Endonasal dacryocystorhinostomy with mucosal flaps

Clinical outcomes of endoscopic dacryocystorhinostomy without preserving mucosal flaps in combination with silicone stent and steroid-soaked gelfoam

PURPOSE

To report clinical outcomes of endoscopic dacryocystorhinostomy (En-DCR) combined with stenting and without preserving the nasal and lacrimal mucosal flaps.

METHODS

In this prospective interventional case series, patients with primary acquired nasolacrimal duct obstruction who were candidates for En-DCR were enrolled. Patients with a known history of previous DCR, sinus surgery, rhinoplasty, nasal trauma, nasal anomaly, canalicular or punctal occlusion, or less than one year of follow-up were excluded. All patients underwent En-DCR and stenting followed by ostial packing using Gelfoam soaked with dexamethasone. The patients were assessed preoperatively, on the first postoperative day, after 2 weeks, 3 months, and 1 year. Postoperative outcomes were anatomical and functional success, defined as patent irrigation test and resolution of epiphora, respectively. The nasolacrimal drainage system was evaluated anatomically and functionally during the follow-up period.

RESULTS

Eighty-three patients with a mean age of 54.36±15.27 years were enrolled. Of these, 61 patients (73.5%) were women. The mean duration of follow-up was 20.7±6.9 months. Anatomical success was achieved in all patients and remained stable during the study duration and at 1 year. Functional failure leading to epiphora was observed in 1 patient 3 months after surgery and resolved after re-DCR at year 1. Preoperative tenderness and purulent reflux were observed in 12%, 33.7% of which completely resolved postoperatively. Moderate and severe hemorrhage was observed in 12 (14.5%) and 2 (2.4%) patients, respectively.

CONCLUSION

En-DCR without mucosal flap preservation in combination with silicone stent and steroid-soaked Gelfoam is a safe and highly successful procedure in patients with primary acquired nasolacrimal duct obstruction.

Y. Comparative Study of Endonasal Endoscopic Dacryocystorhinostomy with or without Preservation of Nasal Mucosal Flap

OBJECTIVE

To analyse the result of endoscopic endonasal dacryocystrhinostomy with or without preservation of nasal mucosal flap.

STUDY DESIGN

Randomised prospective cohort design.

SETTING

Tertiary academic centre.

SUBJECTS AND METHODS

 100 patients who presented with epiphora and diagnosed as chronic dacryocystitis after syringing by ophthalmologist, were selected and randomised into two groups. Standard surgical procedure of endoscopic endonasal dacryocystorhinostomy was carried out except for the preservation of flap in group A and without preservation of flap in group B. Additional surgeries were done according to necessity. Postoperatively, patients were followed up on OPD-basis at the end of 1st week, 2nd week, 1st month, and 3rd month. Symptomatic improvement was assessed and patency checked by syringing by the ophthalmologist.

RESULTS

Nil intraoperative complications (p < 0.05) and nil postoperative complication noted (p < 0.05). Functional and anatomical patency found to be 100% at the end of 1st week in both groups, 96% at 3rd month in case group A and 98%, 92% and 82% respectively at the end of 2nd week, 1st month and 3rd month in group B. Nasal endoscopy of all surgical failures showed restenosis in both groups and synechiae in 2 patients in group B.

CONCLUSIONS

Preservation of nasal mucosal flap with modification around stoma can be used to cover the bared bone with avoidance of granulation tissue formation reducing the risk of closure of ostium with large rhinostomy and improve success of endoscopic endonasal DCR.

A Comparative Study Between Anterior-Posterior and Superior-Inferior Flap Suturing Technique in Endoscopic Dacryocystorhinostomy at our Tertiary Institution

The Nasolacrimal sac inflammation, also known as dacryocystitis, is frequently accompanied by nasolacrimal duct blockage at the confluence of lacrimal sac and duct. Treatment of choice for dacryocystitis is dacryocystorhinostomy (DCR), which can be done through external approach and endoscopic approach. The endoscopic DCR has distinct advantage over the external DCR as there is no facial scar& also it maintains the pump action. We have used flap suturing technique of endoscopic DCR in our study where in lacrimal sac medial flap is sutured to nasal mucosal lateral flap wherein patients were selected into either of the two groups such as Anterior-Posterior type (group A) and Superior-Inferior type (group B) of Flap suturing technique. Aim and objectives of the study were to compare the subjective and objective success rate between group A & B of flap suturing used in endoscopic DCR & to compare the success rate of our techniques with other techniques in literature. Our study was Duration based prospective observational study with a Duration of one year from June 2021 till June 2022 with study population comprised of patients in age group of 20 to 70 years, with complaints of watering of eye (epiphora) attended ENT Department of our institute during this one year. Study population comprised of Total of 86 patients (100 eyes) of which 45 patients (51 EYES) underwent anterior- posterior flap suturing (Group A) and 41 patients (49 eyes) underwent superior- inferior flap suturing (Group B) technique of endoscopic DCR The mean age ± standard error of mean was 45.1765 ± 1.5 and 49.0816 ± 1.9 in group A & B respectively,which was not statistically significant (p value = 0.994). The male and female patients in group A & B was 27.45%,72.54% and 34.69%,65.30% respectively which was not statistically significant (p value = 0.434). At each follow‑up, subjective success rate was more in group A that indicated a better trend of success for that group. However, the difference in the success rate was not statistically significant.The objective success rate between the two groups were more or less similar & was not statistically significant. The subjective success rate in both Anterior-Posterior type (group A)and Superior-Inferior type (group B) of Flap suturing techniques of endoscopic dacryocystorhinostomy were more or less similar with regards to absence of epiphora but objective success rate with regards to the patency, were almost similar with a shift of trend from Group A to group B at 6 months follow up and we also found that complications in both the groups were very few, without statistically significant difference between them. In terms of success rate and complication,The endoscopic DCR with flap suturing technique found to be more or less similar with previous techniques of DCR described in the literature.

Endoscopic Dacryocystorhinostomy With Modified Mucosal Flap Technique

The aim of the present study is to evaluate the success of mucosa-sparing surgery with a modified inverted U flap in endoscopic dacryocystorhinostomy (E-DCR). Forty-two patients who underwent E-DCR without mucosal flap were included in group 1, and 41 patients who underwent E-DCR with modified inverted U mucosal flap technique were included in group 2. The patients were followed up for at least 12 months postoperatively, and the complications and functional success in both groups were analyzed comparatively. The functional success rate was 81% in group 1 and 95.1% in group 2. The difference between the 2 groups is statistically significant (P=0.04). Postoperative granulation tissue development was observed in 9 patients (20.4%) in group 1 and in 2 patients (4.88%) in group 2, and the difference was statistically significant (P=0.02). Mucosa-sparing E-DCR with modified inverted U flap achieves higher functional success than flapless surgery and causes less granulation formation.

Modified Endoscopic Dacryocystorhinostomy: A Clubhead-Shaped Nasal Mucoperiosteal Flap Technique

A modified endoscopic dacryocystorhinostomy technique using a clubhead-shaped nasal flap combined with a posteriorly hinged lacrimal flap was designed for tension-free anastomosis with the surrounding mucoperiosteum. This technique showed satisfactory outcomes that facilitated the maintenance of the rhinostomy in eight cases with nasolacrimal duct obstruction. Laryngoscope, 2022.

Changes in Eyelid Position Following Silicone Tube Insertion and Removal in Dacryocystorhinostomy

AIMS

The authors sought to assess the changes in eyelid position after silicone tube insertion and removal in endoscopic dacryocystorhinostomy.

METHODS

The authors retrospectively reviewed 60 eyes of 48 consecutive patients who underwent endoscopic dacryocystorhinostomy operation at Korea University Guro Hospital, Seoul, Republic of Korea, between April 2019 and November 2019. All cases were evaluated to discern eyelid positioning, focusing on the marginal reflex distance 1, medial palpebral fissure, central palpebral fissure (PF-2), lateral palpebral fissure (PF-3), and medial canthal angle (MCA) before surgery and at 1 week and 1, 2, 3, and 4 months postoperatively.

RESULTS

Twelve patients (25%) were operated on bilaterally and 36 patients (75%) were operated on unilaterally. The average patient age was 56.5 years and 9 men (18.8%) and 39 women (81.3%) were included in this study. At 2 months postoperatively, all values of interest (marginal reflex distance 1 , medial palpebral fissure, PF-2, PF-3, and MCA) had decreased significantly (P < 0.05, Friedman test), but the changes in PF-3 immediately after surgery were not significant (P = 0.062, Wilcoxon rank-sum test). From 2 to 3 months after surgery, all 5 indicators of interest increased significantly. After silicone tube removal, whereas there was no statistically significant difference in medial palpebral fissure, PF-3, and marginal reflex distance 1 values; the changes in PF-2 and MCA values as compared with before surgery was 0.47 mm (P = 0.02, Wilcoxon test) and 3.25° (P = 0.000, Wilcoxon test), respectively, which was significantly different. However, with these small gaps, it will be difficult to notice the changes in PF-2 and MCA values during clinical examination.

CONCLUSION

Insertion of a silicone tube during endoscopic dacryocystorhinostomy leads to temporary deformation of the lid position. However, after silicone tube removal, all eyelids recovered to their original shape.

In vivo analysis of endocanalicular light pipe transillumination in endoscopic dacryocystorhinostomy: Anatomic considerations and cautions for the transitioning

Purpose: Localization of the lacrimal sac is a critical step during endoscopic dacryocystorhinostomy (endo-DCR). A "light pipe" can be used to transilluminate the lacrimal sac endonasally. We hypothesized that this may misguide the surgeon learning endo-DCR to create an osteotomy mostly posterior to the maxillary line if only the bone overlying the transillumination was to be removed, as the thinner lacrimal bone will transmit light more readily than the thicker maxillary bone of the frontal process of the maxilla that forms the anterior lacrimal sac fossa.Methods: The charts of 32 patients with primary acquired nasolacrimal duct obstruction in whom a lighted system was used during endo-DCR at Massachusetts Eye and Ear from April 2015 through October 2016 were reviewed. Patients with prior history of lacrimal surgery or trauma directly to the lacrimal sac fossa were excluded. Location of the maximal point of transillumination in relation to the maxillary line was observed and noted intraoperatively.Results: Of a total of 39 endo-DCR surgeries performed, the intraoperative transillumination point was entirely posterior to the maxillary line in 32 instances (82%).Conclusions: Use of an endocanalicular light pipe preferentially illuminates posterior to the maxillary line endonasally. The anterior lacrimal sac fossa (maxillary line and anterior as visualized endonasally) is rarely transilluminated, likely due to thicker bone in that region. Surgeons learning how to perform endo-DCR using a light pipe should be aware of this phenomenon.

Efficacy of Triamcinolone-Soaked Nasal Packing on Endoscopic Dacryocystorhinostomy

PURPOSE

To evaluate the efficacy of triamcinolone-soaked nasal packing in endoscopic dacryocystorhinostomy (EDCR).

METHODS

Patients who underwent EDCR between September 2012 and August 2017 were included. They were assigned to triamcinolone (201 eyes) or control (206 eyes) group based on the order of surgery. Granulation occurrence and outcome were assessed at 3 and 6 months postoperatively, respectively.

RESULTS

The success rates were 94.3% (overall anatomical success), 90.4% (complete anatomical success), 92.1% (overall functional success), and 76.7% (complete functional success). The overall functional success rate was significantly higher in the triamcinolone group (95.0% vs. 89.3%, p = 0.033). The overall anatomical success rate (96.0% vs. 92.7%, p = 0.149) and complete functional success rate (79.6% vs. 73.8%, p = 0.166) were also higher in the triamcinolone group, but this difference was not statistically significant. Granulation occurred in 62 eyes (15.2%); the incidence was significantly lower in the triamcinolone group (10.0% vs. 20.4%, p = 0.003).

CONCLUSION

The authors suggest that use of triamcinolone-soaked nasal packing in EDCR is effective in significantly reducing the incidence of postoperative granulation and epiphora.

Influence of Surgical Techniques on Endoscopic Dacryocystorhinostomy: A Systematic Review and Meta-analysis

Objective

Endoscopic endonasal dacryocystorhinostomy (END-DCR) has increased as a valid alternative to the classic external approach to treat distal lacrimal obstruction. Different surgical varieties of the END-DCR approach have been proposed with no clear understanding of the best surgical technique.

Data Source

A comprehensive research was performed in PubMed, Embase, SCOPUS, and Cochrane databases with a final search on March 2020.

Review Methods

The aim of this search was to identify relevant END-DCR procedures performed with mechanical (Mecn-END-DCR) and powered (Pow-END-DCR) approaches to compare their functional success rate. In addition, the influence of mucosal flaps was evaluated. Articles were selected only if they were published later than 2000 and had at least 50 single-clinician surgical procedures performed. Excluded articles included acute infections, cancers, mixed cohort study, and revision cases.

Results

A total of 11,445 publications were identified and 2741 reviewed after screening; 15 articles were included after full-text review (0.6% of the initial articles reviewed). The mean success rate was 91.34% (95% CI, 87.1%-94.3%) for Pow-END-DCR and 89.5% (95% CI, 86.5%-91.9%) for Mecn-END-DCR with no significant difference between the surgical approaches ( P = .43). For mucosal flaps performed during END-DCR, the mean success rate was 89% (95% CI, 86%-91%) if mucosal flaps were used and 92% (95% CI, 88%-95%) if they were not used, with no statistical difference present ( P = .14).

Conclusions

Our analyses suggest that there are no differences in outcomes between mechanical and powered approaches in END-DCR and that mucosal flap preservation is not essential to achieve a superior END-DCR outcome.

Association between septoplasty, Lund-Mackay score and Lund-Kennedy score with endoscopic dacryocystorhinostomy results

PURPOSE

To compare endoscopic dacryocystorhinostomy (endo-DCR) + septoplasty with endo-DCR alone and determine the relationship between sinusitis and endo-DCR surgery results.

METHODS

Our study included 55 patients with nasolacrimal duct obstruction (NLDO) between June 2017 and June 2019. Patients were divided into two groups as endo-DCR alone and endo-DCR + septoplasty. Patients' symptoms were thoroughly evaluated and scored using the Lund-Mackay (LM) score and the Lund-Kennedy (LK) system. According to LK endoscopy scoring; those with a score of 0 were determined as group 1 (40 (58.8%) cases); and those with a score greater than 0 were determined as group 2 (28(41.2%) cases). According to LM CT scoring system, cases whose score was 0 were determined as group 1 (44(%66.2) cases); those greater than 0 were determined as group 2 (23(33.8%) cases).

RESULTS

A total of 68 endo-DCR surgeries, 42 unilateral and 13 bilateral, were performed. Forty one cases (60.3%) were managed with endo-DCR alone, and septoplasty surgery was performed in 27 (39.7%) cases in addition to endo-DCR due to septum deviation. There was no statistically significant difference in functional and anatomical success between the two groups in terms of surgery type (anatomical success p = .353, functional success p = .528); LK endoscopy scoring (anatomical success p = .956, functional success p = .925) and LM CT scoring system (anatomical success p = .202, functional success p = .172).

CONCLUSION

LK endoscopy and LM CT scores did not show any influence on functional and anatomic outcomes in endo-DCR cases.

Surgical outcomes of endoscopic dacryocystorhinostomy: analysis of age effect

There is limited evidence in literature determining age effect on outcomes of endoscopic dacryocystorhinostomy (EDCR) in adult patients with primary acquired nasolacrimal duct obstruction (NLDO). We aimed to analyze the outcomes of EDCR according to age in primary acquired NLDO. A retrospective study was performed on consecutive adult patients and patients were divided into two age groups; group 1 (aged to 61 years) and group 2 (aged 62 to 89 years) based on the average value. The minimum required follow-up period was 6 months. A total of 441 EDCRs performed in 342 patients were enrolled. The anatomical success rate was not significantly different between the two groups (91.8% and 88.2%, P = 0.209). However, the functional success rate was significantly lower in the group 2 (85.1% and 76.9%; P = 0.036). Functional failure was associated with old age and a history of diabetes mellitus (P  = 0.024 and P  = 0.008). In subgroup analysis of patients with anatomical success but functionally failed EDCR, group 2 had significantly more comorbid conditions such as eyelid laxity (P = 0.026). In conclusion, the comorbid conditions which increase with age may affect functional outcome, especially eyelid laxity, careful preoperative examination of the eyelid and conjunctiva should be emphasized to lacrimal surgeons before performing EDCR.

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.

Endoscopic dacryocystorhinostomy with and without mucosal flap-is there any difference?

BACKGROUND

The nasal mucosa is sacrificed in conventional endoscopic dacryocystorhinostomies (EDCRs). Some surgeons, however, modify the technique by elevating a mucosal flap prior to creating the osteotomy with the aim of preserving the mucosa. To our knowledge, no clear-cut benefit of a mucosal flap has been established. The aim of this study is to examine the differences in surgical techniques and success rates of EDCRs with and without mucosal flap preservation.

METHODS

We carried out a medical record review of all patients who underwent primary EDCR at the Goldschleger Eye Institute from October 2009 to October 2017. The following data were retrieved from the medical database and analyzed: patient demographics (age at diagnosis and gender), medical history, examination findings, surgical details, postoperative success, complications, and follow-up.

RESULTS

A total of 107 patients who underwent 117 EDCRs participated in the study. Fifty-one patients comprised the group without a mucosal flap and 56 patients comprised the group with mucosal flap preservation. The medical history, presenting complaints, and preoperative examination findings were similar for both groups. The surgical success rate was not significantly different between the groups (82.1% without flap vs. 86.8% with flap, P = 0.478, Chi-square).

CONCLUSION

The findings of this comparison of EDCRs with and without mucosal flap preservation in a large patient population revealed no differences in surgical success or complications rates between the two procedures and, therefore, no benefit for adding flap preservation to conventional EDCRs.

The Fibrin Glue Application Enhances Surgical Success Rate in Endonasal Endoscopic Dacryocystorhinostomy With Lacrimal Sac Preservation

The purpose of this study to compare lacrimal sac flap preserving techniques with or without fibrin glue in patients undergoing endoscopic endonasal dacryocystorhinostomy. A retrospective study included 132 patients who underwent unilateral endonasal dacryocystorhinostomy between February 2011 and March 2016. Patients were divided into 2 groups: the nonfibrin glue group (n = 66) and fibrin glue anastomosis group (n = 66). Surgical success was defined as the patients' subjective report of relief of epiphora and objective endoscopic confirmation of ostium patency confirmed by a positive functional dye test. These parameters were compared between the 2 groups. Both groups were similar, in terms of demographic and clinical characteristics. The surgical success rate was significantly higher in the fibrin glue anastomosis group (95.5%) than in the nonfibrin glue group (84.8%; P = .041). Complication rate was 6.1% in the nonfibrin glue group, whereas in the fibrin glue anastomosis group, it was 4.5%. The complication rate was similar in both groups (P = .99). Creation of an anastomosis between the lacrimal sac flaps and the nasal mucosa using fibrin glue improves the outcome of endonasal endoscopic dacryocystorhinostomy.

Relationship Between Lacrimal Bone Thickness and Lacrimal Sac in Chronic Dacryocystitis

BACKGROUND

Chronic inflammation in the lacrimal sac may lead to thickening of the surrounding bony tissues. This study aimed to assess the thickness of lacrimal bone surrounding the lacrimal sac, and the thickness of maxilla, based on the presence of purulent secretion in the lacrimal sac in patients who underwent EDCR.

MATERIAL AND METHODS

Lacrimal bone thickness and the maximum and midpoint maxillary bone thickness of 70 patients (mean age of 49.07 years) who underwent EDCR, were assessed along 3 planes (upper, middle, and lower) using CT of the paranasal sinus. The patients were divided into 2 groups: the 1 who had purulent secretion in the lacrimal sac during the intraoperative period (Group 1) and another who did not have purulent secretion (Group 2).

RESULTS

No significant difference was detected between the 2 groups in terms of maximum and midpoint maxillary bone thickness. The increase in the thickness of lacrimal bone in Group 1 was statistically significant in all the 3 planes as compared to that in Group 2. Cutoff values for the thickness of the upper, middle, and lower plane of lacrimal bone were detected to be 0.710 mm, 0.685 mm, and 0.675 mm, respectively.

CONCLUSION

The presence of purulent secretion in the lacrimal sac, along with the detected increase in the thickness of the lacrimal bone, as assessed by CT, offers an insight on the lacrimal sac before the surgery.

[The nasal mucosa and outcomes of dacryocystorhinostomy]

OBJECTIVE

To investigate the impact of the nasal mucosa on the outcomes of dacryocystorhinostomy on the basis of morphologic findings.

MATERIAL AND METHODS

The investigation enrolled 73 patients who had undergone endonasal endoscopic dacryocystorhinostomy. Nasal mucosal biopsies were intraoperatively taken from all the patients. The obtained samples were subjected to standard histological examination, as well as to immunohistochemical study using an anti-alpha-smooth muscle actin antibody. To determine the intensity of inflammation in the tissue sample, a chronic inflammation score was calculated. The cell elements positively stained with α-smooth muscle actin were estimated using a semi-automatic method. The patients were divided into groups in accordance with the outcome of surgical treatment after 6 months.

RESULTS

An unfavorable outcome of dacryocystorhinostomy was observed in 10 (13.7%) patients. The samples obtained from the patients showed a higher chronic inflammation score (8.33%) and a larger number of the cell elements positively stained with α-smooth muscle actin (6026.38±1944.29). The correlation between the outcome of surgical intervention and the quantitative characteristics of myofibroblasts was statistically significant (p<0.05).

CONCLUSION

These studies suggest that there is a direct correlation of the efficiency of endonasal endoscopic dacryocystorhinostomy with the presence and degree of chronic nasal mucosal inflammation at baseline.

Chronic conjunctivitis as a prognosis factor of dacryocystorhinostomy: a retrospective case-controlled study

OBJECTIVE

To determine whether the history of chronic conjunctivitis increases the likelihood of epiphora after an external dacryocystorhinostomy (Ex-DCR) and to elucidate other factors that may affect the prognosis of this surgery.

METHODS

This is a retrospective case-controlled study. Patients who had epiphora after an Ex-DCR were compared with patients who did not present epiphora. Medical history of conjunctivitis, use of antiglaucomatous drops, rhinitis, and nasal pathology were evaluated.

RESULTS

A total of 129 adult patients undergoing external DCR were evaluated, of which 73% had decreased tearing. Forty-five percent of the patients who continued with epiphora had a history of conjunctivitis, compared to the 20% of those who did not (p = 0.003). At the same time, the 20% of those who continued with epiphora had a history of rhinitis compared to the 8% of those who did not (p = 0.043).

CONCLUSION

Patients with a history of chronic conjunctivitis are less likely to improve the epiphora after performing an Ex-DCR. We consider that it is important to evaluate this antecedent before surgery.

Use of an image-guided navigation system for routine endonasal endoscopic dacryocystorhinostomy

OBJECTIVE

This study aimed to evaluate the results of routine endonasal endoscopic dacryocystorhinostomy combined with computed tomography guided navigation in patients with nasolacrimal duct obstruction.

METHOD

This was a retrospective study of all patients with lacrimal drainage obstruction undergoing stereotactic endoscopic dacryocystorhinostomy between 1st January 2016 and 1st April 2018. Computed tomography dacryocystography was used for intra-operative navigation. Patients with a presaccal obstruction site location were excluded from the study.

RESULTS

Endoscopic dacryocystorhinostomy with computed tomography guided navigation was successfully performed in all 17 cases without complications. Early post-operative dislocation of the inserted bicanalicular silicone stent occurred in two patients. Two other patients developed post-operative bacterial infection within the lacrimal sac. Otherwise, the silicone tube was removed three months after surgery, and after further follow up of 8 weeks, 94 per cent of the study population reported complete remission of epiphora.

CONCLUSION

The use of computed tomography guidance in routine endoscopic dacryocystorhinostomy enhanced safety for the patient and avoided unnecessary damage of bone and mucosa surrounding the lacrimal drainage system. Therefore, routine endoscopic dacryocystorhinostomy with additional stereotactic guidance by computed tomography navigation can contribute to high success rates with endoscopic dacryocystorhinostomy.

Long-term outcomes after endoscopic dacryocystorhinostomy without mucosal flap preservation

OBJECTIVE

A growing body of evidence demonstrates that endonasal endoscopic dacryocystorhinostomy (eDCR) techniques provide comparable results to conventional external techniques. The purpose of this study was to evaluate long-term outcomes after powered endoscopic DCR without preservation of mucosal flaps for the management of acquired nasolacrimal duct obstruction performed by a single surgical team.

METHODS

A retrospective review was performed of patients with epiphora secondary to acquired nasolacrimal duct obstruction who underwent eDCR without mucosal flap preservation from May 2003 to April 2013 at a tertiary referral medical center. Main outcome measures were subjective improvement in epiphora and assessment of anatomic patency based on lacrimal irrigation and endoscopic evaluation.

RESULTS

Eighty patients (69 primary and 11 revision) totaling 103 procedures (87 primary, 16 revision) were available for analysis at a mean follow-up of 28.7 (range 6-114) months. At the most recent follow-up, 92 of 103 (89.3%) procedures had complete resolution of epiphora, and 10 of 103 procedures achieved mild intermittent epiphora. Complete resolution of epiphora was noted in 93.1% (81 of 87) of primary procedures and 68.8% (11 of 16) of revision procedures. Objective anatomic patency was confirmed in 98% (101 of 103). A revision procedure was required in 5.8% (6 of 103).

CONCLUSION

Outcomes of powered eDCR without the preservation of mucosal flaps compare favorably to previously reported results in the literature. These long-term results suggest that mucosal flap preservation is not required to achieve successful outcomes with eDCR.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:12-17, 2020.

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.

[Influence of fibrosis mediators on the outcomes of endoscopic endonasal dacryocystorhinostomy]

INTRODUCTION

Fibrosis is the most important pathologic condition involved in undesirable outcomes of dacryocystorhinostomy. A number of biochemical factors are currently known to have an effect on wound healing by promoting excessive scarring. Isoforms of transforming growth factor β (TGF-β1) are considered the 'main' pro-fibrotic factor, but wound healing is also affected by other cytokines such as connective tissue growth factor (CTGF), which stimulates fibrosis, and fibroblast growth factor (FGF-2), which acts as antagonist to it.

PURPOSE

To investigate correlations between endoscopic endonasal dacryocystorhinostomy outcomes and certain mediators of fibrosis.

MATERIAL AND METHODS

The study included 45 cases of endoscopic endonasal dacryocystorhinostomy. The patients were grouped according to surgery outcome: patients with unsuccessful surgical treatment were assigned to group 1 (n=10); patients with successful surgical treatment - to group 2 (n=34). One patient was excluded from the study. Full-layer biopsy specimen were taken from patients' nasal mucosa before the surgery. TGF-β1, TGF-β2, TGF-β3, CTGF, FGF-2 concentrations were evaluated using ELISA and normalized by total protein concentration.

RESULTS

Surgical failure was observed in 10 cases (22.72%). CTGF concentration was significantly correlated with negative outcome (p<0.05) and was elevated in most specimen obtained from group 1. No significant correlation was noted between the concentrations of other evaluated cytokines in nasal mucosa specimens and the surgical outcome.

CONCLUSION

The study found a correlation between CTGF concentration in nasal mucosa and dacryocystorhinostomy outcome, which supports the hypothesis suggested by several authors linking dacryocystorhinostomy failure with chronic inflammation in nasal mucosa.

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%.

A Systematic Review of Benefit of Silicone Intubation in Endoscopic Dacryocystorhinostomy

Objectives

Insertion of a silicone stent during endoscopic dacryocystorhinostomy (DCR) is the most common procedure to prevent rhinostomy closure. It has been claimed that silicone intubation improves the surgical outcomes of endoscopic DCR. However, many reports have documented an equally high success rate for surgery without silicone intubation. Accordingly, we conducted a systematic review and meta-analysis to clarify the outcomes of endoscopic DCR with and without silicone intubation and determine whether silicone intubation is actually beneficial for patients.

Methods

PubMed, Embase, and Cochrane Library databases were searched to identify relevant controlled trials evaluating endoscopic DCR with and without silicone intubation. The search was restricted to English articles published between January 2007 and December 2016. Relevant articles were reviewed to obtain information pertaining to interventions and outcomes. We also performed a meta-analysis of the relevant literature.

Results

In total, 1,216 patients included in 12 randomized controlled trials were pooled. A total of 1,239 endoscopic DCR procedures were performed, and silicone stents were used in 533 procedures. The overall success rate for endoscopic DCR was 91.9% (1,139/1,239), while the success rates with and without silicone intubation were 92.9% (495/533) and 91.2% (644/706), respectively. There was no statistically significant heterogeneity among the included studies. A meta-analysis using a fixed-effects models showed no significant difference in the success rate between endoscopic DCR with silicone intubation and that without silicone intubation (OR, 1.38; 95% CI, 0.89 to 2.12; P=0.148; z=1.45). Furthermore, there were no significant differences with regard to surgical complications such as synechia, granulation, and postoperative bleeding.

Conclusion

The findings of our meta-analysis suggest that the success rate and postoperative complication rate for endoscopic DCR is not influenced by the use of silicone intubation during the procedure.

Outcomes after Endoscopic Dacryocystorhinostomy without Mucosal Flap Preservation

Background

The purpose of this study was to evaluate outcomes of powered endoscopic dacryocystorhinostomy (DCR) without the preservation of mucosal flaps for the management of acquired nasolacrimal duct obstruction.

Methods

A retrospective review was performed of patients undergoing endoscopic DCR without mucosal flap preservation from May 2003 to October 2006 at a tertiary referral medical center. Twenty-seven procedures were performed on 20 patients with epiphora secondary to acquired nasolacrimal duct obstruction. Main outcome measures were subjective improvement in epiphora and assessment of anatomic patency based on lacrimal irrigation.

Results

Mean follow-up was 16 months. Mild intermittent postoperative epiphora or complete resolution of epiphora was noted in 100% (27/27) of procedures; complete resolution was recorded in 93% (25/27) of procedures. Eighteen patients (25 procedures) were available for lacrimal irrigation at a mean of 16 months follow-up. Anatomic patency was confirmed in 100% (25/25) of procedures.

Conclusion

Our results with endoscopic DCR are comparable with previously published outcomes. These data suggest that successfully powered DCR may be performed without the preservation of mucosal flaps.

Transnasal endoscopic assisted dacryocystorhinostomy

Transnasal endoscopic dacryocystorhinostomy is a good alternative for external DCR. It is considered a safe and efficient technique with successful results, comparable or even better than the external technique. Advanced knowledge of the endoscopic anatomy and the lacrimal system is necessary to perform the procedure safely, and to obtain good surgical outcomes.

The aim of the paper is to analyze the changes of the endoscopic technique and to improve it. The transnasal endoscopic dacryocystorhinostomy surgical technique is described in a “step by step” manner. Also the surgical technologies that can be used for this intervention are presented, focusing on the cold instruments.

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.

Double Posterior Based Flap Technique in Primary Endoscopic Dacryocystorhinostomy With and Without Using Powered Instrument

To demonstrate the surgical technique and outcomes of double posterior based flap technique in primary endoscopic dacryocystorhinostomy (DCR) with and without use of powered instrument. 28 patients of nasolacrimal duct obstruction were included in the study from September 2012 to February 2015. All underwent endoscopic dacryocystorhinostomy with double posterior based nasal and lacrimal flap technique. In patients of group A (14 patients), bone removal was done with the help of Smith-Kerrison punch forceps and in patients of group B (14 patients), powered drill has been used for the same. Patients were visited the endoscopic clinic at 1, 3, 6 months and 1 year after the surgery for post operative evaluation. Of 28 patients, 26(92.85%) were found free of symptoms at the end of 1, 3 and at 6 months. One from each group had recurrence of symptoms. At the end of 12 months of 25 patients, 3(12%) patients were found to have recurrence of symptoms of which 1(8.33%) patients was from group A and 2(15.38%) were from group B and failures were because of granulation tissue and stomal stenosis. Patients assisted with powered drill had more postoperative complications compared to cold instrument. Double posterior based flap technique in primary endoscopic DCR without the assistance of powered drill could be an effective surgical option for the patients of chronic nasolacrimal duct obstruction enabling early epithelisation by preventing peristomal granulation tissue resulting in encouraging surgical outcome with least postoperative complication.

Effectiveness of indocyanine green gel in the identification and complete removal of the medial wall of the lacrimal sac during endoscopic endonasal dacryocystorhinostomy

OBJECTIVE

We investigated the effect of using indocyanine green (ICG) gel, a mixture of ICG and Viscoat, on complete removal of the medial wall of the lacrimal sac as well as the success rate of endoscopic endonasal dacryocystorhinostomy (DCR) for primary acquired nasolacrimal duct obstruction.

METHODS

Consecutive cases of endoscopic endonasal DCR between January and December 2010 were included in a retrospective, comparative manner. A total of 91 patients with primary acquired nasolacrimal duct obstruction were enrolled. Surgical method was selected according to time period. In the ICG gel group, we used ICG gel, which is a fluorescent-colored viscoelastic substance made of ICG dye (25 mg) and Viscoat. ICG gel was injected into the lacrimal sac via the inferior canaliculus prior to lacrimal sac dissection. The anatomic and functional surgical success rates of endoscopic endonasal DCR in each group were compared.

RESULTS

Our study included 49 cases in the ICG gel group and 42 cases in the control group. The functional success rate of endoscopic endonasal DCR reached 93.9% (46 of 49) in the ICG gel group compared with 71.4% (30 of 42) in the control group (Pearson's χ² test, p value = 0.004). In contrast, there was no statistically significant correlation between use of ICG gel and anatomic success rate of endoscopic endonasal DCR.

CONCLUSIONS

Using ICG gel during lacrimal sac dissection may enhance the functional success rate of endoscopic endonasal DCR for primary acquired nasolacrimal duct obstruction by facilitating easier identification and subsequent complete removal of the medial wall of the lacrimal sac.

Paediatric endonasal dacryocystorhinostomy using an otology set: How I do it

INTRODUCTION

Endonasal DCR is safely performed in children presenting with persistent epiphora, not responding to conservative management. The surgical technique of endoscopic DCR in the paediatric age group essentially remains the same as that performed in adults, but children have narrower nasal passages and relatively larger inferior turbinates which limit the surgeon's working space. The standard 2.7 mm paediatric nasal endoscope gives a smaller surgical work field as compared to the 4 mm adult endoscope. Hence, we have used the otology set of instruments for performing endoscopic DCR in children to allow the negotiation of a wider 4 mm scope which gives a larger field of surgery and better illumination.

MATERIALS AND METHODS

It is a prospective study of 23 children done over the last 5 years at our tertiary care hospital. We have successfully used this less invasive technique of endoscopic dacryocystorhinostomy who didn't respond to conservative management.

RESULTS

The overall success rate was 95.65% without any major complications.

CONCLUSION

Using the fine delicate otology set for endonasal DCR is advantageous as it not only allows the use of a 4 mm endoscope but also allows the surgeon to perform a more meticulous surgery by preventing unnecessary mucosal abrasions and creation of raw areas thereby improving surgical outcome. It thus combines a high success rate with a lesser invasive technique. At the same time, it is important to have an experienced surgeon due to the variable anatomy and technical accuracy required in children.

Nonendoscopic endonasal dacryocystorhinostomy: Outcome in 134 eyes

AIMS

To evaluate the outcome of nonendoscopic endonasal dacryocystorhinostomy (NEN-DCR) in patients with nasolacrimal duct obstruction (NLDO) in India.

METHODS

Retrospective case series of NEN-DCR between July 2012 and October 2014. All patients had follow-up >3 months. Success was defined anatomically as patency on irrigation and functionally as relief from epiphora.

STATISTICAL ANALYSIS USED

Fischer's exact test and Chi-square test.

RESULTS

A total of 122 patients (134 eyes; 81 female; mean age 37 ± 18 years) were included. Indications were primary acquired NLDO in 92 (68%) eyes of adults (>18 years), NLDO in children (<18 years) in 22 eyes (16%), acute dacryocystitis in 13 eyes, failed prior DCR in six eyes, and secondary acquired NLDO in one eye. Mean duration of surgery was 36 min (range: 16-92). At a median follow-up of 6 months (range: 3-15), 86% eyes had functional success and 85% had anatomical success. Revision NEN-DCR was successful in 13/16 eyes. All patients with acute dacryocystitis were completely symptom-free at final visit. In children, (17/22) 77% achieved functional success after primary NEN-DCR which improved to 100% after one revision. Tube-related epiphora and granuloma in ten eyes resolved after removal.

CONCLUSION

NEN-DCR gives good outcome in primary NLDO and is also effective in those with acute dacryocystitis and in children with NLDO. The technique obviates the need for an endoscope and has an acceptable safety profile and thus may be particularly suited for the developing nations.

Endoscopic DCR using bipedicled interlacing mucosal flaps

OBJECTIVE

Obstruction of the nasolacrimal duct is a relatively common condition that affects patients of all ages, races, and sexes. The surgical gold standard for complete nasolacrimal duct obstruction and dacryocystitis is dacryocystorhinostomy (DCR). The purpose of this study was to describe a novel, bipedicled interlacing mucosal sparing flap technique for endoscopic DCR (eDCR).

METHODS

A posteriorly based mucosal flap over the fundus is combined with a novel, anteriorly based mucosal flap over the intraosseus portion of the nasolacrimal duct (NLD). This exposes a wide area of the maxillary bone, allowing for exposure and identification of the NLD/sac complex in a safer, more inferior position. The interlacing mucosal flaps may be replaced at the conclusion of the procedure, thereby minimizing bone exposure and maintaining excellent long-term patency.

RESULTS

The authors have utilized this technique in 55 procedures with 100% positive identification of the NLD and lacrimal sac, 0% complication rate, 100% anatomical patency rate, and 96.4% success rate after a minimal follow-up of 6 months.

DISCUSSION

The bipedicled interlacing flap technique for eDCR provides for safe and reproducible identification of the NLD and lacrimal sac while minimizing bone exposure and restenosis rate.

CONCLUSION

The bipedicled interlacing flap technique for eDCR provides for safe and reproducible identification of the NLD and lacrimal sac while minimizing bone exposure and restenosis rate.

LEVEL OF EVIDENCE

NA. Laryngoscope, 128:794-797, 2018.

Outcomes of endoscopic dacryocystorhinostomy: Experience of a fellowship trainee at a tertiary care center

Aim:

The study aims to report a single trainee's experience of learning and performing endoscopic endonasal dacryocystorhinostomy (En-DCR).

Settings and Design:

This study was a retrospective, interventional case series.

Subjects and Methods:

Fifty-four eyes of fifty patients presenting at a tertiary eye care center over 1 year were included in the study. All cases underwent endoscopic DCR with mitomycin-C and silicone intubation. The parameters studied included demographics, clinical features, intraoperative details, and postoperative ostium evaluation. Stent removal and nasal endoscopy were performed at 6 weeks and a further ostium evaluation at 3 and 6 months following surgery. Anatomical success rate was defined as patent irrigation, and functional success rate was defined as positive functional endoscopic dye test and absence of epiphora.

Results:

Fifty-four eyes of fifty patients were operated, and three cases were lost to follow-up after surgery. The mean age at presentation was 34 (4–75) years. Clinical diagnosis included primary acquired nasolacrimal duct (NLD) obstruction in 72% (39/54), acute dacryocystitis in 15% (8/54), failed DCR in 7% (4/54), and persistent congenital NLD obstruction in 5% (3/54). The first five cases needed intervention by the mentor for superior osteotomy. Common variations in anatomical landmarks were posterior location of sac, large ethmoidal bulla, high internal common opening, and thick maxillary bone. Surgical time taken in the last 27 eyes was significantly lesser compared to the surgical duration taken in the initial 27 cases (P < 0.05). Anatomical and functional success rate was 94% (48/51) at 6 months follow-up period.

Conclusions:

Endoscopic En-DCR has a good success rate when performed by oculoplastic surgery trainees. Nasal anatomical variations, instrument handling, and adaptation to monocular view of endoscope are few of the challenges for beginners. Structured skill transfer can help trainees to learn and perform En-DCR with acceptable success rates.

A Modified Preserved Nasal and Lacrimal Flap Technique in Endoscopic Dacryocystorhinostomy

Here we describe a modified preserved nasal and lacrimal mucosal flap technique in endonasal endoscopic dacryocystorhinostomy (EES-DCR) for patients with epiphora secondary to primary acquired nasolacrimal duct obstruction (PANDO) and evaluate its outcomes. Twenty-five patients with PANDO were retrospectively reviewed. Modified preserved nasal and lacrimal mucosal flap technique in EES-DCR was applied in all 27 eyes of 25 patients. The patients were evaluated with objective (anatomical patency) and subjective (symptomatic cure) success rates within the duration of follow-up. In the present study, all of the patients’ surgical procedures were successful. There were 2 cases of flap dislocation from the rhinostomy site 1 week post-operation. After a mean follow-up of 4.9 ± 1.8 months, the success rate of anatomical patency was 100% (27/27) and the success rate of symptomatic cure was 92.6% (25/27). No significant complications occurred intraoperatively. We concluded that the modified preserved nasal and lacrimal mucosal flap technique in EES-DCR for treating PANDO is simple and safe, can effectively cover the bare bone around the opened sac, and provide a similar or even better clinical outcome compared with other routine treatment techniques used for this condition.

Impact of endoscopic dacryocystorhinostomy on sinonasal quality of life

BACKGROUND

Dacryocystorhinostomy (DCR) is the criterion standard of surgical treatment for complete nasolacrimal obstruction and dacryocystitis. There has been an expansion in the indication of the endonasal DCR (eDCR), but the impact of surgical manipulating an otherwise healthy nasal mucosa on postoperative sinonasal quality of life remains unknown. The purpose of this study was to determine whether patients who underwent eDCR experienced any decrement in sinonasal quality of life.

METHODS

A retrospective chart review of 44 patients who underwent eDCR between June 2012 and May 2015. The primary outcome was the total and nasal-specific domain 1 scores of the disease specific validated Sino-Nasal Outcomes Test 22. Preoperative scores were compared with the postoperative scores on days 0-30, 30-90, and 90-180 visits. A subgroup analysis of patients without nasal symptoms who underwent concomitant nasal surgical procedures was also performed.

RESULTS

A statistically significant increase was observed between the preoperative score and the first postoperative score (days 0-30) in both total (7.5 [0-44] to 24 [0-51], median [interquartile range]) and domain 1 (2.5 [0-11] to 9 [0-18]) scores (p = 0.0066 and p = 0.0001, respectively). In contrast, there was no statistically significant difference between the pre- and postoperative scores on days 30-90 or 90-180. Similar results were observed in the subgroup analysis.

CONCLUSION

Analysis of our findings indicated that, in general, eDCR was well tolerated by patients and nasal symptom scores returned to baseline values within 30-90 days of surgery. The concomitant performance of septoplasty in the setting of asymptomatic septal deviation did not confer any long-term improvement in symptoms of nasal obstruction.

Transconjunctival dacryocystorhinostomy: An aesthetic approach

PURPOSE

To report the anatomical and cosmetic outcome of transconjunctival dacryocystorhinostomy (TDCR) in an Asian Indian population.

METHODS

TDCR was initially performed in cadaver eyes followed by patients with primary acquired nasolacrimal duct obstruction (NLDO). This was a prospective noncomparative case series of all consecutive TDCRs performed between April 2013 and June 2015. Outcome measures were anatomical patency, epiphora, presence of diplopia, aesthetic outcome, and health status.

RESULTS

A total of 17 (18 eyes) patients with a mean age 43.9 ± 11.8 years (range, 32-75) were included in the study. Eight were males, and one patient underwent TDCR in both eyes. TDCR was successfully performed in 15/18 (82%) eyes under local anesthesia. Procedure converted to transcutaneous external DCR in two and dacryocystectomy in one patient each. Mean duration of surgery was 52.6 (range, 29-110) min. Anatomical patency and relief from epiphora was achieved in all (15/15) eyes after TDCR at a median follow-up of 15.5 months. At final follow-up, objective assessment of the cosmetic outcome graded the surgical scar at the lateral canthus as invisible in all except one and conjunctival fornix as visible only after eyelid eversion in all patients. Disturbance of the medial fat pad was not seen in any patient. A questionnaire-based health status evaluation showed marked improvement in anxiety/depression before and after TDCR with an overall well-being score of 88 on a scale of 0-100 (worst-best) after TDCR.

CONCLUSIONS

TDCR offers a promising aesthetic approach in patients with primary acquired NLDO and gives excellent functional and cosmetic outcome.

Mucosal and lacrimal flaps for endonasal dacryocystorhinostomy: a systematic review

BACKGROUND

Historically dacryocystorhinostomy (DCR) has been performed externally with very good outcomes. Current literature shows comparable success rates between endonasal and external approaches. A common reason for the failure of a DCR is the reclosure of the nasolacrimal stoma by granulation tissue and synechiae.

OBJECTIVE OF REVIEW

A systematic review and critical evaluation of the evidence relating to the preservation of nasal mucosal flaps in DCR surgery.

TYPE OF REVIEW AND EVALUATION METHOD

A systematic review using the consort guidance for review of randomised control trials.

SEARCH STRATEGY

A search of the following evidence-based medicine databases was performed: Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effectiveness, Cochrane Central Register of Controlled Trials, Ovid, Medline, EMBASE and PubMed. The search was limited to English language articles, and the following key words were used: Endonasal, Endoscopic, Dacryocystorhinostomy, DCR, Mucosal Flaps, between years 1970 and 2015.

RESULTS

The best available evidence was level 1B, comprising two randomised control trials and three comparative studies included in the review. The main outcome measures used were lacrimal irrigation and absence of epiphora. Two of the studies demonstrated a statistically significant benefit of mucosal sparing either with nasal mucosal flaps or with lacrimal flaps. More debridement was needed, and granulation tissue was also seen in the groups without mucosal preservation. There was no difference in surgical complications between a mucosal and non-mucosal-sparing technique.

CONCLUSIONS

The overall quality of current evidence is poor, and there does however appear to be a trend towards improved outcomes and reduced granulation in groups where nasal mucosal and lacrimal flaps were preserved, but this is not clear-cut. There was no evidence of increased complication rates with mucosal-sparing techniques. We recommend that until further good quality research is available we should be performing a mucosal-sparing technique when performing DCR routinely.

The benefit of silicone stents in primary endonasal dacryocystorhinostomy: a systematic review and meta-analysis

OBJECTIVE

To critically evaluate the evidence comparing success rates of endonasal dacryocystorhinostomy (EN-DCR) with and without silicone tubing and to thus determine whether silicone intubation is beneficial in primary EN-DCR.

DESIGN

Systematic review and meta-analysis.

SEARCH STRATEGY

A literature search was performed on AMED, EMBASE, HMIC, MEDLINE, PsycINFO, BNI, CINAHL, HEALTH BUSINESS ELITE, CENTRAL and Cochrane Ear, Nose and Throat disorders groups trials register using a combination of various MeSH. The date of last search was January 2016. This review was limited to randomised controlled trials (RCTs) in English language. Risk of bias was assessed using the Cochrane Collaboration's risk of bias tool. Chi-square and I² statistics were calculated to determine the presence and extent of statistical heterogeneity.

EVALUATION METHOD

Study selection, data extraction and risk of bias scoring were performed independently by two authors in concordance with the PRISMA statement.

RESULTS

Five RCTs (447 primary EN-DCR procedures in 426 patients) were included for analysis. Moderate interstudy statistical heterogeneity was demonstrated (Chi² = 6.18; d.f. = 4; I² = 35%). Bicanalicular silicone stents were used in 229 and not used in 218 procedures. The overall success rate of EN-DCR was 92.8% (415/447). The success rate of EN-DCR was 93.4% (214/229) with silicone tubing and 92.2% (201/218) without silicone tubing. Meta-analysis using a random-effects model showed no statistically significant difference in outcomes between the two groups (P = 0.63; RR = 0.79; 95% CI = 0.3-2.06).

CONCLUSIONS

Our review and meta-analysis did not demonstrate an additional advantage of silicone stenting. A high-quality well-powered prospective multicentre RCT is needed to further clarify on the benefit of silicone stents.

Effectiveness of Synthetic Polyurethane Foam as a Nasal Packing Material in Endoscopic Endonasal Dacryocystorhinostomy

PURPOSE

To compare the effects of 2 nasal packing materials, synthetic polyurethane foam (absorbable) and expandable polyvinyl acetate (nonabsorbable), on the surgical success rate and postoperative complications after endoscopic endonasal dacryocystorhinostomy (EDCR).

METHODS

A retrospective medical review of 459 patients (580 eyes) who underwent EDCR for primary acquired nasolacrimal duct obstruction at Korea University Guro Hospitals from January 2009 to February 2014. Surgical success rate (anatomical, functional), postoperative complications (granuloma, synechia, bleeding, and infection) were compared between the 2 groups, absorbable (318 eyes) and nonabsorbable (262 eyes).

RESULTS

The absorbable group showed better results in surgical success rate regarding anatomical (90.5% versus 76.3%, P = 0.00) and functional (89.3% versus 75.9%, P = 0.00). Granulomas developed less frequently in the absorbable group (24.5% versus 38.9%, P = 0.00). Also, bleeding and crust were less frequent in the absorbable group (P = 0.00). Infections were less frequent in the nonabsorbable group (1.52%) compared with the absorbable group (7.86%, P = 0.00). The rate of revision surgery was lower in the absorbable group (7.86% versus 20.9%, P = 0.00). As for the influence of secondary outcomes to the surgical success by multiple logistic regression, granulomas had the largest effect on surgical success either anatomical or functional (odds ratio = 82.393 to anatomical and 44.058 to functional). Synechia had the second largest effect on surgical success (odds ratio = 11.897 to anatomical and 9.605 to functional).

CONCLUSIONS

The authors suggest that using a synthetic polyurethane foam as a nasal packing material is not only a surgical option, but also a crucial and essential procedure in EDCR.

Ultrasonic bone aspirator assisted endoscopic dacryocystorhinostomy

OBJECTIVE

To evaluate the ultrasonic bone aspirator versus traditional powered drill technique for use in endoscopic dacryocystorhinostomy.

STUDY DESIGN

Retrospective chart review.

SETTING

Academic institution.

SUBJECTS AND METHODS

A retrospective chart review of all patients undergoing endoscopic dacryocystorhinostomy from June 2010 through May 2014 was performed. Data were collected from 63 eyes of 63 patients. Recorded data points include: age, gender, etiology of epiphora, procedure type, success rate, need for septoplasty, and length of follow-up. Surgical failure was defined as no improvement in epiphora, postoperative dacryocystitis, or inability to irrigate the lacrimal system post-operatively.

RESULTS

Sixty three consecutive patients underwent endonasal endoscopic dacryocystorhinostomy. Twenty nine patients underwent powered microdrill DCR (pDCR); 34 patients underwent ultrasonic bone aspirator DCR (uDCR). There was no statistically significant difference between groups in terms of age or gender. The success rates were: pDCR 86.2% and uDCR 94.1% (p=0.4). Concurrent septoplasty was performed in 48% of pDCR patients and 21% of uDCR patients (p=0.03) There was no significant difference in surgical success when septoplasty was controlled for (p=0.39).

CONCLUSION

Ultrasonic bone aspirator dacryocystorhinostomy has a similar success rate to traditional powered microdrill dacryocystorhinostomy.

Comparison of impact of four surgical methods on surgical outcomes in endoscopic dacryocystorhinostomy

PURPOSE

To evaluate differences in the surgical outcomes of endoscopic dacryocystorhinostomy (DCR) according to four different surgical methods.

MATERIAL AND METHODS

This retrospective study included 222 patients who underwent endoscopic DCR from 2011 to 2013. All patients were assigned to one of four groups according to instruments for incision of nasal mucosa and the formation of mucosal flap: group 1, a sickle knife with mucosal flap; group 2, a sickle knife without mucosal flap; group 3, electrocautery with mucosal flap; and group 4, electrocautery without mucosal flap. The follow up period was at least 6 months.

RESULTS

There were 33 eyes in group 1, 44 eyes in group 2, 49 eyes in group 3, and 97 eyes in group 4. There were no significant differences in success rate between groups (P = 0.878). Wound healing time was significantly different between groups (P < 0.001). In post hoc analysis, wound healing time was significantly shorter in group 1 and group 2 than in group 3 and group 4. The vertical ostium size and postsurgical complication were not significantly different between groups.

CONCLUSIONS

The use of cold instruments such as sickle knife may be more helpful and effective for shortening wound healing time rather than making mucosal flaps in endoscopic DCR.

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.

Modified approach to powered endoscopic dacryocystorhinostomy

OBJECTIVE

This paper presents modifications to powered endoscopic dacryocystorhinostomy without stenting for the management of acquired nasolacrimal duct obstruction.

STUDY DESIGN

A retrospective, non-randomised review.

METHOD

A total of 105 patients with epiphora secondary to acquired nasolacrimal duct obstruction were operated on by our modified powered endoscopic dacryocystorhinostomy approach.

RESULTS

Of 105 patients, 100 (95.2 per cent) have remained asymptomatic. One patient with a narrow ostium had improved symptoms, while four patients continued to experience persistent symptoms (treatment failures).

CONCLUSION

The modified powered endoscopic dacryocystorhinostomy approach led to excellent results, without bone exposure and granulations, and with early mucosalisation.

The Learning Curve in Endoscopic Dacryocystorhinostomy: Outcomes in Surgery Performed by Trainee Oculoplastic Surgeons

PURPOSE

To report outcomes of endoscopic DCR (En-DCR) performed by oculoplastic trainees and describe factors to improve success rates for trainees.

METHODS

Retrospective, single-centre audit of En-DCR procedures performed by three consecutive trainee oculoplastic surgeons, over a 3-year period. Trainees also completed a reflective-learning questionnaire highlighting challenging and technically difficult aspects of En-DCR surgery, with relevant tips.

RESULTS

Thirty-eight consecutive independently-performed en-DCR procedures on 38 patients (mean age 58.6 ± 21.4 years) were studied. Mean time spent in the operating-theatre was 95.7 ± 27.3 minutes. Success rate for each year was 15/17(88%), 8/8(100%) and 7/13(54%), respectively, at mean follow-up 12.5 ± 12 months. The lowest success rate year coincided with use of silicone stents in 31% cases compared to 94% and 100% in the previous 2 years. In cases that failed, video-analysis highlighted inadequate superior bony rhinostomy (2 cases), incomplete retroplacement of posterior-nasal mucosal-flaps (3 cases), significant bleeding (1 case). Those who underwent revision surgery (n = 6), were found to have soft-tissue ostium and sac closure requiring flap revision. Two-cases required further bone removal supero-posterior to the lacrimal sac. Trainees-tips that helped improve their surgery related to patient positioning, instrument handling, bone removal and posture.

CONCLUSION

Good surgical outcomes are achievable training in en-DCR surgery. Adequate operating time needs to be planned. Failure was primarily due to closure of the soft-tissue ostium, either secondary to inadequate osteotomy and sac-marsupialisation or postoperative scarring. Intra-operative mucosal trauma is higher amongst trainees and adjuvant silicone stenting during the training period may be of value where mucosal adhesions are anticipated.

The effectiveness of a simultaneous medial spindle procedure for involutional punctal ectropion with lid laxity in patients who require endonasal dacryocystorhinostomy instead of external dacryocystorhinostomy to prevent pump failure

PURPOSE

The aim of this study was to determine the effectiveness of a concurrent medial spindle procedure (MS) to address involutional punctal ectropion and the proportion of combined surgery in patients who need endonasal dacryocystorhinostomy (DCR) instead of external dacryocystorhinostomy to prevent pump failure.

METHODS

We conducted a retrospective, interventional study on endonasal DCR and MS procedures performed between March 2004 and January 2009 by a single surgeon (S.H.B.). Patient age, sex, the results of a medial distraction test, the surgical procedure, follow-up duration, and cause of failed surgery were recorded. The indication for the medial spindle procedure was punctal eversion on slit lamp biomicroscopic examination with classifications of grades 2 and 3 on the medial distraction test.

RESULTS

Endonasal DCRs were performed on 169 eyes in 121 patients, and DCR and MS (D + M) were performed on 23 eyes in 17 patients. The proportion of combined surgery to total DCR was 13.6%. Our primary success rate was 86.9% in the combined surgery group and 87.2% in the DCR group (P = 0.39).

CONCLUSIONS

The MS for correction of punctal ectropion concurrently performed with endonasal DCR will be an effective tool to manage epiphora caused by complex situations, such as nasolacrimal duct obstruction and involutional punctal ectropion. We recommend careful examination of the punctum, which is invisible in normal conditions, under slit lamp biomicroscopy before endonasal DCR.

The Frequency of Concomitant Adjunctive Nasal Procedures in Powered Endoscopic Dacryocystorhinostomy

PURPOSE

To assess the frequency of concomitant adjunctive nasal procedures performed in powered endoscopic dacryocystorhinostomy (DCR).

METHODS

Retrospective review of 269 consecutive powered endoscopic DCR's performed in 202 patients over a period of 10 years from 2003 to 2013. Patient records were reviewed for demographic data, clinical profiles and surgical notes. Concomitant adjunctive procedures were studied with relation to number of patients, indications, types of procedures (septoplasty, middle turbinoplasty and functional endoscopic sinus surgery or FESS) and complications.

RESULTS

269 powered endoscopic DCR's were performed on 202 patients. The mean age at surgery was 58.4 years (range 20-91 years). Adjunctive nasal procedures were performed in 53.4% (108/202) of the patients. 47% (95/202) required a septoplasty. Among the 95 septoplasty patients, 85 required solo septoplasty and 10 had additional sinus procedure. Middle turbinoplasty was performed in 5.9% (12/202) and septal papilloma excision was performed in 0.49% (1/202). No additional morbidity was noticed with adjunctive procedures. Successful outcomes of DCR were achieved in 96.5% of patients.

CONCLUSION

Simultaneous adjunctive nasal procedures were commonly required with powered endoscopic DCR. Septoplasty and middle turbinoplasty when performed as needed, provides an additional access to lacrimal region and may facilitate successful outcomes.

Nasolacrimal duct mucocele: case report and literature review

Introduction Mucoceles are benign expansive cystic formations, composed of a mucus-secreting epithelium (respiratory or pseudostratified epithelium). Nasolacrimal mucocele occurs in a small proportion of children with nasolacrimal duct obstruction and is characterized by a cystic mass in the medial canthus with dilation of the nasolacrimal duct; although dacryocystoceles are rare in adults, they have been reported in patients with trachoma. Objective Discuss clinical aspects, diagnosis, and therapeutic management of mucocele of nasolacrimal duct based on literature review. Resumed Report The authors report a case of bilateral congenital nasolacrimal duct cysts in a 30-year-old man, identified as a tumor in the topography of both lacrimal sacs since birth without associated symptoms. The patient underwent successive surgical treatments, leading to recurrence of the tumor at the right side and recurrent local infections. Conclusion Endoscopic dacryocystorhinostomy has been increasingly used with good results and success rates similar to the external access.