Abstract
Objective
The primary surgical procedure for nasolacrimal duct obstruction is dacryocystorhinostomy (DCR). The purpose of this study was to compare non-laser endoscopic dacryocystorhinostomy (NL-EnDCR) and transcanalicular diode laser-supported endoscopic dacryocystorhinostomy (TDLS-EnDCR).
Materials and method
The data of patients who underwent DCR with the diagnosis of epiphora and chronic dacryocystitis between the years 2010 and 2016 were examined retrospectively. The patients who underwent NL-EnDCR and TDLS-EnDCR were included in the study. Success of the procedure was defined as the complete disappearance of epiphora, and lack of anatomical occlusions with lacrimal serum irrigation.
Results
74 patients who met the study criteria were included in the study. 39 patients (21 males and 18 females) who underwent TDLS-EnDCR were assigned as Group 1, and their mean age was 46 (33–64). 35 patients (18 males and 17 females) who underwent NL-EnDCR were assigned as Group 2, and their mean age was 48 (24–81). In the postoperative follow-ups, no watering of the eyes was demonstrated in 34 (87.2%) out of 39 patients in Group 1 (TDLS-EnDCR), and 22 (62.9%) out of 35 patients in Group 2 (NL-EnDCR), and that the newly formed ostium was clear with serum irrigations. A statistically significant difference in success rate was observed between the two groups ( p = 0.028).
Conclusions
The TDLS-EnDCR procedure was more successful than NL-EnDCR with respect to the outcomes assigned. Use of transcanalicular diode laser in endoscopic DCR may increase the success of endoscopic DCR.
1
Introduction
Dacryocystorhinostomy (DCR) is the process of creating a permanent new pathway between the lachrymal sac and nasal mucosa . The first known DCR was performed in 1904 by Toti ; transnasal endoscopic DCR was defined by McDonogh and Meiring . Endoscopic DCR is a minimally invasive procedure in which the nasolacrimal duct is bypassed. Simply, it is the process of creating a fistula with the lacrimal sac in nasolacrimal duct obstruction .
The most important factors that influence the success of DCR are the width and localization of the ostium that is created in DCR, the granulation tissue that appears around the ostium in postoperative period and synechiae . Techniques and simultaneous procedures that can prevent the closure of the newly-formed ostium and increase the success of DCR include application of silicon intubation , application of mucosal flap in cases where wide osteotomy is performed , application of mitomycin C and partial middle concha resections .
The purpose of this study was to compare the outcomes of primary non-laser endoscopic DCR (NL-EnDCR) and transcanalicular diode laser-supported primary endoscopic DCR (TDLS-EnDCR) operations. According to our findings, there are few studies on the use of transcanalicular diode laser in endoscopic DCR.
2
Materials and methods
The data of patients diagnosed with epiphora and chronic dacryocystitis who underwent DCR between 2010 and 2016 were examined retrospectively. The local ethics committee approved this study. Carefully annotated records that were examined included the type of operation, the use of stent, duration of hospitalization, complications, outcomes of the surgery, and follow-up data of the patients.
Ophthalmologic and otolaryngologic examinations were conducted on the patients in preoperative evaluations, and factors that might cause watering in the eyes like blepharitis, ectropion, entropion, lagophthalmus, trichiasis, conjunctivitis and keratitis were excluded. The diagnosis of nasolacrimal duct obstruction was confirmed with symptoms such as watering of the eye and lacrimal irrigation studies in patients. In case of the existence of nasal pathologies, the patients received additional rhinologic interventions when needed. Only those patients who received NL-EnDCR and TDLS-EnDCR were included in the current study. Patients under follow-up care and those who had previous naso-orbital trauma history were excluded from the study.
2.1
Surgical procedure for non-laser endoscopic dacryocystorhinostomy (NL-EnDCR).
Following the placement of cotton pieces absorbed with adrenalin for mucosal decongestion in the nasal cavity, local anesthesia (2% lidocaine, adrenalin 1:100,000) was applied to the front of the connection area of the middle concha and the 1 cm 2 mucosa there was incised with the help of a sickle knife. The mucosa, which was elevated with the help of an elevator, was taken out. The maxillary fissure was recognized, the lachrymal bone and the frontal process of the maxilla were drilled, thereby making the medial face of the lachrymal sac visible, and the osteotomy area was expanded. Both puncta were dilated. With the help of a probe sent from the punctum, the true localization was confirmed before incision of the sac. Vertical incision was applied to the sac and with the help of forceps it was marsupialized as much as possible to allow for expansion. After the opening of the sac was evaluated with irrigation, O’ Donoghue silicon intubation tube was placed and the free ends were looped in the nose.
2.2
Surgical procedure for transcanalicular diode laser-supported endoscopic DCR (TDLS-EnDCR)
The same procedures as the non-laser endoscopic DCR were repeated for TDLS-EnDCR; the bone osteotomy area was created in the lateral wall with the help of a drill, the medial side of the sac was put forth, and the lower and upper puncta was dilated using a dilatator. Following this, a 600 μm laser probe (Intermedic/Spain) was directed to the medial side of the sac from the upper punctum. The fiber laser light was recognized on the medial face of the sac with the help of 30-degree rigid endoscopes and the laser was activated. Firstly, a fistula was opened between the nasolacrimal sac and nasal cavity, and the medial wall of the sac was evaporated widely with repetitive laser pulses. The opening of the lacrimal passage was confirmed by serum lavage and the O’ Donoghue silicon intubation tube was placed.
In the postoperative period, the patients were prescribed with eyedrops containing tobramycin, oral amoxicillin clavulanic acid, and nasal serum physiologic drops for 2 weeks. The patients were discharged on the postoperative 1st day and were evaluated endoscopically in the first week, first month, third month, sixth month, ninth month and twelfth month after surgery.
During the follow-up examinations, granulation tissue and crusts around the ostium were cleared. Success was defined as the complete disappearance of the epiphora and the complete lack of anatomic obstruction with lacrimal serum irrigation.
All procedures were performed under general anesthesia by the same otolaryngologist (G.Ö) and ophthalmologist (Y.S).
2
Materials and methods
The data of patients diagnosed with epiphora and chronic dacryocystitis who underwent DCR between 2010 and 2016 were examined retrospectively. The local ethics committee approved this study. Carefully annotated records that were examined included the type of operation, the use of stent, duration of hospitalization, complications, outcomes of the surgery, and follow-up data of the patients.
Ophthalmologic and otolaryngologic examinations were conducted on the patients in preoperative evaluations, and factors that might cause watering in the eyes like blepharitis, ectropion, entropion, lagophthalmus, trichiasis, conjunctivitis and keratitis were excluded. The diagnosis of nasolacrimal duct obstruction was confirmed with symptoms such as watering of the eye and lacrimal irrigation studies in patients. In case of the existence of nasal pathologies, the patients received additional rhinologic interventions when needed. Only those patients who received NL-EnDCR and TDLS-EnDCR were included in the current study. Patients under follow-up care and those who had previous naso-orbital trauma history were excluded from the study.
2.1
Surgical procedure for non-laser endoscopic dacryocystorhinostomy (NL-EnDCR).
Following the placement of cotton pieces absorbed with adrenalin for mucosal decongestion in the nasal cavity, local anesthesia (2% lidocaine, adrenalin 1:100,000) was applied to the front of the connection area of the middle concha and the 1 cm 2 mucosa there was incised with the help of a sickle knife. The mucosa, which was elevated with the help of an elevator, was taken out. The maxillary fissure was recognized, the lachrymal bone and the frontal process of the maxilla were drilled, thereby making the medial face of the lachrymal sac visible, and the osteotomy area was expanded. Both puncta were dilated. With the help of a probe sent from the punctum, the true localization was confirmed before incision of the sac. Vertical incision was applied to the sac and with the help of forceps it was marsupialized as much as possible to allow for expansion. After the opening of the sac was evaluated with irrigation, O’ Donoghue silicon intubation tube was placed and the free ends were looped in the nose.
2.2
Surgical procedure for transcanalicular diode laser-supported endoscopic DCR (TDLS-EnDCR)
The same procedures as the non-laser endoscopic DCR were repeated for TDLS-EnDCR; the bone osteotomy area was created in the lateral wall with the help of a drill, the medial side of the sac was put forth, and the lower and upper puncta was dilated using a dilatator. Following this, a 600 μm laser probe (Intermedic/Spain) was directed to the medial side of the sac from the upper punctum. The fiber laser light was recognized on the medial face of the sac with the help of 30-degree rigid endoscopes and the laser was activated. Firstly, a fistula was opened between the nasolacrimal sac and nasal cavity, and the medial wall of the sac was evaporated widely with repetitive laser pulses. The opening of the lacrimal passage was confirmed by serum lavage and the O’ Donoghue silicon intubation tube was placed.
In the postoperative period, the patients were prescribed with eyedrops containing tobramycin, oral amoxicillin clavulanic acid, and nasal serum physiologic drops for 2 weeks. The patients were discharged on the postoperative 1st day and were evaluated endoscopically in the first week, first month, third month, sixth month, ninth month and twelfth month after surgery.
During the follow-up examinations, granulation tissue and crusts around the ostium were cleared. Success was defined as the complete disappearance of the epiphora and the complete lack of anatomic obstruction with lacrimal serum irrigation.
All procedures were performed under general anesthesia by the same otolaryngologist (G.Ö) and ophthalmologist (Y.S).
3
Results
A total of 74 patients were included in the study. The patients were divided into two groups according to the type of surgery: Group 1 comprised of 39 patients (21 males and 18 females) who underwent TDLS-EnDCR with a median age of 46 (33–64). Group 2 comprised of 35 patients (18 males and 17 females) who underwent NL-EnDCR with a median age of 48 (24–81). The average follow-up durations of the patients were 14 months (range 12–36 months) in Group 1, and 14 months (range 12–22 months) in Group 2 ( Table 1 ).
