Anat Sci Int (2010) 85:8–12
DOI 10.1007/s12565-009-0044-z
ORIGINAL ARTICLE
Surgical anatomy of the nasolacrimal duct on the lateral
nasal wall as revealed by serial dissections
Ertugrul Tatlisumak Æ Asim Aslan Æ
Ayhan Cömert Æ Samet Ozlugedik Æ
Halil Ibrahim Acar Æ Ibrahim Tekdemir
Received: 4 February 2009 / Accepted: 17 March 2009 / Published online: 15 April 2009
Japanese Association of Anatomists 2009
Abstract The anatomy of the nasolacrimal duct (NLD)
in relation with the lateral nasal wall was studied in 15
half-heads of human adult cadavers by serial photographs
of the dissection of the lateral nasal wall. The aim of the
study was to determine the intranasal anatomical relationships of the NLD with the lateral nasal wall for surgical
reference during endoscopic dacryocystorhinostomy. Following removal of the nasal mucosa anterior to the
uncinate process, the exposed bone was removed by drilling. The entire NLD was exposed intranasally. The
relationships of the NLD with the maxillary sinus ostium
and anterior nasal spine were determined, and the length of
the NLD was measured. The morphology of the NLD
opening was observed, and its distance from several landmarks were measured. There were three types of intranasal
orifice: pin-point, triangular and slit-like. The NLD is
located, on average, 24.6 ± 3.56 mm posterior to the
anterior nasal spine. The nearest distances between
the opening of the NLD and the nasal floor and between
the opening of the NLD and the most anterior attachment
E. Tatlisumak
Department of Anatomy, School of Medicine,
Celal Bayar University, Manisa, Turkey
A. Aslan (&)
Department of Otorhinolaryngology, School of Medicine,
Celal Bayar University, Manisa, Turkey
e-mail: asimas98@yahoo.com
A. Cömert H. I. Acar I. Tekdemir
Department of Anatomy, School of Medicine,
Ankara University, Ankara, Turkey
S. Ozlugedik
First Otorhinolaryngology Clinic,
Numune Education and Research Hospital, Ankara, Turkey
123
of the inferior nasal concha were 13.7 ± 3.15 and
14.3 ± 2.05 mm, respectively. The length of the NLD was
21.9 ± 2.03 mm on average. The nearest distances
between the NLD and the maxillary sinus ostium was
3.9 ± 0.88 mm. Cadaver dissections and the photographs
of the fine dissections provide a more accurate description
of the lateral nasal wall anatomy. These data provide
valuable anatomical information to the surgeon performing
endonasal dacryocystorhinostomy.
Keywords Anatomy Eye Lacrimal apparatus
Nasolacrimal duct Sense organs
Introduction
The endoscopic technique is currently the most favored
procedure for the surgical treatment of sinonasal pathologies. This technique allows direct visualization, evaluation
and treatment of the intranasal abnormalities, three distinct
advantages which make it preferable to external dacryocystorhinostomy for the surgical treatment of epiphora. In
addition, the endoscopic technique obviates the need for a
skin incision, which is an undesirable consequence of the
external approach (Metson 1991; Weidenbecher et al.
1994; Sprekelsen and Barberan 1996; Unlu et al. 2000;
Unlu et al. 2002). The nasolacrimal apparatus is intimately
associated with the lateral nasal wall and may readily be
approached using an endoscopic technique, which minimizes functional interference with the physiological action
of the lacrimal apparatus.
Despite these favorable results compared with conventional surgical treatment, complications can still easily
occur because the endoscope only allows monocular
vision, which may cause the surgeon to become spatially
Nasolacrimal duct on the lateral nasal wall
disoriented, and a limited scope of the operative field. The
success and safety of intranasal endoscopic surgery primarily depend on the surgeon’ s knowledge of intranasal
anatomy, especially that of the lateral nasal wall. Although
there have been a number of reports on the surgical anatomy of the nasolacrimal duct (NLD) in relation to the
lateral nasal wall, these involve either drawings or computed tomography (CT) scans (McDonogh and Meiring
1989; Kurihashi et al. 1991; Rebeiz et al. 1992; Thanaviratananich et al. 1996; Groell et al. 1997; Unlu et al. 2000;
Wormald et al. 2000). Current anatomical knowledge of
this region is inadequate in terms of preparing the surgeons
for intranasal interventions. Due to the possibility that such
drawings are inconsistent and inaccurate, cadaver studies
are still an invaluable approach by which surgeons can
increase their knowledge and understanding of the anatomy
of the area (Lucente and Schoenfeld 1990).
The aim of this study was to review of the anatomy of the
nasolacrimal apparatus in relation to the lateral nasal wall
by presenting photographs taken during the various steps of
NLD dissection and to measure the distances of surgically
important landmarks from relevant structures as a means for
assisting the surgeon to grasp three-dimensional anatomy.
Materials and methods
The study was conducted on 15 half-heads of adult human
cadavers (two female, 13 male), of which seven were the
left side and eight were the right side. No information was
available on the ages of the cadavers. All dissections were
made under an operating microscope. The first step was to
identify the orifice of the NLD in the inferior nasal meatus.
To obtain a better exposure, a rectangular area (approx.
0.5 9 1 cm) of the inferior nasal concha, i.e. inferior turbinate (IT), was completely removed (Figs. 1, 2a, 3). The
morphology of the orifice was noted. To have a better view,
the anterior part of the middle nasal concha, i.e. middle
turbinate (MT), was resected vertically up to its anterior
attachment (Fig. 2b). Next, the mucosa on the lateral nasal
wall was removed completely, starting from the level of the
inferior nasal concha up to the anterior attachment of the
middle nasal concha (Fig. 2c). The thin bone over the NLD
orifice was removed, and the most inferior part of the NLD
was observed (Fig. 2d). To see the relationship with the
maxillary sinus ostium (MSO), i.e. maxillary sinus antrum
and frontal recess and frontal sinus ostium, the uncinate
process and anterior part of the MT were resected, leaving
a small stump of MT for orientation (Fig. 2e). Bone
removal was continued by drilling up to the anterior
attachment of the MT, and the entire course of the NLD on
the lateral nasal wall was obtained (Fig. 2f). The removal
of mucosa and bone was continued superiorly to the
9
Fig. 1 Measurement points on the left lateral nasal wall. The pinpoint orifice (o) is seen (probe). aMT Anterior attachment of middle
turbinate, aIT anterior attachment of inferior turbinate (dashed black
arrow), NF nasal floor (black vertical arrow), ns nasal spine (leftsided black arrow), big black arrow nasolacrimal duct, right-sided
white arrow maxillary sinus ostium, asterisk superior attachment of
inferior turbinate
anterior attachment of the MT to expose the nasolacrimal
sac (NLS) (Fig. 2g).
The following parameters were measured (Fig. 1) and
noted: (all measurements were made using a digital caliper
and rounded off to the nearest millimeter):
•
•
•
•
•
length of the NLD (from the transition area between the
sac and duct up to the intranasal orifice);
nearest distance from the NLD to the MSO;
nearest distance from the NLD to the anterior nasal
spine;
nearest distance of the intranasal orifice of the NLD to
the nasal floor;
nearest distances of the intranasal orifice of the NLD to
anterior attachment of the IT.
The SPSS ver. 10.0 program (SPSS, Chicago, IL) was
used for statistics. Mean, standard deviation and the minimum and maximum values of all measurements were
determined, and the values were rounded into values having two digits after the points.
Results
The intranasal orifice of the NLD is located at the roof of the
inferior nasal meatus, just inferior to the superior attachment of the inferior nasal concha to the lateral nasal wall
(Figs. 1, 2a, 3). Because of this position, it is difficult to
observe the intranasal orifice of the NLD directly, even by
endoscopes; consequently, a small amount of inferior nasal
concha at that position should be removed to enable the
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10
E. Tatlisumak et al.
Fig. 2 a Left lateral nasal wall. A small part of the inferior turbinate
(IT) was resected to see the intranasal orifice of the nasolacrimal duct
(NLD, arrow). The orifice is triangular in shape. MT Middle turbinate.
b Middle turbinate was resected. UP uncinate process, IT inferior
turbinate, arrow intranasal orifice of the nasolacrimal duct. c Resection of the mucosa covering the NLD was started, and the bone of the
NLD was uncovered (arrows). UP uncinate process, BE Bulla
ethmoidalis. d The bone over the NLD was removed and NLD was
exposed (arrows). UP Uncinate process. e Uncinate process was also
resected. Note the close relationship between the maxillary sinus
antrum (Ma) and NLD (arrows). Asterisk Anterior attachment of MT.
BE Bulla ethmoidalis. f Superior part of the middle turbinate was
resected. Frontal sinus (FS) was entered. aMT Anterior attachment of
the middle turbinate, white arrow frontal recess, black arrow NLD,
asterisk nasolacrimal sac. g Bone dissection was enlarged to expose
the nasolacrimal sac (NLS) more. Black arrow Transition area from
NLS to the NLD. FS frontal sinus, FR frontal recess
surgeon to have a direct view. The intranasal orifice of the
NLD was observed to be located an average of 25 mm from
the anterior nasal spine. It was 13.7 ± 3.15 mm away from
the nasal floor and 14.3 ± 2.05 mm distant from the anterior attachment of the inferior nasal concha. Three different
types of orifice were observed: pin-point, trianguler and slitlike (Figs. 1, 2a, 3). Five pin-point (33.3%), four triangular
(26.6%) and six slit-like (40%) orifices were identified.
Starting from the intranasal orifice, the NLD was followed in the anterior and superior direction up to the
anterior attachment of the MT (Fig. 2a–f). Anterior to the
NLD there is only compact bone, without any important
anatomical structure. This allows the surgeon to safely
remove bone to expose the entire NLD. Posteriorly, the
NLD has an intimate relationship with the uncinate process
and maxillary sinus ostium (Fig. 2c–e). A transition area
from NLD to the NSC was observed. The NLD was an
average of 4 mm anterior to the MSO at the level of the
anterior attachment of the MT (Fig. 2f, g). This area is
located just anterior to the frontal recess area (Fig. 2f, g).
Measurements of the NLD and neigbouring structures are
presented in Table 1.
123
Discussion
The use of endoscopes in rhinology has increased the
interest of surgeons to expose the nasolacrimal apparatus
intranasally for surgical treatment of epiphora as an alternative to external dacryocystorhinostomy (DSR) (Metson
Nasolacrimal duct on the lateral nasal wall
Table 1 Measurements of the
nasolacrimal duct
NLD nasolacrimal duct, MSO
maxillary sinus ostium, ANS
anterior nasal spine, NF nasal
floor, AIT anterior attachment of
inferior turbinate, SD standard
deviation
11
Cadaver/side
NLD
length (mm)
NLD-MSO
(mm)
NLD-ANS
(mm)
NLD-NF
(mm)
NLD-AIT
(mm)
1 Left
21
5
18
17
15
2 Left
18
5
20
13
16
3 Right
24
3
31
7
18
4 Right
22
4
28
13
16
5 Right
22
3
26
18
15
6 Right
24
3
27
16
11
7 Left
25
3
27
16
11
8 Left
20
5
25
15
13
9 Right
23
5
26
9
12
10 Right
24
3
26
10
16
11 Right
12 Left
20
23
3
4
21
27
12
17
13
16
13 Left
19
4
20
13
14
14 Right
22
5
24
15
13
15 Left
21
4
23
14
15
Mean/SD
21.9 ± 2.03
3.9 ± 0.88
24.6 ± 3.56
13.7 ± 3.15
14.3 ± 2.05
Fig. 3 Slit-like morphology of the orifice (white arrow) of nasolacrimal duct (NLD). Right lateral nasal wall
1991; Weidenbecher et al. 1994; Sprekelsen and Barberan
1996; Unlu et al. 2000; Unlu et al. 2002). Successful surgical results using this approach depend on a detailed
knowledge of intranasal anatomy of the NLS and NLD
(McDonogh and Meiring 1989; Kurihashi et al. 1991;
Rebeiz et al. 1992; Thanaviratananich et al. 1996; Groell
et al. 1997; Unlu et al. 2000; Wormald et al. 2000).
Accurate knowledge of the position of the NLD on the
lateral nasal wall is essential for internal endoscopic DSR
(Kurihashi et al. 1991; Unlu et al. 2000, 2002). A number
of landmarks can be utilized to localize the NLD on the
lateral nasal wall. For example, the anterior nasal spine and
anterior attachment of the inferior nasal concha can be used
to estimate the position of the NLD at the beginning of
endoscopic surgery. The intranasal orifice of the NLD is
located approximately 25 mm away from the anterior nasal
spine and 15 mm from the anterior attachment of the
inferior nasal concha. The NLD passes superiorly and
anteriorly from the orifice to the anterior attachment of the
middle nasal concha. This course should be kept in mind
during lateral osteotomies in rhinoplasty operations. Lateral osteotomy begins from the apertura pyriformis, just
superior to the anterior attachment of inferior nasal concha.
It follows posteriorly on the lateral nasal wall bone in
which there is no obvious anatomical structure up to the
NLD. Care should be taken not to violate the NLD during
this procedure; it should be noted that the NLD has always
been at risk during rhinoplasty operations (Unlu et al. 1996;
Yigit et al. 2004).
The uncinate process and maxillary sinus ostium are
also important landmarks to determine the location of the
NLD. The uncinate process is attached just posterior to
the NLD, which is only 4 mm anterior to the MSO.
These intimate relationships are important during endoscopic sinus surgery. When maxillary sinus antrostomy is
attempted, the uncinate process is first removed and then
the maxillary sinus ostium is enlarged anteriorly using
back-biting forceps. During these maneuvers, the NLD is
at risk of injury due to its close relationship with the
uncinate process and maxillary sinus ostium. A good
familiarity with the surgical anatomical relationships is
therefore important to avoid inadvertent injury during
endoscopic sinus surgery. The complication of injury to
the NLD following endoscopic sinus surgery has been
123
12
reported to be 0.3–1.7% (Kennedy et al. 1987; Serdahl
et al. 1990; Bolger et al. 1992; Unlu et al. 2001).
In addition, during endoscopic DSR, the mucosa on the
lateral nasal wall anterior to the uncinate process should be
removed in order to expose the bone covering of the NLD.
We found that the mean length of the NLD is about
22 mm, indicating that at least 2 cm of mucosa should be
removed to expose the entire NLD. However, this amount
of the mucosa removal may not be necessary for endoscopic DSR. In cases of epiphora, the sac is dilated due to
obstruction in the NLD. Hence, the proximal part of the
obstruction or the sac directly should be opened into the
nasal cavity on the lateral nasal wall. In the majority of
cases, the NLS is located above the anterior attachment
of the MT (Fig. 2f, g) (Groell et al. 1997). Hence, removal
of the mucosa should include the obstructed area and the
proximal part of the NLD. A vertical incision, approximately 1 mm in length, starting from the anterior attachment of the MT in a downward direction is sufficient to
expose the obstructed area (Fig. 2f, g) (Unlu et al. 2000).
This is the region where the rhinostomy opening should be
located. It is also important to note that this region is just
anterior to the frontal recess area (Fig. 2f, g). This anatomical relationship should be kept in mind during bone
dissection in this area in order to avoid inadvertent injury
to the frontal recess. Moreover, an agger nasi cell, which
is the most anteriorly placed frontal ethmoid cell and
is anterior to the MT, can be encountered in this area
(Calhoun et al. 1990; Wormald 2003). This might lead to
confusion when searching for the NLS.
We noted three different types of NLD orifice morphology: triangular, pin-point and slit-like (Figs. 1, 2a, 3).
Pin-point and slit-like openings indicate that even a very
small diameter of the NLD orifice is sufficient for its
patency. This observation is in agreement with the study of
Lindberg et al. (1982), who found that even a very small
(1.8 mm) ostium resulted in excellent functional outcome
after an external operation.
The intranasal orifice of the NLD can also be utilized to
determine the approximate position of the NLD. We found
that the former is located 25 mm posterior to the anterior
nasal spine and can be seen on the ceiling of the inferior
nasal meatus. The NLD courses superiorly toward the
anterior attachment of the MT. Hence, the NLD should be
searched for on the line between the orifice and anterior
attachment of the MT. The mean length of the NLD is
about 22 mm.
The data reported here provide some important clues for
surgical orientation during endoscopic DSR. Nevertheless,
further studies involving a larger series are required to
accurately determine the anatomical relationship of the
NLD with the frontal recess and agger nasi cells.
123
E. Tatlisumak et al.
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