Operative Technique

After induction of general anesthesia, neurosurgical cottonoids moistened with oxymetazoline hydrochlo-ride 0.05% (Afrin spray) are placed medial and lateral to the inferior turbinate for vasoconstriction to im-

Fig. 4.2. The punctal dilator is used to dilate the inferior punctum, and then the superior punctum
Fig. 4.3. Bowman probe 0 or 00 is passed horizontally with lateral lower eyelid traction until the bone is palpated with the probe
Fig. 4.4. Same as Fig. 4.3
Avoid this by placing the upper lid on lateral traction as the probe is advanced

prove visualization as well as decrease bleeding. Fiber-optic headlight is used to aid visualization of the nose. Baynonette forceps are used to position cotto-noids 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 a blunt punctual dilator for a distance of 2 mm. The punctual dilator is now rotated horizontally and parallel 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before 2 mm of vertical dilation so as to avoid damage to the vertical part of the canaliculus.The punctal dilator is withdrawn and a no. 0 or 1 Bowman probe is passed immediately after withdrawal of the punctual dilator vertically for 2 mm and then reoriented horizontally.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. 4.6. In skull with typical nasal bridge, probe at brow will be directed at 10-15° angles from a superior to inferior direction

Fig. 4.7. Broadened nasal bridge probe direction will be parallel to each other as probe passes through nasolacrimal ducts

Nasolacrimal Duct Probing
Fig. 4.8. Note inferomedial direction of Bowman probe as it passes through the canaliculus, lacrimal sac, nasolacrimal duct and the valve of Hasner

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 supraorbital 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 necessary if the turbinate prevents visualization of the inferior meatus and the probe within it. Gentle pressure is applied with the periosteal elevator against the inferior 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.

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 eternally is encountered. Some nasal bleeding may develop with this maneuver. Pediatric merocel packing is useful in stopping the bleeding

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 eternally is encountered. Some nasal bleeding may develop with this maneuver. Pediatric merocel packing is useful in stopping the bleeding

Fig. 4.11. With Crawford tube passed into the nose, and manipulated superiorly, the retrieval hook is passed into the inferior meatus to grasp the olive tip of the probe. When grasped, the metal probe is pulled in a superior direction from above to fortify the grasp, and the probe is then pulled out of the nose in a slightly medial direction

Fig. 4.11. With Crawford tube passed into the nose, and manipulated superiorly, the retrieval hook is passed into the inferior meatus to grasp the olive tip of the probe. When grasped, the metal probe is pulled in a superior direction from above to fortify the grasp, and the probe is then pulled out of the nose in a slightly medial direction

This will define the length of the tube required to the probe through the ostium of the duct and into the nares The Crawford metal probes are thinner and more difficult to pass than the firm Bowman probe.

The olive tips are placed first through the upper canalicular and nasolacrimal duct, and then the lower canaliculus.

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 millimeters 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).

Once both stents have been passed into the nose, proper positioning of the loop of silastic tubing within the eye should be evaluated in the eye. The metallic probes are pulled off or cut off. The loose tubing is pulled anteriorly using needle holders and, following 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 tubes are then allowed to retract into the nose. Observe for intranasal bleeding at this time. Prior to ex-tubation, if bleeding is noted, gently pack the nose with a narrow merocel dampened with xylocaine and epinephrine (Fig. 4.12).

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