Lary 24111 PDF

The Laryngoscope
C 2013 The American Laryngological,

V
Rhinological and Otological Society, Inc.
Is Postoperative Stenting Necessary in Endoscopic

Dacryocystorhinostomy?
Jonathan Liang, MD; Andrew Lane, MD
BACKGROUND support from prospective studies and refinements in en-

Dacryocystorhinotomy (DCR) is a common proce- doscopic postoperative outcome assessment.
dure used to treat nasolacrimal duct obstruction. The There is strong evidence that both external and en-
modern external DCR, in which the lacrimal sac is doscopic DCR achieve high success rates of >90%. The
opened directly into the nasal cavity, was first described advantages to the endoscopic approach are numerous,
in 1904 by Toti.1 Since that time, DCR techniques have including better visualization, avoidance of external
evolved, including a transnasal endoscopic approach scars, ability to correct associated nasal pathology,
that has gained popularity in parallel with the growth of decreased operating time and costs, and preservation of
endoscopic sinus surgery. Endoscopic DCR has chal- the natural pumping mechanism. Despite the fact that
lenged the external approach as the gold standard for endoscopic DCR allows the rhinostomy to be performed
addressing mechanical nasolacrimal duct obstruction. in a controlled and minimally traumatic fashion, bicana-
With either method, a transcanalicular stent is typically licular intubation remains commonly performed to stent
placed at the time of surgery to maintain patency of the the newly created ostium. Soft silastic tubing (Guibor
DCR ostium. The importance of postoperative stenting is lacrimal tubing) is looped through the superior and infe-
an ongoing topic of controversy among both otolaryngolo- rior canaliculi and secured intranasally. In the litera-
gists and ophthalmologists. This article reviews the evi- ture, stents have been maintained in the postoperative
dence regarding the impact of stenting on endoscopic period from 4 weeks to 6 months in duration. Arguments
DCR outcomes. against the routine use of stents include granulation tis-
sue formation, infection, canalicular injury, dislodge-
LITERATURE REVIEW ment, and patient discomfort. In addition, stents often
Transcanalicular stenting was first described in the entail more involved postoperative care and mainte-
1950s for external DCR and in the 1960s for endoscopic nance. Finally, increased operative time and surgical
DCR. Thereafter, stents rapidly became favored by oph- costs have been cited as additional disadvantages of
thalmologists. Outcome studies in the 1980s that stenting with endoscopic DCR.
reported high success rates with external DCR stenting There have been three recent randomized control
largely account for its routine practice today. Early trial (RCT) studies evaluating outcomes of endoscopic
reports suggested a benefit of stenting primarily in the DCR with and without stenting. Outcomes were com-
setting of excessive bleeding, previous DCR failure, or monly measured by patient symptoms, dye testing, and
concurrent canalicular disease. Silicone tubing was pre- DCR ostium patency on endoscopy. The first RCT was
ferred for its nonantigenic properties and its ease of performed by Smirnov et al. and included 46 cases (44
stenting the common canaliculus and rhinostomy. Early patients) followed over a 6-month period and outcomes
critics, who were in the minority, challenged the routine were evaluated by symptoms and in-office dye testing to
placement of stents, even suggesting an association with assess patency.2 This was followed by a RCT by Unlu
failure. This idea has gained momentum recently, with et al., which included 38 cases (38 patients) followed
over a 100-month period and evaluated by endoscopy
and dye testing.3 The largest of these RCTs was a recent
study by Al-Qahtani that included 173 cases (173
From the Department of Otolaryngology–Head and Neck Surgery,
Johns Hopkins School of Medicine, Baltimore, Maryland, U.S.A. patients) followed over a 12-month period and evaluated
The authors have no funding, financial relationships, or conflicts by symptoms and endoscopy.4 All of these RCTs found no
of interest to disclose. significant difference between stented and nonstented
Send correspondence to Andrew Lane, MD, Department of Otolar-
yngology–Head and Neck Surgery, Johns Hopkins School of Medicine, patients who underwent endoscopic DCR. Interestingly,
601 N. Caroline St., JHOC 6th Floor, Baltimore, MD 21287. E-mail: Unlu et al. did note an increased incidence of granula-
alane3@jhmi.edu
tion at the rhinostomy site in the intubation group, but
DOI: 10.1002/lary.24111 this was not statistically significant.3 Also of note, all of
Laryngoscope 123: November 2013 Liang and Lane: Stenting in Endoscopic Dacryocystorhinostomy
2589
TABLE I.
Summary of Randomized Control Trials on Stents in Endoscopic Dacryocystorhinostomy.
Study Cases Outcomes Follow-up Stent Duration Results
Al-Qahtani, 20124 173 Symptoms, endoscopy 12 months Not specified Stented group 97% success; nonstented group 90%
in study success; no significant difference
Unlu et al., 20093 38 Endoscopy, dye test 100 months 8 weeks Stented group 90% success; nonstented group 95%
success; no significant difference
Smirnov et al., 20082 46 Symptoms, dye test 6 months 8 weeks Stented group 78% success; nonstented group 100%
success; No significant difference
the failures in the Smirnov et al. study were in the nasolacrimal duct obstruction. Based on the external
stented group.2 A summary of these RCTs is listed in Ta- DCR literature and the established practice of
ble I. ophthalmologic surgeons, silicone stents have been
The lack of a clear benefit provided by stenting is fur- favored with endoscopic DCR and remain widely uti-
ther suggested by two recent meta-analyses. Feng et al. an- lized today. However, review of the current literature
alyzed five RCTs and four cohort studies and demonstrated demonstrates comparable outcomes in endoscopic
no advantage to the use of silicone stents in primary DCR DCR whether stents are used or not. Endoscopic DCR
(either external or endonasal).5 Gu and Cao analyzed two without stenting reduces the intensity of postoperative
RCTs and concluded that there was no difference in the management and avoids the potential for stent-related
success rates in endoscopic DCR, with a relative risk of complications.
0.85 and a 95% confidence interval of 0.71 to 1.02.6
A related unresolved issue is the duration of stent LEVEL OF EVIDENCE
placement, which is highly variable among surgeons. The level of evidence for review in the endoscopic
There have been no investigations comparing DCR out- dacryocystorhinostomy literature is strong, with multi-
comes as a function of the length of time stents remain ple level 1 evidence studies (RCTs).
in place after endoscopic DCR. Furthermore, the place-
ment of stents in specific clinical settings is not well
established. Early reports suggested a benefit of stents
BIBLIOGRAPHY
in cases of revision surgery and concurrent canalicular
1. Toti A. Nuovo metodo conservatore di cura radicale delle suporazioni cro-
disease, but this has not been revisited in recent litera- niche del sacco lacrimale (dacriocistorinostomia). Clin Mod Firenze
ture. There have been no published analyses of the role 1904;10:385–389.
2. Smirnov G, Tuomilehto H, Terasvirta M, Nuutinen J, Seppa J.
of stents in endoscopic DCR in patients with concurrent Silicone tubing is not necessary after primary endoscopic dacryocystorhi-
rhinosinusitis. The technique of endoscopic DCR and nostomy: a prospective randomized study. Am J Rhinol 2008;22:
214–217.
postoperative management in specific clinical scenarios 3. Unlu HH, Gunhan K, Baser EF, Songu M. Long-term results in endoscopic
will continue to evolve, and strong level 1 evidence stud- dacryocystorhinostomy: is intubation really required? Otolaryngol Head
Neck Surg 2009;140:589–595.
ies will help illustrate optimal treatment strategies. 4. Al-Qahtani AS. Primary endoscopic dacryocystorhinostomy with or without
silicone tubing: a prospective randomized study. Am J Rhinol Allergy
2012;26:332–334.
5. Feng YF, Cai JQ, Zhang JY, Han XH. A meta-analysis of primary dacryo-
BEST PRACTICE cystorhinostomy with and without silicone intubation. Can J Ophthal-
mol 2011;46:521–527.
Endoscopic dacryocystorhinostomy is a safe and 6. Gu Z, Cao Z. Silicone intubation and endoscopic dacryocystorhinostomy:
effective surgery for treatment of epiphora due to a meta-analysis. J Otolaryngol Head Neck Surg 2010;39:710–713.
Laryngoscope 123: November 2013 Liang and Lane: Stenting in Endoscopic Dacryocystorhinostomy
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The Laryngoscope

C 2013 The American Laryngological,

Is Postoperative Stenting Necessary in Endoscopic

Jonathan Liang, MD; Andrew Lane, MD

BACKGROUND support from prospective studies and refinements in en-

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