The Laryngoscope C 2015 The American Laryngological, V
Rhinological and Otological Society, Inc.
Long-Term Outcomes of Powered Endoscopic Dacryocystorhinostomy in Acute Dacryocystitis Naja Chisty, BS; Manpreet Singh, MS; Mohammad Javed Ali, FRCS; Milind N. Naik, MD Objectives/Hypothesis: Endoscopic dacryocystorhinostomy (DCR) is rapidly gaining recognition as a primary modality of management in acute dacryocystitis and lacrimal abscess. The purpose of the present study is to report long-term outcomes of powered endoscopic DCR in cases of acute dacryocystitis. Study Design: Prospective interventional case series. Methods: Twenty-one powered endoscopic DCRs were performed in 21 patients presenting with acute dacryocystitis. All cases were operated by a single surgeon (M.J.A.) using earlier published techniques. All lacrimal systems were intubated for 6 weeks. A minimum follow-up of 1 year after stent removal was considered for final analysis. Main outcome measures were the anatomical and functional success of the surgical procedure. Results: The mean age of patients at presentation was 31.8 years. A total of 14.3% (3/21) were pediatric patients with known history of persistent congenital nasolacrimal duct obstruction (CNLDO), and 9.5% (2/21) had a history of external DCR in the past. All patients received postoperative antibiotics. Additional procedures included distal canalicular trephination, septoplasty, and middle turbinoplasty in one patient each. All cases showed resolution of pain and swelling at 1 week followup. At the mean follow-up of 15.4 months, anatomical success was achieved in 85.7% of the patients (18/21), and functional success was achieved in 80.9% (17/21). Conclusion: Powered endoscopic DCR is a useful modality in the management acute dacryocystitis, with good outcomes that are maintained over a long duration of time. Key Words: Powered endoscopic DCR, long-term, acute dacryocystitis, lacrimal abscess, outcomes. Level of Evidence: 4. Laryngoscope, 126:551–553, 2016
INTRODUCTION Acute dacryocystitis is defined as “a medical urgency which is clinically characterized by rapid onset of pain, erythema and swelling, classically below the medial canthal tendon with or without pre-existing epiphora mainly resulting from the acute infection of the lacrimal sac and perisac tissues.”1,2 If left untreated or inadequately managed, it can lead to complications such as orbital cellulitis, orbital abscess, superior ophthalmic vein thrombosis, and meningitis.3–5 One of the major limiting factors in performing an external dacryocystorhinostomy (DCR) in acute dacryocystitis is the degree of inflammation, which makes the surgical procedure difficult and may subsequently impact the outcomes.6–14 In contrast, the role of endoscopic DCR during the acute phase of dacryocystitis is increasingly being recognized as a safe alternative that decreases morbidity and hastens recovery.1,6–14 With the establishment of endoscopic
From the Rocky Vista University College of Osteopathic Medicine (N.C.), Parker, Colorado, U.S.A.; and the Dacryology Service, L.V. Prasad Eye Institute (M.S., M.J.A., M.N.N.), Hyderabad, India. Editor’s Note: This Manuscript was accepted for publication April 17, 2015. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Mohammad Javed Ali, FRCS, L.V. Prasad Eye Institute, Road No 2, Banjara Hills, Hyderabad-34, India. E-mail: [email protected] DOI: 10.1002/lary.25380
Laryngoscope 126: March 2016
DCR as an equally effective modality for the treatment of persistent and complex congenital nasolacrimal duct obstruction (CNLDO), recurrent pediatric acute dacryocystitis is also being recognized as one of the indications for surgery during the acute phase.1,14–16 The success rates of endoscopic DCR in acute dacryocystitis are reported up to 96.2% after primary and revision surgeries. Although long-term outcomes of primary endoscopic DCR for routine cases have been reported to be in the range of 81% to 97.7%,17–20 very few studies analyzed the long-term outcomes in cases of acute dacryocystitis.10,11,13 The purpose of present study is to report the long-term outcomes of powered endoscopic DCR in patients with acute dacryocystitis.
MATERIALS AND METHODS A prospective study was performed that included 21 powered endoscopic DCRs in 21 patients presenting with acute dacryocystitis at a tertiary eye care center. Consecutive patients were selected, and thus the sample also included pediatric patients refractory to probing and intubation and past failed external DCRs. Institutional review board approval was obtained, and the study adhered to the tenets of the Declaration of Helsinki. Informed consent was obtained from all of patients and parents of pediatric patients. All cases were operated during the acute stage by a single surgeon (M.J.A.) using the techniques described earlier.1,20 In brief, incisions are taken 10 mm above the axilla of the middle turbinate and extended anteriorly for 10 mms. A vertical incision is then taken from this point to the insertion of inferior turbinate before directing it back to the
Chisty et al.: Endoscopic DCR in Acute Dacryocystitis
551
insertion of the uncinate process. A posteriorly based nasal mucosal flap is raised centered over the lacrimal drainage system to expose the frontal process of the maxilla and the lacrimal–maxillary suture line. The thin lacrimal bone is removed, and the frontal process of the maxilla over the nasolacrimal duct and lower half of the lacrimal sac is punched out using the Hajek-Kopfler punch (Karl Storz, Tuttlingen, Germany). The portion of the bone over the superior half of the lacrimal sac is quite thick and is removed by using a curved, high-speed diamond DCR burr (Medtronic Xomed, Jacksonville, FL). The osteotomy is continued until complete exposure of the entire lacrimal sac is obtained. A Bowman’s probe is used to tent the medial sac wall, and a full-length marsupialization of the lacrimal sac is achieved to create anterior and posterior flaps. Horizontal incisions are taken at the superior and inferior end of the flaps to open up the entire lacrimal sac like a book on the lateral nasal wall. A 360-degree mucosa-to-mucosa approximation is achieved to encourage healing by primary intention. Mitomycin C (MMC) application (0.02%, 3 minutes), as described earlier by authors21 was used to inhibit the myofibroblasts and subsequent scarring, which is well known to occur more in cases of severe inflammation, as in the present series. Nasolacrimal stents were left in place for 6 weeks. Antibiotics were initiated intraoperatively and continued in the postoperative period. Long-term outcomes were evaluated at a minimum of 12 months follow-up after stent removal.20 Main outcome measures were resolution of the acute infection and anatomical and functional success of the surgical procedure. Anatomical success was defined as a patent ostium on irrigation, and functional success as a free flow of dye into the ostium and resolution of the epiphora.
RESULTS Among the patients, there was a female preponderance (80.9%, 17/21). Left-sided involvement was more common (61.9%, 13/21).The mean age at presentation was 31.8 years (range: 4 months–68 years). A total of 14.3% (3/ 21) were pediatric patients with a known history of persistent CNLDO, and 9.5% (2/21) had a history of external DCR in the past. Comorbidities in the form of diabetes mellitus were noted in 14.3% (3/21) of the patients. Additional procedures included distal canalicular trephination, septoplasty, and middle turbinoplasty in one patient each. Although intraoperative bleeding was a little more than in the routine cases, this is not unexpected and did not pose difficulties in any of the patients. All of the cases showed resolution of pain and swelling at 1 week follow-up. No cases of mucosal burns were noted at sites of MMC application. At the mean follow-up of 15.4 months (range: 12– 24 months), anatomical success was achieved in 85.7% (18/21) of the patients and functional success in 80.9% (17/ 21). Of the three patients who showed anatomical failure, two were secondary to complete cicatricial closure of the ostium and one was the revision surgery that failed secondary to an organized ostium granuloma in front of internal common opening. One patient had a patent miniostium22 with persistent epiphora and was diagnosed as a functional failure.
DISCUSSION The current study analyzed the long-term results of powered endoscopic DCR during acute phases of dacryocystitis in primary and revision cases. At a mean followup of 15.4 months, the anatomical and functional Laryngoscope 126: March 2016
552
successes were maintained in approximately 86% and 81%, respectively. Cicatricial closure of the ostium was the most common cause of failure. Surgical management of acute dacryocystitis, with an external DCR in the acute phase, is not preferred due to risk of spread of infection, subsequent development of fistula, and associated surgical difficulties.1,9–11 Although DCR can be performed following conservative treatment and resolution of infection in a more controlled setting, performing it in an acute setting provides additional advantages of reducing morbidity, preventing complications and gaining an overall economic benefit.9–13 Whereas various endonasal techniques have been described in settings of acute dacryocystitis, powered endoscopic DCR has certain distinct advantages such as the creation of a large osteotomy, full-length sac marsupialization, and 360-degree mucosa-to-mucosa approximation, which facilitates primary intention healing.1,20 Wu et al.10 performed a prospective randomized study on 72 patients in which 40 patients underwent an endoscopic DCR and 32 patients were treated conservatively, followed by an external DCR. Intubation was performed in all patients and retained for 3 months. At 12 months follow-up after stent removal, ostial patency were noted in 90% in the endoscopic group and in 66% in the external DCR group, and this difference was statistically significant (P < 0.05). The interesting observations in this study were with regard to symptom resolution. Although all patients showed resolution of symptoms, the mean time 6 standard deviation for pain relief and resolution of swelling were 1.0 6 0.7 days and 3.4 6 1.0 days, respectively, in the endoscopic group versus 5.5 6 1.1 days and 8.3 6 1.3 days, respectively, in the external DCR group. These figures reflect the decreased postoperative morbidity and quicker resolution of symptoms in the endoscopic group (P < 0.001). The outcomes of endoscopic DCR in acute dacryocystitis in other studies ranged from 81.8% to 96.2%.9,11,13 Kamal et al.,1 in their series of primary powered endoscopic DCR performed in 20 patients of acute dacryocystitis and lacrimal abscess, showed that at a follow-up of 6 months, anatomical and functional success was noted in 95% (n 5 19) and 90% (n 5 18) of the patients, respectively. Anatomical failure was ascribed to complete cicatricial closure; however, no definite cause could be attributed to the functional failure. Naik et al.12 performed an interesting comparison between mechanical endoscopic DCR (group A, n 5 13) versus incision and drainage (group B, n 5 18) in their series on lacrimal abscess. Pain perception was recorded using the visual analog scale (VAS). The mean VAS score on postoperative day 1 was 3.14 in group A versus 4.64 in group B. The mean blood loss from an endoscopic DCR in a setting of lacrimal abscess was calculated to be 65 ml. Adjunctive endoscopic procedures performed in their series include septoplasty, functional endoscopic sinus surgery (FESS), concha bulloplasty, and polypectomy. At 6 months follow-up, they reported success in 92.3% (n 5 12) of the patients. Pediatric endoscopic DCR is now a well established modality for treating certain refractory cases of CNLDO.15,16 However, the surgery poses special Chisty et al.: Endoscopic DCR in Acute Dacryocystitis
challenges because of narrow anatomic confines, differences in anatomical boundaries, use of specialized pediatric instruments, and unclear roles of adjunctive therapies such as MMC and intubation. Recurrent acute dacryocystitis and dacryocystoceles, refractory to other modalities of treatment, are gaining rapid ground as indications for an endoscopic DCR in an acute stage.1,14,23 Although few series on endoscopic DCR in acute dacryocystitis had pediatric patients, useful interpretations could not be drawn because of the low sample size. Nonetheless, the authors did not find any deviant behaviors in the postoperative course or outcomes of their three pediatric patients. The strengths of the current study are single operating surgeon, uniform surgical techniques, and a long follow-up. The limitation of the current study is small sample size, although comparable to most in the literature.7,9,11,13 In conclusion, powered endoscopic DCR is a safe and effective modality for primary treatment of acute dacryocystitis, with good short-term success rates that are well maintained at long-term follow-ups.
Acknowledgment The authors wish to acknowledge the help of Ms. Sabera Banu for the provision of literature.
BIBLIOGRAPHY 1. Kamal S, Ali MJ, Pujari A, Naik MN. Primary powered endoscopic dacryocystorhinostomy in the setting of acute dacryocystitis and lacrimal abscess. Ophthal Plast Reconstr Surg 2014. Epub ahead of print. 2. Ali MJ, Joshi SD, Naik MN, Honavar SG. Clinical profile and management outcome of acute dacryocystitis: two decades of experience in tertiary eye care centre. Semin Ophthalmol 2015;30:118–123. doi: 10.3109/ 08820538.2013.833269. Epub 2013. 3. Maheshwari R, Maheshwari S, Shah T. Acute dacryocystitis causing orbital cellulitis and abscess. Orbit 2009;28:196–199. 4. Schmitt N, Beatty RL, Kennerdell JS. Superior ophthalmic vein thrombosis in a patient with dacryocystitis-induced orbital cellulitis. Ophthal Plast Reconstr Surg 2005;21:387–389.
Laryngoscope 126: March 2016
5. Baskin DE, Reddy AK, Chu YI, Coats DK. The timing of antibiotic administration in the management of infant dacryocystitis. J AAPOS 2008;12: 456–459. 6. Lee TS, Woog JJ. Endonasal dacryocystorhinostomy in the primary treatment of acute dacryocystitis with abscess formation. Ophthal Plast Reconstr Surg 2001;17:180–183. 7. Morgan S, Austin M, Whittet H. The treatment of acute dacryocystitis using laser assisted endonasal dacryocystorhinostomy. Br J Ophthalmol 2004;88:139–141. 8. Choi JS, Lee JH, Paik HJ. A silastic sheet found during endoscopic transnasal dacryocystorhinostomy for acute dacryocystitis. Korean J Ophthalmol 2006;20:65–69. 9. Duggal P, Mahindroo NK, Chauhan A. Primary endoscopic dacryocystorhinostomy as treatment for acute dacryocystitis with abscess formation. Am J Otolaryngol 2008;29:177–179. 10. Wu W, Yan W, MacCallum JK, et al. Primary treatment of acute dacryocystitis by endoscopic dacryocystorhinostomy with silicone intubation guided by a soft probe. Ophthalmology 2009;116:116–122. 11. Madge SN, Chan W, Malhotra R, et al. Endoscopic dacryocystorhinostomy in acute dacryocystitis: a multicenter case series. Orbit 2011;30:1–6. 12. Naik SM, Appaji MK, Ravishankara S, Mushannavar AS, Naik SS. Endonasal DCR with silicone tube stents: a better management for acute lacrimal abscess. Indian J Otolaryngol Head Neck Surg 2013;65:343–349. 13. Lombardi D, Mattavelli D, Accorona R, et al. Acute dacryocystitis with empyema of the lacrimal sac. Is immediate endoscopic dacryocystorhinostomy justified? Otolaryngol Head Neck Surg 2014;150:1071–1077. 14. Mladina R, Stiglmayer N, Dawidowsky K, Jukic T, Jurlina M, TrupkovicFotivec Bl. Endonasal endoscopic dacryocystorhinostomy for dacryocystocele in a 4 month old infant. Br J Ophthalmol 2001;85:113–114. 15. Vanderveen DK, Jones DT, Tan H, Petersen RA. Endoscopic dacryocystorhinostomy in children. J AAPOS 2001;5:143–147. 16. Cunnigham MJ. Endoscopic management of pediatric nasolacrimal anomalies. Otolaryngol Clin N Am 2006;39:1059–1074. 17. Durvasula VSP, Gatland DJ. Endoscopic dacryocystorhinostomy: long-term results and evolution of surgical technique. J Laryngol Otol 2004;118: 628–632. 18. Zenk J, Karatzanis AD, Pschycogios G, et al. Long-term results of endonasal dacryocystorhinostomy. Eur Arch Otorhinolaryngol 2009;266: 1733–1738. 19. Mohamad SH, Khan I, Shakeel M, Nandapalan V. Long-term results of endonasal dacryocystorhinostomy with and without stents. Ann R Coll Surg Eng 2013;95:196–199. 20. Ali MJ, Psaltis AJ, Bassiouni A, Wormald PJ. Long-term outcomes of primary powered endoscopic dacryocystorhinostomy. Br J Ophthalmol 2014;98:1678–1680. 21. Kamal S, Ali MJ, Naik MN. Circumostial injection of mitomycin C (COSMMC) in external and endoscopic dacryocystorhinostomy: efficacy, safety profile, and outcomes. Ophthal Plast Reconstr Surg 2014;30:187–190. 22. Ali MJ, Psaltis AJ, Wormald PJ. Dacryocystorhinostomy ostium: parameters to evaluate and the DCR ostium scoring. Clin Ophthalmol 2014;8: 2491–2499. 23. Campollataro BN, Leuder GT, Tychsen L. Spectrum of pediatric dacryocystitis: medical and surgical management of 54 cases. J Pediatr Ophthalmol Strabismus 1997;34:143–153.
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Rhinological and Otological Society, Inc.
Long-Term Outcomes of Powered Endoscopic Dacryocystorhinostomy in Acute Dacryocystitis Naja Chisty, BS; Manpreet Singh, MS; Mohammad Javed Ali, FRCS; Milind N. Naik, MD Objectives/Hypothesis: Endoscopic dacryocystorhinostomy (DCR) is rapidly gaining recognition as a primary modality of management in acute dacryocystitis and lacrimal abscess. The purpose of the present study is to report long-term outcomes of powered endoscopic DCR in cases of acute dacryocystitis. Study Design: Prospective interventional case series. Methods: Twenty-one powered endoscopic DCRs were performed in 21 patients presenting with acute dacryocystitis. All cases were operated by a single surgeon (M.J.A.) using earlier published techniques. All lacrimal systems were intubated for 6 weeks. A minimum follow-up of 1 year after stent removal was considered for final analysis. Main outcome measures were the anatomical and functional success of the surgical procedure. Results: The mean age of patients at presentation was 31.8 years. A total of 14.3% (3/21) were pediatric patients with known history of persistent congenital nasolacrimal duct obstruction (CNLDO), and 9.5% (2/21) had a history of external DCR in the past. All patients received postoperative antibiotics. Additional procedures included distal canalicular trephination, septoplasty, and middle turbinoplasty in one patient each. All cases showed resolution of pain and swelling at 1 week followup. At the mean follow-up of 15.4 months, anatomical success was achieved in 85.7% of the patients (18/21), and functional success was achieved in 80.9% (17/21). Conclusion: Powered endoscopic DCR is a useful modality in the management acute dacryocystitis, with good outcomes that are maintained over a long duration of time. Key Words: Powered endoscopic DCR, long-term, acute dacryocystitis, lacrimal abscess, outcomes. Level of Evidence: 4. Laryngoscope, 126:551–553, 2016
INTRODUCTION Acute dacryocystitis is defined as “a medical urgency which is clinically characterized by rapid onset of pain, erythema and swelling, classically below the medial canthal tendon with or without pre-existing epiphora mainly resulting from the acute infection of the lacrimal sac and perisac tissues.”1,2 If left untreated or inadequately managed, it can lead to complications such as orbital cellulitis, orbital abscess, superior ophthalmic vein thrombosis, and meningitis.3–5 One of the major limiting factors in performing an external dacryocystorhinostomy (DCR) in acute dacryocystitis is the degree of inflammation, which makes the surgical procedure difficult and may subsequently impact the outcomes.6–14 In contrast, the role of endoscopic DCR during the acute phase of dacryocystitis is increasingly being recognized as a safe alternative that decreases morbidity and hastens recovery.1,6–14 With the establishment of endoscopic
From the Rocky Vista University College of Osteopathic Medicine (N.C.), Parker, Colorado, U.S.A.; and the Dacryology Service, L.V. Prasad Eye Institute (M.S., M.J.A., M.N.N.), Hyderabad, India. Editor’s Note: This Manuscript was accepted for publication April 17, 2015. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Mohammad Javed Ali, FRCS, L.V. Prasad Eye Institute, Road No 2, Banjara Hills, Hyderabad-34, India. E-mail: [email protected] DOI: 10.1002/lary.25380
Laryngoscope 126: March 2016
DCR as an equally effective modality for the treatment of persistent and complex congenital nasolacrimal duct obstruction (CNLDO), recurrent pediatric acute dacryocystitis is also being recognized as one of the indications for surgery during the acute phase.1,14–16 The success rates of endoscopic DCR in acute dacryocystitis are reported up to 96.2% after primary and revision surgeries. Although long-term outcomes of primary endoscopic DCR for routine cases have been reported to be in the range of 81% to 97.7%,17–20 very few studies analyzed the long-term outcomes in cases of acute dacryocystitis.10,11,13 The purpose of present study is to report the long-term outcomes of powered endoscopic DCR in patients with acute dacryocystitis.
MATERIALS AND METHODS A prospective study was performed that included 21 powered endoscopic DCRs in 21 patients presenting with acute dacryocystitis at a tertiary eye care center. Consecutive patients were selected, and thus the sample also included pediatric patients refractory to probing and intubation and past failed external DCRs. Institutional review board approval was obtained, and the study adhered to the tenets of the Declaration of Helsinki. Informed consent was obtained from all of patients and parents of pediatric patients. All cases were operated during the acute stage by a single surgeon (M.J.A.) using the techniques described earlier.1,20 In brief, incisions are taken 10 mm above the axilla of the middle turbinate and extended anteriorly for 10 mms. A vertical incision is then taken from this point to the insertion of inferior turbinate before directing it back to the
Chisty et al.: Endoscopic DCR in Acute Dacryocystitis
551
insertion of the uncinate process. A posteriorly based nasal mucosal flap is raised centered over the lacrimal drainage system to expose the frontal process of the maxilla and the lacrimal–maxillary suture line. The thin lacrimal bone is removed, and the frontal process of the maxilla over the nasolacrimal duct and lower half of the lacrimal sac is punched out using the Hajek-Kopfler punch (Karl Storz, Tuttlingen, Germany). The portion of the bone over the superior half of the lacrimal sac is quite thick and is removed by using a curved, high-speed diamond DCR burr (Medtronic Xomed, Jacksonville, FL). The osteotomy is continued until complete exposure of the entire lacrimal sac is obtained. A Bowman’s probe is used to tent the medial sac wall, and a full-length marsupialization of the lacrimal sac is achieved to create anterior and posterior flaps. Horizontal incisions are taken at the superior and inferior end of the flaps to open up the entire lacrimal sac like a book on the lateral nasal wall. A 360-degree mucosa-to-mucosa approximation is achieved to encourage healing by primary intention. Mitomycin C (MMC) application (0.02%, 3 minutes), as described earlier by authors21 was used to inhibit the myofibroblasts and subsequent scarring, which is well known to occur more in cases of severe inflammation, as in the present series. Nasolacrimal stents were left in place for 6 weeks. Antibiotics were initiated intraoperatively and continued in the postoperative period. Long-term outcomes were evaluated at a minimum of 12 months follow-up after stent removal.20 Main outcome measures were resolution of the acute infection and anatomical and functional success of the surgical procedure. Anatomical success was defined as a patent ostium on irrigation, and functional success as a free flow of dye into the ostium and resolution of the epiphora.
RESULTS Among the patients, there was a female preponderance (80.9%, 17/21). Left-sided involvement was more common (61.9%, 13/21).The mean age at presentation was 31.8 years (range: 4 months–68 years). A total of 14.3% (3/ 21) were pediatric patients with a known history of persistent CNLDO, and 9.5% (2/21) had a history of external DCR in the past. Comorbidities in the form of diabetes mellitus were noted in 14.3% (3/21) of the patients. Additional procedures included distal canalicular trephination, septoplasty, and middle turbinoplasty in one patient each. Although intraoperative bleeding was a little more than in the routine cases, this is not unexpected and did not pose difficulties in any of the patients. All of the cases showed resolution of pain and swelling at 1 week follow-up. No cases of mucosal burns were noted at sites of MMC application. At the mean follow-up of 15.4 months (range: 12– 24 months), anatomical success was achieved in 85.7% (18/21) of the patients and functional success in 80.9% (17/ 21). Of the three patients who showed anatomical failure, two were secondary to complete cicatricial closure of the ostium and one was the revision surgery that failed secondary to an organized ostium granuloma in front of internal common opening. One patient had a patent miniostium22 with persistent epiphora and was diagnosed as a functional failure.
DISCUSSION The current study analyzed the long-term results of powered endoscopic DCR during acute phases of dacryocystitis in primary and revision cases. At a mean followup of 15.4 months, the anatomical and functional Laryngoscope 126: March 2016
552
successes were maintained in approximately 86% and 81%, respectively. Cicatricial closure of the ostium was the most common cause of failure. Surgical management of acute dacryocystitis, with an external DCR in the acute phase, is not preferred due to risk of spread of infection, subsequent development of fistula, and associated surgical difficulties.1,9–11 Although DCR can be performed following conservative treatment and resolution of infection in a more controlled setting, performing it in an acute setting provides additional advantages of reducing morbidity, preventing complications and gaining an overall economic benefit.9–13 Whereas various endonasal techniques have been described in settings of acute dacryocystitis, powered endoscopic DCR has certain distinct advantages such as the creation of a large osteotomy, full-length sac marsupialization, and 360-degree mucosa-to-mucosa approximation, which facilitates primary intention healing.1,20 Wu et al.10 performed a prospective randomized study on 72 patients in which 40 patients underwent an endoscopic DCR and 32 patients were treated conservatively, followed by an external DCR. Intubation was performed in all patients and retained for 3 months. At 12 months follow-up after stent removal, ostial patency were noted in 90% in the endoscopic group and in 66% in the external DCR group, and this difference was statistically significant (P < 0.05). The interesting observations in this study were with regard to symptom resolution. Although all patients showed resolution of symptoms, the mean time 6 standard deviation for pain relief and resolution of swelling were 1.0 6 0.7 days and 3.4 6 1.0 days, respectively, in the endoscopic group versus 5.5 6 1.1 days and 8.3 6 1.3 days, respectively, in the external DCR group. These figures reflect the decreased postoperative morbidity and quicker resolution of symptoms in the endoscopic group (P < 0.001). The outcomes of endoscopic DCR in acute dacryocystitis in other studies ranged from 81.8% to 96.2%.9,11,13 Kamal et al.,1 in their series of primary powered endoscopic DCR performed in 20 patients of acute dacryocystitis and lacrimal abscess, showed that at a follow-up of 6 months, anatomical and functional success was noted in 95% (n 5 19) and 90% (n 5 18) of the patients, respectively. Anatomical failure was ascribed to complete cicatricial closure; however, no definite cause could be attributed to the functional failure. Naik et al.12 performed an interesting comparison between mechanical endoscopic DCR (group A, n 5 13) versus incision and drainage (group B, n 5 18) in their series on lacrimal abscess. Pain perception was recorded using the visual analog scale (VAS). The mean VAS score on postoperative day 1 was 3.14 in group A versus 4.64 in group B. The mean blood loss from an endoscopic DCR in a setting of lacrimal abscess was calculated to be 65 ml. Adjunctive endoscopic procedures performed in their series include septoplasty, functional endoscopic sinus surgery (FESS), concha bulloplasty, and polypectomy. At 6 months follow-up, they reported success in 92.3% (n 5 12) of the patients. Pediatric endoscopic DCR is now a well established modality for treating certain refractory cases of CNLDO.15,16 However, the surgery poses special Chisty et al.: Endoscopic DCR in Acute Dacryocystitis
challenges because of narrow anatomic confines, differences in anatomical boundaries, use of specialized pediatric instruments, and unclear roles of adjunctive therapies such as MMC and intubation. Recurrent acute dacryocystitis and dacryocystoceles, refractory to other modalities of treatment, are gaining rapid ground as indications for an endoscopic DCR in an acute stage.1,14,23 Although few series on endoscopic DCR in acute dacryocystitis had pediatric patients, useful interpretations could not be drawn because of the low sample size. Nonetheless, the authors did not find any deviant behaviors in the postoperative course or outcomes of their three pediatric patients. The strengths of the current study are single operating surgeon, uniform surgical techniques, and a long follow-up. The limitation of the current study is small sample size, although comparable to most in the literature.7,9,11,13 In conclusion, powered endoscopic DCR is a safe and effective modality for primary treatment of acute dacryocystitis, with good short-term success rates that are well maintained at long-term follow-ups.
Acknowledgment The authors wish to acknowledge the help of Ms. Sabera Banu for the provision of literature.
BIBLIOGRAPHY 1. Kamal S, Ali MJ, Pujari A, Naik MN. Primary powered endoscopic dacryocystorhinostomy in the setting of acute dacryocystitis and lacrimal abscess. Ophthal Plast Reconstr Surg 2014. Epub ahead of print. 2. Ali MJ, Joshi SD, Naik MN, Honavar SG. Clinical profile and management outcome of acute dacryocystitis: two decades of experience in tertiary eye care centre. Semin Ophthalmol 2015;30:118–123. doi: 10.3109/ 08820538.2013.833269. Epub 2013. 3. Maheshwari R, Maheshwari S, Shah T. Acute dacryocystitis causing orbital cellulitis and abscess. Orbit 2009;28:196–199. 4. Schmitt N, Beatty RL, Kennerdell JS. Superior ophthalmic vein thrombosis in a patient with dacryocystitis-induced orbital cellulitis. Ophthal Plast Reconstr Surg 2005;21:387–389.
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