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Endonasal Dacryocystorhinostomy Location of Lacrimal Sac with Forceps

INTRODUCTION Endonasal dacryocystorhinostomy (EDCR), first described in 1893 by Caldwell, did not gain popularity and was not used for many years because of limited visualization, complications associated with endonasal surgery, and difficulty in locating the sac endoscopically. EDCR became the widely accepted procedure for lacrimal surgery in the 1980s and the 1990s with the advent of new instrumentation—rigid fiberoptic endoscope and techniques for endoscopic sinus surgery—with which EDCR can be performed easily and safely. At present, external and endonasal dacryocystorhinostomies are used to correct primary and recurrent nasolacrimal obstruction, and both approaches have their advantages and limitations. The most important step in the successful performance of EDCR is proper intranasal identification of the lacrimal sac. There are many methods used for lacrimal sac location, including endonasal transillumination with the transcanalicular light pipe and the knowledge of intranasal anatomic landmarks. Despite the fact that the sac is consistently near the superior attachment of the middle turbinate to the lateral nasal wall, it can not always be easily identified. Orientation can be more difficult in patients with a narrow nasal cavity, anteriorly located head of the middle turbinate, and with septal deviation, or if EDCR is complicated by bleeding. The loss of orientation can lead to increased risk of complications such as misdirected drilling, and adverse effects include orbital fat prolapse, hematoma, emphysema, mucosal burn, or the damage of other structures. In this article, we present a simple method of lacrimal sac location with the help of a nasal bayonet forceps.