OBJECTIVES/HYPOTHESIS: To evaluate the surgical outcome of primary endoscopic dacryocystorhinostomy (DCR) in nasolacrimal duct obstruction (NLDO) in our set up. STUDY DESIGN: Retrospective non randomized study of consecutive 571 DCR performed in MIMER Medical College, Talegaon-Dabhade, Pune, India during January 2006 to December 2013 with a follow up period of minimum 1 year.METHODS: Retrospective analysis of 571 consecutive primary endoscopic DCR procedures performed without stenting was done. Nasolacrimal system irrigation was used for preoperative assessment. Success was defined as absence of symptoms and patent nasolacrimal system.RESULTS: The overall success rate was 87.39% (499/571).CONCLUSIONS: Our study suggests that the surgical outcomes of primary endoscopic DCR in nasolacrimal duct obstruction are good

Parab, Sapna

English

Varna Medical University Press: Journals

Scripta Scientica Medica, vol. 47, No 4, 2015, pp. 47-50  Copyright © Medical University of Varna  47ORIGINAL ARTICLESSTUDY OF PRIMARY ENDOSCOPIC DACRYOCYSTORHINOSTOMY WITHOUT LACRIMAL STENTMubarak Khan, Sapna ParabDepartment of Otorhinolaryngology, M.I.M.E.R. Medical College, Pune, INDIAAddress for correspondence:  Dr. Mubarak M Khan Department Of Otorhinolaryngology  M.I.M.E.R. Medical College Pune, INDIA –410507mobile: +91 98226 46207fax: +91 2114 223916е-mail: ent.khan@gmail.comReceived: November 3, 2015Accepted: December 1, 2015ABSTRACTOBJECTIVES/HYPOTHESIS: To evaluate the surgical outcome of primary endoscopic dacryocystorhinos-tomy (DCR) in nasolacrimal duct obstruction (NLDO) in our set up.STUDY DESIGN: Retrospective non randomized study of consecutive 571 DCR performed in MIMER Med-ical College, Talegaon-Dabhade, Pune, India during January 2006 to December 2013 with a follow up peri-od of minimum 1 year.METHODS: Retrospective analysis of 571 consecutive primary endoscopic DCR procedures performed with-out stenting was done. Nasolacrimal system irrigation was used for preoperative assessment. Success was de-fined as absence of symptoms and patent nasolacrimal system. RESULTS: The overall success rate was 87.39% (499/571). CONCLUSIONS: Our study suggests that the surgical outcomes of primary endoscopic DCR in nasolacrimal duct obstruction are good.Keywords: Endoscopic dacryocystorhinostomy (DCR)INTRODUCTIONDacryocystorhinostomy (DCR) is the treat-ment of choice for patients with chronic stenosis and obstruction of the nasolacrimal duct. This can be caused by chronic stenosis of the nasolacrimal duct and can be congenital or acquired. Nasolacri-mal duct obstruction (NLDO) is common but is not a serious condition. Presenting symptoms include ex-cessive epiphora (tearing) and dacryocystitis (infec-tion). Usually, cases have been refractory to conven-tional treatment such as warm compresses, massage and probing the nasal passage. The external DCR is standard treatment. Endoscopic DCR is a minimal-ly invasive procedure performed by otorhinolaryn-gologists to unblock NLDO and correct other causes of decreased patency of the nasal passages. External dacryocystorhinostomy (EXT-DCR) was first de-scribed by Toti (1,2) in 1904. The endonasal approach was first introduced in 1893 by Caldwell (3,4), but it was inherently limited by poor visibility of endonasal anatomy during surgery. The introduction of high-resolution fiberoptic endoscopes in the late 1980s en-abled adequate visualisation of the nasal cavities, and permitted minimally invasive surgery, under local anaesthesia, avoiding visible facial scarring (5,6). En-donasal dacryocystorhinostomy (ENL-DCR) can be 48 Scripta Scientica Medica, vol. 47, No 4, 2015, pp. 47-50 Copyright © Medical University of Varna Study of primary endoscopic dacryocystorhinostomy without lacrimal stentperformed either entirely surgically (7) or with the assistance of laser to create the fistula. A rigid endoscope is inserted into the nasal cav-ity to the lacrimal sac via the lacrimal duct to explore and confirm the nature of the obstruction. A decon-gestant is administered to clear the nasal passage first and then gauze, soaked with anaesthesia that numbs the area and constricts blood vessels, is inserted. The nasal mucous membrane is incised and removed, to allow for the creation of a window on the lacrimal sac and upper nasolacrimal duct. A portion of the lacri-mal and maxilla bone is removed and using a blade, a vertical incision is made in the lacrimal sac and naso-lacrimal duct. This study is carried out to evaluate the surgical outcome of primary endoscopic dacryocysto-rhinostomy (DCR) in nasolacrimal duct obstruction (NLDO) without nasolacrimal stent in our set up.METHODS AND MATERIALSRetrospective analysis of 571 from January 2006 to December 2010 with a follow up period of minimum 12 months. The patients ranged from 13 to 82 years of age. Our study consisted of 309 females and 262 males. Bilateral endoscopic dacryocystorhi-nostomy was done in 42 patients. In 73 patients, sep-toplasty was done along with endoscopic dacryo-cystorhinostomy. Informed consent was taken in all patients. Sac syringing was done every weekly for 1 month and thereafter 1 monthly for 6 months and thereafter at the end of 1 year.In our study, indications for endoscopic dac-ryocystorhinostomy included chronic dacryocysti-tis (acquired and congenital), lacrimal sac mucocoele and lacrimal abscess.All patients were operated under local anaes-thesia (2 percent xylocaine with adrenaline) and ade-quate sedation except 29 patients who were operated under general anaesthesia.PROCEDURE OF ENDOSCOPIC DACRYOCYSTORHINOSTOMY Endoscopic DCR is a minimally invasive proce-dure used to bypass the nasolacrimal duct. The pa-tient is positioned in a supine position with the head turned. The nose is packed with 4% xylocaine one hour before the surgery.A Zero degree 4 mm Hopkins rigid endoscope is inserted into the nasal cavity to the lacrimal sac via the lacrimal duct to explore and confirm the nature of the obstruction. The middle turbinate is identified and its anterior arch is traced laterally as the max-illary line. The area in front of maxillary line is the lacrimal sac area. The sac is covered by the lacrimal bone which is removed during the surgical approach to lacrimal sac.2% xylocaine with adrenaline (1:100,000) (if no contraindication of adrenaline) is infiltrated into the lacrimal sac area. The lacrimal bone area is exposed and the bone is removed with a Kerrison DCR punch forceps. The confirmation of the lacrimal sac is done by the movement of medial wall of sac in endoscopic view. The lacrimal punctum is then cannulated and the lacrimal sac is filled with saline. A vertical inci-sion is created in the lacrimal sac with no.12 bladeThis newly created stoma is enlarged. The lacri-mal probe is cannulated from lower punctum of the eye and negotiated to come out from newly created stoma inside the nose to break any adhesion at open-ing of nasolacrimal duct near the sac. The sac syring-ing is done. The free flow of saline indicates success-ful surgery.RESULTSThe success rate of our technique of endoscop-ic DCR without lacrimal stenting is 87.39% (499/571).The success or patency of the endoscopic DCR depends on the size of the stoma. The larger the sto-ma created on the medial wall of lacrimal sac, the greater are the chances of success rate. The success is indicated by the smooth/ free flow of fluid dur-ing lacrimal sac syringing and the patient appreciat-ing the fluid in the throat. Failure is indicated when there is no patency of the stoma.Chronic Dacryocystitis 387Mucocele 79Congenital Chronic Dacryocystitis 5Mucocele and Dacryocystitis 68Lacrimal abscess 32TOTAL 571Table 1. Pre-operative lacrimal drainage system abnormalitiesScripta Scientica Medica, vol. 47, No 4, 2015, pp. 47-50  Copyright © Medical University of Varna  49Mubarak Khan, Sapna ParabDISCUSSIONEndoscopic DCR is a well-established surgical technique with some advantages compared to the conventional external-DCR. These include limita-tion of tissue injury to the discrete fistula site, avoid-ance of a skin incision, excellent haemostasis, the ability to perform a lacrimal bypass operation on an outpatient basis, quicker patient rehabilitation, decreased overall health care expense and patients’ preference [8, 9]. Main limitations of the technique are its steep learning curve, the higher equipment cost and its contraindication in cases of severe pre-existing nasal deformities or scarring and suspected lacrimal sac neoplasms (9).ENL-DCR avoiding the use of laser is a well de-scribed procedure. Several surgical instruments have been employed to remove the bone overlying the lacrimal sac, including drills, osteotomes, curettes and rongeurs. Weidenbecher reported resolution or improvement of symptoms in 95% of the patients (6). In another study of surgical ENL-DCR results, Sprekelsen achieved good results on 96% of the oper-ations (5). Both studies describe no major complica-tions associated with the technique.ENL-DCR performed under local anaesthe-sia is reported to be generally well tolerated by the patients (10). In our study, all operations were per-formed under local anaesthesia, except for 29 pa-tients who were operated under general anaesthe-sia. No significant discomfort was reported by any of our patients, which confirms the reported positive patients’ views. Reported complications associated with ENL-DCR include per-operative or post-opera-tive haemorrhage, punctal erosion related to silicone intubation, silicone tubing prolapse, canalicular ob-struction, orbital fat herniation, orbital and subcu-taneous emphysema, conjunctival fistula formation, retrobulbar haemorrhage, and transient medial rec-tus paresis (11). In our series, no severe per-operative or post-operative complications were encountered.Utilising the excellent vision of the intrana-sal cavity afforded by the nasal endoscope, our ex-perience shows us that the usual cause of endoscop-ic DCR (and conventional external DCR) failure is scarring at the nasal mucosal and submucosal lev-el. There have been no studies performed to indicate the ideal rhinostomy size required for a function-ing DCR, but studies have shown that patency is still achieved even after scarring has reduced a rhinosto-my size to 1.8 mm (12). As there does not seem to be any evidence of bony regrowth or bony encroachment upon the rhi-nostomy size, we therefore feel that the key to in-creasing the success rate of endoscopic DCR may lie in trying to reduce nasal mucosal scarring response and making a wide opening into the lacrimal sac. The endoscopic approach of DCR has several advantages, including the following: ❖ It provides a better aesthetic result with no ex-ternal scar. ❖ It allows a one-stage procedure to also correct associated nasal pathology that  ❖  may be causative. ❖ It avoids injury to the medial canthus and/or pathologic scar formation. ❖ It preserves the pumping mechanism of the or-bicularis oculi muscle. ❖ Active infection of the lacrimal system is not a contraindication to surgery. ❖ It is especially superior to the external approach in revision surgery. ❖ It is much less bloody and messy than the exter-nal approach. ❖ Because of the facility of the approach, the peri-operative time is shorter. ❖ The success rate is comparable to the external approach.CONCLUSIONS1. The success rate of endoscopic dacryocystorhi-nostomy is 87.39%. Asymptomatic 434Signicant improvement  (no further procedure required)65Symptoms unchanged 59Symptoms deteriorated 13Total success 499Table 2. Success rate50 Scripta Scientica Medica, vol. 47, No 4, 2015, pp. 47-50 Copyright © Medical University of Varna Study of primary endoscopic dacryocystorhinostomy without lacrimal stent2. The success of the endoscopic dacryocystorhi-nostomy depends on the size of the stoma and by avoiding trauma to the nasal mucosa.3. There were no post operative complications in our study.REFERENCES1. Toti A. Nuovo metodo conservatore dicura rad-icale delle soppurzioni croniche del sacco lacri-male (dacriocistorinostomia). Clin Mod Firenze. 1904;10:385-387. 2. Hofmann T, Lackner A, Muellner K, Luxenberger W, Wolf G. Endolacrimal KTP laser-assisted dac-ryocystorhinostomy. Arch Otolaryngol Head Neck Surg. 2003;129:329-332.3. Caldwell GW. Two new operations for obstruction of the nasal duct. N Y J Med. 1893;57:581-582. 4. Allen KM, Berlin AJ. Dacryocystorhinostomy failure:association with nasolacrimal silicone intu-bation. Ophthalmic Surg.1989;20:486-489.5. Sprekelsen MB, Barberan MT. Endoscopic dacryo-cystorhinostomy: surgical technique and results. Laryngoscope. 1996;106:187-189. 6. Weidenbecher M, Hosemann W, Buhr W. Endo-scopic endonasal dacryocystorhinostomy: results in 56 patients. Ann Otol Rhinol Laryngol 1994, 103:363-367. 7. Jokinen K, Karja J. Endonasal dacryocystorhinos-tomy. Arch Otolaryngol. 1974;100:41-44. 8. Massaro BM, Gonnering RS, Harris GJ. Endonasal laser dacryocystorhinostomy. A new approach to nasolacrimal duct obstruction. Arch Ophthalmol. 1990;108:1172-1176. 9. Bartley GB: The pros and cons of laser dacryocys-torhinostomy. Am J Ophthalmol 1994, 117:103-106.10. Tripathi A, Lesser TH, O’Donnell NP, White S: Lo-cal anaesthetic endonasal endoscopic laser dacryo-cystorhinostomy: analysis of patients’ acceptabil-ity and various factors affecting the success of this procedure. Eye. 2002;16:146-149.11. Sadiq SA, Ohrlich S, Jones NS, Downes RN: Endo-nasal laser dacryocystorhinostomy--medium term results. Br J Ophthalmol.1997;81:1089-1092.12. Lindberg JV, Anderson RL, Bumstead RM, Barreras R. Study of intranasal ostium exter-nal dacryocystorhinostomy. Arch Ophthalmol. 1992;100:1758–1762.

Study of primary endoscopic dacryocystorhinostomy without lacrimal stent

https://journals.mu-varna.bg/index.php/ssm/article/download/1434/1343

Study of primary endoscopic dacryocystorhinostomy without lacrimal stent

Abstract

Similar works

Full text

Available Versions

Varna Medical University Press: Journals