1

Introduction

External dacryocystorhinostomy (EXT-DCR) is the gold standard in the treatment of acquired nasolacrimal duct obstruction ( Fig. 1 ). Toti first described the procedure in 1904 and in 1921, Dupuy-Dutemps and Bourguet modified it . Success rates are high and range from 87% to 93% . Failures, however, do occur and are attributed to small bony ostia, mucosal fibrosis, nasal granulation tissue, nasal polyps, hypertrophic middle turbinates, synechiae, and septal deviation . Revision dacryocystorhinostomy (DCR) can be performed via the external approach or the endoscopic endonasal approach. No matter the approach, the cause of failure must be identified and addressed during the revision surgery. It has been observed that failed primary EXT-DCR that are revised via an endoscopic endonasal approach yielded higher rates of additional nasal procedures (e.g. septoplasty, sinus surgery, nasal polypectomy, etc.) . It has been suggested that an endoscopic endonasal dacryocystorhinostomy (END-DCR) is advantageous in a revision case due to the ability to diagnose and treat the cause of failure at the time of revision surgery .

Severe nasal septal deviation can contribute to EXT-DCR failure. (A) In this figure, the location of the newly created ostia would be in very close proximity to the nasal septum. (B) After septoplasty, the deviated septum is corrected and the location of the newly created ostia will no longer be in close proximity to the nasal septum.

Our practice during the evaluation of a tearing patient is to have the oculoplastic surgeon perform a nasal speculum exam to determine if intranasal pathology may contribute to the clinical picture or post-operative course. If such pathology is identified, the patient is referred to an otolaryngologist/facial plastic surgeon for further evaluation. In the present study, we examine the causes of failure in our patient population and propose that concomitant treatment of nasal pathology at the initial surgery can mitigate the need for revision surgery.

2

Materials and methods

The study and data accumulation were carried out according to the guidelines of the Indiana University School of Medicine institutional review board (IRB# 1309131239). Patient charts were reviewed between April 2008 and August 2013. Patients were included if they were diagnosed with an acquired nasolacrimal duct obstruction (NLDO) based on presenting symptoms and nasolacrimal probing. Post-operative failures were established if the patient had persistent tearing in the absence of eyelid malposition with the inability to flush the nasolacrimal system. All patients included in this study underwent a nasal speculum exam by the oculoplastic surgeon. If an intranasal pathology was identified as the cause of failure or a potential cause of failure, the patient was referred to an otolaryngologist/facial plastic surgeon for an evaluation. Both the nasal pathology and revision EXT-DCR were performed under the same anesthetic. Surgical success was defined by resolution of presenting symptoms.

2

Materials and methods

The study and data accumulation were carried out according to the guidelines of the Indiana University School of Medicine institutional review board (IRB# 1309131239). Patient charts were reviewed between April 2008 and August 2013. Patients were included if they were diagnosed with an acquired nasolacrimal duct obstruction (NLDO) based on presenting symptoms and nasolacrimal probing. Post-operative failures were established if the patient had persistent tearing in the absence of eyelid malposition with the inability to flush the nasolacrimal system. All patients included in this study underwent a nasal speculum exam by the oculoplastic surgeon. If an intranasal pathology was identified as the cause of failure or a potential cause of failure, the patient was referred to an otolaryngologist/facial plastic surgeon for an evaluation. Both the nasal pathology and revision EXT-DCR were performed under the same anesthetic. Surgical success was defined by resolution of presenting symptoms.

3

Results

From April 2008 to February 2012, a total of 12 EXT-DCR failures were identified. There were 4 males and 8 females with an average age of 50.3 years. The average time from their initial surgery to failure was 7.2 months. The causes of failure were identified as: nasal septal deviation (8) and soft tissue periorbital factors (5). One patient had both of these issues that contributed to their failure. The patients diagnosed with a nasal septal deviation as the cause of failure underwent a combined septoplasty and revision EXT-DCR by an otolaryngologist/facial plastic surgeon and oculoplastic surgeon, respectively. Post-operatively, all of these patients did well and their presenting symptoms resolved. The average time of follow up after the revision surgery was 7.5 months.

From March 2012 to August 2013, a second cohort of patients utilized the approach of performing a septoplasty on primary EXT-DCR patients who presented with nasal septal deviations during initial examination by the oculoplastic surgeon. They were referred to an otolaryngologist/facial plastic surgeon for a septoplasty. Utilizing this approach, 8 consecutive patients were identified for the combined procedure. In this group, 3 were males and 5 were females and the average age was 53.1 years. A total of 10 primary EXT-DCRs and 8 septoplasties were performed concurrently. One patient also underwent sinus surgery to address chronic sinusitis and one underwent bilateral EXT-DCRs. Nine of the 10 EXT-DCRs were successful (90%) and there was one failure (10%). The one patient who failed underwent bilateral EXT-DCRs in which one side was successful and the other side failed due to a common canalicular obstruction that will be addressed with a conjunctivodacryocystorhinostomy. The average follow up time after surgery was 2.7 months.