Abstract
Purpose
Endonasal dacryocystorhinostomy is known as an increasingly attractive and effective approach for the surgical treatment of nasal duct obstruction with minimal complications and best cosmetic consequences. In a relatively large-scale case-series study over a 5-year period, we describe the surgical technique and 12-month follow-up results of microscopic laser dacryocystorhinostomy with particular regard to the effect of various pre-/postoperational factors (ie, patients’ sex, age, symptoms chronicity, previous interventions, duration of silicone intubation) on the surgical outcome.
Materials and methods
A total of 162 cases in 151 patients with chronic epiphora, mucocele, or recurrent episodes of dacryocystitis were included in the study. Endonasal laser dacryocystorhinostomy was performed using a surgical microscope with transcanalicular lacrimal sac illumination. The laser types used were potassium-titanyl-phosphate and neodymium:yttrium-aluminum-garnet for ablation of nasal mucosa and application to bone, respectively. Patients were evaluated 6 months and 1 year later. Data were analyzed by χ 2 tests.
Results
There were no major complications during or after the operations. Complete cure occurred in 89.5% (after 6 months) and 74.2% (after 1 year) of the cases. Anatomical patency was shown by lacrimal system irrigation with fluorescein in 81.5% of the cases after the 12-month follow-up. It was found that patients younger than 55 years, with symptoms lasting less than 1 year, and without history of nasal problems, had significantly higher surgical success rates ( P < .05). Moreover, rates of failure were significantly lower in cases whose canaliculi were intubated for 5 to 6 months ( P < .05).
Conclusions
Endonasal microscopic laser dacryocystorhinostomy is a safe and minimally invasive procedure with reasonable results. It has many advantages over external or other conventional approaches. Successful results could be further enhanced by more wisely selecting the patients and by silicone extubation after 6 months.
1
Introduction
Dacryocystorhinostomy (DCR) consists of surgically forming a permanent anastomosis between the lacrimal sac and the nasal cavity and is performed in cases of lacrimal duct obstruction, which may manifest with epiphora, recurrent dacryocystitis or canaliculitis, and mucocele . It was first reported by Toti in 1904 via an external approach to the sac through a skin incision in the medial canthus and resecting the adjacent lacrimal sac and nasal mucosa with their intervening bone. In 1921, Dupuy-Dutemp and Bourguet , and later Falk in 1961, improved rates of successful fistulization by directly suturing the edges of nasal and lacrimal sac mucosal flaps. These approaches with minor modifications are still practical as the routine method by ophthalmologists and carry success rates of ∼90%, especially if accomplished with silicone tubing . However, there are many disadvantages with this technique, such as surgical scar formation, damage to surrounding tissues of the medial canthus (eg, medial palpebral ligaments and angular facial vessels), periorbital echymosis, nasal bleeding, as well as delayed complications such as fistula closure or medial turbinate adhesion to the lateral or septal walls which may in turn lead to sinus duct obstruction and sinusitis . There is another approach, the so-called endonasal method, which was initially described by Caldwell in 1893 for nasal duct obstructions and was later modified by West (1910) and Halle (1914) . It lacks the aforementioned limitations of external DCR. However, this approach fell out of favor because of difficult visualization of the endonasal anatomy during the operation and access to the lacrimal sac . Upon introduction of modern rigid endoscopes and surgical microscopes, these difficulties have been overcome resulting in reemergence of the endonasal approach . Interestingly, it has success rates comparable to the external approach . McDonogh and Meiring and Rice published the first reports of endoscopic intranasal DCR on small groups of patients and cadavers. In 1990, Massaro et al introduced endonasal laser DCR using a high-energy Ar laser device and the operating microscope. Later on, potassium-titanyl-phosphate (KTP), CO 2 , neodymium:yttrium-aluminum-garnet (Nd:YAG), Holmium:YAG, and Er:YAG lasers were used . In our experience with DCR, which was performed for the first time in Iran in 1999, we report 12-month follow-up results of 168 cases (151 patients) treated with endonasal laser DCR using a surgical microscope.
2
Materials and methods
2.1
Type of study
A case-series study was designed to evaluate the effectiveness and complications of laser DCR operation performed by endonasal microscopic approach on patients referring to the 504 ENT and Eye Hospital between June 1999 and May 2004. The experiment was approved by the hospital review board and the university clinical governance unit.
2.2
Patient selection
Demographic statistics as well as preoperational data of the cases are shown in Table 1 . Patients referring to the ophthalmology clinic with signs and symptoms of lacrimal duct obstruction were included in this study. Inclusion criteria for the study were epiphora, mucocele, or chronic dacryocystitis with recurrent exacerbations. Cases with trauma to the lacrimal system, sicca syndrome, or systemic disorders with potential hazards to the surgery were excluded from the study. However, patients with nasal polyps or mild septal deviation in whom proper visualization and laser administration were not impaired were preserved in the study.
| Variable | Value |
|---|---|
| Sex, female (%) | 91 (56.2%) |
| Age range (y) | 7–100 |
| Age mean (y) | 53.1 ± 17.2 ⁎ |
| Age median (y) | 50 |
| Average disease duration (y) | 4.5 ± 3.1 ⁎ |
| Epiphora (%) | 162 (100%) |
| Regurgitation (%) | 71 (43.8%) |
| Previous probing (%) | 43 (26.5%) |
| Previous DCR (%) | 29 (17.9%) |
| Hx of cellulitis or abscess (%) | 34 (21.0%) |
| Hypertrophy of turbinates (%) | 32 (19.8%) |
| Ipsilateral septal deviation (%) | 47 (29.0%) |
2.3
Preoperational evaluation
All patients underwent a thorough ophthalmic examination before the operation, including testing of visual acuity, visual fields, and slit lamp examination. Moreover, they were examined by an otorhinolaryngologist and nasal endoscopy was performed to identify a possible cause for lacrimal obstruction and to assess the feasibility of endonasal manipulation. Patency of the canalicular system was ensured if fluid, mucus, or pus was regurgitated through the punctum on compression of the sac (positive test). Negative results were cannulated by a metal probe followed by irrigating the lacrimal drainage system with/without dacryocystography to confirm lacrimal duct obstruction ( Table 1 ). On the whole, 90 cases (55.6%) had nasal problems including history of previous operations with scars or adhesions, septal deviation, hypertrophy of turbinates, and concha bullosa.
2.4
Surgical procedure
The surgical operations were performed by the first author (ShF). All patients filled out and signed written informed consents. The surgery was performed preferably under general anesthesia (122 patients) or under local anesthesia (29 patients) by injection of 2% lidocaine, if not possible. In all instances, nasal mucosa was prepared by pledgets soaked with 0.25% phenylephrine and 10% lidocaine applied into the nasal passages. The pledgets were removed after 15 minutes. One drop of tetracaine solution was also administered to ipsilateral eyes. Safety precautions for the patients and the operating team were taken. Patients’ eyes and skin were protected by laser-safe dressings.
A fiberoptic light probe lubricated with antibiotic ointment was placed via either canaliculus into the lacrimal sac, so that the lacrimal fossa was identified intranasally by transillumination, unless marked edema or cellulitis was present. In such cases, anatomical intranasal landmarks (anterior end of the middle turbinate, and posterior margin of the frontal process of the maxilla) were used to localize the likely position of the lacrimal sac. The nasal cavity was kept wide open by a speculum, and the microscope was focused onto the site of the operation. The laser fiberoptic tube was then passed through a 30° suction tube. The microbeam of the laser, at its lowest setting, was directed toward the site of transillumination (or the approximated position of the lacrimal sac as determined above) at the lateral wall of the nasal cavity. In some cases, it was necessary to perform laser-assisted partial turbinectomy (55 cases) or polypectomy (5 cases) to obtain proper access to the surgical area. The laser type and adjustments used were KTP laser at 8 to 12 W (continuous or repetitive 0.5-second pulse mode) for mucosal and soft tissue ablation, and Nd:YAG laser at 20 to 25 W (continuous mode) for application to bone (Laserscope, Orion, San Jose, CA).
Ablation of approximately 1 cm 2 of the mucosa overlying the bony ostium followed by evaporization of the lacrimal bone was carried out until a body ostium of at least 1 cm 2 was created and the lacrimal sac was properly visualized. An opening of the sac with a diameter of 10 × 10 mm was then created. Lacrimal fluids and/or purulent secretions rushed out into the nasal cavity immediately afterwards. Remaining lacrimal sac contents were subsequently suctioned out endonasally.
The light probe was replaced with a cannula, and patency was confirmed by lacrimal irrigation. Upon termination of the surgical procedure, bicanalicular intubation was performed by passing a silicone tube through the inferior lacrimal punctum into the newly opened ostium. The superior lacrimal punctum was dilated and intubated with the other end of the lacrimal stent. Both ends of the silicone tube were then tied together intranasally, thus forming a continuous loop through upper and lower canaliculi, common canaliculus, nasolacrimal sac, and the nasolacrimal ostium. In cases of nasal hemorrhage, proper hemostasis was achieved by either KTP laser coagulation or phenylephrine-immersed nasal packings.
No nasal packings were used routinely. Patients were positioned semisupine at 45° and were discharged after complete recovery. Nasal irrigation with saline, twice a day, as well as lubrication of anterior nasal mucosa with 1% tetracycline ointment was recommended. The patients were also prescribed 10% sulfacetamide eye drops (1–2 gtt q4h) for 1 week. The silicone tube was intended to remain in place for 6 months. Successful DCR was defined as absence of signs and symptoms, and patency of the nasolacrimal apparatus to irrigation with fluorescein after the follow-up period.
2.5
Postoperational evaluation
Patients were examined by an ophthalmologist 1 week, 2 weeks, 1 month, 6 months, and 1 year after the operation. They were asked about recurrence/persistence of symptoms (eg, epiphora, discharge, etc) followed by evaluation of the lacrimal system with irrigation.
2.6
Data analysis
Data were analyzed using SPSS version 14 statistical software (SPSS, Inc, Chicago, IL). Quantitative data are presented as mean ± SD. To evaluate the effect of various factors on the outcome of the operation, nominal data were generated by subdividing the patients based on age, sex, symptoms chronicity, and present history of nasal problems (ie, ipsilateral septal deviation, hypertrophy of turbinates, previous surgical scars or adhesions) as well as the time for which the silicone tubes remained in place after the operation. The data were then analyzed by χ 2 test. P values less than .05 were considered statistically significant.
2
Materials and methods
2.1
Type of study
A case-series study was designed to evaluate the effectiveness and complications of laser DCR operation performed by endonasal microscopic approach on patients referring to the 504 ENT and Eye Hospital between June 1999 and May 2004. The experiment was approved by the hospital review board and the university clinical governance unit.
2.2
Patient selection
Demographic statistics as well as preoperational data of the cases are shown in Table 1 . Patients referring to the ophthalmology clinic with signs and symptoms of lacrimal duct obstruction were included in this study. Inclusion criteria for the study were epiphora, mucocele, or chronic dacryocystitis with recurrent exacerbations. Cases with trauma to the lacrimal system, sicca syndrome, or systemic disorders with potential hazards to the surgery were excluded from the study. However, patients with nasal polyps or mild septal deviation in whom proper visualization and laser administration were not impaired were preserved in the study.
| Variable | Value |
|---|---|
| Sex, female (%) | 91 (56.2%) |
| Age range (y) | 7–100 |
| Age mean (y) | 53.1 ± 17.2 ⁎ |
| Age median (y) | 50 |
| Average disease duration (y) | 4.5 ± 3.1 ⁎ |
| Epiphora (%) | 162 (100%) |
| Regurgitation (%) | 71 (43.8%) |
| Previous probing (%) | 43 (26.5%) |
| Previous DCR (%) | 29 (17.9%) |
| Hx of cellulitis or abscess (%) | 34 (21.0%) |
| Hypertrophy of turbinates (%) | 32 (19.8%) |
| Ipsilateral septal deviation (%) | 47 (29.0%) |
2.3
Preoperational evaluation
All patients underwent a thorough ophthalmic examination before the operation, including testing of visual acuity, visual fields, and slit lamp examination. Moreover, they were examined by an otorhinolaryngologist and nasal endoscopy was performed to identify a possible cause for lacrimal obstruction and to assess the feasibility of endonasal manipulation. Patency of the canalicular system was ensured if fluid, mucus, or pus was regurgitated through the punctum on compression of the sac (positive test). Negative results were cannulated by a metal probe followed by irrigating the lacrimal drainage system with/without dacryocystography to confirm lacrimal duct obstruction ( Table 1 ). On the whole, 90 cases (55.6%) had nasal problems including history of previous operations with scars or adhesions, septal deviation, hypertrophy of turbinates, and concha bullosa.
2.4
Surgical procedure
The surgical operations were performed by the first author (ShF). All patients filled out and signed written informed consents. The surgery was performed preferably under general anesthesia (122 patients) or under local anesthesia (29 patients) by injection of 2% lidocaine, if not possible. In all instances, nasal mucosa was prepared by pledgets soaked with 0.25% phenylephrine and 10% lidocaine applied into the nasal passages. The pledgets were removed after 15 minutes. One drop of tetracaine solution was also administered to ipsilateral eyes. Safety precautions for the patients and the operating team were taken. Patients’ eyes and skin were protected by laser-safe dressings.
A fiberoptic light probe lubricated with antibiotic ointment was placed via either canaliculus into the lacrimal sac, so that the lacrimal fossa was identified intranasally by transillumination, unless marked edema or cellulitis was present. In such cases, anatomical intranasal landmarks (anterior end of the middle turbinate, and posterior margin of the frontal process of the maxilla) were used to localize the likely position of the lacrimal sac. The nasal cavity was kept wide open by a speculum, and the microscope was focused onto the site of the operation. The laser fiberoptic tube was then passed through a 30° suction tube. The microbeam of the laser, at its lowest setting, was directed toward the site of transillumination (or the approximated position of the lacrimal sac as determined above) at the lateral wall of the nasal cavity. In some cases, it was necessary to perform laser-assisted partial turbinectomy (55 cases) or polypectomy (5 cases) to obtain proper access to the surgical area. The laser type and adjustments used were KTP laser at 8 to 12 W (continuous or repetitive 0.5-second pulse mode) for mucosal and soft tissue ablation, and Nd:YAG laser at 20 to 25 W (continuous mode) for application to bone (Laserscope, Orion, San Jose, CA).
Ablation of approximately 1 cm 2 of the mucosa overlying the bony ostium followed by evaporization of the lacrimal bone was carried out until a body ostium of at least 1 cm 2 was created and the lacrimal sac was properly visualized. An opening of the sac with a diameter of 10 × 10 mm was then created. Lacrimal fluids and/or purulent secretions rushed out into the nasal cavity immediately afterwards. Remaining lacrimal sac contents were subsequently suctioned out endonasally.
The light probe was replaced with a cannula, and patency was confirmed by lacrimal irrigation. Upon termination of the surgical procedure, bicanalicular intubation was performed by passing a silicone tube through the inferior lacrimal punctum into the newly opened ostium. The superior lacrimal punctum was dilated and intubated with the other end of the lacrimal stent. Both ends of the silicone tube were then tied together intranasally, thus forming a continuous loop through upper and lower canaliculi, common canaliculus, nasolacrimal sac, and the nasolacrimal ostium. In cases of nasal hemorrhage, proper hemostasis was achieved by either KTP laser coagulation or phenylephrine-immersed nasal packings.
No nasal packings were used routinely. Patients were positioned semisupine at 45° and were discharged after complete recovery. Nasal irrigation with saline, twice a day, as well as lubrication of anterior nasal mucosa with 1% tetracycline ointment was recommended. The patients were also prescribed 10% sulfacetamide eye drops (1–2 gtt q4h) for 1 week. The silicone tube was intended to remain in place for 6 months. Successful DCR was defined as absence of signs and symptoms, and patency of the nasolacrimal apparatus to irrigation with fluorescein after the follow-up period.
2.5
Postoperational evaluation
Patients were examined by an ophthalmologist 1 week, 2 weeks, 1 month, 6 months, and 1 year after the operation. They were asked about recurrence/persistence of symptoms (eg, epiphora, discharge, etc) followed by evaluation of the lacrimal system with irrigation.
2.6
Data analysis
Data were analyzed using SPSS version 14 statistical software (SPSS, Inc, Chicago, IL). Quantitative data are presented as mean ± SD. To evaluate the effect of various factors on the outcome of the operation, nominal data were generated by subdividing the patients based on age, sex, symptoms chronicity, and present history of nasal problems (ie, ipsilateral septal deviation, hypertrophy of turbinates, previous surgical scars or adhesions) as well as the time for which the silicone tubes remained in place after the operation. The data were then analyzed by χ 2 test. P values less than .05 were considered statistically significant.
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