Endonasal (Endoscopic) Dacryocystorhinostomy (DCR)

Definition and Rationale

Epiphora (tears draining down the face) must be distinguished from a "watery eye" (thick tear film without overflow) - the former has surgical indications, the latter is usually medical.

Anatomy (Key Landmarks)

• Upper 1/3 of sac: just superior to the anterior insertion of the middle turbinate
• Lower 2/3: oriented vertically just under the anterior maxillary line (lacrimomaxillary suture)

• Frontal process of maxilla (thicker, anterior)
• Lacrimal bone (thinner, posterior)

1. Superior punctum | 2. Superior canaliculus | 3. Inferior punctum | 4. Inferior canaliculus | 5. Medial canthal ligament | 6. Common canaliculus | 7. Lacrimal sac | 8. Lacrimal duct | 9. Middle turbinate | 10. Lacrimal bone | 11. Inferior turbinate | 12. Hasner valve

Indications

Pre-operative Diagnostics

Physical Examination

1. Exclude lid laxity, malposition, punctal anomalies, blepharitis
2. Palpation over lacrimal sac - reflux of mucopurulence = dacryocystitis = obstruction amenable to DCR
3. Dye disappearance test - 2% fluorescein in conjunctival fornix; normal = complete symmetrical disappearance in 5 minutes
4. Jones I test - cotton swab in inferior meatus confirms fluorescein flow

Jones II Test (Probing)

• Hard stop: probe impacts medial wall of sac/bone = canalicular system patent = obstrucion is distal
• Soft stop: probe impeded before entering sac = canalicular stenosis = DCR alone insufficient

Lacrimal Irrigation

• Patient tastes saline = rules out complete obstruction but suggests partial/functional block
• No taste = complete obstruction

Radiologic Evaluation

• Dacryocystography (DCG) - anatomic obstruction: dye fails to penetrate to nasal cavity
• Lacrimal scintigraphy - functional obstruction: dye reaches nasal cavity on DCG but fails to clear on 25-min scintigraphy
• CT scan: useful pre-operatively to assess bony anatomy and sac position

Surgical Technique (Powered Endoscopic DCR)

Setup

• General or local anaesthesia
• Topical decongestion (oxymetazoline) + local infiltration (lidocaine with epinephrine) at axilla of middle turbinate
• 0-degree and 30-degree 4 mm rigid endoscopes

Step-by-Step

• A powered microdebrider with a cutting burr removes the frontal process of maxilla (thicker bone anteriorly)
• The thinner posterior lacrimal bone is removed with through-cutting forceps (Kerrison rongeurs)
• Critical: bone removal must be complete, medial to the entire lacrimal sac - "saucerization" of surrounding bone

• The lacrimal sac is identified by light transillumination from a canalicular probe placed by the ophthalmology team
• The medial wall of the sac is incised with a sickle knife/needle and marsupialised using through-cutting forceps to create anterior and posterior flaps

• Anterior sac flap is anastomosed to anterior nasal mucosal flap
• Posterior sac flap is laid against the lateral nasal wall
• Goal: complete mucosal coverage of the osteotomy site to prevent stenosis

• A bicanalicular silicone stent is threaded from upper and lower puncta, through the canaliculi into the sac, and retrieved endoscopically from the nose
• Ends secured with a clip or cotton swab loop intranasally (no tension on puncta)
• Removed at 3-6 months

Advantages Over External DCR

Outcomes

• Success rates for endoscopic DCR are equivalent to external DCR (both ~85-95%)
• Anatomic obstruction > functional obstruction in terms of outcomes
• Inadequate marsupialization of the lacrimal sac is the primary cause of failure
• Children: excellent success rates comparable to adult DCR
• A 2023 network meta-analysis (PMID 37184641) compared external, endonasal, and transcanalicular laser DCR with/without silicone stenting across RCTs

Complications

Common

Rare but Serious

Missed lacrimal sac tumour

• Tumour presents in delayed fashion in ~1/3 of DCR failures
• Warning signs: bloody nasal drainage, medial canthal swelling, proptosis
• Common benign: squamous/transitional papilloma; malignant: SCC/transitional cell carcinoma
• Management: combined external + endoscopic extirpation + adjuvant radiotherapy for malignant lesions

Revision DCR

Key Points Summary

• Goal: widest possible marsupialization of medial sac wall
• Critical landmark: axilla of middle turbinate (upper sac); lacrimomaxillary suture (lower sac)
• Don't miss: common canalicular obstruction (soft stop on probing) = DCR won't work alone
• Success: complete bone removal + mucosal flap apposition + adequate sac opening
• Primary failure cause: inadequate bony removal with incomplete sac opening
• Best team approach: otolaryngologist (endoscopic anatomy) + oculoplastic surgeon (lacrimal system)

• Cummings Otolaryngology Head and Neck Surgery, Chapter 49 - Endoscopic DCR
• Scott-Brown's Otorhinolaryngology Head & Neck Surgery Vol 2 - DCR section
• Evereklioglu C et al. Network meta-analysis of DCR techniques. Graefes Arch Clin Exp Ophthalmol 2023 [PMID: 37184641]
• Li J et al. Early endonasal DCR for acute dacryocystitis: meta-analysis. Am J Rhinol Allergy 2024 [PMID: 38444220]

Tongue Tie (Ankyloglossia) and Its Release

Definition

Epidemiology

• Incidence: 0.02% to 10.7% of newborns (wide range due to varying diagnostic criteria)
• More common in males: M:F ratio 1.5-2.6:1
• No racial predilection
• 21-50% of individuals report a family history - genetic basis
• Associated with X-linked cleft palate via mutations in the TBX22 gene
• Incidence appears to decrease with age, suggesting some resolve spontaneously as frenulum naturally stretches or breaks

Classification

• Types I & II = "anterior" or classic ankyloglossia
• Types III & IV = "posterior" ankyloglossia (harder to identify, increasingly recognised)
• ~60% of cases are Type III

Clinical Features and Diagnosis

Physical Signs

• Heart-shaped or notched tongue on protrusion (midtethering causes bifid appearance)
• Tongue may roll or curl rather than extend straight
• Inability to elevate tongue tip to upper dentition
• Impaired side-to-side tongue movement
• Tongue fails to extend past lower lip (though some with tongue tie can protrude past the lip)
• Diastasis (gap) between lower central incisors in some cases

Assessment Tools

Interincisal Distance Test

Sequelae / Clinical Problems

In Infants (Breastfeeding)

• 15-44% of babies with ankyloglossia have breastfeeding problems
• Poor latch due to inability to extend and cup the tongue adequately
• Infant unable to bring sufficient breast tissue into mouth
• Maternal nipple pain - most common complaint (28% of mothers in first 6 days postpartum)
• Ineffective milk transfer leading to poor weight gain / failure to thrive
• Premature breastfeeding cessation

In Older Children/Adults

• Speech articulation difficulties - particularly lingual sounds (l, r, t, d, n, th, s, z)
• Dental: diastasis of lower central incisors; dental caries on anterior maxillary incisors (from poor oral hygiene access); periodontal disease/gingival recession
• Difficulty licking lips, playing wind instruments, kissing
• Mechanical eating difficulties

Treatment Indications

• Breastfeeding difficulties with documented latch problems AND poor maternal-infant dyad
• Failure to thrive due to poor milk transfer
• Significant speech articulation problems not responsive to therapy
• Symptomatic dental/periodontal consequences

• Anatomic tie present but no functional problems
• Breastfeeding progressing well
• No speech difficulties

Note: There is ongoing controversy about treatment - especially for posterior ties and in the absence of clear functional deficits.

Surgical Procedures

Frenotomy (Neonatal - Most Common)

1. Infant is swaddled and positioned supine
2. Tongue elevated with grooved director or two-fingered technique
3. Frenulum is visualised - the avascular midline tissue is identified
4. Sharp scissors divide the frenulum transversely, close to the tongue underside, parallel to and away from Wharton's ducts
5. Results in a diamond-shaped wound (Fig. below) that heals by secondary intention

• Neonates: no general anaesthesia required - procedure done awake
• 24% oral sucrose is effective for procedural pain reduction in neonates
• Do NOT use topical lidocaine or benzocaine in neonates - FDA boxed warning due to risk of seizures and methemoglobinemia
• Older children: local infiltration or GA depending on age and compliance

• Otolaryngologists, pediatricians, pediatric dentists, midwives/nurses
• Laser frenotomy (CO2 or diode) increasingly used by dentists

Frenuloplasty (Older Children/Adults)

• Performed under GA or outpatient local depending on patient age
• Z-plasty technique: vertical incision from gingival margin to vestibule, with two oblique incisions at 60 degrees - transposition of triangular flaps lengthens the floor of mouth
• Alternatively, the diamond-shaped defect after frenuloplasty can be closed with sutures (mucosal apposition) to prevent re-tethering
• Provides more durable release, especially for thick posterior ties

Complications

Evidence and Outcomes

Breastfeeding (Primary Indication)

• A 2024 meta-analysis (PMID 37608056) found frenotomy produces a quantitative improvement in breastfeeding outcomes - maternal pain and infant latch scores improved
• A 2026 umbrella review (PMID 40990400) confirmed lingual frenotomy benefits breastfeeding infants
• The FROSTTIE RCT (PMID 37839892) - UK multicenter trial - compared frenotomy + breastfeeding support vs. breastfeeding support alone; found limited additional benefit of frenotomy over support alone for some outcomes, adding to ongoing debate
• The 2025 RCT (PMID 40319911) specifically examined lingual frenotomy in newborns with ankyloglossia

Speech

• Evidence for speech improvement after frenotomy is weaker - speech therapy is generally tried first
• Surgery is reserved for those failing therapy with confirmed structural restriction

Beyond Breastfeeding (Scoping Review, PMID 37606583)

• Evidence for ankyloglossia causing sleep-disordered breathing, TMJ disorders, and postural problems is insufficient and controversial

Key Points

• Ankyloglossia is common (up to 10%); functional impact is present in only a subset
• Type I/II (anterior) = easy to identify; Type III/IV (posterior) = often missed
• Neonatal frenotomy is a quick, safe, low-risk procedure without GA
• Avoid topical LA (lidocaine/benzocaine) in neonates - FDA warning
• Key risk during surgery: Wharton's ducts (submandibular duct orifices) just lateral to the frenulum base
• For older patients or thick/posterior ties, Z-plasty frenuloplasty provides more reliable release
• A multidisciplinary approach (ENT/paediatric dentist + lactation consultant + speech therapist) gives the best outcomes