Management of acquired nasolacrimal duct obstruction: external and endonasal dacryocystorhinostomy. Is there a third way?

Although the first bony osteotomy was described by Celsus (25 bc to ad 50) (the bone was burned with a red-hot iron which led to sloughing of the bone),1 every lacrimal surgeon knows that the era of modern, successful lacrimal surgery began when the Florentine ear, nose and throat surgeon, Addeo Toti, described the external dacryocystorhinostomy (DCR) in 1904.2 Dupuy-Dutemps and Bourget introduced anastomosis of the lacrimal and nasal mucosal flaps.3 The procedure has remained largely unchanged since, with improvement in success rates largely due to advances in suture materials, anaesthesia and instruments. The external DCR, the procedure by which all other techniques are judged, gives a success rate of between 90 and 95%4567 although the occasional modern study still shows success rates around 75%.8

Endonasal or intranasal DCR was described even earlier, by Caldwell, in 1893.9 Unlike the external DCR, this approach was limited by technical difficulties: difficulty in visualising the surgical site, achieving effective soft tissue and bone removal, and controlling haemorrhage. So, although some surgeons like West in 191010 claimed a 90% success rate, the procedure was uncommonly used through most of the 20th century. With the advent of the rigid fibreoptic endoscope and its use in paranasal sinus surgery, there has been renewed interest over the past two decades in endonasal surgery to correct primary and recurrent nasolacrimal duct (NLD) obstruction.4101112 The many variations include non-endoscopic endonasal DCR, endonasal mechanical DCR, endonasal laser DCR, creation of mucosal flaps, different sizes of osteotomies, different sites of osteotomies, use of stents, use of mitomycin C and others. Invariably, this wide range of procedures, coupled with the variable experience of surgeons reporting on the procedures, has resulted in success rates from 50% to 100%.13 …