Acta Oto-Laryngologica, 2009; 129: 992
995 ORIGINAL ARTICLE Endoscopic dacryocystorhinostomy for acquired nasolacrimal duct obstruction: creating a window with a drill without use of mucosal flaps Acta Otolaryngol Downloaded from informahealthcare.com by University of Padova on 10/27/13 For personal use only. A. SARATZIOTIS1, E. EMANUELLI1, H. GOUVERIS2 & G. BABIGHIAN1 1 Department of Otorhinolaryngology and Otologic Surgery, University of Padova, Italy and 2Department of Otorhinolaryngology, University of Thessalia at Larissa, Greece Abstract Conclusion. Success and complication rates of endoscopic dacrycystorhinostomy (DCR) creating a window with a drill and without using mucosal flaps are similar to those of external DCR. Moreover, any intranasal or paranasal disease can be treated simultaneously and a superior cosmetic result is achieved. Objectives. To present success and complication rates of a case series of patients treated with the same technique of endoscopic DCR for acquired nasolacrimal duct obstruction (NLDO). Patients and methods. This was a retrospective case review of 46 patients (25 female, 21 male; mean age 57 years). All patients had acquired NLDO with epiphora. Additionally, chronic dacryocystitis was evident at presentation in five patients. The cause of NLDO was primary acquired NLDO in 35 patients and lacrimal sac mucocele in 11 patients. An endonasal endoscopic approach using a drill was performed. Temporary silicone stenting of the nasolacrimal duct system was applied. In 19 patients additional surgery (11 FESS, 3 septoplasties, 5 FESS and septoplasty) was necessary. Patient follow-up ranged between 3 and 27 months. Results. A successful functional result was obtained in 97.8% of patients. No major complications were observed. Minor complications (acute dacryocystitis or periorbital ecchymosis) occurred in four patients and were treated with antibiotics or resolved spontaneously. Keywords: Surgery, endonasal, drill, nasolacrimal, epiphora Introduction Patients and methods Various methods have been proposed for formation of the lateral nasal wall osteotomy, and especially for the removal of the thick bone of the maxilla at the region of the lacrimal sac fossa, during endonasal dacryocystorhinostomy (DCR). Laser beam, forceps, curettes, neurosurgical microrongeurs and drills with diamond burr have been used [1]. Some reports in the literature advocate a higher success rate for endoscopic DCR than for external DCR (84% versus 70% [2]). We report on our results of endoscopic endonasal DCR using a drill in patients with primary acquired NLDO and emphasize the intraoperative steps and postoperative measures which, in our opinion, lead to a high functional success rate. We conducted a retrospective case review study of 46 consecutive patients (25 female, 21 male; mean age 57 years, age range 15
84 years) who had undergone surgery for NLDO by means of an endoscopic endonasal procedure using a drill for formation of the lateral nasal wall osteotomy in a tertiary academic medical centre between July 2003 and December 2005. All patients had NLDO with clinical evidence of chronic dacryocystitis at presentation in 10.9% and epiphora in 100% of them. Diagnosis was made by clinical examination including lacrimal irrigation, fluorescein tests (Jones I and II tests), as well as probing of the canaliculi with a blunt probe up to bony contact with the lacrimal sac fossa performed by an ophthalmologist, a CT scan of Correspondence: Athanasios Saratziotis MD, Department of Otorhinolaryngology and Otologic Surgery (Unita operativa di Otochirugia), University of Padova, Via Giustiniani 2, 35128 Padova, Italy. Tel. 39 49 8211993. Fax. 39 49 8211994. E-mail: athanasios_saratziotis@yahoo.it (Received 21 July 2008; accepted 18 September 2008) ISSN 0001-6489 print/ISSN 1651-2251 online # 2009 Informa UK Ltd. (Informa Healthcare, Taylor & Francis As) DOI: 10.1080/00016480802495396 Acta Otolaryngol Downloaded from informahealthcare.com by University of Padova on 10/27/13 For personal use only. Endoscopic DCR with a drill the paranasal sinuses, dacryocystography and an endoscopic endonasal examination performed by an otorhinolaryngologist. The charts of patients with suspected endonasal malignancy involving the lacrimal duct system, previous lacrimal surgery, post-traumatic bony deformity and lower lid problems involving the canaliculi were excluded from the review. The cause of NLDO was primary acquired NLDO in 35 patients and lacrimal sac mucocele in 11 patients. All patients who were treated through a DCR procedure as the sole surgical intervention underwent day surgery under general anaesthesia. If an additional endonasal procedure were performed, then the total length of hospital stay was 3 days. An endonasal endoscopic approach using a drill for formation of the lateral nasal wall osteotomy was performed (Figure 1). Two patients with acquired stenosis underwent bilateral primary DCR procedures. Details of the procedure After decongestion and vasoconstriction of the nasal mucosa with injection of adrenaline solution 1/100 000 with 2% lidocaine solution, catheterization of the lacrimal duct system by an opthalmologist with a light pipe through (usually) the inferior lacrimal canaliculus and insertion of the optical fibre to transilluminate the lacrimal sac through the lateral nasal wall was performed. The area of maximal illumination as seen from an endonasal point of view corresponds to the posterior (dorsal) part of the lacrimal sac, which is covered medially by a thin bony plate. This area is situated 1 mm to 1 cm ventrally to the axilla of the middle turbinate. 993 Drilling of the bone at this area with a cutting burr on an angled hand-piece followed, with formation of a round-shaped window 1 cm in diameter until the medial wall of the lacrimal sac was exposed. Then, a vertical incision of the medial wall of the lacrimal sac was performed by use of a sickle knife and the greatest part of the medial wall of the lacrimal sac was removed using an angled, Castelnuovo-type (no. 3 or 4) cutting forceps. Bicanalicular intubation with a silicone stent was performed by an ophthalmologist and the stent ends were knotted together endonasally. No nasal packing was performed. In 19 patients additional surgery (10 FESS, 3 septoplasty, 6 FESS and septoplasty) was necessary. Concomitant FESS was performed if the patient had symptoms of chronic sinusitis and evidence of chronic sinusitis on CT scan. Concomitant septoplasty was performed if a deviation of the nasal septum was present in its cranial anterior segment, leading to an obstruction of the access of the drill to the area of the lateral nasal wall where the bone window should be created. If additional endonasal procedures (i.e. septoplasty or FESS) were planned, then DCR was performed at the end of the other procedures. In that case, nasal packing was done and left in place for 2 or 3 days postoperatively. Oral antibiotic therapy was initiated on the day of surgery and continued for 5 days. Concomitant topical therapy with antibiotic and steroid solutions (eye drops) was also given. Lacrimal duct system irrigation was performed by an ophthalmologist once a week during the first month, twice a month during the second month and once a month during the third month postoperatively. Endoscopic endonasal examination to test the patency of the duct system was performed 15, 21 and 30 days postoperatively. Silicone stents were removed 4
12 weeks postoperatively. Postoperative patient follow-up ranged between 3 and 27 months. Functional success was considered as any marked improvement in tearing (epiphora), no single episode of dacryocystitis postoperatively and ability to irrigate the lacrimal system postoperatively. Anatomical success was considered the finding of a patent lateral nasal wall bone window on nasal endoscopy postoperatively, as well as the unobstructed intranasal flow of saline during syringing via the lacrimal puncta. Results Figure 1. Intraoperative view of the area of the (right-sided) lateral nasal wall where drilling is performed. A successful functional result was obtained in 97.8% of patients (45 of 46 patients). One patient had an unsuccessful functional result, with complete duct system obstruction. The reason for the obstruction in this patient was inappropriate removal of the silicone 994 A. Saratziotis et al. Acta Otolaryngol Downloaded from informahealthcare.com by University of Padova on 10/27/13 For personal use only. stent postoperatively, with stent rests remaining in the lacrimal sac area causing granuloma formation locally. No major complications (i.e. complications involving the extraocular muscles or the optic nerve) were observed. No periorbital fat exposure was noted. Minor complications occurred in 4 of 46 patients (8.7%); 1 patient developed acute dacryocystitis that was treated successfully with a 1 week course of topical and oral antibiotic therapy and 3 patients had periorbital ecchymosis that resolved spontaneously within 3 days postoperatively. No patient experienced postoperative nose bleeding. Discussion Symptomatic success rates and complication rates of the endoscopic endonasal approach with use of the drill for formation of the lateral nasal wall osteotomy are similar to those achieved by means of an external surgical approach. Primary success rates of endoscopic DCR range between 70% and 95% [2
5]. Results of the presented series are comparable to those of the more successful series published in the literature. Application of meticulous surgical technique with correction of any coexisting obstructing intranasal pathology (e.g. septal deviation) and prevention of synechiae building between the osteotomy site and the nasal septum and/or the lateral aspect of the middle turbinate may be the reason for the relatively high success rates obtained in our series. We do not advocate creation of mucosal flaps at the bony window area, because they are associated with increased risk of postoperative fibrosis and obstruction. According to other authors, building of mucosal nasal and lacrimal sac flaps through an endonasal approach does not increase the success rate of endoscopic DCR [4]. Repeated meticulous irrigation of the duct system carried out by an ophthalmologist during the first 3 postoperative months should also be considered a major factor contributing to the observed functional and anatomical success. Functional failure with no evidence of anatomical obstruction at the fistula site on nasal endoscopy can occur in 51% of failed surgeries [2]. Preoperative nasal endoscopy and CT scan are very important in order to assess the feasibility of an endonasal DCR and the necessity and planning of an additional septal or sinus procedure. Use of the drill is particularly advantageous for bone removal at the area of the lateral nasal wall cranially to the insertion of the middle turbinate that covers medially the superior half of the lacrimal sac [6]. Care should be taken not to place the osteotomy window too cranially during endonasal DCR, so as to prevent Figure 2. Side view of a cadaveric (left-sided) lateral nasal wall bony specimen. The shaded oval-shaped area demarcates the area where drilling should not be performed, so as to prevent development of lacrimal sump syndrome. The black line demonstrates the area where drilling should be done. development of the lacrimal sump syndrome [7], a major cause of DCR failure (Figure 2). This syndrome occurs when residual lacrimal sac forms a blind pouch where tears are collected. Recurrent dacryocystitis may follow. By means of an endoscopic endonasal approach, any intranasal or paranasal pathology can be treated simultaneously and a superior cosmetic result without any use of a cutaneous incision is achieved. Additionally, a possible disruption of the medial canthal ligaments and a disturbance of the pump mechanism of the orbicularis oculi muscle, which may complicate surgery by means of an external approach, are avoided. The advantages of DCR by means of an external approach comprise ease of visualization of the lacrimal sac for pathology and ease of suturing the sac and nasal mucosal flaps. Many authors advocate that external DCR is technically less demanding than endonasal DCR. We do not perform routine histological exam of the excised part of the medial lacrimal sac, because the incidence of neoplasia is very low (0.7%) if routine exam, without respective clinical suspicion, is performed [8]. Time to stent removal may range from 4
6 weeks [6] to 2
3 months postoperatively [2]. Duration of silicone intubation was not found to differ significantly between successful and failed cases in the series of Ben Simon et al. [2]. According to our experience, surgery failure usually occurs within the first 3 months after surgery. This is why we use a minimum period of 3 months postoperatively when assessing outcome of surgery. Moore et al. also advocate that complications that Endoscopic DCR with a drill may result in surgery failure occur up to 3 months postoperatively [3]. Revision surgery was performed endonasally in one of our patients who showed functional failure. In this patient functional success was observed at 3 months’ postoperative follow-up. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. [3] [4] [5] Acta Otolaryngol Downloaded from informahealthcare.com by University of Padova on 10/27/13 For personal use only. [6] References [7] [1] Watkins LM, Janfaza P, Rubin PAD. The evolution of endonasal dacryocystorhinostomy. Surv Ophthalmol 2003;48:73
84. [2] Ben Simon GJ, Joseph J, Lee S, Schwarcz RM, McCann JD, Goldberg RA. External versus endoscopic dacryocystorhi- [8] View publication stats 995 nostomy for acquired nasolacrimal duct obstruction in a tertiary referral center. Ophthalmology 2005;112:1463
8. Moore WM, Bentley CR, Olver JM. Functional and anatomic results after two types of endoscopic andonasal dacryocystorhinostomy: surgical and holmium laser. Ophthalmology 2002;109:1575
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