Journal of Cranio-Maxillo-Facial Surgery 43 (2015) 7e10
Contents lists available at ScienceDirect
Journal of Cranio-Maxillo-Facial Surgery journal homepage: www.jcmfs.com
Long-term outcomes of endoscopic endonasal conjunctivodacryocystorhinostomy with Jones tube placement: A thirteen-year experience Minwook Chang a, Hwa Lee b, Minsoo Park c, Sehyun Baek b, * a b c
Department of Ophthalmology, Dongguk University Ilsan Hospital, Goyang, Republic of Korea Department of Ophthalmology, Korea University College of Medicine, Seoul, Republic of Korea Department of Ophthalmology, KEPCO Medical Center, Seoul, Republic of Korea
a r t i c l e i n f o
a b s t r a c t
Article history: Paper received 7 March 2014 Accepted 1 October 2014 Available online 7 October 2014
Purpose: To report thirteen years of experience with endoscopic-assisted endonasal primary conjunctivodacryocystorhinostomy (CDCR) and revision with Jones tube placement in Korean patients. Methods: Thirty-three patients who underwent primary endoscopic endonasal CDCR with a Jones tube and were followed for over 6 months and 22 patients who underwent revision CDCR were retrospectively reviewed. We evaluated the cause of obstruction, operation time, tube length, success rate (at 6, 12 and 24 months), and the cause of failure for primary and revision procedures. Results: The most common cause for operation in primary CDCR was trauma. The mean operation time was 26 min and 24 min in the primary and revision groups. The initial success rate was 87.9% vs. 74.3% at 6 months postoperative and 63.6% vs. 60% at two years after surgery in the primary and revision group. The most common reason for failure in both groups was medial migration of the tube, and the mean onset of these complications was about 10 months postoperative. Other major reasons for failure were inappropriate length of tube insertion in the primary group and inflammation in the revision group. Conclusion: Fatal complications which lead to failure may develop many months into the procedure, so long-term follow-up is necessary. The most common cause of failure was medial migration of the Jones tube; however, inappropriate tube insertion in primary surgery and severe inflammation in revision may also be concerns. © 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
Keywords: Endoscopic endonasal CDCR Success rate Cause of failure Operation time Primary and revisional surgery Length of Jones tube
1. Introduction Conjunctivodacryocystorhinostomy (CDCR) with Jones tube placement is the gold standard for complete or severe canalicular obstruction, and is performed as an additional procedure for failed canalicular surgery, unsuccessful dacryocystorhinostomy (DCR) and refractory lacrimal pump failure (Jones, 1965; Busse, 1982; Lamping and Levine, 1983; Zapala et al., 1992). There have been many reports on the long-term outcomes of CDCR. Aakalu et al. reported their sixteen-year experience using the Putterman-
* Corresponding author. Department of Ophthalmology, Guro Hospital, Korea University College of Medicine, 97 Gurodong-gil, Guro-gu, Seoul 152-703, Republic of Korea. Tel.: þ82 2 2626 1260; fax: þ82 2 857 8580. E-mail address: [email protected] (S. Baek).
Gladstone (PG) tube during CDCR (Aakalu et al., 2012). However, most previous reports have investigated an external approach to CDCR. Trotter and Meyer reported that endoscopic CDCR appears to be more beneficial and reasonable even though the success rates of external and endoscopic CDCR were not significantly different (Trotter and Meyer, 2000). Lee et al. reported a 5-year study of 120 endoscopic endonasal CDCRs using medpor-coated tear drains (MCTD) in an Asian country (Seo and Lee, 2009). Most of reports on CDCR have focused on primary surgery and the initial success rate. Park et al. first reported revision CDCR using endoscopy (Park et al., 2007). To the best of our knowledge, there are no studies on the long-term results of endoscopic endonasal CDCR for both primary and revision procedures. Therefore, the purpose of this study was to evaluate the efficacy of endoscopic endonasal CDCR in both primary and revision procedures by reporting our experience from the past 13 years.
http://dx.doi.org/10.1016/j.jcms.2014.10.001 1010-5182/© 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
8
M. Chang et al. / Journal of Cranio-Maxillo-Facial Surgery 43 (2015) 7e10
2. Patients and methods This retrospective, cross-sectional, non-comparative study was conducted from March 2000 to February 2013 in the oculoplastic clinic at Korea University Hospital. The study was approved by the Institutional Review Board of Korea University Guro Hospital. All study patients with tearing secondary to severe canalicular obstruction underwent endoscopic CDCR using the PG tube performed by a single surgeon (S.B.) and were followed for more than 6 months. The preoperative examination included lacrimal irrigation, probing of canaliculi, general ophthalmic evaluation and nasal cavity examination by endoscopy. Patients with lacrimal duct obstruction due to a tumor, bone deformity or sinusitis were excluded in this study. Endoscopic CDCR was performed under general or local anesthesia based on the condition and age of the patient. The surgical technique of both the primary and revision procedure has been described in Park's report (Park et al., 2007). Each patient visited the clinic every week for the first month postoperative, fortnightly during the second month, and at monthly intervals after that. Jones tube irrigation and endoscopic examination of the nasal cavity were performed at each visit to evaluate the patency of the lacrimal pathway and to detect possible postoperative complications. When the patients had no epiphora and good patency of the tube throughout the postoperative period, the surgery was defined as a success. Occasional epiphora due to mucus plugging of the tube or reversible tube malfunction were also considered compatible with a successful operation. Data were collected and patient characteristics including sex, age, diagnosis, operation time, success rate, cause of failure and postoperative complications were analyzed. 3. Results In the primary group, 24 patients were male and 9 patients were female. In the revision group, 16 patients were male and 6 were
Table 1 Patient demographics and characteristics.
Patient (male/female) Age (range) (years) Cause of surgery
Onset of failure (months) Mean operation time (minutes) Mean tube length (range) (mm) Male (cases) Female (cases) Success rate (6/12/24 months) (%) Male Female Follow up (range) (months)
Primary CDCR
Revision CDCR
33 (24/9) 48.6 (23e77) 1st medial migration 2nd extrusion
22 (16/6) 46.6 (25e75) 1st medial migration 2nd severe inflammation (obstruction of the conjunctival side of the tube, such as a granuloma) 3rd conjunctival synechiae 4th extrusion
3rd loss of tube 4th severe inflammation Mean: 9.8; median: 13 26 (15e38)
Mean: 10.1; median: 6 24 (15e38)
18.7 (15e24)
19.2 (15e24)
18.5 (18 mm: 5; 20 mm: 5) 19.3 (18 mm: 3; 19 mm: 4) 87.9/78.8/63.6
Longer: 12; shorter: 4
74.3/71.4/60.0
87.5/79.2/62.5 88.9/77.8/66.7 21 (6e93)
73.1/69.2/61.5 77.7/66.7/55.6 20 (6e73)
CDCR: conjunctivodacryocystorhinostomy.
Longer: 1; shorter: 3
female. The mean age of the primary and revision groups were 48.6 (range 23e77) and 46.6 (range 25e75) years, respectively. The most common cause of surgery was trauma (22 patients). In the revision cases, medial migration of the Jones tube was the most common reason for operation. The mean operation time was 26 (range 15e38) minutes in primary surgery and 24 (range 15e38) minutes in revision CDCR. The mean tube length inserted was 18.7 (range 15e24) mm in primary surgery and 19.2 (range 15e24) mm in revision procedures. Tubes 18 mm and 20 mm in length were most commonly used in primary CDCR. In revision procedures, the tube was changed in 20 cases (56%) and, among these, replaced with a longer one in 14 cases (70%). The success rate of primary CDCR was 87.9% at 6 months, 78.8% at one year and 63.6% two years after surgery. On the other hand, in revision CDCR, the success rate was 74.3% at 6 months, 71.4% at one year, and 60% two years after surgery. The mean follow-up period was 31 (range 6e93) months in primary surgery and 30 (range 6e73) months in revision cases. In revision CDCR cases, 36 cases involving 22 patients were included. The mean number of revisions was 1.6 (range 1e5) and the average period to onset of failure after primary surgery was 10.1 months (range 3e40 months). The most common cause of failure in revision surgery was medial migration of the tube (5 cases) and severe inflammation, which resulted in obstruction of the conjunctival side of tube due to granuloma (4 cases) or conjunctival synechiae (3 cases) among other etiologies (Table 1). 4. Discussion In the present study, we evaluated the long-term outcomes of both primary and revision endoscopic CDCR. There were several notable patient characteristics. First, on the contrary to most previous reports, wherein the majority of the patients included were women (Trotter and Meyer, 2000; Lim et al., 2004; Wojno, 2010; Aakalu et al., 2012), men were predominant in our study, comprising 24 of 33 patients. We believe that this may reflect differences in the cause of canalicular obstruction. In western reports, the most common cause of disease was iatrogenic or infection. On the other hand, the most common cause in our study was trauma. Therefore, our study showed a distinct sex ratio, which may contribute to the differences in the results in our study, such as the success rate. Although we did not compare the outcomes of external and endonasal approaches to CDCR, there are several advantages to endoscopic endonasal CDCR, as suggested by our previous experiences with external CDCR. Some reports have demonstrated the effectiveness of endonasal CDCR. Boboridis and Downes reported a 75% success rate for 16 cases (Boboridis and Downes, 2005); Park et al. reported a 78.6% success rate for 14 cases (Park et al., 2007) and Trotter and Mayer reported a 100% success rate for 7 cases (Trotter and Meyer, 2000). To the best of our knowledge, there is only one report that has compared the two techniques, which demonstrated some advantages of endonasal CDCR (Trotter and Meyer, 2000). First, the operation time was relatively short (endonasal vs. external: 59 vs. 74 min). Second, endonasal CDCR resulted in less bleeding in (endo vs. external: 3.5 vs. 4.4 ml) (Trotter and Meyer, 2000). However, the authors reported no significant difference in success between the two techniques. While this study was limited by a relatively small sample size and varying follow-up duration, it demonstrated the advantages of endonasal CDCR. In a previous report from 2007, the primary success rate of endonasal CDCR was 78.6% at 6 months postoperative and the mean operation time was 24 min (Park et al., 2007). In the present study, the primary success rate was 87.9% and the mean operation time was 26 min. The advantages of endonasal CDCR include a shorter operation times, less bleeding, more precise and direct
M. Chang et al. / Journal of Cranio-Maxillo-Facial Surgery 43 (2015) 7e10
detection of the proper length and degree of the tube, and lastly, no visible scarring of the skin. Nonetheless, a comparative study is necessary to confirm the higher success rate of this procedure over external CDCR. In our study, the most common cause of re-operation was tube malposition such as medial migration or extrusion (Fig. 1). As the most common cause of canalicular obstruction was trauma, our hypothesis is that trauma-induced laxity around medial canthal area resulted in frequent Jones tube malposition, as the tube was not securely held. To support this hypothesis, most of the cases of tube malposition had a history of trauma. However, we did not check for medial canthal laxity or otherwise evaluate the medial canthus, which is a limitation of the study. Therefore, further evaluation and investigation in this regard is necessary. According to most previous cases, postoperative complications tend to occur within the first six months (Rosen et al., 1994). In particular, extrusion of the Jones tube typically occurs within six months of the operation (Nissen and Sorensen, 1987; Zilelioglu and Gunduz, 1996; Lee et al., 2001). Otherwise known as early extrusion after CDCR, the mean time to extrusion in our study was 9.6 months, which was longer than six months. Similarly, Aakalu et al. (Aakalu et al., 2012) reported a median time to tube extrusion of 8 months and a mean time of 16 months. Furthermore, in our study, the success rate gradually decreased with time. At 6 months, the success rate was almost 88%, but decreased to 63% at two years postoperative. These results indicate that long-term follow-up in CDCR surgery is necessary even if no severe complications occur within the first 6 months. In our study, we also evaluated revision surgery for CDCR. Aside from a 2007 report by Park et al. (Park et al., 2007), there have been no other reports on revision CDCR to date. Park et al. reported a 100% success rate 6 months postoperative and a mean operation time of 21 min. Similarly, in our study, the success rate 6 months after surgery was 74.3% and mean operation time was 24 min. However, we found that the success rates fell with time to 60% 2 years postoperative. The tendency for the success rate to decrease proportional to the follow-up period was observed in both primary and revision surgery. The most common cause of reoperation was the same in primary and revision surgery; however, in revision cases second most common cause was severe inflammation, such as conjunctival granulomas, which blocked the opening of the tube (Fig. 2) and synechiae, which differed from primary surgery. Therefore, it is important to monitor for and prevent severe inflammation after revision surgery. Accordingly, the use of anti-proliferative drugs such as 5-FU or MMC may be
Fig. 1. The Jones tube is extruded and migrated to the lateral side.
9
Fig. 2. The opening of the tube is obstructed with a large conjunctival granuloma.
effective in these situations and should be considered (Cordeiro et al., 2000). Inappropriate length of tube insertion is another condition that requires a revision operation. When a tube has migrated medially, it may touch the nasal septum and become functionally impaired (Fig. 3). On the other hand, when the tube inserted is shorter than necessary, the entrance of the tube may be buried and eventually become obstructed, or the tip of the tube may be located inappropriately in the nasal cavity, causing impaired function. In our study, the length of the tube most commonly used was 18 and 20 mm. However, among 36 cases, tube exchange was required in 20 cases and, in 70% of these cases, longer tubes were newly inserted. In contrast, shorter tubes were inserted less commonly during revision (too long vs. too short, 13 vs. 7 cases). Although we do not know the exact reason for this, we suggest three possible mechanisms. First, the angle of the tube inserted into the nasal cavity can change according to the migration of the tube and, as a result, the tip of tube can touch the nasal cavity. Second, as wound healing proceeds, the adhesion and contracture or fibrosis of the tissues surrounding the tube can also alter the position of the tube in the nasal cavity. Third, excessive nasal packing before surgery can widen the nasal cavity and the operator can mistakenly select a tube that is too long and only appropriate in this dilated state. We surmise that the appropriate length of the Jones tube may differ between Asian and western populations because of variations in anatomy. Woo et al. demonstrated the differences in anatomy between eastern and western people (Woo et al., 2011). According to their report, the operculum of the middle turbinate was attached to the lacrimal sac fossa (93.4%), the frontal process of the maxilla occupied a significant portion of the lacrimal sac fossa and the height and length of the nasal bone was negatively correlated with the thickness of the frontal process of the maxilla (Woo et al., 2011). Therefore, these points should be considered, especially in revision operations, for precise determination of the length of Jones tube needed. In summary, endoscopic endonasal CDCR has many merits such as a short operation time, reduced bleeding and direct visualization of the tube during the operation. Second, the most common cause of failure was tube malposition, which usually occurred after six months postoperative, suggesting that long-term follow-up is necessary. Third, even though the success rates and the main cause of failure were similar between primary and revision procedures, in revision operations, severe inflammation and synechiae more frequently developed. Fourth, the most commonly used tube lengths were 18 and 20 mm in this study and inappropriate length
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M. Chang et al. / Journal of Cranio-Maxillo-Facial Surgery 43 (2015) 7e10
Fig. 3. The Jones tube is well placed in the nasal cavity (left); however, the tube touches the nasal septum (right).
of tube insertion may be one of the main causes of failure. Our results indicated that tube exchange was performed in 56% of revision operations, and in 70% of them, longer tubes were necessary for replacement. However, this study has some limitations. It was a retrospective chart review study and, thus, a non-comparative study. Therefore, we could not precisely evaluate the two techniques and statistical power may be limited. In addition, the follow-up periods and the number of patients enrolled were insufficient for evaluation of long-term results, so further studies are necessary. 5. Conclusion Even though endoscopic endonasal CDCR is a very effective technique that can improve the success of both primary and revision operations, surgery can fail after one year postoperative. Accordingly, long-term follow-up is essential. The most common cause of failure was medial migration of the tube, which may be avoided through appropriate tube selection and proper fixation techniques. In primary CDCR, inappropriate length of the tube insertion may be the main reason for re-operation, so tube selection requires close attention. Severe inflammation is an important cause of failed revision operations so this problem must also be addressed. Financial support None. Conflict of interest The authors have no conflicts of interest to report.
References Aakalu V, Groat RS, Putterman A: Sixteen-year experience with the PuttermanGladstone tube for conjunctival dacryocystorhinostomy. Ophthal Plast Reconstr Surg 28: 393e395, 2012 Boboridis KG, Downes RN: Endoscopic placement of Jones lacrimal tubes with the assistance of holmium YAG laser. Orbit 24: 67e71, 2005 Busse H: Indications and techniques of implantation of hydrophilic lacrimal tubes. J Maxillofac Surg 10: 116e118, 1982 Cordeiro MF, Chang L, Lim KS, Daniels JT, Pleass RD, Siriwardena D, et al: Modulating conjunctival wound healing. Eye 14(Pt 3B): 536e547, 2000 Jones LT: Conjunctivodacryocystorhinostomy. Am J Ophthalmol 59: 773e783, 1965 Lamping K, Levine MR: Jones' tubes. How good are they? Arch Ophthalmol 101: 260e261, 1983 Lee JS, Jung G, Lee JE, Oum BS, Lee SH, Rho HJ: The treatment of lacrimal apparatus obstruction with the use of an inner canthal Jones tube insertion via a transcaruncular route. Ophthalmic Surg Lasers 32: 48e54, 2001 Lim C, Martin P, Benger R, Kourt G, Ghabrial R: Lacrimal canalicular bypass surgery with the Lester Jones tube. Am J Ophthalmol 137: 101e108, 2004 Nissen JN, Sorensen T: Conjunctivorhinostomy. A study of 21 cases. Acta Ophthalmol 65: 30e36, 1987 Park MS, Chi MJ, Baek SH: Clinical study of endoscopic endonasal conjunctivodacryocystorhinostomy with Jones tube placement. Ophthalmologica 221: 36e40, 2007 Rosen N, Ashkenazi I, Rosner M: Patient dissatisfaction after functionally successful conjunctivodacryocystorhinostomy with Jones tube. Am J Ophthalmology 117: 636e642, 1994 Seo IH, Lee TS: Five-year study of 120 endoscopic conjunctivodacryocystorhinostomy using porous polyethylene-coated tear drain. J Korean Ophthalmol Soc 50(6), 2009 Trotter WL, Meyer DR: Endoscopic conjunctivodacryocystorhinostomy with Jones tube placement. Ophthalmology 107: 1206e1209, 2000 Wojno T: Experience with a medpor-coated tear drain. Ophthal Plast Reconstr Surg 26: 327e329, 2010 Woo KI, Maeng HS, Kim YD: Characteristics of intranasal structures for endonasal dacryocystorhinostomy in Asians. Am J Ophthalmol 152: 491e498, 2011 Zapala J, Bartkowski AM, Bartkowski SB: Lacrimal drainage system obstruction: management and results obtained in 70 patients. J Craniomaxillofac Surg 20: 178e183, 1992 Zilelioglu G, Gunduz K: Conjunctivodacryocystorhinostomy with Jones tube. A 10year study. Doc Ophthalmol 92: 97e105, 1996
Contents lists available at ScienceDirect
Journal of Cranio-Maxillo-Facial Surgery journal homepage: www.jcmfs.com
Long-term outcomes of endoscopic endonasal conjunctivodacryocystorhinostomy with Jones tube placement: A thirteen-year experience Minwook Chang a, Hwa Lee b, Minsoo Park c, Sehyun Baek b, * a b c
Department of Ophthalmology, Dongguk University Ilsan Hospital, Goyang, Republic of Korea Department of Ophthalmology, Korea University College of Medicine, Seoul, Republic of Korea Department of Ophthalmology, KEPCO Medical Center, Seoul, Republic of Korea
a r t i c l e i n f o
a b s t r a c t
Article history: Paper received 7 March 2014 Accepted 1 October 2014 Available online 7 October 2014
Purpose: To report thirteen years of experience with endoscopic-assisted endonasal primary conjunctivodacryocystorhinostomy (CDCR) and revision with Jones tube placement in Korean patients. Methods: Thirty-three patients who underwent primary endoscopic endonasal CDCR with a Jones tube and were followed for over 6 months and 22 patients who underwent revision CDCR were retrospectively reviewed. We evaluated the cause of obstruction, operation time, tube length, success rate (at 6, 12 and 24 months), and the cause of failure for primary and revision procedures. Results: The most common cause for operation in primary CDCR was trauma. The mean operation time was 26 min and 24 min in the primary and revision groups. The initial success rate was 87.9% vs. 74.3% at 6 months postoperative and 63.6% vs. 60% at two years after surgery in the primary and revision group. The most common reason for failure in both groups was medial migration of the tube, and the mean onset of these complications was about 10 months postoperative. Other major reasons for failure were inappropriate length of tube insertion in the primary group and inflammation in the revision group. Conclusion: Fatal complications which lead to failure may develop many months into the procedure, so long-term follow-up is necessary. The most common cause of failure was medial migration of the Jones tube; however, inappropriate tube insertion in primary surgery and severe inflammation in revision may also be concerns. © 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
Keywords: Endoscopic endonasal CDCR Success rate Cause of failure Operation time Primary and revisional surgery Length of Jones tube
1. Introduction Conjunctivodacryocystorhinostomy (CDCR) with Jones tube placement is the gold standard for complete or severe canalicular obstruction, and is performed as an additional procedure for failed canalicular surgery, unsuccessful dacryocystorhinostomy (DCR) and refractory lacrimal pump failure (Jones, 1965; Busse, 1982; Lamping and Levine, 1983; Zapala et al., 1992). There have been many reports on the long-term outcomes of CDCR. Aakalu et al. reported their sixteen-year experience using the Putterman-
* Corresponding author. Department of Ophthalmology, Guro Hospital, Korea University College of Medicine, 97 Gurodong-gil, Guro-gu, Seoul 152-703, Republic of Korea. Tel.: þ82 2 2626 1260; fax: þ82 2 857 8580. E-mail address: [email protected] (S. Baek).
Gladstone (PG) tube during CDCR (Aakalu et al., 2012). However, most previous reports have investigated an external approach to CDCR. Trotter and Meyer reported that endoscopic CDCR appears to be more beneficial and reasonable even though the success rates of external and endoscopic CDCR were not significantly different (Trotter and Meyer, 2000). Lee et al. reported a 5-year study of 120 endoscopic endonasal CDCRs using medpor-coated tear drains (MCTD) in an Asian country (Seo and Lee, 2009). Most of reports on CDCR have focused on primary surgery and the initial success rate. Park et al. first reported revision CDCR using endoscopy (Park et al., 2007). To the best of our knowledge, there are no studies on the long-term results of endoscopic endonasal CDCR for both primary and revision procedures. Therefore, the purpose of this study was to evaluate the efficacy of endoscopic endonasal CDCR in both primary and revision procedures by reporting our experience from the past 13 years.
http://dx.doi.org/10.1016/j.jcms.2014.10.001 1010-5182/© 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
8
M. Chang et al. / Journal of Cranio-Maxillo-Facial Surgery 43 (2015) 7e10
2. Patients and methods This retrospective, cross-sectional, non-comparative study was conducted from March 2000 to February 2013 in the oculoplastic clinic at Korea University Hospital. The study was approved by the Institutional Review Board of Korea University Guro Hospital. All study patients with tearing secondary to severe canalicular obstruction underwent endoscopic CDCR using the PG tube performed by a single surgeon (S.B.) and were followed for more than 6 months. The preoperative examination included lacrimal irrigation, probing of canaliculi, general ophthalmic evaluation and nasal cavity examination by endoscopy. Patients with lacrimal duct obstruction due to a tumor, bone deformity or sinusitis were excluded in this study. Endoscopic CDCR was performed under general or local anesthesia based on the condition and age of the patient. The surgical technique of both the primary and revision procedure has been described in Park's report (Park et al., 2007). Each patient visited the clinic every week for the first month postoperative, fortnightly during the second month, and at monthly intervals after that. Jones tube irrigation and endoscopic examination of the nasal cavity were performed at each visit to evaluate the patency of the lacrimal pathway and to detect possible postoperative complications. When the patients had no epiphora and good patency of the tube throughout the postoperative period, the surgery was defined as a success. Occasional epiphora due to mucus plugging of the tube or reversible tube malfunction were also considered compatible with a successful operation. Data were collected and patient characteristics including sex, age, diagnosis, operation time, success rate, cause of failure and postoperative complications were analyzed. 3. Results In the primary group, 24 patients were male and 9 patients were female. In the revision group, 16 patients were male and 6 were
Table 1 Patient demographics and characteristics.
Patient (male/female) Age (range) (years) Cause of surgery
Onset of failure (months) Mean operation time (minutes) Mean tube length (range) (mm) Male (cases) Female (cases) Success rate (6/12/24 months) (%) Male Female Follow up (range) (months)
Primary CDCR
Revision CDCR
33 (24/9) 48.6 (23e77) 1st medial migration 2nd extrusion
22 (16/6) 46.6 (25e75) 1st medial migration 2nd severe inflammation (obstruction of the conjunctival side of the tube, such as a granuloma) 3rd conjunctival synechiae 4th extrusion
3rd loss of tube 4th severe inflammation Mean: 9.8; median: 13 26 (15e38)
Mean: 10.1; median: 6 24 (15e38)
18.7 (15e24)
19.2 (15e24)
18.5 (18 mm: 5; 20 mm: 5) 19.3 (18 mm: 3; 19 mm: 4) 87.9/78.8/63.6
Longer: 12; shorter: 4
74.3/71.4/60.0
87.5/79.2/62.5 88.9/77.8/66.7 21 (6e93)
73.1/69.2/61.5 77.7/66.7/55.6 20 (6e73)
CDCR: conjunctivodacryocystorhinostomy.
Longer: 1; shorter: 3
female. The mean age of the primary and revision groups were 48.6 (range 23e77) and 46.6 (range 25e75) years, respectively. The most common cause of surgery was trauma (22 patients). In the revision cases, medial migration of the Jones tube was the most common reason for operation. The mean operation time was 26 (range 15e38) minutes in primary surgery and 24 (range 15e38) minutes in revision CDCR. The mean tube length inserted was 18.7 (range 15e24) mm in primary surgery and 19.2 (range 15e24) mm in revision procedures. Tubes 18 mm and 20 mm in length were most commonly used in primary CDCR. In revision procedures, the tube was changed in 20 cases (56%) and, among these, replaced with a longer one in 14 cases (70%). The success rate of primary CDCR was 87.9% at 6 months, 78.8% at one year and 63.6% two years after surgery. On the other hand, in revision CDCR, the success rate was 74.3% at 6 months, 71.4% at one year, and 60% two years after surgery. The mean follow-up period was 31 (range 6e93) months in primary surgery and 30 (range 6e73) months in revision cases. In revision CDCR cases, 36 cases involving 22 patients were included. The mean number of revisions was 1.6 (range 1e5) and the average period to onset of failure after primary surgery was 10.1 months (range 3e40 months). The most common cause of failure in revision surgery was medial migration of the tube (5 cases) and severe inflammation, which resulted in obstruction of the conjunctival side of tube due to granuloma (4 cases) or conjunctival synechiae (3 cases) among other etiologies (Table 1). 4. Discussion In the present study, we evaluated the long-term outcomes of both primary and revision endoscopic CDCR. There were several notable patient characteristics. First, on the contrary to most previous reports, wherein the majority of the patients included were women (Trotter and Meyer, 2000; Lim et al., 2004; Wojno, 2010; Aakalu et al., 2012), men were predominant in our study, comprising 24 of 33 patients. We believe that this may reflect differences in the cause of canalicular obstruction. In western reports, the most common cause of disease was iatrogenic or infection. On the other hand, the most common cause in our study was trauma. Therefore, our study showed a distinct sex ratio, which may contribute to the differences in the results in our study, such as the success rate. Although we did not compare the outcomes of external and endonasal approaches to CDCR, there are several advantages to endoscopic endonasal CDCR, as suggested by our previous experiences with external CDCR. Some reports have demonstrated the effectiveness of endonasal CDCR. Boboridis and Downes reported a 75% success rate for 16 cases (Boboridis and Downes, 2005); Park et al. reported a 78.6% success rate for 14 cases (Park et al., 2007) and Trotter and Mayer reported a 100% success rate for 7 cases (Trotter and Meyer, 2000). To the best of our knowledge, there is only one report that has compared the two techniques, which demonstrated some advantages of endonasal CDCR (Trotter and Meyer, 2000). First, the operation time was relatively short (endonasal vs. external: 59 vs. 74 min). Second, endonasal CDCR resulted in less bleeding in (endo vs. external: 3.5 vs. 4.4 ml) (Trotter and Meyer, 2000). However, the authors reported no significant difference in success between the two techniques. While this study was limited by a relatively small sample size and varying follow-up duration, it demonstrated the advantages of endonasal CDCR. In a previous report from 2007, the primary success rate of endonasal CDCR was 78.6% at 6 months postoperative and the mean operation time was 24 min (Park et al., 2007). In the present study, the primary success rate was 87.9% and the mean operation time was 26 min. The advantages of endonasal CDCR include a shorter operation times, less bleeding, more precise and direct
M. Chang et al. / Journal of Cranio-Maxillo-Facial Surgery 43 (2015) 7e10
detection of the proper length and degree of the tube, and lastly, no visible scarring of the skin. Nonetheless, a comparative study is necessary to confirm the higher success rate of this procedure over external CDCR. In our study, the most common cause of re-operation was tube malposition such as medial migration or extrusion (Fig. 1). As the most common cause of canalicular obstruction was trauma, our hypothesis is that trauma-induced laxity around medial canthal area resulted in frequent Jones tube malposition, as the tube was not securely held. To support this hypothesis, most of the cases of tube malposition had a history of trauma. However, we did not check for medial canthal laxity or otherwise evaluate the medial canthus, which is a limitation of the study. Therefore, further evaluation and investigation in this regard is necessary. According to most previous cases, postoperative complications tend to occur within the first six months (Rosen et al., 1994). In particular, extrusion of the Jones tube typically occurs within six months of the operation (Nissen and Sorensen, 1987; Zilelioglu and Gunduz, 1996; Lee et al., 2001). Otherwise known as early extrusion after CDCR, the mean time to extrusion in our study was 9.6 months, which was longer than six months. Similarly, Aakalu et al. (Aakalu et al., 2012) reported a median time to tube extrusion of 8 months and a mean time of 16 months. Furthermore, in our study, the success rate gradually decreased with time. At 6 months, the success rate was almost 88%, but decreased to 63% at two years postoperative. These results indicate that long-term follow-up in CDCR surgery is necessary even if no severe complications occur within the first 6 months. In our study, we also evaluated revision surgery for CDCR. Aside from a 2007 report by Park et al. (Park et al., 2007), there have been no other reports on revision CDCR to date. Park et al. reported a 100% success rate 6 months postoperative and a mean operation time of 21 min. Similarly, in our study, the success rate 6 months after surgery was 74.3% and mean operation time was 24 min. However, we found that the success rates fell with time to 60% 2 years postoperative. The tendency for the success rate to decrease proportional to the follow-up period was observed in both primary and revision surgery. The most common cause of reoperation was the same in primary and revision surgery; however, in revision cases second most common cause was severe inflammation, such as conjunctival granulomas, which blocked the opening of the tube (Fig. 2) and synechiae, which differed from primary surgery. Therefore, it is important to monitor for and prevent severe inflammation after revision surgery. Accordingly, the use of anti-proliferative drugs such as 5-FU or MMC may be
Fig. 1. The Jones tube is extruded and migrated to the lateral side.
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Fig. 2. The opening of the tube is obstructed with a large conjunctival granuloma.
effective in these situations and should be considered (Cordeiro et al., 2000). Inappropriate length of tube insertion is another condition that requires a revision operation. When a tube has migrated medially, it may touch the nasal septum and become functionally impaired (Fig. 3). On the other hand, when the tube inserted is shorter than necessary, the entrance of the tube may be buried and eventually become obstructed, or the tip of the tube may be located inappropriately in the nasal cavity, causing impaired function. In our study, the length of the tube most commonly used was 18 and 20 mm. However, among 36 cases, tube exchange was required in 20 cases and, in 70% of these cases, longer tubes were newly inserted. In contrast, shorter tubes were inserted less commonly during revision (too long vs. too short, 13 vs. 7 cases). Although we do not know the exact reason for this, we suggest three possible mechanisms. First, the angle of the tube inserted into the nasal cavity can change according to the migration of the tube and, as a result, the tip of tube can touch the nasal cavity. Second, as wound healing proceeds, the adhesion and contracture or fibrosis of the tissues surrounding the tube can also alter the position of the tube in the nasal cavity. Third, excessive nasal packing before surgery can widen the nasal cavity and the operator can mistakenly select a tube that is too long and only appropriate in this dilated state. We surmise that the appropriate length of the Jones tube may differ between Asian and western populations because of variations in anatomy. Woo et al. demonstrated the differences in anatomy between eastern and western people (Woo et al., 2011). According to their report, the operculum of the middle turbinate was attached to the lacrimal sac fossa (93.4%), the frontal process of the maxilla occupied a significant portion of the lacrimal sac fossa and the height and length of the nasal bone was negatively correlated with the thickness of the frontal process of the maxilla (Woo et al., 2011). Therefore, these points should be considered, especially in revision operations, for precise determination of the length of Jones tube needed. In summary, endoscopic endonasal CDCR has many merits such as a short operation time, reduced bleeding and direct visualization of the tube during the operation. Second, the most common cause of failure was tube malposition, which usually occurred after six months postoperative, suggesting that long-term follow-up is necessary. Third, even though the success rates and the main cause of failure were similar between primary and revision procedures, in revision operations, severe inflammation and synechiae more frequently developed. Fourth, the most commonly used tube lengths were 18 and 20 mm in this study and inappropriate length
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Fig. 3. The Jones tube is well placed in the nasal cavity (left); however, the tube touches the nasal septum (right).
of tube insertion may be one of the main causes of failure. Our results indicated that tube exchange was performed in 56% of revision operations, and in 70% of them, longer tubes were necessary for replacement. However, this study has some limitations. It was a retrospective chart review study and, thus, a non-comparative study. Therefore, we could not precisely evaluate the two techniques and statistical power may be limited. In addition, the follow-up periods and the number of patients enrolled were insufficient for evaluation of long-term results, so further studies are necessary. 5. Conclusion Even though endoscopic endonasal CDCR is a very effective technique that can improve the success of both primary and revision operations, surgery can fail after one year postoperative. Accordingly, long-term follow-up is essential. The most common cause of failure was medial migration of the tube, which may be avoided through appropriate tube selection and proper fixation techniques. In primary CDCR, inappropriate length of the tube insertion may be the main reason for re-operation, so tube selection requires close attention. Severe inflammation is an important cause of failed revision operations so this problem must also be addressed. Financial support None. Conflict of interest The authors have no conflicts of interest to report.
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