrease bleeding. Fi- ber-optic headlight is used to aid visualization of the nose. Baynonette forceps are used to position cottonoids beneath and medial to the inferior turbinate. The cottonoids are removed after 5–10 min. We perform the probing first through the upper canaliculus and then through the inferior canaliculus. The length of the Bowman probe is measured prior to using the dilator in order to assess length of passage through the nasolacrimal canal or nose, repec- tively. The upper canaliculus is dilated carefully with Fig. 4.3. Bowman probe 0 or 00 is passed horizontally with lat- a blunt punctual dilator for a distance of 2 mm. The eral lower eyelid traction until the bone is palpated with the punctual dilator is now rotated horizontally and par- probe allel to the superior horizontal canaliculus. It is important to not rotate the punctual dilator horizontally before 2 mm of vertical dilation so as to avoid damage to the vertical part of the canaliculus.The punctal dilator is withdrawn and a no. 0 or 1 Bowman probe is passed immediately after withdrawal of the punctual dilator vertically for 2 mm and then reoriented horizontally. The same gentle lateral lid retraction will decrease the risk of false passageway (Figs. 4.2–4.4). The probe is advanced medially until a hard stop is felt. The lid is pulled laterally to ensure that the horizontal canaliculus is not kinked as false passageways must be avoided (Fig. 4.5). The Bowman probe is then gently rotated vertically within the bony nasolacrimal canal while hug- Fig. 4.4. Same as Fig. 4.3 56 L. Pierroth, D.A. Della Rocca, R.C. Della Rocca

Fig. 4.6. In skull with typical nasal bridge, probe at brow will be Fig. 4.7. Broadened nasal bridge probe direction will be paral- directed at 10–15° angles from a superior to inferior direction lel to each other as probe passes through nasolacrimal ducts

ging the brow superiorly. Bowman probe position that more easily allows advancement of the probe into the nose rests on the medial brow close to the supraor- bital notch. When the nasal bridge is wide, the probe may have to be directed more medially (Figs.4.6, 4.7). In our experience, probing is easier when using a somewhat larger-gauge (no. 0 or 1) Bowman probe. Little resistance is felt when passing the probe into the nose. You may feel a rubbery resistance or “pop” when passing through the valve of Hasner. The probe is passed 18–20 mm in children before entering the nose through the obstructed site typically at the valve of Hasner (Fig. 4.8). The probe may be identified 20 mm into the nares either by direct or endoscopic visualization or palpated with a periosteal elevator. Medial infracture or displacement of the inferior turbinate may be neces- sary if the turbinate prevents visualization of the infe- Fig. 4.8. Note inferomedial direction of Bowman probe as it rior meatus and the probe within it. Gentle pressure is passes through the canaliculus, lacrimal sac, nasolacrimal duct applied with the periosteal elevator against the infe- and the valve of Hasner rior turbinate in order to displace it towards the nasal septum. You sometimes feel the turbinate “give” or even a slight crack with displacement of the turbinate (Fig. 4.9). Prior to passing the Crawford probe and tube, the Bowman probe is passed through the nasolacrimal duct before passing the stent in order to define the anatomy of the passage and direction of the probe. Nasolacrimal Probing and Intubation Chapter 4 57

Fig. 4.9. Freer elevator is used to displace the inferior turbinate Fig. 4.10. A retrieval hook grasping the Crawford probe with medially to facilitate passage of Bowman probe when resistance tube externally is encountered. Some nasal bleeding may develop with this ma- neuver. Pediatric merocel packing is useful in stopping the bleeding

They may be received with the Crawford hook (C106 from Roger Klein, Palmer Puerto Rico) or a small hemostat. The Crawford retrieval hook is placed perpendicular to the operating room table towards the inferior turbinate while hugging the lateral wall. Be sure you know where the open face of the hook is facing. The stent is palpated with the Crawford hook or freer elevator. The hook is advanced a few millime- ters with the eye of the hook facing laterally. The olive tip of the probe is palpated, hooked, and advanced out the nose as the Crawford probe is gently pushed from above. Limit grasping the nasal mucosa with the hook (Figs. 4.10, 4.11). Fig. 4.11. With Crawford tube passed into the nose, and ma- Once both stents have been passed into the nose, nipulated superiorly, the retrieval hook is passed into the infe- proper positioning of the loop of silastic tubing with- rior meatus to grasp the olive tip of the probe. When grasped, in the eye should be evaluated in the eye. The metallic the metal probe is pulled in a superior direction from above to probes are pulled off or cut off. The loose tubing is fortify the grasp, and the probe is then pulled out of the nose in pulled anteriorly using needle holders and, following a slightly medial direction a single tie to allow the tubes to retract 15 mm into the nose, four more knots are completed preferably tying the knots over a no. 1 Bowman probe. The tied This will define the length of the tube required to the tubes are then allowed to retract into the nose. Ob- probe through the ostium of the duct and into the na- serve for intranasal bleeding at this time. Prior to ex- res The Crawford metal probes are thinner and more tubation, if bleeding is noted, gently pack the nose difficult to pass than the firm Bowman probe. with a narrow merocel dampened with xylocaine and The olive tips are placed first through the upper epinephrine (Fig. 4.12). canalicular and nasolacrimal duct, and then the lower canaliculus. 58 L. Pierroth, D.A. Della Rocca, R.C. Della Rocca

Fig. 4.12. Silastic tube ends are tied with five single knots and Fig. 4.13. With Bowman probe in place the finger is placed over allowed to retract 15 mm into the nose the anterior lacrimal crest to help direct the probe into the duct. This obviates the creation of false passages

4.6 Postoperative Care and Complications Bloody tears or bloody discharge from the nose can be expected up to 2 weeks after probing and Topical combined antibiotic and steroid ointment need no further treatment unless more than a few (e.g., Tobradex) is to be used four times daily for a pe- drops. riod of 1 week after nasolacrimal duct probing or in- The surgical pitfall of displacing the probe prior to tubation. Systemic antibiotics, preferably Amoxacil- entering the nasolacrimal duct is prevented by plac- lin, is used for 3–4 days postoperatively. If some ing the index finger over the anterior lacrimal crest as persistence of intranasal bleeding exists and prior to the probe goes into the duct (Fig. 4.13). extubation use, merocel to pack the nose dampened Erosion of the punctum or canaliculus may occur with osymetazoline hydrochloride 0.05% (Afrin) or if tubes are too tightly secured. Chaffing or erosion xylocaine 1% with 1:100,000 epinephrine solution is may be avoided with proper tension when tying the used. Await for bleeding to subside and in most in- tubes. If erosion or extension medially of the canalic- stances the packing can be removed prior to ex- ulus has occurred, the tubes need to be removed and tubaion. The child can usually be discharged several the erosion will suitably heal. hours after completion of the procedure in an ambu- Prolapse of the nasolacrimal tubing may occur be- latory setting. Significant epiphora and chronic dac- cause the child rubs the eye too vigorously. It is advis- ryocystitis with mucous discharge in a child 6– able to inform the family of the child of this possibil- 13 months of age can usually be treated successfully ity to limit their concern if it occurs. Tube prolapse with nasolacrimal probing alone. Nasolacrimal prob- can be avoided by having the child wear an eye shield ing done after 15 months of age or older requires the early after probing which can be kept in place at bed- use of silastic intubation. Good correlation of surgical time for several weeks. Tube reposition can be anatomy, planning, and appropriate timing of the achieved with a bayonette forceps and a headlight or procedure increases the success rate and decreases the nasal endoscope for visualization with mask anesthe- possibility of complications. The silastic tube is left in sia. Less frequently, the tube is removed. Strong effort place for 4–6 months, if possible. Early on, it is advis- to reposition is particularly important during the first able to place and tape at periphery of perforated pro- month after placement. tective shield over the eye with sufficient openings for Granulomas may occur at the punctum which the child to see out of the eye. need to be excised. We recommend removal of the Nasolacrimal Probing and Intubation Chapter 4 59 tubing system at the same time. If granuloma is small, Reference allow the tube to remain in place for as long as possible. 1. Crawford JS: Intubation of obstructions in the lacrimal system. Can J Ophthalmol 1977;12:289–292 2. Bedrossian EJ Jr: The lacrimal system. In: Tasman W, Jae- ger E (eds) Duane’s foundation of clinical ophthalmology, 4.7 Tube Removal vol 1, 1996; 30:179–187 3. Katowitz JA, Welsh MG: Timing of initial probing and Generally, the tube is left in place for at least 6 months irrigation in congenital nasolacrimal duct obstruction. after intubation and once symptoms are stable [4]. If Ophthalmology 1987; 94:698–704 4. Welsh MG, Katowitz JA: Timing of silastic tubing removal there is unroofing or stretching of the canaliculus, after intubation for congenital nasolacrimal duct obstruc- earlier removal may be considered. tion. Ophthalmol Plast Reconstr Surg 1989; 5:43–48 After 3–6 months, the tube can be removed . It can sometimes be done in the office but in most instances Suggested Reading: requires mask anesthesia in the operating room. In Lemke BN, Della Rocca RC: Surgery of the eyelids and orbit: an anatomical approach. East Norwalk, CT: Appleton and the office, a drop of anesthetic is applied to the fornix. Lange, 1990. (Available through McGraw-Hill) Similarly, in the office or with mask anesthesia, the Della Rocca RC, Bedrossian EH, Arthurs BP: Ophthalmic tube is grasped superiorly and transected. The tube is plastic surgery: Decision making and techniques. New then retrieved through the superior canaliculus. York: McGraw-Hill, 2003: 165–179, 181–187 When the tube is attached to the septum it may be difficult to remove the tube through the canaliculus. An antibiotic/steroid eye drop four times daily is rec- ommended for 10 days after removal of the tube.