Original Investigation
Powered Endoscopic Dacryocystorhinostomy: A Decade of Experience Mohammad Javed Ali, M.D., F.R.C.S.*, Alkis James Psaltis, Ph.D., F.R.A.C.S.†, Jae Murphy, M.B.B.S.†, and Peter John Wormald, M.D., F.R.A.C.S.† *Dacryology Service, L.V.Prasad Eye Institute, Hyderabad, India; and †Department of Surgery-Otolaryngology, Head and Neck Surgery, University of Adelaide, Adelaide, Australia
Purpose: To report a decade long experience with powered endoscopic dacryocystorhinostomy (DCR). Methods: A retrospective review of all consecutive patients undergoing powered endoscopic DCR was performed at this institution over a period of 11 years from 2002 to 2013. All patients completed a minimum of 3 months follow up following stent removal. Patient records were reviewed for demographic data, clinical and surgical profiles, adjunctive procedures, complications, and success rates at the last follow up. Anatomical success was defined as patent ostium on irrigation and functional success as free flow of dye into ostium on functional endoscopic dye test and resolution of epiphora. Results: Two hundred eighty-three powered endoscopic DCRs were performed on 214 patients. The mean age at surgery was 59.5 years (range, 3–95 years). All patients presented with epiphora. A total of 91.6% patients (196/214) had a primary DCR and 8.4% (18/214) had a revision DCR. In all, 50.4% patients (108/214) underwent adjunctive endonasal procedures. The mean follow up was 17.1 months (range, 3–103 months). At the last follow up, the final anatomical success was achieved in 96.9% cases of primary DCRs and 91.3% cases of revision DCRs. Functional success was achieved in 93% cases of primary DCRs and 86.9% cases of revision DCRs. Conclusions: Powered endoscopic DCR is a safe procedure and offers excellent results both in primary and revision DCRs. The threshold to perform adjunctive endonasal procedures should be very low when indicated. (Ophthal Plast Reconstr Surg 2015;31:219–221)
T
he advent of rigid fibreoptic endoscopes was a major contributor in establishing endoscopic dacryocystorhinostomy (DCR) as a treatment for nasolacrimal duct obstructions.1,2 The major advantages of an endoscopic approach include avoidance of a cutaneous incision with subsequent scar, less disruption of the lacrimal pump, ability to address concurrent nasal abnormalities, ability to operate during acute dacryocystitis, ability
Accepted for publication June 18, 2014. This study has been reviewed by the ethics committee and has been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki. Informed consent was obtained from the patients. The authors have no financial or conflicts of interest to disclose. Address correspondence and reprint requests to Peter John Wormald, M.D., F.R.A.C.S., Department of Otolaryngology Head and Neck Surgery, Level 4, Maternity Building, Adelaide University, Adelaide, South Australia. E-mail: [email protected] DOI: 10.1097/IOP.0000000000000261
Ophthal Plast Reconstr Surg, Vol. 31, No. 3, 2015
to identify etiological factors of failure, less operative time, less postoperative morbidity, and early rehabilitation.2–6 Powered endoscopic DCR as described by Wormald and colleagues is a technique that allows creation of largest possible osteotomy and complete sac marsupialization, and hence achieve high success rates comparable to that of external DCR.7–12 Although the short-term results of an endoscopic DCR are satisfactory, the long-term success rates range from 81% to 94%.13–17 The current study reports demographic, clinical, surgical, and outcome profiles of powered endoscopic DCR in a very large series over a decade long-study period.
METHODS After obtaining institutional review board’s approval for this study, a retrospective review was performed for all patients undergoing powered endoscopic DCR over an 11-year period from 2002 to 2013 at the Otorhinolaryngology department, University of Adelaide, Australia. A detailed history and examination was performed including lacrimal probing, syringing, and functional testing with topical fluorescein. As part of the workup, all patients also underwent lacrimal imaging with dacryocystography and dacryoscintigraphy to establish the diagnosis. All patients completed a minimum of 3 months follow up following stent removal, which was removed in a mean duration of 6.7 weeks (range, 4–12) after surgery. Patient records were reviewed for demographic data, clinical and surgical profiles, adjunctive procedures, complications, and success rates at the last follow up. Anatomical success was defined as patent ostium on irrigation and functional success as free flow of dye into ostium on functional endoscopic dye test and resolution of epiphora. Surgical Technique. Under general anesthetic, all the patients underwent powered endoscopic DCR as described by Wormald et al.7–12 Total intravenous anesthesia with propofol and remifentanil was used with mean arterial blood pressures maintained between 60 mm·Hg and 75 mm·Hg to reduce intraoperative bleeding. Nasal mucosa was decongested with neuro patties soaked in a solution of 2 ml normal saline, 2 ml 10% cocaine, and 1 ml 1:1,000 adrenaline. The lateral wall and head of the middle turbinate were injected with 2% xylocaine with 1:80,000 adrenaline. In brief, the technique described by Wormald et al. can be summarized as follows. Using a 30° nasal endoscope, the procedure begins by raising a posteriorly based mucosal flap centered over the lacrimal sac. The incision of this flap begins 8 mm above the axilla of the middle turbinate and is continued anteriorly approximately 8 mm to 10 mm. A vertical incision is continued inferiorly to the insertion of the inferior turbinate before a horizontal incision is directed posteriorly back to the insertion of uncinate process. Using a suction freer elevator, the mucosal flap is then raised off the lateral wall to expose the frontal process of maxilla and its junction with lacrimal bone. A small round knife is then used to remove the thin lacrimal bone from the sac before using a Hajek-Kopfler forward punch (Karl Storz, Tuttlingen, Germany) to remove the remaining bone covering nasolacrimal duct and frontal
219
Copyright © 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
Ophthal Plast Reconstr Surg, Vol. 31, No. 3, 2015
P. J. Wormald et al.
process of maxilla. Once the bone becomes thick and is not amenable to punch removal above the axilla of the MT, a curved 25° high-speed diamond DCR burr (Medtronic Xomed, Jacksonville, FL, U.S.A.) is used to remove the rest of the bone to expose the sac completely. The agger nasi is exposed during this process since the fundus of sac extends above the axilla of middle turbinate. Once the entire sac is fully exposed, a Bowman’s probe tents the medial sac wall, which is incised vertically along its entire length to create anterior and posterior flaps. Horizontal cuts superiorly and inferiorly in lacrimal sac flaps allow them to be reflected onto the lateral nasal wall like an open book. The initial nasal mucosal flap that was raised to expose the sac is now refashioned and reflected back to cover the superior and inferior exposed bone as well as to create apposition with the mucosa of the opened lacrimal sac. The lacrimal system is then intubated with O’Donoghue stents, a silastic spacer placed over the tubes before they are secured with ligar clips. A gel foam patch is used to keep the flaps in position in early postoperative period. All patients in this series received postoperative oral and topical antibiotics and were instructed to perform regular saline douching from day 1 for 6 weeks to prevent drying and crusting of the nasal mucosa. The follow up was scheduled at 1, 3, 6, 12, 18, 24, and 36 months. Stents were commonly removed at 4 weeks unless associated canalicular stenosis was noted intraoperatively, in which case they were left for longer duration based on regular assessment. At each visit, the ostium was evaluated, wounds were cleaned, and fluorescein dye disappearance test was performed.
RESULTS Two hundred eighty-three powered endoscopic DCRs were performed on 214 patients. The mean age at surgery was 59.5 years (range, 3–95 years). The male to female ratio was 1:2 (71:143). All patients presented with epiphora, 14% (30/214) with discharge and 2.8% (6/214) with a mucocele. Of the 214 patients, 145 patients underwent unilateral DCR and 69 patients a bilateral DCR. Nine of the unilateral DCRs were pediatric patients who had persistent epiphora following failed probing earlier. In all, 91.6% patients (196/214) had a primary DCR (260 DCRs) and 8.4% (18/214) had a revision DCR (23 DCRs). A total of 66.8% patients (143/214) were operated by a consultant and remaining by fellows. Among the revision cases, 77.7 patients (14/18) were referred from elsewhere. In all, 50.4% patients (108/214) underwent adjunctive endonasal procedures. About 44.3% patients (95/214) required septoplasty and 5.6% patients (12/214) middle turbinoplasty. Among the septoplasty group, 85 patients underwent solo septoplasty and 10 patients had an additional sinus procedure performed. An associated lacrimal anomaly noted on dacryocystography was common canalicular stenosis in 1.4% patients (3/214) and punctal stenosis in 0.46% patients (1/214). All patients except 4 underwent silicone intubation. The mean duration of stent placement was 6.7 weeks (range, 4–12 weeks). The mean follow up was 17.1 months (median, 12 months; range, 3–103 months). Complications noted include mild postoperative bleeding not requiring a return to operating theatre (n = 3), ostium granulomas (n = 5), stent prolapse (n = 2), synechiae (n = 2), and a membrane over internal common opening (n = 1). All ostium granulomas underwent excision followed by base cautery with silver nitrate. An endocanaliculotomy was performed for the patient with membrane over internal common opening. At the last follow up in the primary DCR group (n = 260), 8 DCRs showed a cicatricial closure of the ostium resulting in anatomical failure and 10 eyes had persistent epiphora despite patent ostia. All the pediatric DCRs (n = 9) were successful at the final follow up. Among the revision group, 2 patients had a cicatricial closure of ostium and 1 had persistent epiphora despite patent ostia. At the last follow up, the final anatomical success was achieved in 96.9% cases of primary DCRs and 91.3% cases of revision DCRs. The success rate if analyzed for the fellows separately showed an anatomical success of 95% (n = 100) in the primary cases. No revision cases were operated by the fellows. The functional success was achieved in 93% cases of primary DCRs and 86.9% cases of revision DCRs.
220
DISCUSSION This large case series documents excellent success rates in patients undergoing primary and revision endoscopic DCRs. While anatomical success rates exceed 96% in primary DCRs and 91% in revision cases, functional success is slightly lower at 93% and 87%, respectively. Success appears maintained at longterm follow up with the mean follow for this cohort approaching 1.5 years. All patients underwent lacrimal imaging using dacryocystography (DCG) and dacryoscintigrapy (DSG) to confirm the diagnosis, assess the functional status, and accurately plan the surgery in revision cases. Although the authors did not find any patient with unsuspected abnormalities and some surgeons may not consider it necessary, it has been a standard protocol at the University's Otolaryngology department. Unlike previous studies, a higher rate of concurrent surgical performance of adjunctive endonasal procedures (50.4%) was reported, possibly reflecting the need of a good access for comfortable insertion of powered instruments and the rhinological experience of the surgeons performing the DCRs in this series. Although these surgeries were performed from 1999 onwards without any change in the surgical technique, this study included cases from 2002, since patients operated earlier have already been published in smaller case series with a comparable success rate of 95%.7,8,11 Although the success rates of endoscopic DCR are good, the main causes of failure have been attributed to failure in locating the sac, insufficient osteotomy, inadequate sac opening, failure to organize granulation tissue, fibrosis, and bone neogenesis.18,19 Anatomic studies by Wormald et al.20 accurately defined the intranasal location of lacrimal sac and found that major portion of it lies above the axilla of middle turbinate rather than anteroinferior to the axilla as was believed earlier. This knowledge led to the development of mechanical and powered endoscopic DCR, which has shown a consistent and comparable success rate of more than 95%.7–12 Dietrich et al.13 studied 74 DCRs (60 primary and 14 revision) of 70 patients, and at a mean follow up of 3.1 years reported a success rate of 84% in primary cases and 81% overall. Zenk et al.16 studied 165 patients of endoscopic DCR at 5 years after surgery and reported an overall success of 81.8% with a poor correlation between clinical findings and subjective evaluation. Onerci et al.17 evaluated 108 consecutive endoscopic DCRs by experienced surgeons, and at a mean follow up of 49 months, reported a success rate of 94.4%. The causes of failures (n = 6) reported were peritubal granulation tissues (n = 4), atonic sac (n = 1), and inadequate osteotomy (n = 1). Studies comparing the external and endoscopic approaches showed comparable success with both the procedures.3,21,22 Huang et al.22 conducted a systematic review and meta-analysis assessing both the approaches, which included 4 randomized controlled trials and 15 cohort comparisons. The outcomes between external and mechanical endoscopic DCRs were comparable (relative risk, 1.02; confidence interval, 0.98–1.06). The relative risks for scarring, bleeding, and infections with endonasal DCR versus external DCR was 0.07 (confidence interval, 0.02–0.22), and the rates of reported revision surgeries were similar in both the approaches. Powered endoscopic DCR specifically has also shown comparable results with that of an external DCR.12 Pediatric DCRs pose unique issues to the surgeon on account of different anatomical considerations and an altered healing response. Consequently, the very small series published to date report lower success rates compared to adult studies. In their series of 4 pediatric patients, Dietrich et al.13 reported success in 3 patients at a mean follow up of 5.1 years. Zenk et al.16 similarly reported 2 DCR failures of their 6 patients in 5 years follow up. Both the failures were complex congenital
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
Copyright © 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
Ophthal Plast Reconstr Surg, Vol. 31, No. 3, 2015
nasolacrimal duct obstructions with associated craniofacial abnormalities, which are known to have a poor prognosis. In the current study, the authors had 9 pediatric patients, all with a failed earlier probing, and although all were successful, a subgroup analysis could not be performed just like other studies because of the small sample size. However, Celenk et al.23 performed 83 endoscopic DCRs in 71 pediatric patients and reported a high success rate of 92.7%, which is comparable with that of an adult endoscopic DCR. Through review of the present series, key features were identified for successful long-term outcomes in an endoscopic DCR. These include accurate localization of sac, creation of a large osteotomy sufficient to expose the entire lacrimal sac, complete sac marsupialization, and a perfect mucosa to mucosa apposition allowing healing by primary intention. All these goals can be accurately achieved through a well-performed powered endoscopic DCR. In conclusion, the outcomes of both the primary and revision powered endoscopic DCRs are comparable with the best of external DCR, although good results have also been reported in the literature with nonpowered endoscopic DCR techniques.24 A good knowledge of intranasal anatomy, meticulous surgical techniques, and lower threshold for performing adjunctive endonasal procedures where indicated could yield excellent results with powered endoscopic DCRs that are maintained over a long period of time.
REFERENCES 1. McDonogh M, Meiring JH. Endoscopic transnasal dacryocystorhinostomy. J Laryngol Otol 1989;103:585–7. 2. Watkins LM, Janfaza P, Rubin PA. The evolution of endonasal dacryocystorhinostomy. Surv Ophthalmol 2003;48:73–84. 3. Hartikainen J, Antila J, Varpula M, et al. Prospective randomized comparison of endonasal endoscopic dacryocystorhinostomy and external dacryocystorhinostomy. Laryngoscope 1998;108:1861–6. 4. Woog JJ, Kennedy RH, Custer PL, et al. Endonasal dacryocystorhinostomy: a report by the American Academy of Ophthalmology. Ophthalmology 2001;108:2369–77. 5. Sprekelsen MB, Barberan MT. Endoscopic dacryocystorhinostomy. Surgical techniques and results. Laryngoscope 1996;106:187–9. 6. Madge SN, Chan W, Malhotra R, et al. Endoscopic dacryocystorhinostomy in acute dacryocystitis: a multicenter case series. Orbit 2011;30:1–6. 7. Wormald PJ. Powered endonasal dacryocystorhinostomy. Laryngoscope 2002;112:69–71.
Effectiveness of Powered Endoscopic Dacryocystorhinostomy
8. Tsirbas A, Wormald PJ. Endonasal dacryocystorhinostomy with mucosal flaps. Am J Ophthalmol 2003;135:76–83. 9. Wormald PJ, Tsirbas A. Investigation and treatment for functional and anatomical obstruction of the nasolacrimal duct system. Clin Otolaryngol 2004;29:352–6. 10. Wormald PJ. Powered endoscopic DCR. Otolaryngol Clin North Am 2006;539–49. 11. Tsirbas A, Wormald PJ. Mechanical endonasal dacryocystorhinostomy with mucosal flaps. Br J Ophthalmol 2003;87:43–7. 12. Tsirbas A, Davis G, Wormald PJ. Mechanical endonasal dacryocystorhinostomy versus external dacryocystorhinostomy. Ophthal Plast Reconstr Surg 2004;20:50–6. 13. Dietrich C, Mewes T, Kühnemund M, et al. Long-term follow-up of patients with microscopic endonasal dacryocystorhinostomy. Am J Rhinol 2003;17:57–61. 14. Durvasula VS, Gatland DJ. Endoscopic dacryocystorhinostomy: long-term results and evolution of surgical technique. J Laryngol Otol 2004;118:628–32. 15. Mohamad SH, Khan I, Shakeel M, et al. Long term results of endonasal dacryocystorhinostomy with and without stents. Ann R Coll Surg Eng 2013;95:196–9. 16. Zenk J, Karatzanis AD, Psychogios G, et al. Long-term results of endonasal dacryocystorhinostomy. Eur Arch Otorhinolaryngol 2009;266:1733–8. 17. Onerci M, Orhan M, Ogretmenoğlu O, et al. Long-term results and reasons for failure of intranasal endoscopic dacryocystorhinostomy. Acta Otolaryngol 2000;120:319–22. 18. Wormald PJ, Roithmann R. Endoscopic and external dacryocystorhinostomy (DCR): which is better? Braz J Otorhinolaryngol 2012;78:2. 19. Roithmann R, Burman T, Wormald PJ. Endoscopic dacryocystorhinostomy. Braz J Otorhinolaryngol 2012;78:113–21. 20. Wormald PJ, Kew J, Van Hasselt A. Intranasal anatomy of the nasolacrimal sac in endoscopic dacryocystorhinostomy. Otolaryngol Head Neck Surg 2000;123:307–10. 21. Moras K, Bhat M, Shreyas CS, et al. External dacryocystorhinostomy versus endoscopic dacryocystorhinostomy: a comparison. J Clin Diag Res 2011;5:182–6. 22. Huang J, Malek J, Chin D, et al. Systematic review and meta-analysis on outcomes for endoscopic versus external dacryocystorhinostomy. Orbit 2014;33:81–90. 23. Celenk F, Mumbuc S, Durucu C, et al. Pediatric endonasal endoscopic dacryocystorhinostomy. Int J Pediatr Otorhinolaryngol 2013;77:1259–62. 24. Naraghi M, Tabatabaii Mohammadi SZ, Sontou AF, et al. Endonasal endoscopic dacryocystorhinostomy: how to achieve optimal results with simple punch technique. Eur Arch Otorhinolaryngol 2012;269:1445–9.
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
221
Copyright © 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
Powered Endoscopic Dacryocystorhinostomy: A Decade of Experience Mohammad Javed Ali, M.D., F.R.C.S.*, Alkis James Psaltis, Ph.D., F.R.A.C.S.†, Jae Murphy, M.B.B.S.†, and Peter John Wormald, M.D., F.R.A.C.S.† *Dacryology Service, L.V.Prasad Eye Institute, Hyderabad, India; and †Department of Surgery-Otolaryngology, Head and Neck Surgery, University of Adelaide, Adelaide, Australia
Purpose: To report a decade long experience with powered endoscopic dacryocystorhinostomy (DCR). Methods: A retrospective review of all consecutive patients undergoing powered endoscopic DCR was performed at this institution over a period of 11 years from 2002 to 2013. All patients completed a minimum of 3 months follow up following stent removal. Patient records were reviewed for demographic data, clinical and surgical profiles, adjunctive procedures, complications, and success rates at the last follow up. Anatomical success was defined as patent ostium on irrigation and functional success as free flow of dye into ostium on functional endoscopic dye test and resolution of epiphora. Results: Two hundred eighty-three powered endoscopic DCRs were performed on 214 patients. The mean age at surgery was 59.5 years (range, 3–95 years). All patients presented with epiphora. A total of 91.6% patients (196/214) had a primary DCR and 8.4% (18/214) had a revision DCR. In all, 50.4% patients (108/214) underwent adjunctive endonasal procedures. The mean follow up was 17.1 months (range, 3–103 months). At the last follow up, the final anatomical success was achieved in 96.9% cases of primary DCRs and 91.3% cases of revision DCRs. Functional success was achieved in 93% cases of primary DCRs and 86.9% cases of revision DCRs. Conclusions: Powered endoscopic DCR is a safe procedure and offers excellent results both in primary and revision DCRs. The threshold to perform adjunctive endonasal procedures should be very low when indicated. (Ophthal Plast Reconstr Surg 2015;31:219–221)
T
he advent of rigid fibreoptic endoscopes was a major contributor in establishing endoscopic dacryocystorhinostomy (DCR) as a treatment for nasolacrimal duct obstructions.1,2 The major advantages of an endoscopic approach include avoidance of a cutaneous incision with subsequent scar, less disruption of the lacrimal pump, ability to address concurrent nasal abnormalities, ability to operate during acute dacryocystitis, ability
Accepted for publication June 18, 2014. This study has been reviewed by the ethics committee and has been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki. Informed consent was obtained from the patients. The authors have no financial or conflicts of interest to disclose. Address correspondence and reprint requests to Peter John Wormald, M.D., F.R.A.C.S., Department of Otolaryngology Head and Neck Surgery, Level 4, Maternity Building, Adelaide University, Adelaide, South Australia. E-mail: [email protected] DOI: 10.1097/IOP.0000000000000261
Ophthal Plast Reconstr Surg, Vol. 31, No. 3, 2015
to identify etiological factors of failure, less operative time, less postoperative morbidity, and early rehabilitation.2–6 Powered endoscopic DCR as described by Wormald and colleagues is a technique that allows creation of largest possible osteotomy and complete sac marsupialization, and hence achieve high success rates comparable to that of external DCR.7–12 Although the short-term results of an endoscopic DCR are satisfactory, the long-term success rates range from 81% to 94%.13–17 The current study reports demographic, clinical, surgical, and outcome profiles of powered endoscopic DCR in a very large series over a decade long-study period.
METHODS After obtaining institutional review board’s approval for this study, a retrospective review was performed for all patients undergoing powered endoscopic DCR over an 11-year period from 2002 to 2013 at the Otorhinolaryngology department, University of Adelaide, Australia. A detailed history and examination was performed including lacrimal probing, syringing, and functional testing with topical fluorescein. As part of the workup, all patients also underwent lacrimal imaging with dacryocystography and dacryoscintigraphy to establish the diagnosis. All patients completed a minimum of 3 months follow up following stent removal, which was removed in a mean duration of 6.7 weeks (range, 4–12) after surgery. Patient records were reviewed for demographic data, clinical and surgical profiles, adjunctive procedures, complications, and success rates at the last follow up. Anatomical success was defined as patent ostium on irrigation and functional success as free flow of dye into ostium on functional endoscopic dye test and resolution of epiphora. Surgical Technique. Under general anesthetic, all the patients underwent powered endoscopic DCR as described by Wormald et al.7–12 Total intravenous anesthesia with propofol and remifentanil was used with mean arterial blood pressures maintained between 60 mm·Hg and 75 mm·Hg to reduce intraoperative bleeding. Nasal mucosa was decongested with neuro patties soaked in a solution of 2 ml normal saline, 2 ml 10% cocaine, and 1 ml 1:1,000 adrenaline. The lateral wall and head of the middle turbinate were injected with 2% xylocaine with 1:80,000 adrenaline. In brief, the technique described by Wormald et al. can be summarized as follows. Using a 30° nasal endoscope, the procedure begins by raising a posteriorly based mucosal flap centered over the lacrimal sac. The incision of this flap begins 8 mm above the axilla of the middle turbinate and is continued anteriorly approximately 8 mm to 10 mm. A vertical incision is continued inferiorly to the insertion of the inferior turbinate before a horizontal incision is directed posteriorly back to the insertion of uncinate process. Using a suction freer elevator, the mucosal flap is then raised off the lateral wall to expose the frontal process of maxilla and its junction with lacrimal bone. A small round knife is then used to remove the thin lacrimal bone from the sac before using a Hajek-Kopfler forward punch (Karl Storz, Tuttlingen, Germany) to remove the remaining bone covering nasolacrimal duct and frontal
219
Copyright © 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
Ophthal Plast Reconstr Surg, Vol. 31, No. 3, 2015
P. J. Wormald et al.
process of maxilla. Once the bone becomes thick and is not amenable to punch removal above the axilla of the MT, a curved 25° high-speed diamond DCR burr (Medtronic Xomed, Jacksonville, FL, U.S.A.) is used to remove the rest of the bone to expose the sac completely. The agger nasi is exposed during this process since the fundus of sac extends above the axilla of middle turbinate. Once the entire sac is fully exposed, a Bowman’s probe tents the medial sac wall, which is incised vertically along its entire length to create anterior and posterior flaps. Horizontal cuts superiorly and inferiorly in lacrimal sac flaps allow them to be reflected onto the lateral nasal wall like an open book. The initial nasal mucosal flap that was raised to expose the sac is now refashioned and reflected back to cover the superior and inferior exposed bone as well as to create apposition with the mucosa of the opened lacrimal sac. The lacrimal system is then intubated with O’Donoghue stents, a silastic spacer placed over the tubes before they are secured with ligar clips. A gel foam patch is used to keep the flaps in position in early postoperative period. All patients in this series received postoperative oral and topical antibiotics and were instructed to perform regular saline douching from day 1 for 6 weeks to prevent drying and crusting of the nasal mucosa. The follow up was scheduled at 1, 3, 6, 12, 18, 24, and 36 months. Stents were commonly removed at 4 weeks unless associated canalicular stenosis was noted intraoperatively, in which case they were left for longer duration based on regular assessment. At each visit, the ostium was evaluated, wounds were cleaned, and fluorescein dye disappearance test was performed.
RESULTS Two hundred eighty-three powered endoscopic DCRs were performed on 214 patients. The mean age at surgery was 59.5 years (range, 3–95 years). The male to female ratio was 1:2 (71:143). All patients presented with epiphora, 14% (30/214) with discharge and 2.8% (6/214) with a mucocele. Of the 214 patients, 145 patients underwent unilateral DCR and 69 patients a bilateral DCR. Nine of the unilateral DCRs were pediatric patients who had persistent epiphora following failed probing earlier. In all, 91.6% patients (196/214) had a primary DCR (260 DCRs) and 8.4% (18/214) had a revision DCR (23 DCRs). A total of 66.8% patients (143/214) were operated by a consultant and remaining by fellows. Among the revision cases, 77.7 patients (14/18) were referred from elsewhere. In all, 50.4% patients (108/214) underwent adjunctive endonasal procedures. About 44.3% patients (95/214) required septoplasty and 5.6% patients (12/214) middle turbinoplasty. Among the septoplasty group, 85 patients underwent solo septoplasty and 10 patients had an additional sinus procedure performed. An associated lacrimal anomaly noted on dacryocystography was common canalicular stenosis in 1.4% patients (3/214) and punctal stenosis in 0.46% patients (1/214). All patients except 4 underwent silicone intubation. The mean duration of stent placement was 6.7 weeks (range, 4–12 weeks). The mean follow up was 17.1 months (median, 12 months; range, 3–103 months). Complications noted include mild postoperative bleeding not requiring a return to operating theatre (n = 3), ostium granulomas (n = 5), stent prolapse (n = 2), synechiae (n = 2), and a membrane over internal common opening (n = 1). All ostium granulomas underwent excision followed by base cautery with silver nitrate. An endocanaliculotomy was performed for the patient with membrane over internal common opening. At the last follow up in the primary DCR group (n = 260), 8 DCRs showed a cicatricial closure of the ostium resulting in anatomical failure and 10 eyes had persistent epiphora despite patent ostia. All the pediatric DCRs (n = 9) were successful at the final follow up. Among the revision group, 2 patients had a cicatricial closure of ostium and 1 had persistent epiphora despite patent ostia. At the last follow up, the final anatomical success was achieved in 96.9% cases of primary DCRs and 91.3% cases of revision DCRs. The success rate if analyzed for the fellows separately showed an anatomical success of 95% (n = 100) in the primary cases. No revision cases were operated by the fellows. The functional success was achieved in 93% cases of primary DCRs and 86.9% cases of revision DCRs.
220
DISCUSSION This large case series documents excellent success rates in patients undergoing primary and revision endoscopic DCRs. While anatomical success rates exceed 96% in primary DCRs and 91% in revision cases, functional success is slightly lower at 93% and 87%, respectively. Success appears maintained at longterm follow up with the mean follow for this cohort approaching 1.5 years. All patients underwent lacrimal imaging using dacryocystography (DCG) and dacryoscintigrapy (DSG) to confirm the diagnosis, assess the functional status, and accurately plan the surgery in revision cases. Although the authors did not find any patient with unsuspected abnormalities and some surgeons may not consider it necessary, it has been a standard protocol at the University's Otolaryngology department. Unlike previous studies, a higher rate of concurrent surgical performance of adjunctive endonasal procedures (50.4%) was reported, possibly reflecting the need of a good access for comfortable insertion of powered instruments and the rhinological experience of the surgeons performing the DCRs in this series. Although these surgeries were performed from 1999 onwards without any change in the surgical technique, this study included cases from 2002, since patients operated earlier have already been published in smaller case series with a comparable success rate of 95%.7,8,11 Although the success rates of endoscopic DCR are good, the main causes of failure have been attributed to failure in locating the sac, insufficient osteotomy, inadequate sac opening, failure to organize granulation tissue, fibrosis, and bone neogenesis.18,19 Anatomic studies by Wormald et al.20 accurately defined the intranasal location of lacrimal sac and found that major portion of it lies above the axilla of middle turbinate rather than anteroinferior to the axilla as was believed earlier. This knowledge led to the development of mechanical and powered endoscopic DCR, which has shown a consistent and comparable success rate of more than 95%.7–12 Dietrich et al.13 studied 74 DCRs (60 primary and 14 revision) of 70 patients, and at a mean follow up of 3.1 years reported a success rate of 84% in primary cases and 81% overall. Zenk et al.16 studied 165 patients of endoscopic DCR at 5 years after surgery and reported an overall success of 81.8% with a poor correlation between clinical findings and subjective evaluation. Onerci et al.17 evaluated 108 consecutive endoscopic DCRs by experienced surgeons, and at a mean follow up of 49 months, reported a success rate of 94.4%. The causes of failures (n = 6) reported were peritubal granulation tissues (n = 4), atonic sac (n = 1), and inadequate osteotomy (n = 1). Studies comparing the external and endoscopic approaches showed comparable success with both the procedures.3,21,22 Huang et al.22 conducted a systematic review and meta-analysis assessing both the approaches, which included 4 randomized controlled trials and 15 cohort comparisons. The outcomes between external and mechanical endoscopic DCRs were comparable (relative risk, 1.02; confidence interval, 0.98–1.06). The relative risks for scarring, bleeding, and infections with endonasal DCR versus external DCR was 0.07 (confidence interval, 0.02–0.22), and the rates of reported revision surgeries were similar in both the approaches. Powered endoscopic DCR specifically has also shown comparable results with that of an external DCR.12 Pediatric DCRs pose unique issues to the surgeon on account of different anatomical considerations and an altered healing response. Consequently, the very small series published to date report lower success rates compared to adult studies. In their series of 4 pediatric patients, Dietrich et al.13 reported success in 3 patients at a mean follow up of 5.1 years. Zenk et al.16 similarly reported 2 DCR failures of their 6 patients in 5 years follow up. Both the failures were complex congenital
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
Copyright © 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
Ophthal Plast Reconstr Surg, Vol. 31, No. 3, 2015
nasolacrimal duct obstructions with associated craniofacial abnormalities, which are known to have a poor prognosis. In the current study, the authors had 9 pediatric patients, all with a failed earlier probing, and although all were successful, a subgroup analysis could not be performed just like other studies because of the small sample size. However, Celenk et al.23 performed 83 endoscopic DCRs in 71 pediatric patients and reported a high success rate of 92.7%, which is comparable with that of an adult endoscopic DCR. Through review of the present series, key features were identified for successful long-term outcomes in an endoscopic DCR. These include accurate localization of sac, creation of a large osteotomy sufficient to expose the entire lacrimal sac, complete sac marsupialization, and a perfect mucosa to mucosa apposition allowing healing by primary intention. All these goals can be accurately achieved through a well-performed powered endoscopic DCR. In conclusion, the outcomes of both the primary and revision powered endoscopic DCRs are comparable with the best of external DCR, although good results have also been reported in the literature with nonpowered endoscopic DCR techniques.24 A good knowledge of intranasal anatomy, meticulous surgical techniques, and lower threshold for performing adjunctive endonasal procedures where indicated could yield excellent results with powered endoscopic DCRs that are maintained over a long period of time.
REFERENCES 1. McDonogh M, Meiring JH. Endoscopic transnasal dacryocystorhinostomy. J Laryngol Otol 1989;103:585–7. 2. Watkins LM, Janfaza P, Rubin PA. The evolution of endonasal dacryocystorhinostomy. Surv Ophthalmol 2003;48:73–84. 3. Hartikainen J, Antila J, Varpula M, et al. Prospective randomized comparison of endonasal endoscopic dacryocystorhinostomy and external dacryocystorhinostomy. Laryngoscope 1998;108:1861–6. 4. Woog JJ, Kennedy RH, Custer PL, et al. Endonasal dacryocystorhinostomy: a report by the American Academy of Ophthalmology. Ophthalmology 2001;108:2369–77. 5. Sprekelsen MB, Barberan MT. Endoscopic dacryocystorhinostomy. Surgical techniques and results. Laryngoscope 1996;106:187–9. 6. Madge SN, Chan W, Malhotra R, et al. Endoscopic dacryocystorhinostomy in acute dacryocystitis: a multicenter case series. Orbit 2011;30:1–6. 7. Wormald PJ. Powered endonasal dacryocystorhinostomy. Laryngoscope 2002;112:69–71.
Effectiveness of Powered Endoscopic Dacryocystorhinostomy
8. Tsirbas A, Wormald PJ. Endonasal dacryocystorhinostomy with mucosal flaps. Am J Ophthalmol 2003;135:76–83. 9. Wormald PJ, Tsirbas A. Investigation and treatment for functional and anatomical obstruction of the nasolacrimal duct system. Clin Otolaryngol 2004;29:352–6. 10. Wormald PJ. Powered endoscopic DCR. Otolaryngol Clin North Am 2006;539–49. 11. Tsirbas A, Wormald PJ. Mechanical endonasal dacryocystorhinostomy with mucosal flaps. Br J Ophthalmol 2003;87:43–7. 12. Tsirbas A, Davis G, Wormald PJ. Mechanical endonasal dacryocystorhinostomy versus external dacryocystorhinostomy. Ophthal Plast Reconstr Surg 2004;20:50–6. 13. Dietrich C, Mewes T, Kühnemund M, et al. Long-term follow-up of patients with microscopic endonasal dacryocystorhinostomy. Am J Rhinol 2003;17:57–61. 14. Durvasula VS, Gatland DJ. Endoscopic dacryocystorhinostomy: long-term results and evolution of surgical technique. J Laryngol Otol 2004;118:628–32. 15. Mohamad SH, Khan I, Shakeel M, et al. Long term results of endonasal dacryocystorhinostomy with and without stents. Ann R Coll Surg Eng 2013;95:196–9. 16. Zenk J, Karatzanis AD, Psychogios G, et al. Long-term results of endonasal dacryocystorhinostomy. Eur Arch Otorhinolaryngol 2009;266:1733–8. 17. Onerci M, Orhan M, Ogretmenoğlu O, et al. Long-term results and reasons for failure of intranasal endoscopic dacryocystorhinostomy. Acta Otolaryngol 2000;120:319–22. 18. Wormald PJ, Roithmann R. Endoscopic and external dacryocystorhinostomy (DCR): which is better? Braz J Otorhinolaryngol 2012;78:2. 19. Roithmann R, Burman T, Wormald PJ. Endoscopic dacryocystorhinostomy. Braz J Otorhinolaryngol 2012;78:113–21. 20. Wormald PJ, Kew J, Van Hasselt A. Intranasal anatomy of the nasolacrimal sac in endoscopic dacryocystorhinostomy. Otolaryngol Head Neck Surg 2000;123:307–10. 21. Moras K, Bhat M, Shreyas CS, et al. External dacryocystorhinostomy versus endoscopic dacryocystorhinostomy: a comparison. J Clin Diag Res 2011;5:182–6. 22. Huang J, Malek J, Chin D, et al. Systematic review and meta-analysis on outcomes for endoscopic versus external dacryocystorhinostomy. Orbit 2014;33:81–90. 23. Celenk F, Mumbuc S, Durucu C, et al. Pediatric endonasal endoscopic dacryocystorhinostomy. Int J Pediatr Otorhinolaryngol 2013;77:1259–62. 24. Naraghi M, Tabatabaii Mohammadi SZ, Sontou AF, et al. Endonasal endoscopic dacryocystorhinostomy: how to achieve optimal results with simple punch technique. Eur Arch Otorhinolaryngol 2012;269:1445–9.
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
221
Copyright © 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
