Indian Journal of Basic and Applied Medical Research – Otorhinolaryngology special issue, March 2017, 6 (2), 26-30

Original article:
Study of causes of failure in external DCR and endonasal DCR
1Dr C Anand Kumar* , 2Dr Nitin Kulkarni, 3Dr Aniket Lathi , 4Dr Ashish Gupta , 5Dr Shruti Rashinkar ,
6Dr Arka Roy ,7Dr Farha Maloo

1,2 Associate Professor , ENT Department , Kaminee Academy of Medical Sciences & Research center , Hyderabad , India
3Associate Professor, ENT Department, Rural Medical College, PIMS (DU) , Loni , Maharashtra , India
4-7 Resident, , ENT Department, Rural Medical College, PIMS (DU) , Loni , Maharashtra , India
Corresponding author*

Abstract:
Introduction: The external dacryocystorhinostomy (DCR) is the gold standard procedure for treatment of chronic dacryocystitis
till today by which all other newer methods of dacryocystorhinostomy procedures are assessed1. With the recent introduction of
endoscopes and microscopes, the original procedure of external dacryocystorhinostomy with extensive dissection have been
questioned by some surgeons which has led to interest in less invasive procedures like endonasal endoscopic
dacryocystorhinostomy.
Materials and methods: Patients attending ophthalmology outpatient department at Rural Medical College, Loni, for the
symptom of epiphora and diagnosed as primary acquired nasolacrimal duct obstruction or chronic dacryocystitis.
Results: By applying Z test of difference between two proportions presence of synechiae formation is more significant in group
B as compared to group A and improper ostium placement is more significant in group A as compared to group B. (p<0.01)
Conclusion: In the light of these results, we concluded that External DCR had higher success rate than the endonasal DCR. An
endonasal procedure has the advantage of dealing with associated deviated nasal septum, avoidance of cutaneous scar.
Keywords: endonasal DCR

INTRODUCTION avoidance of cutaneous wound, and limited tissue

The external dacryocystorhinostomy (DCR) is the dissection and co-existing nasal pathology can be
gold standard procedure for treatment of chronic dealt simultaneously in the same operation. However,
dacryocystitis till today by which all other newer complete visualization, removing of lacrimal bone
methods of dacryocystorhinostomy procedures are and control of excessive bleeding were the major
1
assessed . With the recent introduction of endoscopes problems unsolved with endonasal endoscopic
and microscopes, the original procedure of external dacryocystorhinostomy. There are very few
dacryocystorhinostomy with extensive dissection prospective studies comparing the outcome of the
have been questioned by some surgeons which has two techniques. Therefore, this study was undertaken.
led to interest in less invasive procedures like MATERIALS AND METHODS
endonasal endoscopic dacryocystorhinostomy. Mc Patients attending ophthalmology outpatient
2
Donogh and Meiring (1989), were the first to department at Rural Medical College, Loni, for the
describe the technique of endoscopic intranasal symptom of epiphora and diagnosed as primary
dacryocystorhinostomy. The major advantages being

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Indian Journal of Basic and Applied Medical Research – Otorhinolaryngology special issue, March 2017, 6 (2), 26-30

acquired nasolacrimal duct obstruction or chronic 2) Detailed ocular and systemic history was
dacryocystitis. taken. A detailed ocular examination and
Inclusion criteria: anterior rhinological examination was done.
All symptomatic epiphora cases diagnosed for Anterior rhinoscopy was done by
primary acquired nasolacrimal duct obstruction or otorhinolaryngologist and looked for any
chronic dacryocystitis. significant deviation of nasal septum,
Exclusion criteria: polyposis and hypertrophy of turbinates. If
Following patients were excluded from study they were having any co-existing disease,
1) Canalicular and punctal obstruction they were all dealt at the same sitting.
2) Failed cases of dacryocystorhinostomy 3) The patency of nasolacrimal duct was
3) Ectropion/ entropion/ lower lid laxity checked by lacrimal syringing. Mucoid/
4) Post traumatic bone deformity of lacrimal mucopurulent regurgitation, presence or
region absence of mucous flakes and the punctum
5) History of radiation therapy of lacrimal from which regurgitation occurred was
region noted.
6) History of sino nasal malignancy and OBSERVATIONS AND RESULTS
granulomatous conditions In the present study, total 60 cases comprising 30
7) Atrophic rhinitis cases in the external dacryocystorhinostomy (group
Sample size: A) and 30 cases in endonasal dacryocystorhinostomy
The study included 60 cases that were diagnosed as (group B) were involved who underwent
nasolacrimal duct obstruction or chronic corresponding surgeries, following observations were
dacryocystitis and who were fulfilling inclusion made:
criteria during the study period. The success rate was defined by the presence of
Data collection: patent lacrimal passage by lacrimal sac syringing at
The patients were evaluated as follows: the end of complete follow up. In our study the
1) Cases selected were subjected to a complete success rate for group A was in 26 cases (86.67%)
examination according to a defined and failure was seen in 4 cases (13.33%). In group B,
proforma. the success rate was seen in 21 cases (70%) and
failure was seen in 9 cases (30%).
Table No.1: Comparison of Result in Group A and Group B:
Result Group A(n=30) Group B(n=30)
No. (%) No. (%)

Success 26 (86.67%) 21 (70%)

Failure 4 (13.33%) 9 (30%)

Total 30 30

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Indian Journal of Basic and Applied Medical Research – Otorhinolaryngology special issue, March 2017, 6 (2), 26-30

By applying Z test, difference between two followed by improper ostium placement in 1 case
proportions, there is a highly significant difference (3.33%) on diagnostic nasal endoscopy (DNE).
between the success rate in Group A and in Group B. In group B, synechiae formation between the lacrimal
(p<0.01) sac flap and nasal mucosal flap was seen in 6 cases
Causes of failure: (20%) followed by blocked rhinostomy site by
Out of 4 cases failed in group A, blocked rhinostomy granulation tissue is seen in 3 cases (10%) on
site by granulation tissue was found in 3 cases (10%) diagnostic nasal endoscopy (DNE).

Table No.2: Diagnostic nasal endoscopy in failed cases in Group A and Group B:
Causes of failure Group A(n=30) Group B(n=30)
No. (%) No. (%)
Blocked rhinostomy site by Granulation Tissue 3(10%) 3 (10%)

Synechiae formation 0 6 (20%)

Improper ostium placement 1 (3.33%) 0
Total 4 (13.33%) 9 (30%)

By applying Z test of difference between two dacryocystorhinostomy. Our study correlates well
proportions presence of synechiae formation is more with the other studies.
significant in group B as compared to group A and All the patients with blocked lacrimal syringing
improper ostium placement is more significant in underwent nasal endoscopy. 3 cases (10%) showed
group A as compared to group B. (p<0.01) obstruction at rhinostomy site by granulation tissue
DISCUSSION formation. 1 patient (3.33%) showed an improper
In our study the success rate for group A was in 26 ostium placement. Welham et al7 have noted ostium
cases (86.67%) and failure was seen in 4 cases related problem as a cause of failure in 52% cases.
(13.33%). In group B, the success rate was seen in 21 Other contributing factors were scarring and
cases (70%) and failure was seen in 9 cases (30%). intervening ethmoid. Our study had showed only 1
3
Hartikainen et al had primary success rate of 91% case (3.33%) of failed external
for external dacryocystorhinostomy and 75% for dacryocystorhinostomy surgery because of ostium
endonasal dacryocystorhinostomy. Study done by related problem, which was very low as compared to
5
Cokkesser et al showed the success rate of 89.9% Welham et al.
for external dacryocystorhinostomy and 88.2% for Study by Kuldeep Moras et al8 had showed the
endonasal dacryocysto-rhinostomy. Ibrahim et al57 obstruction at the rhinostomy site in 2 cases (10%).
in their study had success rate of 82% for external Our study correlates well with this study. Repeat
dacryocystorhinostomy and 58% for endonasal endonasal dacryocystorhinostomy surgery was
dacryocystorhinostomy. Mirza et al6 in their study advised to all the patients. On repeat endoscopic
had success rate of 94% for external examination, 3 patients (10%) showed obstruction at
dacryocystorhinostomy and 64% for endonasal rhinostomy site by granulation tissue formation and

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Indian Journal of Basic and Applied Medical Research – Otorhinolaryngology special issue, March 2017, 6 (2), 26-30

narrow bony ostium. All of them were advised Patients were advised to undergo repeat endonasal
revision endoscopic surgery. dacryocysto-rhinostomy surgery. Post operatively
9
Study by Kuldeep Moras et al had showed the almost all the patients in group B and few patients in
obstruction at the rhinostomy site in 2 cases (10%). group A underwent nasal endoscopic examination for
10
Study by A Tsirbas and P J Wormald had showed intranasal cleaning of mucus, debris and for removal
scarring of the osteotomy in 5 cases that led to the of synechiae.
failure of the surgery. • Success rate for group A was 86.67% and
Postoperative scarring at the site of the rhinostomy is for group B, it was 70%.
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one of the major causes of DCR failure . • The failed cases showed obstruction of
Our study correlates well with the other studies. rhinostomy site by granulation tissue in
6 patients (20%) showed synechiae formation group A and synechiae formation between
between the lacrimal sac flap and nasal mucosal flap. the lacrimal sac flap and nasal mucosal flap
Ostium could not be visualised. The synechiae were in group B.
so extensive that probe could not enter the meatus. • The failed cases were advised to undergo
12
Study by Kuldeep Moras et al had showed the endonasal DCR again.
synechiae formation in 1 case (5%). Passorn CONCLUSION
13
Preechawai in their study had found that 3 cases In the light of these results, we concluded that
(7.1%) out of 42 who had failed results showed External DCR had higher success rate than the
fibrosis at the nasal mucosa. Our study correlates endonasal DCR. An endonasal procedure has the
well with the other studies. advantage of dealing with associated deviated nasal
septum, avoidance of cutaneous scar.

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