1

Introduction

Dacryocystorhinostomy (DCR) is a surgical procedure to create drainage between the lacrimal sac and nasal cavity. Dacryocystorhinostomy has been traditionally performed as an external procedure via an incision along the side of the nose to gain access into the lacrimal sac. Because endoscopic sinus surgery became popular in the 1990s, interest in endonasal endoscopic DCR has been growing.

The aim of this retrospective study was to evaluate outcomes between nonlaser endoscopic and external DCR in our center and to compare the results with previously published UK studies. A literature review for endoscopic DCR outcomes, published by UK departments, was also undertaken.

2

Method

Warrington General Hospital, United, Kingdom, is a moderate-sized general hospital, serving an area of approximately 350 000 people in the northwest of England. Office for Population Censuses and Surveys version 4.3 codes (C253, 254, 255, 258, 271) were used to identify cases of DCR performed between August 2003 and August 2007. The case notes were reviewed for patient demographics, type of surgery, stent used, the duration of hospital stay, follow-up interval, complications, and outcome at clinic discharge. Patients who were still under clinic review and those who had not had their stents removed were excluded. All patients were sent a questionnaire ( Appendix A ). A second questionnaire was sent 4 weeks later to those who had not returned their initial form. Patients who had bilateral DCR were regarded as having 2 separate procedures and were thus given 2 questionnaires to complete for each operated side. Similarly, patients who had contralateral DCR performed during the review period were also given 2 separate questionnaires. This questionnaire included a visual analogue scale (VAS) for their symptoms, as well as questions exploring their perception of outcomes and success after surgery. Mann-Whitney U test for unpaired nonparametric data was used to calculate the difference in the average VAS between the 2 cohorts.

The National Institute for Health and Clinical Excellence (NICE) is an independent organization responsible for providing UK national guidance on the promotion of good health and the prevention and treatment of disease. NICE issued guidance in February 2005 on endoscopic DCR after evaluating all relevant studies until October 2003 . A systematic review of PubMed, EMBASE, and Cochrane using “dacryocystorhinostomy” was undertaken, specifically at the period from October 2003 to April 2008. To compare with national outcomes, we included only case series from the UK.

2

Method

Warrington General Hospital, United, Kingdom, is a moderate-sized general hospital, serving an area of approximately 350 000 people in the northwest of England. Office for Population Censuses and Surveys version 4.3 codes (C253, 254, 255, 258, 271) were used to identify cases of DCR performed between August 2003 and August 2007. The case notes were reviewed for patient demographics, type of surgery, stent used, the duration of hospital stay, follow-up interval, complications, and outcome at clinic discharge. Patients who were still under clinic review and those who had not had their stents removed were excluded. All patients were sent a questionnaire ( Appendix A ). A second questionnaire was sent 4 weeks later to those who had not returned their initial form. Patients who had bilateral DCR were regarded as having 2 separate procedures and were thus given 2 questionnaires to complete for each operated side. Similarly, patients who had contralateral DCR performed during the review period were also given 2 separate questionnaires. This questionnaire included a visual analogue scale (VAS) for their symptoms, as well as questions exploring their perception of outcomes and success after surgery. Mann-Whitney U test for unpaired nonparametric data was used to calculate the difference in the average VAS between the 2 cohorts.

The National Institute for Health and Clinical Excellence (NICE) is an independent organization responsible for providing UK national guidance on the promotion of good health and the prevention and treatment of disease. NICE issued guidance in February 2005 on endoscopic DCR after evaluating all relevant studies until October 2003 . A systematic review of PubMed, EMBASE, and Cochrane using “dacryocystorhinostomy” was undertaken, specifically at the period from October 2003 to April 2008. To compare with national outcomes, we included only case series from the UK.

3

Results

Seventy patients ( Table 1 ) were identified during the review period, of which 27 were males and 43 females. The average age of the patient at the time of surgery was 62 years (range, 9–89 years). Thirty-five patients had external DCR and 35 patients had endoscopic DCR. Three patients had bilateral endoscopic DCR at the same surgery. Seven patients in the endoscopic DCR group had endoscopic surgery for the contralateral eye during the review period. Hence, a total of 80 procedures were performed (45 endoscopic, 35 external), of which 20 were revision procedures performed on 19 patients (1 external, 19 endoscopic). Of the 19 patients, 17 (1 external, 9 laser DCR, 7 endoscopic DCR) were referred from other hospitals. The remaining 2 patients (2 laser DCR) had their primary DCR previously at our institution. None of the patients in this study had revision surgery during the review period, nor did any patients have both types of DCR.

The most common indication for surgery was epiphora (92%), followed by chronic dacryocystitis (8%). All patients managed by endoscopic DCR by the Department of Otolaryngology had been previously assessed by the Department of Ophthalmology for site of obstruction. The most common site of lacrimal obstruction was at the nasolacrimal duct (71%), followed by canaliculi (25%) and pump failure (4%).

All procedures were performed under general anesthesia by the senior surgeons (SH and MH). O’Donoghue silastic stents were used in all cases. There were no conversions from endoscopic to external DCR. Most patients who had endoscopic DCR were either discharged on the same day of surgery (71%) or the following day (24%). One patient stayed for 3 days and another for 8 days because of social reasons. All external DCR patients were discharged the following day, except for one who stayed for 3 days because of social reasons. In addition to simple analgesics, all endoscopic DCR patients were discharged on corticosteroid nasal drops, saline nasal douching, and xylometazoline nasal spray, whereas those who had external DCR were discharged with chloramphenicol eye drops.

The average duration before stent removal was 23 weeks (range, 7–60 weeks) for external DCR compared with 14 weeks (range, 2–20 weeks) for endoscopic DCR. The average clinic follow-up duration for external DCR was 28 weeks (range, 8–72 weeks) compared with 27 weeks (range, 11–64 weeks) for endoscopic DCR. Success was defined as completely resolved epiphora or improved epiphora at discharge. At clinic discharge, 80% of external DCR patients reported being asymptomatic, whereas 14% reported partial improvement and 6% having persistent epiphora. In comparison, 72% of those who had endoscopic DCR reported being asymptomatic at discharge, followed by 14% with partial improvement and 14% with persistent symptoms. Of the 18 patients who had endoscopic DCR (1 bilateral, 17 unilateral) as a revision procedure, 74% were asymptomatic at discharge, 15% experienced partial improvement, and 11% remained symptomatic. In the remaining 17 patients whose endoscopic DCR was the primary treatment modality, 73% were asymptomatic, 12% had partial improvement, and 15% continued to experience epiphora. The single patient who underwent external DCR as a revision procedure was asymptomatic at discharge.

In all procedures, 11 patients were found to have experienced complications after surgery. The external DCR group had 7 (20%) reported complications compared with 4 (9%) in the endoscopic DCR group ( Table 2 ), all of which resolved before discharge from clinic. Of the 11 patients, 6 reported being asymptomatic on discharge, 2 had improved outcomes, and 3 reported failures.

Table 2

Complications and outcomes at discharge

Patient	Complication	Outcome at discharge
External DCR
1	Acute dacryocystitis	Asymptomatic
2	Acute dacryocystitis	Persistent epiphora
3	Surgical emphysema	Partial improvement
4	Conjunctivitis	Partial improvement
5	Wound granuloma	Asymptomatic
6	Cellulitis	Asymptomatic
7	Sinusitis	Asymptomatic
Endoscopic DCR
1	Postoperative epistaxis	Asymptomatic
2	Surgical emphysema	Persistent epiphora
3	Surgical emphysema	Asymptomatic
4	Vestibulitis	Persistent epiphora

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