Intranasal Localization of the Lacrimal Sac

Abstract

Objective: To optimize the approach to the lacrimal sac during intranasal dacryocystorhinostomy.Design: Microscopic measurement of anatomical landmarks in cadaver sagittal head sections. Setting:The anatomy department of a large university hospital.Participants: Twenty adult cadaver sagittal head sections (12 right and 8 left) fixed with 10% formaldehyde solution were evaluated.Intervention: During endoscopic dissections, the maxillary line, lacrimomaxillary suture, nasolacrimal duct, and lacrimal sac were exposed. Main Outcome Measures:Greater knowledge of the relationship among anatomical structures.Results: The entire lacrimal sac was in 2 of 20 sides anterior and in 3 of 20 sides posterior to the axilla of the middle nasal concha. The fornix of the lacrimal sac was situated above the axilla in all sides. We evaluated the localization of the lacrimal sac to the maxillary line, which is of clinical importance in intranasal osteotomy during dacryocystorhinostomy. In 17 of 20 sides it is possible to reveal the axilla of the middle nasal concha during osteotomy.Conclusions: Underexposure or lack of true localization of the sac are the most frequently encountered reasons for dacryocystorhinostomy failure. The maxillary line and adhesion point of the middle nasal concha are the 2 most important landmarks in localization of the sac. A mucosal incision anterior to the maxillary line and dissection up to the point where the middle concha adheres, followed by osteotomy on the lacrimomaxillary suture, nearly always ensure the exposure of the sac.

Topography of the nasolacrimal duct on the lateral nasal wall in Koreans

“…Relevant landmarks are required for better localization of the NLD and lacrimal sac on the lateral nasal wall. The maxillary line and axilla of the middle nasal concha are the most frequently used anatomical landmarks [3,17].…”

“…Orhan et al [17] observed 20 hemisectioned heads and reported overlap of the maxillary line with the lacrimal sac at a ratio of 18:20 (90%). However, in this study, overlap of the maxillary line with the NLD was observed in only 24 of 36 cases (67%).…”

Surgical and topographic anatomy of the maxillary line: An important landmark for endoscopic nasal surgery

“…Distances from the NLD opening, anterior nasal spine, maxillary sinus ostium, uncinate process, and other landmarks have been reported previously for assisting with localization of the lacrimal sac (Kim et al, 2012;Orhan et al, 2009;Tatlisumak et al, 2010;Yung and Logan, 1999). The maxillary line serves as a consistent anatomical landmark for endoscopic DCR surgery.…”

“…The maxillary line is an important landmark for uncinectomy, endoscopic DCR, and endoscopic orbital decompression (Chastain et al, 2005;Metson et al, 1994;Kingdom and Durairaj, 2006;Sindwani and Metson, 2008;Orhan et al, 2009;Shams et al, 2012). It is a curvilinear eminence on the lateral nasal cavity wall which projects from the axilla of the middle turbinate to the dorsum of the anterior attachment of the inferior turbinate.…”

“…These early operations have been hindered by the limited visualization of the lacrimal sac intranasally, limited anatomical knowledge, and inadequate surgical instrumentation. The intranasal approach to the lacrimal sac have gained popularity since then with better understanding of the surgical anatomy, introduction of endoscopic surgical techniques, improved instrumentation, and image guidance technology (Raut et al, 2000;Chastain et al, 2005;Wormald et al, 2000;Kim et al, 2012;Sindwani and Metson, 2008;Orhan et al, 2009;Ricardo et al, 2010).…”