What is the post-operative protocol for endonasal DCR (dacryocystorhinostomy)?

Post-Operative Protocol for Endonasal DCR

The optimal post-operative management for endonasal dacryocystorhinostomy (DCR) includes saline nasal irrigations beginning 24-48 hours after surgery, avoidance of activities that increase intranasal pressure for 2-4 weeks, and regular endoscopic follow-up to monitor healing and remove crusting or granulation tissue.

Immediate Post-Operative Care (0-48 hours)

• Maintain head elevation (15-30 degrees) to reduce edema and bleeding
• Bed rest for 24-48 hours with gradual return to normal activities
• Monitor for signs of bleeding, which may require nasal packing if severe 1
• Administer pain management with acetaminophen as first-line therapy (opioids rarely needed)
• Begin antibiotic eye drops (antibiotic + corticosteroid combination) 2

Early Post-Operative Period (Days 2-14)

• Begin saline nasal irrigations 24-48 hours after surgery using isotonic solution 2-3 times daily 3
• Avoid activities that increase intranasal pressure for at least 2-4 weeks:
  • No nose blowing
  • No straining during bowel movements
  • No heavy lifting (>10 pounds)
  • No bending with head below heart level 3
• Continue topical nasal corticosteroid sprays to reduce inflammation
• First follow-up visit at 1 week for endoscopic examination and removal of crusts/debris 2

Intermediate Post-Operative Period (Weeks 2-6)

• Silicone stent management:
  • If stents were placed, they are typically removed at 4-6 weeks post-operation 4
  • Evidence suggests stents may not be necessary in routine cases and may actually increase granulation tissue formation 2, 5
• Continue saline irrigations to prevent crusting and maintain patency
• Second follow-up at 3-4 weeks for endoscopic examination and further debridement if needed

Long-Term Follow-Up (Months 2-6)

• Endoscopic examination at 3 months to assess final healing and patency 3
• Evaluate for common complications:
  • Distal stenosis from progressive healing closure (7.0%)
  • Recurrence of lacrimal mucocele (1.7%)
  • Adhesions between ostium and septum (0.6%) 1
• Success rates for endonasal DCR approach 90% with proper technique and post-operative care 2

Special Considerations

• Patients who underwent simultaneous sinonasal procedures (septoplasty, FESS) may require more intensive post-operative care but still achieve comparable success rates (85-94%) 5
• Mucosal flap preservation does not significantly impact outcomes when appropriate post-operative care is provided 5, 4
• Mitomycin C application is not routinely indicated based on current evidence 2

Key Elements for Success

• Regular removal of fibrin, crusts, and granulations during follow-up visits
• Consistent use of saline irrigations to maintain patency
• Patient education regarding activity restrictions to prevent complications
• Prompt recognition and management of complications such as bleeding or synechiae formation

The success of endonasal DCR depends significantly on meticulous post-operative care, with endoscopic follow-up being essential to prevent synechiae formation and subsequent recurrence of obstruction 2.