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S Patel, D Howard; An Anatomic Analysis of the Surgical Relationship Between the Lacrimal Sac and the Middle Turbinate . Invest. Ophthalmol. Vis. Sci. 2002;43(13):3021.
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© ARVO (1962-2015); The Authors (2016-present)
Purpose: To evaluate the surgical anatomic relationship of the the lacrimal sac and the middle tubinate of the nasal cavity. Nasal anatomy is important to understand for all ophthalmic surgeons performing orbital and lacrimal surgery. With the popularity of endoscopic surgery for dacryocystorhinostomy (DCR), this knowledge becomes even more essential. A DCR creates a connection between the lacrimal sac and the nasal cavity. In endo-DCR, a light source is passed through the canalicular system into the lacrimal sac where it abuts the nasal wall, and can be seen through the nasal mucosa. The middle turbinate (middle concha), overlying the middle meatus, is an important nasal landmark during this surgery. It is attached to the lateral nasal wall posteriorly at the level of the cribiform plate. Thus, surgery around the middle turbinate must be done carefully to avoid a CSF leak. The incidence of CSF leak in primary nasal surgery is less than one percent, but it is a well-documented complication. Methods: Thirty cadaver heads were examined. The middle turbinate was identified and its relationship to the lacrimal sac was clarified. Specifically, a probe was passed perpendicular to the lacrimal sac, through the medial orbital wall, into the nose. The entrance point in the nasal cavity was identified, and was determined to be either above or below the level of the middle turbinate. If above, the entrance point is in the superior meatus; if below, in the middle meatus. Results: Of the thirty specimens, twenty-one had a middle turbinate covering the entrance to the lacrimal sac, so the opening was in the middle meatus. Conversely, nine of the cadavers had a middle turbinate surrounding, but not directly covering, the entrance to the lacrimal sac, so the passage to the lacrimal sac was through the superior meatus. Conclusion: In approximately two-thirds of patients, the middle turbinate marks the level of the lacrimal sac. These patients may require careful manipulation of the turbinate to fully visualize the portion of the nasal mucosa that must be excised to reach the lacrimal sac. Additionally, in a third of patients the lacrimal sac is best approached by the superior meatus. An understanding of this anatomic variation will prevent vigorous handling of the middle meatus and inadvertent damage to the cribiform plate.
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