Early experience using a new modified bone nibbler for superior osteotomy during endonasal dacryocystorhinostomy

The authors report their experience of using a modified bone nibbler as an adjunct to achieving an adequate superior osteotomy for full lacrimal sac exposure during endoscopic dacryocystorhinostomy.

Prospective interventional case series of 19 procedures performed from September 2008 to May 2009. Nasal mucosal flaps were fashioned and osteotomy was started using a Kerrison punch. The modified bone nibbler was then used to complete superior osteotomy to allow full sac exposure beyond its fundus. Lacrimal sac marsupialization and flaps were completed. Primary success was defined as full sac exposure equivalent to that normally achieved using powered instrumentation (PI) in our unit. PI was used if adequate osteotomy had not been achieved. Secondary success was defined as anatomical patency and symptom relief based on fluorescein flow on nasoendoscopy and patency to lacrimal syringing.

Nineteen endoscopic dacryocystorhinostomy procedures in 18 patients were carried out with the nibbler by, or under supervision of, the senior surgeon over an 8-month period. The mean patient age was 52 years (range, 26-78 years). The median follow up was 6 months (4-36 weeks). Septoplasty was required in 4 (21%) cases. In 16/19 (84.2%) cases, full sac exposure was achieved with the nibbler. Three patients required PI to complete the osteotomy. Symptomatic and anatomical success with a patent nasolacrimal system was achieved in all cases (100%).

We report the use of a new modified bone nibbler for removal of superior bone, even as high as the nasal roof, which previously in our practice could be removed only with PI. It allows a large osteotomy comparable to that achieved with powered endoscopic dacryocystorhinostomy yet avoids the disposable costs of PI.