Anatomy, Head and Neck, Eye Nasolacrimal


Article Author:
Megan Cochran


Article Editor:
Craig Czyz


Editors In Chief:
Shane Havens
Jim Wang
Koushik Tripathy


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Trevor Nezwek
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
1/4/2019 3:20:47 PM

Introduction

The purpose of the nasolacrimal system is to drain tears from the ocular surface to the lacrimal sac and ultimately the nasal cavity. Blockage of the nasolacrimal system can cause tears to flow over the eyelid and down the cheek. This is known as epiphora.

Structure and Function

Both the upper eyelid and the lower eyelid have a small opening on the surface of the eyelid margin near the medial canthus. These are called puncta. Each puncta leads to a drainage canal that eventually flows into the lacrimal sac and then the nasal cavity. The drainage canal connecting the ocular surface to the nasal cavity consists of multiple parts.

Within the lower eyelid, the punctum leads to a 2 mm long ampulla which runs perpendicular to the eyelid margin. The ampulla turns 90 degrees medially becoming the inferior canaliculus and travels 8 to 10 mm before reaching the common canaliculus. The upper canaliculus travels 2 mm superiorly in the eyelid before turning 90 degrees medially and moving 8 to 10 mm before connecting to the common canaliculus. The common canaliculus drains into the lacrimal sac. Within the junction between the common canaliculus and the lacrimal sac is the valve of Rosenmuller. This is a one-way valve that prevents reflux from the lacrimal sac to the puncta.

The lacrimal sac drains inferiorly to the nasolacrimal duct which is bordered medially by palatine bone and the inferior turbinate in the nose and laterally by maxillary bone. The nasolacrimal duct opens at the inferior meatus located underneath the inferior nasal turbinate. The lacrimal sac is approximately 10 to 15 mm in axial length and 13 to 20 mm in corneal length, and the nasolacrimal duct is 12 to 18 mm long. The inferior nasal meatus is partially covered by a mucosal fold known as the Valve of Hasner. [1][2][3]

Embryology

The nasolacrimal duct starts forming around 5 weeks of gestation. It starts out as a linear thickening of ectoderm located in a groove between the nasal and maxillary prominences. This thickening eventually separates into a solid cord and sinks into the surrounding mesenchyme. Over time the cord canalizes forming the lacrimal sac and the beginning of the nasolacrimal duct. The nasolacrimal duct extends intranasally until it exits under the inferior turbinate. The lacrimal sac extends caudally to complete the canalicular system. The inside of the canal breaks down and forms a lumen so that the nasolacrimal system is patent. This process is generally complete by the time of birth. [4]

Blood Supply and Lymphatics

Blood supply to the nasolacrimal area of the face is generally from the angular artery. The angular artery is considered a branch of the facial artery; however, some studies have shown that it can originate from the ophthalmic artery in some individuals. It terminates in anastomosis with the dorsal nasal branch of the ophthalmic artery. The angular artery and vein are located along the nose near the medial orbit. A correlating angular vein drains this region.

The medial and lateral portions of the eyelids have different lymphatic drainage systems. The medial one-third of the upper eyelid and the medial two-thirds of the lower eyelid drain to the submandibular lymph nodes. The lateral two-thirds of the upper eyelid and the lateral one-third of the lower eyelid drain to the pre-auricular lymph nodes.

Nerves

Cranial nerve VII supplies the motor innervation to the muscles of the face. The movement of these muscles aid in proper drainage of the tears through the nasolacrimal system by what is known as the lacrimal pump mechanism. Cranial nerve III and cranial nerve VII innervate the muscles that control blinking of the eyelids. This action is the primary driver of the lacrimal pump mechanism.

Irritation of the ocular surface stimulates the ophthalmic branch of cranial nerve five which begins the reflex tear arc pathway. The efferent pathway involves cranial nerve VII and parasympathetic fibers. The role of the sympathetic nervous system in tear production is not well understood.

Muscles

The action of the orbicularis muscle and surrounding tissues help propel the flow of tears from the canaliculi to the nasolacrimal duct via the lacrimal pump mechanism.

Surgical Considerations

Eyelid Laceration with Canalicular Involvement

Dilate both upper punctum and lower punctum. If there is an un-involved punctum, probe it to the sac and irrigate to ensure there are no underlying blockages. Then identify the medial and lateral ends of the lacerated canaliculus. A Mini Monoka stent can be used if only one canaliculus is involved. If both are involved, silicone tubing or a Crawford stent can be used. See below for stenting techniques for Mini Monoka and Crawford Stent. Suture skin as described in simple laceration repair.

Mini Monoka Stent

Advance stent through punctum of lacerated canaliculus and out the distal end.  Then insert the stent into the canaliculus opening of the lacerated lateral edge. Ensure stent is seated in punctum. Place 6-0 Vicryl sutures using a curved needle to anastomose the cut edges of the canaliculus and re-approximate the surrounding tissue. Leave these untied. Then place addition interrupted buried 5-0 vicryl sutures to reinforce the medial canthal tendon if needed. After all deep sutures are placed, tie and trim all sutures. Close overlying skin with 6-0 plain gut suture.

Crawford Stent

Place the first end of the stent through punctum of lacerated canaliculus and out distal end. Then pass the same end through the previously identified proximal end and then advance through lacrimal and nasal lacrimal duct. Retrieve end of the stent from the nasal cavity. Pass the other end of the stent in a similar fashion through intact canaliculus. Place a cotton swab or similar product underneath the tubing loop between the upper and lower puncta. Pull the ends of the tubing taught through the nose and tie them together. Cut the excess tubing below the knot and then proceed to skin closure. [5][6][7][8]

Clinical Significance

One of the most common pathologies of the nasolacrimal duct is congenital nasolacrimal duct obstruction. This occurs when the distal end of the nasolacrimal duct is not patent. Obstruction of the nasolacrimal duct is symptomatic in 5% of infants at birth, but most infants present with symptoms 4 to 6 weeks after birth. This is because the lacrimal gland does not fully develop until week 6 and therefore infants younger than 6 weeks are not able to produce tears. Without tears, there is nothing for the nasolacrimal system to obstruct.

There are a variety of causes of acquired nasolacrimal duct obstruction that can occur later in life. Depending on the level of obstruction in the nasolacrimal system, different symptoms are produced. Sometimes, obstruction of the nasolacrimal system is the desired effect. For example, punctal plugs are a common therapy for patients suffering from dry eye symptoms [9]


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Anatomy, Head and Neck, Eye Nasolacrimal - Questions

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To which of the following does the pterygopalantine ganglion send secretory and motor fibers?



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Into which of the following does the nasolacrimal duct usually drain?



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The nasolacrimal duct is encased in firm bone just anterior to which of the following structures?



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Which two bones make up the lacrimal fossa?



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From the image shown, at what location will you find the distal opening of the lacrimal duct?

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Tears drain via the lacrimal duct into what part of the nose?



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The nasolacrimal duct drains tears from the lacrimal sac into which of the following?



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Secretory nerve fibers to the lacrimal gland are derived from which of the following?



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From what embryological layer does the nasolacrimal system develop?



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What structure lies medial to the orbit along the nose that is important to note during surgery in the nasolacrimal area?



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Anatomy, Head and Neck, Eye Nasolacrimal - References

References

Modified External Dacryocystorhinostomy in Primary Acquired Nasolacrimal Duct Obstruction., Sharma HR,Sharma AK,Sharma R,, Journal of clinical and diagnostic research : JCDR, 2015 Oct     [PubMed]
[Efficacy of endoscopic nasal lateral wall dissection approach in the treatment of maxillary sinus diseases]., Wang W,Zhan X,Qiang H,Cheng Z,, Lin chuang er bi yan hou tou jing wai ke za zhi = Journal of clinical otorhinolaryngology, head, and neck surgery, 2015 Jun     [PubMed]
An Unusual Case of Nasolacrimal Obstruction Caused by Foodstuffs., Matsumoto H,Matsumoto A,, Case reports in ophthalmology, 2015 Sep-Dec     [PubMed]
Transection of Nasolacrimal Duct in Endoscopic Medial Maxillectomy: Implication on Epiphora., Imre A,Imre SS,Pinar E,Ozkul Y,Songu M,Ece AA,Aladag I,, The Journal of craniofacial surgery, 2015 Oct     [PubMed]
Management of nasolacrimal duct injuries in mid-facial advancement., Balaji SM,, Annals of maxillofacial surgery, 2015 Jan-Jun     [PubMed]
Endoscopic Endonasal Dacryocystorhinostomy with Ostial Stent Intubation Following Nasolacrimal Duct Stent Incarceration., Yıldırım Y,Kar T,Ayata A,Topal T,Çeşmeci E,, Current eye research, 2015 Dec     [PubMed]
Lacrimal Gland Volume Changes in Unilateral Primary Acquired Nasolacrimal Obstruction., Yazici A,Bulbul E,Yazici H,Sari E,Tiskaoglu N,Yanik B,Ermis S,, Investigative ophthalmology & visual science, 2015 Jul     [PubMed]
Incidence of neoplasia in patients with unilateral epiphora., Bewes T,Sacks R,Sacks PL,Chin D,Mrad N,Wilcsek G,Tumuluri K,Harvey R,, The Journal of laryngology and otology, 2015 Jul     [PubMed]
Computed tomography dimensions of the lacrimal gland in normal Caucasian orbits., Tamboli DA,Harris MA,Hogg JP,Realini T,Sivak-Callcott JA,, Ophthalmic plastic and reconstructive surgery, 2011 Nov-Dec     [PubMed]

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