Dacrocystectomy And Dacryocystorhinostomy presentation

About Dacryocystorhinostomy and Dacryocystectomy

1. DEPARTMENT OF SHALAKYATANTRA TOPIC NAME : DACROCYSTECTOMY & DACROCYSTORHINOSTOMY PRESENTED BY : ANIL PAWAR GUIDED BY : DR TUNDALWAR SIR (HOD, DEPARTMENT OF SHALAKYATANTRA )

2. DACROCYSTITIS It is Inflammation of Lacrimal Sac Majorly Of Two types Acute Chronic

3. It is the chronic suppurative inflammation of lacrimal sac due to obstruction in the naso -lacrimal duct . CHRONIC DACROCYSTITIS

4. ETIOLOGY A. Predisposing factors 1. Age - It is more common between 40 and 60 years of age. 2. Se x - The disease is predominantly seen in females (80%) probably due to comparatively narrow lumen of the bony canal. 3. Race - It is rarer among Negroes than in Whites: as in the former NLD is shorter, wider and less sinuous 4. Heredity - It plays an indirect role. It affects the facial configuration and so also the length and width of the borsy canal. 5. Socio-economic status - It is more common in low socio-economic group.6. Poor personal hygiene is also an important predisposing factor

5. B. Factors responsible for stasis of tears in lacrimal sac 1. Anatomical factors, which retard drainage of tears include: comparatively narrow bony canal, partial canalization of membranous NLD and excessive membranous folds in NLD. 2. Foreign bodies in the sac may block opening of NLD. 3. Excessive lacrimation, primary or reflex, causes stagnation of tears in the sac. 4. Mild grade inflammation of lacrimal sac due to associated recurrent conjunctivitis may block the NLD by epithelial debris and mucus plugs. It is the commonest one. 5. Obstruction of lower end of the NLD by nasal diseases such as polyps, hypertrophied inferior concha, marked degree of deviated nasal septum, tumours and atrophic rhinitis causing stenosis may also cause stagnation of tears in the lacrimal sac .

6. C. Source of infection – Lacrimal sac may get infected from the conjunctiva, nasal cavity (retrograde spread), or paranasal sinuses . D. Causative organisms – These include: Staphylococci, Pneumococci, Streptococci and Pseudomonas pyocyanea . Rarely chronic granulomatous infections like tuberculosis, syphilis, leprosy and occasionally chinosporidiosis may also cause dacryocystitis

7. CLINICAL FEATURES 1. Stage of chronic catarrhal dacryocystitis : It is characterised by mild inflammation of the lacrimal sac associated with blockage of NLD. Watering eye is the only symptom in this stage and sometimes mild redness in the inner canthus. On syringing the lacrimal sac, either clear fluid or few mucoid flakes regurgitate. Dacryocystography reveals block in NLD, a normal-sized lacrimal sac with healthy mucosa. 2. Stage of lacrimal macocele : It follows chronic stagnation causing distension of lacrimal sac. Characteristic features include constant epiphora associated with a swelling just below the inner canthus . Regurgitation test. Milky or gelatinous mucoid fluid regurgitates from the lower punctum on pressing the swelling. Dacryocystography at this stage reveals a distended sac with blockage somewhere in the NLD. Encysted mucocele .

8. 3. Stage of chronic supporative dacryocystitis . Due to pyogenic infection, the mucoid discharge becomes purulent, converting the mucocele into ' pyocoele . The condition is characterised by epiphora , associated recurrent conjunctivitis and swelling at the inner canthus with mild erythema of the overlying skin. On regurgitation a frank purulent discharge flows from the lower punctum. If openings of canaliculi are blocked at this stage the so called encysted pyocoele . 4. Stage of chronic fibrotic sac . Low-grade repeated infections for a prolonged period ultimately result in a small fibrotic sac due to thickening of mucosa, which is often associated with persistent epiphora and dischar ge. Dacryocystography , at this stage reveals a very small sac with mucosa

9. MANAGEMENT Medical treatment : Repeated sac syringing with antibiotie -drops may clear the debris obstructing the naso -lacrimal duct in the initial Stage only Surgical treatment : If the condition is no cured by the medical line of treatment then Dacryocystectomy or Dacryocystorhinostomy should be performed .

10. ACUTE DACROCYSTITIS Defination: It is Acute Suppurative Inflammation of Lacrimal Sac

11. ETIOLOGY Acute dacryocystitis may develop in two w ays : 1. As an acute exacerbation of chronic dacryocystitis . 2. As an acute peridacryocystitis due to direct involvement from the neighbouring infected structures such as: paranasal sinuses, surrounding bones and dental abscess or caries teeth in the upper jaw. Causative organisms Commonly involved are Streptococcus , haemolyticus, Pneumococcus and Staphylococcus .

12. CLINICAL FEATURES Severe pain and hot sensation over sac area. Marked swelling with tenderness and redness of skin is seen on the sac area No regurgitation due to blocking of canaliculi due to Oedema.
Slight conjunctival congestion.
Enlarged sub maxillary lymph node.
Fluctuation can be elicited if abscess is formed.
Lacrimal fistula due to repeated attacks .

13. MANAGEMENT Hot compress, local and systemic antibiotic, systemic analgesic and anti inflammatory . For Lacrimal abscess- a vertical incision is given for drainage of the pus. Dacryocystectomy (DCT)-should be done after the inflammation is controlled by medical treatment. After single attack of acute Dacryocystitis , the sac shrinks and becomes fibrous and hence dacryocystorhinostomy can not be performed except in young adults with spontaneous attack i.e. without previous history. In lacrimal fistula complete excision of fistulous tract alongwith excision of the sac should be done .

14. DCT (DACRYOCYSTECTOMY ) Defination: It is a surgical procedure to remove the lacrimal sac. Indications: Elderly persons
After single attack of Acute Dacryocystitis (dacryocysto-rhinostomy can not be performed due to fibrosis of sac wall) Complications : Life Long Epiphora Due to removal of sac

15. PROCEDURE The sac are se is infiltrated with 2% Xylocaine with adrenaline for local anesthesia (adrenaline should not be used in hypertensive patient) A curved 6mm incision is given 3mm to the nasal side of inner canthus. The incision should be 2mm above medial palpebral ligament After splitting the orbicularis oculi muscle, Muller’s sac retractor is applied preserving haemorrhage may occur. Blunt dissection is performed till the sac is visible. Sac is then separated up to the junction of naso lacrimal duct and excised there. Lacrimal fossa is cleaned and cauterized and the wound is sutured preferably with continuous subcuticular Sutures for Cosmetic purpose Post-operatively pad and firm bandage applied Analgesics and anti-biotic should be given

16. DCR (DACRYO-CYSTO-RHINOSTOMY ) Defination: It is a nasal drainage operation in which there is no epiphora post-operatively if the operation is successful Indications : Young patient with Chronic dacrocystitis Complications: Hemorrhage either from angular vein or from nasal mucosa (hence pack should not be removed before 24 hours).
Failed DCR- small opening in the lacrimal bone, fragile mucous membrane due to old age and post operative infection.

17. PROCEDURE The nasal cavity of the same side is packed with a ribbon gauge soaked in 4% xylocaine . All the steps up to the exposure of the sac are same as dacryocystectomy . The lacrimal bone is exposed by incising periosteum over the lacrimal crest. Bone is removed with a gauge and hammer or bone punch so that the nasal mucosa is exposed. A vertical incision is made on the sac and the mucous membrane and their walls are anastomosed. The wound is cleaned and dressed as before. Syringing is done on the first post operative day to test the patency of the passage Post-op Analgesics and anti-biotic should be given