Prognosis of concurrent endoscopic dacryocystorhinostomy and nasal septoplasty for chronic dacryocystitis with moderate nasal septum deviation

CONTEXT

The prognosis of combined septoplasty and endoscopic dacryocystorhinostomy (En-DCR) for moderate nasal septum deviation (NSD) has not yet been fully investigated.

PURPOSE

To evaluate whether septoplasty improves the prognosis of En-DCR for moderate NSD.

SETTINGS AND DESIGN

A retrospective cohort study in a real-world clinical setting.

METHODS

The postoperative FICI DCR ostium grading scores and functional and anatomical information at 1, 2, 3, and 6 months were determined for consecutive patients with chronic dacryocystitis (CD) and moderate NSD who underwent En-DCR.

STATISTICAL ANALYSIS USED

Univariate and generalized estimating equation multivariate analyses were used to compare the outcomes of the septoplasty and non-septoplasty groups.

RESULTS

En-DCR and septoplasty were concurrently performed for 32 (20.1%, 32/158) cases. The total FICI DCR ostial scores for the septoplasty and non-septoplasty groups were highest at the first (4.97 ± 0.177 vs. 4.97 ± 0.176, P > 0.05) and lowest at the sixth (4.41 ± 1.341 vs. 4.50 ± 1.355, P > 0.05) postoperative months. At the end of follow-up, the two groups showed comparable proportions of patients requiring definitive intervention for the ostium (6.3% vs. 7.1%, P > 0.05), comparabe functional success rates (87.5% vs. 90.5%, P > 0.05) and anatomical success rates (93.8% vs. 92.9%, P > 0.05). Only the non-septoplasty group experienced nasal mucosal adhesions (3.2%, 4/126).

CONCLUSIONS

In patients with CD and moderate NSD, nasal septoplasty did not impact En-DCR prognosis, but reduced the complications. Skilled surgeons should reconsider septoplasty in the absence of otolaryngological indications.

External dacryocystorhinostomy: A critical overview of the current evidence

PURPOSE

External dacryocystorhinostomy (ext-DCR) is still considered the gold standard in the treatment of distal lacrimal duct obstruction. Despite an overall high success rate, some patients do relapse after surgery and the ideal perioperative management has not been identified yet. The purpose of this study is to critically discuss the published evidence in the last five years on the medical and surgical management of external dacryocystorhinostomy. Furthermore, the drawbacks of the available literature and the perspectives in this field will be also highlighted.

METHODS

Systematic review of the literature in the last 5 years by using PubMed and Google Scholar.

RESULTS

A total of 64 articles were included. Many technical modifications and surgical refinements have been proposed but a formal comparison among the various techniques is hampered by methodological heterogeneity. The use of local anesthesia, and the perioperative adjunctive techniques to reduce the risk of restenosis are also gaining popularity but the level of evidence remains weak.

CONCLUSION

Ext-DCR offers satisfactory clinical outcomes even though there are many gray areas that need to be addressed in future high-quality studies.

Endoscopic and External Dacryocystorhinostomy: Long Term Result from a Tertiary Center in Portugal

Dacryocystorhinostomy is the gold-standard for distal lacrimal obstructions. This study aims to report the demography, clinical presentation, influence of agger nasi opening, uncinectomy and septoplasty, the use of silicone stent tubes, complications and success of endoscopic and external dacryocystorhinostomy over a period of 11 years. Retrospective review of clinical records, from January 2012 to December 2022, at a tertiary center in Portugal. A total of 249 procedures, 6 external and 243 endoscopic, were performed, including 39 revision cases. There was a female predominance (79.9%) with a mean age at diagnosis of 66.4 years. Recurrent acute dacryocystitis, reported by 33.3%, was associated with higher success (p = 0.053). Agger nasi opening, uncinectomy and septoplasty were performed in 17.7%, 6.0% and 15.3% respectively, although associated with higher success rates, no statistically significant difference was found. Minor complication rates for both external and endoscopic approach was 33.3% and 32.1% respectively. Functional and anatomical success was 100% and 83.3%, respectively, for external dacryocystorhinostomy, and 91.4% and 85.1%, respectively, for endoscopic dacryocystorhinostomy. Revision surgery was associated with a worse anatomical success (p = 0.05). Endoscopic dacryocystorhinostomy is an effective and safe alternative to the external approach. Minor procedures can increase the success rate, but multicentre studies need to be performed for a statistically significant result.

Effect of Topical 5-Fluorouracil on Lacrimal Drainage System: Histopathological Evidence From Animal Experiments and Potential Clinical Implications

PURPOSE

The purpose of this study is to investigate the histopathological changes in the lacrimal drainage system of rabbits following the application of 1% topical 5-fluorouracil (5-FU) for 4 weeks.

METHODS

Ten eyes of 10 healthy New Zealand white rabbits were subjected to topical instillation of 1% (10 mg/mL) 5-FU, 1 drop 4 times a day for 4 weeks. Rabbits underwent a detailed ocular examination including eyelids, ocular surface, punctal, peri-punctal changes, and nasolacrimal duct patency at baseline and after 4 weeks of 5-FU. The rabbits were then sacrificed, and the eyelid, conjunctiva, lacrimal gland, and the entire lacrimal drainage system were retrieved for histopathological analysis as per standard protocols.

RESULTS

Clinically demonstrable peripunctal changes and canalicular stenosis were noted in 6 (60%, 6/10) rabbits. Two of these (20%, 2/10) had additional complete regurgitation of clear fluid, indicating a nasolacrimal duct obstruction. The remaining 4 (40%, 4/10) clinically did not demonstrate lacrimal drainage changes and were patent on irrigation. The conjunctiva showed focal loss of goblet cells in several areas. Significant changes were noted in the canalicular, lacrimal sac, and the nasolacrimal duct tissues in the form of epithelial hyperplasia, subepithelial inflammation, edema, dilated and congested vessels, and fibrosis. The lacrimal gland, eyelid tissue (excluding tarsal conjunctiva), and cornea showed no significant histopathological changes.

CONCLUSIONS

Clinical and histopathological changes were noted in the lacrimal drainage system of rabbits subjected to topical 5-FU application. These findings can have potential clinical implications for patients receiving 5-FU therapy.

Efficacy and Safety of Modified Seamless Endoscopic Dacryocystorhinostomy in Patients with Chronic Dacryocystitis

Objective

To evaluate the efficacy and safety of a modified seamless endoscopic dacryocystorhinostomy (EN-DCR) with chronic dacryocystitis.

Methods

This study included 54 patients (54 eyes) with chronic dacryocystitis treated in our hospital from 2019 to 2021, including 32 patients (32 eyes) who underwent modified and 22 patients (22 eyes) who underwent routine EN-DCR. In the modified EN-DCR, the nasal cavity was filled 30 min before the operation by injection of 1 mg/ml adrenaline hydrochloride and application of ephedrine hydrochloride and nitrofurazone nasal drops. Before the operation, the lacrimal passages were rinsed with a 1 : 2 mixture of dilute methylene blue and normal saline. The “I”-shaped incision was replaced by a ^“C^“-shaped incision near the lateral bone window. In place of suturing, a gelatin sponge was applied at the confluence of the lacrimal sac and nasal mucosa. After the end of the operation, the lacrimal sac was filled with tapered expansion sponge for 1 week. In routine EN-DCR, the nasal cavity was filled with 1 mg/ml epinephrine hydrochloride, and nitrofurazone nasal drops were provided for 5 minutes after the beginning of the operation; and a “I”-shaped incision was made in the nasal mucosa, with one stitch for each anterior and posterior flap. Operation time, intraoperative bleeding, and postoperative lacrimal duct irrigation were compared, with the curative effect evaluated after a follow-up of 6 months.

Results

Operation time was significantly shorter (41.3 ± 12.1 min vs. 65.4 ± 11.6 min; χ² = 7.312, P < 0.05) and intraoperative bleeding was significantly lower (12.5 ± 5.2 ml vs. 60.3 ± 8.9 ml; χ² = 24.883, P < 0.05) in the modified group than in the routine EN-DCR group. After follow-up for 6 months, the effective cure rate was significantly higher in the modified group than in the routine group (96.9% vs. 68.2%; χ² = 6.383, P < 0.05).

Conclusion

Compared with routine EN-DCR, modified seamless EN-DCR can achieve better surgical outcomes, shorten operation time, and reduce intraoperative bleeding.

Endoscopic and external dacryocystorhinostomy: A therapeutic proposal for distal acquired lacrimal obstructions

Endoscopic (END-DCR) and external dacryocystorhinostomies (EXT-DCR) are nowadays considered the gold standard techniques for non-oncologic distal acquired lacrimal disorders (DALO). However, no unanimous consensus has been achieved on which of these surgeries is the most suitable to the individual patient. Herein, we review the available literature of the last 30 years with the aim of defining a simple and reproduceable treatment algorithm to treat DALO. A search of PubMed, EMBASE, Scopus and Cochrane databases was last performed in December 2021 to examine evidence regarding the role of END-DCR and EXT-DCR in primary and revision surgeries. If considered primary surgeries, END-DCR should be preferred in case of intranasal comorbidities, given the possibility to directly visualize and treat potential intranasal pathologies. Conversely, EXT-DCR should be chosen in case of need/preference for local anesthesia, given the major historical experience and wider surgical field that helps to resolve intra-operatory complications (e.g., bleeding) in an uncollaborative patient. In the absence of the abovementioned conditions, the decision of one or other approach should be discussed with the patient. In recurrent cases, END-DCR should be considered the treatment of choice given the major likelihood to visualize the causes of primary failure and directly resolve it. In conclusion, END-DCR should be considered the treatment of choice in revision cases or in primary ones associated with intranasal pathologies, whereas EXT-DCR should be chosen if local anesthesia is needed. In the absence of these scenarios, it is still open to debate which of these two approaches should be used.

Angioleiomyoma of the nasolacrimal duct: case report and literature review

Angioleiomyomas are benign tumors composed of smooth muscle and vascular endothelium. While infrequent in overall prevalence, they are exceptionally rare in the head and neck. Herein, we describe the case of a 65-year-old female who was found to have an angioleiomyoma of the right nasolacrimal duct. Endoscopic excision of the lesion along with medial maxillectomy and dacryocystorhinostomy was performed without complication. The current report is one of the few reported cases of angioleiomyoma of the lacrimal drainage system.