Paediatric endoscopic endonasal dacryocystorhinostomy in congenital nasolacrimal duct obstruction

Congenital Nasolacrimal Duct Obstruction - Early Diagnosis and Graded Therapeutic Approach as Key Points for Successful Management

PURPOSE

Epiphora in childhood is a frequent symptom that is typically associated with Congenital nasolacrimal duct obstruction (CNLDO). Nevertheless, inflammatory pathologies of the ocular surface as well as inside the eye, or even congenital glaucoma, must be considered in the differential diagnosis.

METHODS

A comprehensive literature review concerning CNLDO was conducted. Different therapeutic steps are categorized and summarized in order to reflect the existing staged therapeutic concept.

RESULTS

For CNLDO, a staged therapeutic concept is applicable, resulting in a cure rate of approximately 95% with only conservative or minimally invasive intervention. This concept includes five steps that encompass therapeutic interventions with increasing complexity. It includes conservative techniques, followed by probing and syringing, transcanalicular approaches without or with lacrimal intubation, and dacryocystorhinostomy which is the ultima ratio.

CONCLUSION

To preserve the topographic anatomy as much as possible, therapeutic recommendations enable stepwise and individualized management of children with CNLDO.

Long-Term outcomes of pediatric dacryocystorhinostomy in a single medical center- a retrospective study

PURPOSE

To examine the long-term success rate of pediatric endoscopic DCR surgery via telephone questionnaires, as determined by patients and their parents.

METHODS

This is a retrospective cohort study of all patients who underwent DCR surgery at the Schneider Children's Medical Center of Israel between 2010 and 2020. We performed long-term follow-ups to assess the quality of life, surgical complications, and satisfaction with surgical outcomes.

RESULTS

Our study includes seventy-nine patients with a total of 108 eyes. The mean age at the time of DCR was 7.05 years (Std = 4, min = 0.3, max = 17.7) Mean follow-up time was 5.7 years (Std =2.5, min = 1.4, max = 11.1). Tubes were inserted for a mean of 129 days (Std = 101). Fifty-seven patients (72%) declared they had no complications after surgery, three patients (4%) reported pain after surgery, and 14 patients (17.7%) reported tube extrusion, which occurred 7-21 days after surgery. Forty-four patients (56%) reported no recurrence of symptoms, 29 (37%) complained of mild epiphora, and 18 (23%) reported some ocular discharge. Sixty-eight patients (86%) stated that they did not undergo additional surgery, while the remaining 11 (14%) reported undergoing a revision operation for symptom control. Satisfaction rate (1-7) mean score reported was 6.15 (Std = 1.6). Sixty-two (78%) reported improved quality of life, while 17 (22%) reported no improvement. Our questionnaire results have been compared with the TEARS scores with similar findings.

CONCLUSION

Regardless of its etiology, endoscopic DCR surgery in the pediatric population is safe and efficient, with a high long-term patient satisfaction rate, as reported via a telephone questionnaire.

Preferred Practice Patterns of Congenital Nasolacrimal Duct Obstruction in Jordan

Purpose

Congenital nasolacrimal duct obstruction (CNLDO) is fairly common in newborns. The main aim of this cross-sectional study is to assess the preferred practice patterns of CNLDO among ophthalmologists in Jordan.

Methods

This cross-sectional study was conducted across all ophthalmological practices in Jordan, using convenience sampling. An online questionnaire, designed through Google Forms, was distributed through social media. The survey contained four domains: baseline characteristics of participants and the diagnosis (7 items), medical management (3 items), and surgical management (11 items) of CNLDO. Descriptive statistics were conducted using SPSS (IBM SPSS Corp, SPSS Statistics ver. 26, USA).

Results

Eighty-three physicians responded to the survey, with an average age of 40.6 ± 8.6. More than half of the participants (53.0%, n = 44) were general ophthalmologists. Only 37.3% of our sample (n = 31) regularly evaluated the refraction of a child presenting with epiphora suggestive of CNLDO. Criggler's nasolacrimal duct massage was recommended by 62.7% of respondents (n = 52) for up to 12 months. In addition, 72.3% of respondents (n = 60) recommended 12 months as the minimum age for primary probing of CNLDO. Silicon intubation was considered for primary probing starting at 24 months by 31.3% of ophthalmologists (n = 20). Monocanalicular stent was preferred by 42.2% of respondents (n = 27) while 31.3% (n = 20) preferred bicanalicular stent.

Conclusion

There is considerable variability in preferred practice patterns regarding the diagnosis and management of CNLDO in Jordan. Our findings highlight the gaps in optimum practices which need to be addressed for better management.

Surgical Site Reassessment: An Important Step in Improving Clinical Outcomes Following Pediatric Endoscopic Dacryocystorhinostomy

PURPOSE

To report the authors' experience with endoscopic unpowered dacryocystorhinostomy in the treatment of pediatric nasolacrimal duct obstruction, and to evaluate whether surgical site reassessment (after the appropriate healing period) affects clinical outcomes.

METHODS

This retrospective study included 47 children aged between 1.5 and 17.0 years (mean age: 6.9 years) who underwent endoscopic unpowered dacryocystorhinostomy between 2014 and 2019 at one tertiary care hospital. Twenty-six patients required unilateral and 21 required bilateral endoscopic dacryocystorhinostomy. The main outcome measures were duct patency on lacrimal irrigation ("anatomical success") and resolution of symptoms ("clinical success") over 6 months of postoperative follow-up.

RESULTS

Sixty-eight dacryocystorhinostomy procedures were performed. Surgical site reassessment during tube removal was performed in 52 of 68 cases. Five cases (9.6%) required treatment of local pathologies, only after which was symptomatic relief achieved. Overall anatomical success was observed in 49 (94.2%) of the 52 cases in which nasal endoscopy was performed, including the 5 cases treated during reevaluation. Clinical success was observed in 63 (92.6%) cases.

CONCLUSIONS

Pediatric endoscopic dacryocystorhinostomy is an effective surgical procedure used to correct nasolacrimal system obstruction resistant to conservative measures. The unpowered endoscopic dacryocystorhinostomy technique is practical and safe in the pediatric population. Surgical site reassessment allows treating local pathologies threatening ostium patency and increases clinical success rates. [J Pediatr Ophthalmol Strabismus. 2021;58(3):168-173.].

Outcomes of primary powered endoscopic dacryocystorhinostomy in syndromic congenital nasolacrimal duct obstruction

Purpose: To evaluate the outcomes of powered endoscopic dacryocystorhinostomy (DCR) in syndromic individuals with congenital nasolacrimal duct obstruction (CNLDO).Methods: A retrospective multicenter case series of patients who required a primary powered endoscopic DCR for refractory CNLDO associated with syndromes or congenital craniofacial abnormalities was performed. A minimum follow-up of more than 6 months was considered for final analysis. Main outcome measures were anatomical and functional success at the last follow up.Results: Twenty primary powered endoscopic DCR's were performed in 12 patients (7 males, 5 females) with syndromic anomalies. The mean age at the time of surgery was 7.6 years (range: 2-22 years). The associated systemic anomalies were Down syndrome (42%, 5/12), ectrodactyly-ectodermal dysplasia-clefting (EEC) syndrome (17%, 2/12), gross craniofacial dysgenesis (25%, 3/12) Tessier cleft type 3 (8%, 1/12) and velocardiacfacial syndrome (8%, 1/12). Proximal system agenesis of the upper or lower canaliculus was present in 42% of patients (5 patients, 9 eyes). Adjunctive treatment in the form of Mitomycin C and/or intubation was performed in 55% (11/20) eyes. At a mean postoperative follow-up of 20 months, successful outcomes were noted in 95% of the eyes (19/20). The one eye with an anatomical failure was secondary to a complete cicatricial closure of the ostium and was successfully treated subsequently with a revision endoscopic DCR.Conclusion: Primary powered endoscopic DCR has good outcomes in patients with a CNLDO associated with craniofacial syndromes.

Endoscopic dacryocystorhinostomy to treat congenital nasolacrimal canal dysplasia: a retrospective analysis in 40 children

BACKGROUND

To investigate the therapeutic effectiveness and safety of endoscopic dacryocystorhinostomy (EN-DCR) to treat congenital nasolacrimal canal dysplasia (CNCD).

METHODS

Forty children (50 eyes) with congenital nasolacrimal duct obstruction (CNLDO) and lacrimal bony dysplasia, including 8 children with bony atresia (10 eyes) and 32 with bony stenosis (40 eyes), were recruited in this retrospective study. Standardized EN-DCR was performed in all cases. The postoperative observations included relief of symptoms, fluorescein dye disappearance test (FDDT), syringing of lacrimal passages and anastomotic patency under nasal endoscopy. Patients were followed up for 8-18 months.

RESULTS

Standardized EN-DCR surgery had a success (cure and improvement) rate of 100%, including a cure rate of 82% and an improvement rate of 18%. The cure rate among 40 cases of bony nasolacrimal duct stenosis was 82.5%, while that of 10 cases of bony nasolacrimal duct atresia was 80%. Statistical analysis showed that nether the receipt of other treatments before surgery nor the type of bony nasolacrimal duct dysplasia affected the cure rate. No significant complications were observed during postoperative follow-up except for four cases (4 eyes) that suffered middle turbinate and nasal mucosal adhesion and two cases with sinusitis.

CONCLUSIONS

CNCD is a type of CNLDO that does not respond to conservative and conventional treatment. EN-DCR represents a safe and effective treatment for children with CNCD. In addition, the combination of EN-DCR with lacrimal CT scanning provides advantages over traditional lacrimal surgery in that it has a high success rate with a low incidence of complications.

Pediatric endonasal dacryocystorhinostomy and operative standardization

OBJECTIVE

The objective of this study was to confirm that the standardized endonasal dacryocystorhinostomy (DCR) technique routinely performed in adults can be used in children.

MATERIALS AND METHODS

A consecutive series of children undergoing endonasal DCR between 2003 and 2017 was analysed. The surgical procedure consisted of: preoperative CT scan, anatomical localization of the ideal surgical zone, access to the nasal cavity via an optional planned enlargement, creation of a mucoperiosteal flap, osteotomy with rongeurs and equatorial resection of the medial wall of the lacrimal sac. This pediatric series was compared to a series of adult patients operated according to the same standardized technique.

RESULTS

A total of 20 DCRs (17 patients, with a mean age of 8 years (range: 4-16)) were included. Anatomical localization was effective in 100% of cases without the need for transillumination. With a mean follow-up of 4 years, the success rate was 95%, and no major complications were observed. Comparison with the same surgical technique in adults revealed similar results.

DISCUSSION

Our experience suggests that standardized endonasal DCR can be adapted to the nasal cavities of children. Anatomical localization is effective. The physiologically narrow nasal cavity does not constitute a major obstacle with the use of slightly smaller instruments. The results and complications are similar to those observed in adults.

CONCLUSION

The same standardized endoscopic endonasal DCR surgical technique can be used in adults and children with a similar good success rate.

Outcomes in pediatric powered endoscopic dacryocystorhinostomy: a single-center experience

PURPOSE

The purpose of the article is to report the outcomes of powered endoscopic dacryocystorhinostomy (PEnDCR) in pediatric patients.

METHODS

A single-center, single surgeon, retrospective, interventional, non-comparative case series was performed on all pediatric patients who underwent PEnDCR between July 2014 and July 2017. Patients with associated congenital anomalies like single punctum agenesis or lacrimal fistula were excluded. Surgery was performed as per standard protocols published earlier. Data collected include demographics, clinical presentations, past interventions, indications for the surgery, intraoperative and postoperative complications, postoperative ostium characteristics, and anatomical and functional success.

RESULTS

Ninety-one eyes of 83 children underwent PEnDCR during the study period. Mean age was 8.32 years and epiphora was the most common presentation (81%, 74/91). The most common indication for PEnDCR was persistent congenital nasolacrimal duct obstruction refractory to earlier interventions of probing or intubation. Postoperative ostium assessment at 4 weeks showed a well-healed ostium with a dynamic internal common opening in 86.8% of the eyes. Edge granulomas of the ostium were the most common abnormal finding in the postoperative period (9.8%, 9/91) and all except one could be managed conservatively. At 6 months follow-up, five eyes showed anatomical failure and additional two eyes showeXd functional failure. Two of anatomical failure group and one of functional failure underwent a second intervention. The final anatomical and functional success were noted in 96.7% (88/91) and 95.6% (87/91), respectively.

CONCLUSIONS

This study shows that PEnDCR is a safe surgery for pediatric populations with a high success rate of beyond 95%.

Results of endonasal dacryocystorhinostomy in pediatric patients

We conducted a prospective interventional study to evaluate the role of endoscopic endonasal dacryocystorhinostomy in children. Our study population was made up of 20 patients-18 boys and 2 girls, aged 2 to 12 years (mean: 5.3)-who presented with signs and symptoms suggestive of nasolacrimal duct blockage that was refractory to conventional medical treatment. In all cases, blockage was confirmed by nasolacrimal duct syringing that demonstrated regurgitation from the opposite punctum. The primary outcome measures for success were resolution of symptoms and duct patency on lacrimal irrigation. At 6 months, 17 patients (85%) experienced complete symptomatic relief, 1 (5%) had partial relief, and 2 (10%) reported no relief. Moreover, the nasolacrimal duct was patent in 17 patients, partially patent in 2, and blocked in 1. We conclude that endoscopic endonasal dacryocystorhinostomy is a safe and effective procedure in children with nasolacrimal duct blockage when medical therapy and probing have been unsuccessful.

Limited Approach in Endoscopic Dacryocystorhinostomy of Pediatrics

Background:

Limited spatial nasal cavity in children, make pediatric dacryocystorhinostomy (DCR) a difficult surgical procedure. We apply a limited approach to pediatric DCR and follow them for their consequences.

Materials and Methods:

An experimental study was done in pediatric DCR with limited approach (age < 14-year-old). After written consent, with general anesthesia, with nasal endoscopic surgery, lacrimal bone is exposed and extruded. In contrast with routine procedure, ascending process of maxillary sinus reserve; and marsupialization and wide exposure to lacrimal sac was done only by lacrimal bone defect; and cannulation preserve with temporary silicone tube.

Results:

Between 2006 and 2012, 16 pediatric DCR was done by a unique surgeon in 2 otorhinolaryngologic centers. Before surgery 14 (87.5%) had epiphora, 3 (18.8%) had eye discharge, and 3 (18.8%) had eye sticky eye. Two (12.5%) had history of facial trauma, and 10 (62.5%) had congenital nasolacrimal duct insufficiency. Five (31.3%) had history of dacryocystitis. Patients were followed for 17 ± 9 months. Silicone tube stayed for 4 ± 2.5 months. We could follow 7 patients and minimal improvement or need to revision surgery considered as technical failure. After surgery, 3 patients had no epiphora with complete improvement; 2 had very good improvement with confidence of the patients and parents; 2 cases had unsuccessful surgery in our patients, who needs to another surgery. One of them had several probing and surgery before our endoscopic DCR.

Conclusions:

Limited approach in endoscopic DCR of pediatrics can be done in noncomplicated patients, with minimal manipulation, more confidence, and acceptable results.

Primary nonendoscopic endonasal versus external dacryocystorhinostomy in nasolacrimal duct obstruction in children

PURPOSE

The aim is to compare the outcome of nonendoscopic endonasal dacryocystorhinostomy (NEN DCR) with external DCR (EXT-DCR) in the treatment of nasolacrimal duct obstruction (NLDO) in children.

METHODS

A retrospective, comparative chart analysis of all consecutive children <16 years after EXT-DCR or NEN-DCR between June 2012 and February 2016.

RESULTS

Seventy-one children (79 eyes) underwent DCR in the study, of which 37 children (40 eyes) underwent EXT-DCR and 34 (39 eyes) NEN-DCR. Mean age of both groups (8.7 vs. 7.7 years) was comparable. Etiologically, persistent congenital NLDO was the most common indication (50% vs. 72%), followed by acquired and secondary NLDO. Mean duration was shorter for NEN-DCR (47 vs. 37 min; P = 0.0021). Mitomycin C 0.04% was used more often in NEN-DCR (10% vs. 56.41%). Success after primary EXT-DCR was 100% as compared to 75% for primary NEN-DCR at median follow-up of 12 and 16 months respectively. At revision, the main cause of failure was granuloma (60%). After revision, all eyes were symptom-free at a median follow-up of 9.5 months.

CONCLUSION

Primary NEN-DCR has a poorer outcome than EXT-DCR in the treatment of NLDO in children and is more likely to need a revision procedure.

Pediatric endonasal dacryocystorhinostomy: A multicenter series of 116 cases

We report our experience with pediatric endonasal dacryocystorhinostomy (DCR). Multicenter, retrospective, noncomparative study. Cases of pediatric endonasal DCR during 2006-2011 were included from six oculoplastic units. Patients over the age of 16 years were excluded. The outcomes of pediatric endonasal DCR are presented. Indication for surgery, demographics, previous interventions, intraoperative or postoperative complications, follow-up duration, and success rate (defined as significant improvement of epiphora) were evaluated. In total, 116 endonasal DCRs were performed for 103 patients. The mean follow-up period was 8 months (range 3 months to 4 years), with 1 patient lost to follow-up. There were 48 males (mean age 5 years and 9 months) and 50 females (range of 4 months to 16 years), with a total of 98 cases of congenital nasolacrimal duct obstruction (CNLDO) (84.5%) and 18 cases of acquired nasolacrimal duct obstruction (ANLDO) (15.5%). Previous interventions included probing 75.9% (88/116), massaging 43.1% (50/116), and intubation 39.7% (46/116). There were no intraoperative complications. There was one case of postoperative pyogenic granuloma. There were no cases of postoperative infection and postoperative hemorrhage. Ninety percent of procedures were considered successful. Complete symptom resolution was observed in 78% (90/116), significant improvement in 12% (14/116), partial improvement in 2% (2/116), and no improvement in 8% (9/116). In our series, we demonstrated that endonasal DCR is a safe operation and has an overall success rate of 90% for pediatric NLDO.

Primary endoscopic endonasal dacryocystorhinostomy for pediatric nasolacrimal duct obstruction: A systematic review

BACKGROUND

Epiphora secondary to nasolacrimal duct obstruction is common in the pediatric age group. The mainstay treatment among these young patients has been conservative. Once epiphora becomes recalcitrant, however, an external or an endonasal approach is considered.

OBJECTIVE

Endoscopic dacryocystorhinostomy (EDCR) entails creating an opening from the lacrimal sac directly into the nasal cavity to counteract nasolacrimal duct obstruction. We reviewed the literature to determine the effectiveness and the safety of primary EDCR to treat pediatric nasolacrimal duct obstruction.

METHOD

A literature search was conducted by using a number of medical literature data bases for the period from 1995 to 2016. The following search words were used either individually or in combination: epiphora, nasolacrimal duct obstruction, endoscopic dacryocystorhinostomy, powered endoscopic dacryocystorhinostomy, laser-assisted endoscopic dacryocystorhinostomy, children, congenital, acquired, presaccal obstruction, and postsaccal obstruction. In addition, a few articles were identified based on the experience and information provided by the senior authors (B.A., S.H., D.Y.W.). The search was conducted over a 1-month period (January 2017). Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and the Cochrane Handbook for Systematic Reviews of Interventions were followed when possible.

RESULTS

Only 10 original clinical research articles were selected based on our objectives and selection criteria. All the studies were at level of evidence III: nonrandomized and noncomparative prospective or retrospective case series. Altogether, 313 patients with ages that ranged from 4 months to 18 years were enrolled. A total of 352 EDCRs were performed that were either single sided (n = 313) or bilateral (n = 39). The most common causes of the obstruction were classified as congenital, followed by idiopathic, and then acquired. A meta-analysis was not performed because of the heterogeneity of the patient groups and variability of the methods used to measure outcomes.

CONCLUSION

Analysis of the results indicated that EDCR was an effective, safe therapeutic approach to treating nasolacrimal duct obstruction in pediatric patients. It should be considered as an alternative procedure to external dacryocystorhinostomy after a failed conservative treatment.

Comparing outcomes of pediatric and adult external dacryocystorhinostomy in Nepal: Is age a prognostic factor?

We determine whether age is a prognostic factor for surgical outcomes of external dacryocystorhinostomy (Ex-DCR). This retrospective cohort study conducted at Tilganga Institute of Ophthalmology (Kathmandu, Nepal) compared pediatric Ex-DCR procedures (age ≤ 15 years) to adult Ex-DCR procedures (age > 15 years) and was performed between January 2013 and December 2013, with a minimum follow-up period of 6 months. Primary outcome measure was rate of success, defined as complete resolution of subjective symptom(s) of epiphora (subjective success), combined with patent lacrimal passage on syringing (anatomical success) at last follow-up visit. Other outcome measures included clinical presentation, diagnosis, intraoperative complications and post-operative complications. In total, 154 Ex-DCR procedures were included, with an age range of 8 months to 81 years (mean age 36.4 ± 21.0 years). In all, 38 pediatric Ex-DCR procedures were compared to 116 adult procedures. Success rates were 97% in the pediatric group and 95% in the adult group, with no clinically or statistically significant difference in success rate or complication rate between groups (p > 0.05). Our study yielded high success rates of Ex-DCR in both pediatric and adult age groups suggesting that Ex-DCR remains an optimal treatment choice for all age groups. With no difference in surgical outcomes between pediatric and adult patients, including complication rate, we conclude that age is not a prognostic factor for Ex-DCR failure. We do not recommend adjuvant therapy for pediatric patients.

[Minimally invasive diagnostics and therapy of congenital nasolacrimal duct obstruction]

BACKGROUND

One of the most frequent issues in pediatric ophthalmology concerns congenital nasolacrimal duct obstruction (CNLDO). Typically, irritation of the medial eyelid angle occurs during the first days of life and later increased epiphora appears as tear production is still reduced in young infants. In the case of intrasaccal or postsaccal nasolacrimal duct stenosis, a chronic dacryocystitis develops.

METHODS

Modern minimally invasive diagnostics and therapy of CNLDO are reviewed by means of a search of the recent literature and reflection of own experiences.

RESULTS

An early diagnosis of CNLDO is desirable. If conservative therapeutic approaches fail, invasive procedures have to be considered. Probing and high pressure syringing of the nasolacrimal ducts remains the therapy of choice. Further therapy options, such as balloon dacryoplasty and dacryoendoscopy are also available. Additionally, due to improvement of the surgical techniques a minimally invasive approach is possible even for dacryocystorhinostomy; nevertheless, this procedure should be considered only as a last resort.

CONCLUSION

Precise classification of CNLDO and knowledge about the possible treatment options are important. Lacrimal surgery in childhood is dominated by transcanalicular procedures. Advanced minimally invasive techniques, such as dacryoendoscopy or modern autostable intubation sets have to be emphasized. All therapeutic interventions can be summarized using a staged therapeutic concept, which should be used individually and patient-centered.

Endoscopic dacryocystorhinostomy: long-term experience and outcomes

PURPOSE

To report our experience in endoscopic dacryocystorhinostomy in treating nasolacrimal duct obstruction over a 14-year period.

METHODS

Retrospective case series carried out over a 14-year period from 1999 to 2014. A total of 624 endoscopic dacryocystorhinostomy procedures were performed in 442 patients who were diagnosed with persistent epiphora.

PARTICIPANTS

In total, 624 procedures in a total of 442 patients (<18 yo: 36 and >18 yo: 406) were included. Patients' records were assessed for demographics, intra- and postoperative complications, outcome and follow-up.

RESULTS

In total, 442 patients underwent an endoscopic dacryocystorhinostomy. There were 342 females (77.3%) and 100 males with a mean age of 50.2 years. All patients presented with epiphora: 33 congenital (7.5%), 357 acquired (80.7%) and 52 functional cases (11.8%). The adult dacryocystorhinostomy (n = 577) had an anatomical success of 90.1%. Children's group (<18 yo) n = 36 with a total of 47 procedures and an anatomical success of 91.5%. Functional cases (all adults - n = 52) showed a 91% benefit after operation. In 624 DCRs, we found a complication rate of 3.2%.

CONCLUSION

Endoscopic dacryocystorhinostomy offers good success rates with a safety profile and efficacy equivalent to the traditional external approach is an effective treatment with good outcome results in adults and children with persistent or functional epiphora.

Comprehensive review on endonasal endoscopic sinus surgery

Endonasal endoscopic sinus surgery is the standard procedure for surgery of most paranasal sinus diseases. Appropriate frame conditions provided, the respective procedures are safe and successful. These prerequisites encompass appropriate technical equipment, anatomical oriented surgical technique, proper patient selection, and individually adapted extent of surgery. The range of endonasal sinus operations has dramatically increased during the last 20 years and reaches from partial uncinectomy to pansinus surgery with extended surgery of the frontal (Draf type III), maxillary (grade 3-4, medial maxillectomy, prelacrimal approach) and sphenoid sinus. In addition there are operations outside and beyond the paranasal sinuses. The development of surgical technique is still constantly evolving. This article gives a comprehensive review on the most recent state of the art in endoscopic sinus surgery according to the literature with the following aspects: principles and fundamentals, surgical techniques, indications, outcome, postoperative care, nasal packing and stents, technical equipment.

The outcomes of endoscopic dacryocystorhinostomy in children: A systematic review

OBJECTIVES

To systematically review and discuss the published results about the application of endoscopic dacryocystorhinostomy in treating children with nasolacrimal duct obstruction.

METHODS

In October 2014 an appropriate string was run on PubMed to retrieve all relevant articles. A cross-check was performed by two of the authors on abstracts and full-text articles found using the selected inclusion and exclusion criteria. A non-comparative meta-analysis concerning the procedures' rate of success and failure was performed.

RESULTS

Fourteen studies were identified comprising a total of 346 subjects affected by nasolacrimal duct obstruction (unilateral or bilateral). Overall there were 393 surgical procedures, all performed with an exclusive endoscopic approach. The average length of follow-up was reported in twelve studies resulting 15.2 months and ranging from 3 to 27.1 months. On the basis of our statistical analysis the mean (95% CI) rate of failure was 0.14 (0.09-0.21). The mean (95% CI) rate of success resulted 0.87 (0.80-0.91).

CONCLUSIONS

Although in young patients the nasal anatomy is more complex and narrow than in adults our review showed as the endoscopic dacryocystorhinostomy allows similar results in terms of success compared to the external approach.

Pediatric Endoscopic DCR: The Outcome in 50 Patients

Congenital nasolacrimal duct obstruction is a very common condition affecting 20 % of infants. Pediatric DCR is indicated when there is no response to previous therapy like probing, or is associated with recurrent dacryocystitis. This is a retrospective case series study of 50 pediatric patients who underwent endoscopic DCR in two centers, Jordan University Hospital/Jordan, and Mosul teaching and private hospitals/Iraq. The age ranged from 3 to 12 years with a mean of 6.2 years. The overall success rate of endoscopic DCR was 90 %, and failed cases were mainly due to presaccal obstruction. No major complications were reported, but minor complications occurred in about 60 % of cases. As a conclusion, endoscopic DCR is a safe and effective procedure in pediatric age group.

Pediatric endonasal endoscopic dacryocystorhinostomy

OBJECTIVE

Nasolacrimal duct obstruction is a relatively common problem among children. Although spontaneous resolution is possible and various conservative treatment options are available, dacryocystorhinostomy is recommended for persistent epiphora. The aim of this study was to report our experience of performing 83 procedures of pediatric endoscopic dacryocystorhinostomy.

METHODS

This retrospective study included 71 children who underwent endonasal endoscopic dacryocystorhinostomy between 2000 and 2011. Thirteen of these children had bilateral procedures. The diagnosis of nasolacrimal duct obstruction was based on the presence of eye discharge, the patient's history obtained from his or her parents and the results of testing the patency of the nasolacrimal canal by irrigating the lacrimal sac. The procedure was considered to be successful if the patient's eye discharge was completely resolved and the dacryocystorhinostomy ostium was patent at end of the postoperative first year.

RESULTS

Eighty-three dacrycystorhinostomy procedures were performed in 71 children. There were 35 (49.3%) male and 36 (50.7%) female patients. The age of the patients ranged between 11 months and 14 years, with a mean of 8.9 years. The mean follow-up period was 27.1 months (range of 14-84 months). The overall success rate for primary endoscopic dacryocystorhinostomy was 92.7%. No major complications were encountered in any of the surgical procedures.

CONCLUSION

Pediatric endonasal endoscopic dacryocystorhinostomy is a safe and effective procedure to correct nasolacrimal system obstruction in cases that are unresponsive to conservative treatments. It has a high success rate and a low incidence of complications.

Endonasal dacryocystorhinostomy in a pediatric patient with ectrodactyly-ectodermal dysplasia after failure of external dacryocystorhinostomy and as first procedure

A 9-year-old patient affected by ectrodactyly-ectodermal dysplasia was referred to our clinic complaining of epiphora in both eyes. She had previous external dacryocystorhinostomy in her left eye. Ophthalmic examination revealed absence of the superior tear ducts and discharge in both eyes. Lacrimal irrigation through the inferior canaliculi revealed nasolacrimal duct obstruction on both sides. A bilateral endo-dacryocystorhinostomy was performed as a revision procedure in the left eye and as first procedure in the right eye. A monocanalicular silicone stent through the inferior tear duct was introduced on both sides at the end of the surgery. Follow up was 8 and 5 months for the left and the right eye, respectively. Epiphora was absent, and lacrimal irrigation showed a patent osteum at last follow-up. This case suggests that endo-dacryocystorhinostomy seems to be a safe and effective procedure, both as revision and as first procedure, even in children with ectrodactyly-ectodermal dysplasia.

Pediatric endocanalicular diode laser dacryocystorhinostomy: results of a minimally invasive surgical technique

The purpose of this study was to evaluate the effectiveness of endocanalicular diode laser dacryocystorhinostomy (DCR), which is a minimally invasive surgical technique, in pediatric patients with congenital nasolacrimal duct obstruction (NLDO). A retrospective study was carried out on patients treated between October 2008 and August 2009 for nasolacrimal duct obstruction with an endocanalicular diode laser procedure. Patients diagnosed as having nasolacrimal duct obstruction were included in this study and an endocanalicular diode laser procedure was performed. The main outcome measures were patients' previous treatments, clinical presentation, operative and postoperative complications, postoperative follow-up and resolution of epiphora. Eighteen children (10 girls, 8 boys) with a mean age of 6.11 ± 2.08 years (range, 4-10) underwent 20 endocanalicular laser DCR operations for congenital NLDO. In all eyes (100%), there was a history of epiphora and chronic dacryocystitis; two (10%) presented with acute dacryocystitis. Previous procedures included probing and irrigation of all eyes (100%) and silicone tube intubation in nine eyes (45%). None of the patients underwent any previous DCR operations. During a mean postoperative follow-up period of 20.50 ± 3.24 months (range, 14-24 months), the anatomical success rate (patency of ostium on nasal endoscopy) was 100%, and the clinical success rate (resolution of epiphora) was 85%. Endocanalicular diode laser DCR is an effective treatment modality for pediatric patients with congenital NLDO that compares favorably with the reported success rates of external and endoscopic endonasal DCR. Moreover, it has an added advantage of shorter operative time, less morbidity and avoidance of overnight admission.

Management of congenital nasolacrimal duct obstruction

Our review aims to provide an update of management protocols for congenital nasolacrimal duct obstruction (CNDO). Although early probing performed before the age of 1 year was traditionally recommended, many reports have since confirmed high frequencies of spontaneous resolution during the first year of life. Accordingly, a 'wait-and-see' approach, combined with conservative therapies, is judged to be the best option in infants aged<1 year. By contrast, persistent obstruction beyond 1 year of age warrants probing as a first-line interventional therapy. However, the optimal timing for probing remains controversial. Although there remains a high possibility of spontaneous resolution after the first year of age, this must be balanced against the decrease in success rates for probing that accompanies advancing age. If conservative management fails, persistent CNDO beyond 1 year of age should be managed either by further observation or by primary probing according to the severity of symptoms. In patients in whom probing fails, advanced treatment such as balloon catheter dilation, silicone tube intubation or dacryocystorhinostomy may be considered.

Primary pediatric endonasal dacryocystorhinostomy--a review of 58 procedures

OBJECTIVES

The objectives of this study are to report the outcomes of pediatric patients with lacrimal system obstruction who underwent primary endoscopic dacryocystorhinostomy (EDCR).

STUDY DESIGN

The authors conducted a retrospective noncomparative case series.

METHODS

The operative and postoperative data have been collected in 58 children aged between 3 months and 13 years (mean 4.1 years). The total of 58 primary EDCRs has been performed by two surgeons using a standardized surgical technique. The EDCRs were performed 52 times on one eye, 6 times on both eyes (3 times simultaneously, 3 times at the separate sitting with an interval of 4-6 months). The follow-up evaluations include taking history, clinical examinations including a fluorescein disappearance test.

RESULTS

The follow-up interval ranged from 12 to 36 months (mean 17 months, median 15 months). The success rate was 51/58 (87.9%) in all 58 EDCRs. The success rate was 47/51 (92.2%) in the group of postsaccal obstructions, 3/5 (60.0%) in the group of postsaccal and suprasaccal obstrutcions and 1/2 (50.0%) in presaccal obstructions. The procedures were successful in all eight children aged under 1 year old (100%) and in 14 of 15 children between 1 and 2 years old (93.3%). The silicone intubation was used in 54 EDCRs.

CONCLUSIONS

The endoscopic DCR is a safe and effective procedure for most children with the success rate comparable to that achieved in the external DCR and in adults. The success rate of the postsaccal obstructions is significantly higher than in presaccal or combined pre- and postsaccal obstructions.

A national survey of the management of congenital nasolacrimal duct obstruction in the United kingdom

PURPOSE

To survey national variation in the management of congenital nasolacrimal duct obstruction, particularly the timing of intervention and the use of nasolacrimal intubation, nasal endoscopy, and assistance from an ear, nose, and throat surgeon at different stages of management.

METHODS

A telephone survey was conducted of 100 ophthalmologists in the United Kingdom who were involved in the management of congenital nasolacrimal duct obstruction. A sequential management protocol was established for each, including the nature of procedures, their timing, and the use of nasal endoscopy and ear, nose, and throat surgeons.

RESULTS

Of those surveyed, 49% use the dye disappearance test for diagnosis. Eighty-four percent suggest lacrimal sac massage to parents. No surveyed ophthalmologists perform "office" probing or balloon dilation. Seventy-four percent perform initial probing after 1 year, with 25% using nasal endoscopy. If symptoms persist, 64.5% (60 of 93) repeat the probing, whereas 35.5% (33 of 93) intubate the lacrimal system. The use of nasal endoscopy increases to 50.5% (47 of 93). By the third intervention, 77.6% (45 of 58) perform lacrimal intubation, with 72.4% (42 of 58) using nasal endoscopy. All opt for dacryocystorhinostomy as the fourth intervention and 28.3% (13 of 46) perform this procedure themselves, whereas 71.7% (33 of 46) refer the patient to another practitioner. In total, 65% (65 of 100) use tubes at some stage of management, 58% (58 of 100) make some use of nasal endoscopy, and 33% (33 of 100) involve ear, nose, and throat surgeons.

CONCLUSION

Based on the results of this survey, huge variation exists in the management of congenital nasolacrimal duct obstruction in the United Kingdom. Most ophthalmologists intervene soon after patients reach 1 year of age. The rate of nasal endoscopy increases with successive interventions, especially to aid with nasal intubation, either alone or with the assistance of ear, nose, and throat surgeons.

Pediatric endonasal endoscopic dacryocystorhinostomy

Dacryocystorhinostomy (DCR) in children is indicated in cases of common congenital nasolacrimal duct obstruction (CNLDO) unresponsive to medical therapy, probing or intubation. The purpose of this manuscript is to evaluate the effectiveness of endonasal endoscopic pediatric DCR. The authors present a series of eight children (seven boys and one girl) who underwent a pediatric endonasal DCR between September 2007 and December 2008. The mean age was: 4.3 years (range: 8 months to 9 years old). Three children had a craniofacial abnormality. There were ten primary DCRs and one revision DCR. In nine cases, the indication was a pure primary low mechanical obstruction persistent after one or more probings. In the 10th case there was also a stenosis of the inferior canaliculus diagnosed during the DCR. The revision DCR was indicated because of the closure of the stoma created 3 years ago. A silicone intubation was put in place only in two cases: in case of a stenosis of the inferior canaliculus (3 months) and the other in case of revision DCR (1 month). The follow-up for primary DCRs was 10.5 months (range: 6-15) and for revision surgery 6 months (after the retrieve of the stent). In primary DCRs, there was a complete resolution of symptoms in nine out of 10 cases. The 10th case experienced a transient slight epiphora during a viral rhinitis. In case of revision DCR, the child was free of symptoms. In conclusion pediatric DCR is a very effective and safe procedure for the treatment of a low mechanical obstruction of the lacrimal pathway in children unresponsive to previous probings. Stenosis of the inferior canaliculus can give some slight intermittent epiphora despite a wide and patent stoma. Moreover craniofacial abnormalities are more common in children than in adults undergoing a DCR.

Nonlaser endoscopic endonasal dacryocystorhinostomy with adjunctive mitomycin C in children

PURPOSE

To determine the outcome and safety of pediatric endonasal dacryocystorhinostomy with the use of adjunctive mitomycin C.

METHODS

A prospective, nonrandomized and noncomparative interventional case series study was performed in 71 consecutive procedures. Sixty patients 16 years of age and younger underwent nonlaser endonasal dacryocystorhinostomy with the use of adjunctive mitomycin C. Eleven patients had a simultaneous bilateral procedure performed. All patients underwent a standardized procedure, with an endonasal approach to the lacrimal sac and surgical removal of nasal mucosa, lacrimal bone, and a fragment of the frontal process of the maxilla. The medial wall of the lacrimal sac was completely removed and a neurosurgical cottonoid soaked in mitomycin C at 0.5 mg/ml placed at the osteotomy site for 5 minutes. All patients underwent bicanalicular or monocanalicular silicone intubation.

RESULTS

The main outcome measures were the resolution of epiphora, lacrimal discharge, and patency of the ostium confirmed either by endoscopic visualization and/or irrigation at 6 months or a normal dye disappearance test. Thirteen patients' (18%) final evaluation was via telephone survey. The mean follow-up was 12.3 months. Nonlaser endonasal dacryocystorhinostomy with adjunctive mitomycin C was successful in 67 cases (94.4%). African descent was strongly associated with a higher rate of obstruction (p < 0.001). Infection at the time of surgery (p = 0.051) and less than 3 months intubation (p = 0.059) were also borderline significant. Previous trauma, gender, age, and side operated had no influence on the final outcome. No significant complications were encountered.

CONCLUSIONS

Nonlaser endonasal dacryocystorhinostomy with mitomycin C is a safe and successful procedure for the treatment of congenital nasolacrimal duct obstruction in children. It has the advantage of leaving no scar and of preserving the medial canthal structures. It can be successfully performed as a simultaneous bilateral procedure.