Clinical Effectiveness of Monocanalicular Silicone Intubation for Congenital Nasolacrimal Duct Obstruction Under Nasal Endoscopic Visualization of the Terminal End of the Obstructed Nasolacrimal Duct

The Use of Stents in Children with Nasolacrimal Duct Obstruction Requiring Surgical Intervention: A Systematic Review

Nasolacrimal duct obstruction (NLDO) is the most common cause of childhood epiphora. It is managed conservatively in the first year of life, after which surgical treatment is classically based on a stepwise paradigm of probing, intubation, and dacryocystorhinostomy. This systematic review aims to present the current role of intubation in the management of children with NLDO requiring surgical intervention. A search for English-language articles from the electronic databases PubMed, SCOPUS, and the COCHRANE library was conducted over a period of five months in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and the Cochrane Handbook. The following keywords were used to aid retrieval: stents, children, lacrimal intubation, endoscopic dacryocystorhinostomy, external dacryocystorhinostomy, NLDO, dacryocystitis, congenital, acquired. The primary outcome was defined as the success of the intervention, determined by resolution of symptoms and patency of the lacrimal anatomy confirmed by the fluorescein dye disappearance test or syringing. Secondary outcomes included the presence of complications. A total of 144 articles were identified; of these, 35 fulfilled the study criteria. The majority of the included studies involved lacrimal intubation alone, followed by intubation as an adjunctive procedure to balloon dacryoplasty and dacryocystorhinostomy. The overall success rate of these procedures ranged from 41.1% to 100%. Post-operative complications were reported in 65.7% of the included studies. Lacrimal intubation was most commonly performed as a primary procedure in children with NLDO, with high success rates. The main complication was stent dislodgement. There is lack of evidence regarding the benefit of intubation over probing as primary treatment of congenital NLDO. In the absence of high-quality evidence, the decision of whether to perform lacrimal intubation in children with NLDO requiring surgical intervention depends on clinical judgement and other low-level evidence, such as observational non-randomised trials.

Endoscopically Assisted Crawford Tube Placement Results in Shorter General Anesthesia Times in Pediatric Patients

Background

Crawford tube placement is commonly used to achieve patency of nasolacrimal ducts for epiphora secondary to nasolacrimal duct obstruction. The nasal passages of pediatric patients are narrower than adults, and the result is a relatively higher risk of intranasal complications (e.g., synechiae, bleeding) with Crawford tube placement. There is evidence that general anesthesia may negatively affect the neurocognitive function and behavioral development of children, which prompts efforts to decrease operation times for potential health benefits and also potentially to reduce health care costs. Analysis ofresearch reports supports the use of nasal endoscopy to reduce intranasal complications with Crawford tube placement; however, no publications currently address the effect of nasal endoscopy concurrent with Crawford tube placement on operative times on pediatric patients or the resulting effects on health care costs.

Objective

To determine the difference in procedure time and cost between Crawford tubes placed traditionally and those placed with endoscopic assistance in pediatric patients.

Methods

A chart review was performed from January 1, 2011 to December 31, 2016 for cases using CPT codes 68815 or 31231. Within this group of patients, the patient in whom nasal endoscopy was performed were placed in the “endoscopic” group and the patients without endoscopy were placed in the “traditional” group. Procedure times were noted, and the t-test was performed to examine for any statistically significant difference in operative times. Estimates of anesthesia cost savings were made. We identified 24 patients in the traditional group and 7 patients in the endoscopic group.

Results

The average operative time for the traditional group was 27.3 minutes compared with 14.0 minutes for the endoscopic group (p = 0.02). The cost comparison data revealed no significant difference with the traditional group averaging $9369 per procedure and the endoscopic group averaging $8891 (p = 0.51).

Conclusion

An endoscopically assisted Crawford tube placement resulted in patients who had less time under general anesthesia compared with the traditional technique at no difference in cost.