Initial Management of Pediatric Lower System Problems: Probing and Silicone Stents and Balloons

Fig. 27.1
Crigler method of massage


Fig. 27.2
Obstruction of nasolacrimal ducts. Lacrimal scintigraphy demonstrating obstruction of nasolacrimal ducts. Movement of tear columns following digital massage by the Crigler method

Conservative or Surgical Management for Dacryostenosis: Why and When

There has been long-standing controversy regarding the correct timing for initial probing of a child with nasolacrimal duct obstruction [1821]. The authors recommend that conservative measures be instituted and if this proves unsuccessful then initial probing be done when the patient is approximately 1 year of age. This recommendation is based on a large study by Katowitz and Welsh [21] (Fig. 27.3). In this study of 572 eyes, the success rate with initial probing was 96.4% in patients younger than 13 months. In patients older than 13 months, however, the mean success rate was 54.7%. When broken down into smaller age categories, a stepwise progression in success rates was observed from 76.4% for patients between 13 and 18 months to 33.4% for patients older than 24 months. In addition, the number and complexity of subsequent procedures appeared to increase along with the age at which the initial probing was performed.


Fig. 27.3
Percentage of cure with initial probing (From: Welsh and Katowitz [56]. Reprinted with permission from Wolters Kluwer Health)

In contrast to the declining success rate with age seen in our population group, Robb [22] reported a 92% success rate, in 303 eyes, after probing for congenital nasolacrimal duct obstruction in patients over 1 year of age. There was, in fact, a 92.6% success rate (25 of 29 patients) reported in this series in children probed over 36 months of age. Kushner [23], in contrast, reported an overall success rate of 70% in patients undergoing probing and irrigation between the ages of 18 and 48 months. He categorized obstructions as simple (involving the valve of Hasner) or complicated (involving a narrow duct or mechanical valve-like obstruction in the canaliculus). In children with a simple membrane at the valve of Hasner, 100% had resolution of epiphora following probing and irrigation, regardless of age. In the complicated group, however, the results were only 36% success following probing and irrigation.

Honavar reported a success rate with probing of 73% with one attempt and 80% with repeat probing in 60 eyes of children older than 24 months [24]. Furthermore, he identified factors predictive of probing failure to include age greater than 36 months, bilateral involvement, failed conservative therapy, failed earlier probing, dilated lacrimal sac, and a tight bony canal. In Honavar’s series, outcomes could further be divided into those children with membranous obstruction faring better with 91% success with probing, as compared to those with tight bony obstruction having only 42% success. Similar to the age-dependent findings of Katowitz and Welsh, Honavar noted a stepwise progression in success rates, with 97% success in the age group of 24–36 months, 75% in the age group of 37–48 months, and 42.9% in children beyond 48 months [24]. It would appear that the lower success rates in older children observed in our study and those of Kushner and Honavar may be explained by the suggestion of Paul and Shepard [25] that this may well represent a self-selection process where spontaneous resolution does not occur because a more complex type of obstruction has been present since birth [23].

It is important to consider the actual gestational age of the child. An infant who was born prematurely should be given a period of postnatal time to respond to conservative therapy that is equivalent to that for a full-term infant. Probing should always be the first step regardless of age. Additional steps at the time of the initial procedure should be undertaken only if the clinical situation warrants further intervention.

A major point of controversy regarding congenital dacryostenosis is whether to probe infants in the office or under a general anesthetic in a hospital setting [7, 11, 17, 21, 25, 26]. This controversy primarily applies to initial probing procedures. All children who have had failed in-office probings should have the second procedure repeated under general anesthesia. In deciding whether a general anesthetic should be used for the initial or routine type of probing, the most obvious concern is the associated risk with general anesthesia, particularly during the first 6 months of life. Obviously, the pediatric experience of the anesthesiologist and the hospital operating room staff is a critical factor in opting for a general anesthetic. Parents should be full participants in any decision regarding the choice of office surgery or the use of a general anesthetic. In patients with straightforward nasolacrimal duct obstruction, the chances for spontaneous resolution are excellent. In a child with apparent routine dacryostenosis, we recommend conservative measures until the child is 12 months of age, at which point a general anesthetic should be used for probing to evaluate and possibly treat the nasolacrimal duct obstruction. This permits a more thorough diagnostic evaluation as well as greater therapeutic options.

Irrigation of the infant nasolacrimal system in the office can be difficult and is not recommended, but probing of the duct alone can be accomplished more easily [5, 7, 9, 17]. Some surgeons prefer the lower canaliculus for office probing, but it is usually best to avoid the risks of damaging this channel. Therefore, if possible, we recommend initial probing of the upper canaliculus. The distinction between therapeutic and diagnostic probing is once again important. Office probing in an infant is primarily therapeutic, particularly for dacryocystitis or for an amniotocele in a newborn. Since there is less control over the child in the office, there is less time to safely feel for veils or strictures at various points along the lacrimal drainage system that may influence therapeutic measures. In addition, additional steps that might be needed for more complicated forms of obstruction, such as turbinate infracture, balloon dilation, or silicone intubation, cannot be done in an office probing.

An infant’s nasolacrimal system must be probed very gently because the punctum is so delicate. Wide dilators may tear the punctum. The Jones punctal dilator (OP7002, V. Mueller, Chicago, IL) or a dull safety pin that will not dilate past a #1 Bowman probe size should be used [17]. Because Bowman probe sizes vary depending on the manufacturer, the physician should be familiar with the actual width of the probe in use [18]. During an in-office probing, the child need not be completely mummified. The head can be held firmly, and the surgeon can sit at the child’s head or side, performing the probing from this position. Jones and Wobig [5, 27, 28] prefer to use a #0 or smaller probe in an infant and to leave the probe in place for 5 min after confirming its presence in the inferior meatus of the nose. They believe that this practice allows the mucosa to retract around the probe, which facilitates a successful result.

We consider office probing in patients older than 3–4 months unnecessarily traumatic to the child, the parents, and the surgeon. As long as there is availability for excellent pediatric anesthesia, we prefer a general anesthetic after this age. General anesthesia allows the surgeon to perform a complete diagnostic and therapeutic probing as well as an examination of the inferior nose. It also provides the opportunity for retinoscopy and a complete examination of the fundus if necessary due to difficulties with the child in the outpatient examination. A number of respected surgeons, however, prefer office probing in patients as old as 8 months [18]. Since 90% of these obstructions will clear by 1 year of age, our preference is to follow conservative management until this time and then to do a diagnostic and therapeutic probing under general anesthesia [10]. This also permits infracture of the inferior turbinate and/or silicone intubation to be done at the time of initial probing as indicated [5, 7, 8, 21].

Management of Dacryoceles (Mucoceles/Amniotoceles)

While it usually is not necessary to perform probing before 1 year of age, one exception is a congenital dacryocele, often described as a mucocele or amniotocele [29, 30]. These terms refer to a sterile accumulation of mucus or possibly amniotic fluid, which may become trapped in the lacrimal sac. It is presumed that this can occur due to a combined effect of nasolacrimal duct obstruction at the valve of Hasner and a one-way valve effect at the junction of the common canaliculus (at the valve of Rosenmuller) and the lacrimal sac. The sac becomes dilated and is seen as a bluish mass inferior to the medial canthal tendon (Fig. 27.4). This swelling is frequently misdiagnosed as a hemangioma, because of its similar discoloration. For a congenital dacryocele without signs of infection, the initial approach is to massage the lacrimal sac in an attempt to open the obstruction. Massaging too vigorously, however, can rupture the dilated lacrimal sac and produce a cellulitis. This will require systemic antibiotic therapy and management similar to that required for an acute dacryocystitis. If gentle massage is not effective in opening the obstruction, however, then gentle office probing, as described above, may be indicated. Schnall and Christian [31] also advocate an initial trial of medical management, consisting of massage and warm compresses with topical antibiotic drops for noninfected dacryoceles and intravenous antibiotics for infected cases. If the dacryocele does not resolve within a 1- to 2-week period, they recommend probing the nasolacrimal system. In their study, 76% (16 of 21 dacryoceles) resolved with medical management.


Fig. 27.4
Dacryocele . (a) Dacryocele (amniotocele) seen as bluish mass below the medial canthal tendon on both sides. (b) The same patient 2 weeks after bilateral office probing

All physicians should be aware of the high association of intranasal cysts with dacryoceles, amniotoceles, and frank dacryocystitis. These can also develop at the meatal end of the nasolacrimal duct (Fig. 27.5) in association with dacryoceles. These cysts may be more common than previously recognized before the advent of nasal endoscopy. Payesse et al. reported concurrent intranasal mucoceles in 23 of 30 dacryoceles (77%). In addition, 60% developed dacryocystitis or preseptal cellulitis [32]. Levin et al. found an intranasal cyst in 23/24 patients with either dacryoceles or dacryocystitis [4]. For this reason bilateral dacryoceles should never be probed in the office because the risk of nasal airway obstruction mandates a more controlled procedure under general anesthesia [13]. For unilateral office probings that fail, one should presume that an intranasal cyst is present, and the patient should be scheduled in a timely manner for surgical ablation, if necessary. Some patients with a unilateral cyst may actually have an asymptomatic cyst on the contralateral system. We have found this in a few of our congenital dacryocele patients who were treated in the operating room. Figure 27.6 depicts a 2-month-old with a right-sided dacryocele who was found to have bilateral intranasal cysts below the inferior turbinates. The technique we prefer for removing these cysts involves the introduction of a microdebrider device (2.9-mm trip-cut/shaver, Medtronic) with an inferior turbinate infracture, if necessary. Simple marsupialization of these cysts may not adequately debride them, and recurrence can more easily occur unless a significant portion of the cyst wall is removed.


Fig. 27.5
Nasolacrimal duct cyst viewed through endoscope


Fig. 27.6
Intranasal Cysts . (a) A 2-month-old child with a right-sided dacryocele. (b) and (c) Right and left intranasal cysts below the inferior turbinates. (d) and (e) Cyst walls removed with a microdebrider

Neonatal Dacryocystitis

Acute dacryocystitis of the newborn, in our experience, represents another indication for office or bedside probing of the nasolacrimal duct in patients younger than 12 months (Fig. 27.7) [5, 7, 33]. This is a medical emergency, however, in an infant and requires hospitalization with IV antibiotic therapy and careful monitoring to avoid rapid progression into orbital cellulitis or systemic bacteremia. In acute dacryocystitis, there are other signs of inflammation, and there may also be associated fever and an elevated white blood cell count. During the period of acute inflammation, the lacrimal sac can be tapped with a tuberculin needle and syringe (Fig. 27.8) [33]. This will create a tiny opening that will not fistulize, as might occur with a scalpel incision. It also allows smears to be taken immediately for early diagnosis, as well as material for culture and sensitivity so that specific systemic antibiotics can eventually be utilized. Decompression of the sac is quickly achieved and this gives immediate relief of discomfort. Furthermore, with the needle in position, the syringe can be changed to instill 0.5 mL of a bactericidal antibiotic solution. A broad-spectrum antibiotic is also given intravenously until a more specific antibiotic can be identified by the cultures and sensitivities obtained from the tap. After several days, when the acute inflammation subsides, bedside or office probing is valuable in most cases because it usually opens the duct and allows tear drainage so that repeat dacryocystitis does not occur. Probing must be done very gently, using a very small probing instrument, such as a No. 000 or 0000 Bowman probe (or 0.5-mm- or 0.6-mm-diameter FCI probe). It is usually dangerous to probe the nasolacrimal duct in the setting of acute inflammation because false passages may be created. However, if dacryocystitis recurs after such probing, an evaluation under general anesthesia will be required, and a dacryocystorhinostomy (DCR) may even be necessary to avoid repeated infection [34]. Once again the risk of an associated intranasal cyst is high, thus a low suspicion for an endonasal examination and treatment is paramount.


Fig. 27.7
Neonatal dacryocystitis . (a) Neonatal dacryocystitis. (b) CT scan showing dilated nasolacrimal sac; referral was for an incorrectly diagnosed orbital mass


Fig. 27.8
Neonatal dacryocystitis . (a) Tuberculin syringe tap of the lacrimal sac for neonatal dacryocystitis; note 0.8 mL purulent material withdrawn from lacrimal sac. (b) The same patient 1 week post-office probing with #000 Bowman probe

More recently, we have addressed dacryocystitis surgically with an endonasal endoscopic approach. If there is in fact an intranasal cyst, this is debrided. If, however, there is a bony obstruction under the inferior turbinate, an endonasal endoscopic dacryocystorhinostomy is performed. This technique is addressed in Chap. 28.

Probing and Irrigation Under General Anesthesia

When probing under general anesthesia is planned, a laryngeal masked airway (LMA) can be used as an alternative to intubation because it allows free access to the nose for retrieval of dye and irrigation of fluids (Figs. 27.9 and 27.10) (see Chap. 5) [35]. It also maintains the airway, even if it becomes necessary to perform silicone intubation of the nasolacrimal system. An intravenous drip should be established before the surgeon performs the actual probing and irrigation. The risk of laryngospasm is always a concern, especially when only using a face mask. We prefer the LMA when there is an experienced pediatric anesthesia team monitoring the patient. Laryngospasm is a life-threatening airway emergency that can be avoided by taking care to inject a minimal volume of fluorescein on irrigation (0.5 ml or less) and taking care to minimize bleeding in the nose. It is helpful to spray oxymetazoline 0.05% (Afrin, Schering, Liberty Corners, NJ) into each operative nostril to control hemostasis. If there is any concern about maintaining the child’s airway, then endotracheal intubation should always be done.


Fig. 27.9
Laryngeal mask


Fig. 27.10
Laryngeal mask in position. Laryngeal mask allows better access to the nose and increased safety as compared to a routine face mask

When the child is asleep, careful examination of the puncta and canaliculi should first be performed. Any lacrimal fistula should be noted. If both puncta are present on an operative side, only the upper punctum need be dilated. Great care must be made to minimally dilate the punctum so as not to tear the surrounding orbicularis fibers. This will increase the risk of a monocanalicular stent loss or bicanalicular punctal slitting. An experienced lacrimal surgeon can sometimes probe the punctum without dilating it, but the probe should never be forced, as there is always the risk of creating a false passage.

To probe and irrigate the outflow system, a lacrimal cannula (blunt 23-gauge needle) attached to a 2-mL Luer lock syringe containing several milliliters of a diluted fluorescein solution should be used. The surgeon should feel for veils and strictures in each canaliculus, as well as at the internal common canaliculus, before attempting to probe the nasolacrimal duct. The surgeon can attempt to use hydrostatic pressure irrigation while occluding the opposite punctum, as the initial effort to open the lower (distal) portion of the nasolacrimal system, but in our experience, this is rarely an effective method of clearing the obstruction. If there is regurgitation from the inferior punctum with an associated lower obstruction, then this indicates patency of the inferior canaliculus without the need for an additional step to check this part of the outflow system.

The lacrimal cannula can be used as a probe because its diameter is between a #0 and a #00 Bowman probe. The best cannula tip is smooth with the port on the side. The cannula is shaped into a slight curve and is passed gently into the nasolacrimal duct via the upper canaliculus (Fig. 27.11). The lower canaliculus should be manipulated as little as possible. This is mainly because if the upper is patent, it is unnecessary to stress this channel with probing the lacrimal duct since the lower eyelid must be elevated an additional 45°, thus increasing the risk of upper system injury. Furthermore, as will be described later, in the case of monocanalicular stenting, the upper punctum should be treated since its anatomic location is usually more medial than the lower. Thus, the collarette of this type of stent has less chance of irritating the cornea.


Fig. 27.11
Probing and irrigation of the nasolacrimal system. The cannula is slipped down to the point of obstruction and pushed through gently but firmly. Dye is injected from the syringe, and the patency of the system is confirmed by suctioning the dye from the inferior meatus with a soft pediatric-size plastic suction catheter

If any resistance is encountered because the cannula is too large, the surgeon should withdraw the instrument immediately and use a smaller Bowman probe. The probing instrument is slipped down into the nasolacrimal duct until it meets resistance, which most commonly occurs at the lower end. Regardless of whether the irrigation cannula or a Bowman probe is used, the instrument should slide easily into the duct. Forcing the instrument inferiorly may create a false passage. The surgeon then should turn the curve of the cannula medially and, with a gentle but firm push, enter the nose beneath the inferior turbinate. When the cannula is passed through the duct, any scraping sensation, rather than a smooth, sliding sensation, usually indicates a false passage. In such instances, the instrument should be withdrawn. The surgeon should then make another gentle attempt to find the normal channel. If passage into the nose is not achieved because of a presumed false passage, one can either perform an endonasal examination to identify the patency of the valve of Hasner or consider proceeding immediately to a DCR. Many times, however, it is best to reschedule this for a later date following another attempt at gentle probing first which is sometimes successful after inflammation encountered during the first unsuccessful probing has settled.

Location of the probe in the inferior meatus can be confirmed by metal-to-metal contact with a large second probe placed through the nostril under the inferior turbinate. Direct visualization of the probe can also be instructive, particularly in complicated cases. This can be accomplished by using an endoscope. It is helpful to shrink the nasal mucosa with a 4% cocaine solution or with oxymetazoline 0.05% (Afrin, Schering, Liberty Corners, NJ). During irrigation, dye is then collected from the inferior meatus of the nose with a soft, plastic pediatric-size suction catheter (No. 10 French Argyle oxygen catheter, Dow Corning, New York) [27]. Fluorescein dye is preferred for any system that has a high probability of requiring silicone intubation. In the past, methylene blue was a useful and readily available dye but has the main drawback of staining tissue and instruments. Unless a patient has a known fluorescein allergy, this dye is always preferred over methylene blue which stains the tissues unnecessarily. After these steps are completed, an intranasal examination should always be performed. If the inferior turbinate seems to be impacted over the nasolacrimal duct, it can be infractured medially toward the septum with a Freer elevator (Fig. 27.12). After probing and irrigation with dye is completed, an antibiotic-steroid solution is then irrigated through the upper canaliculus of each nasolacrimal system. The suction catheter is placed in the nasal passage prior to irrigation to minimize the threat of laryngospasm caused by the collection of irrigating fluid in the posterior pharynx. On occasion, there will still be regurgitation of this solution from the opposite canaliculus. It is then useful to occlude the opposite punctum with a cotton-tipped applicator and then to inject more solution through the duct, again collecting this with the suction catheter.


Fig. 27.12
Infracture of the inferior turbinate. A periosteal elevator is slipped into the inferior meatus and advanced along the length of the under surface of the inferior turbinate. The patient’s head is stabilized, and the turbinate is pushed medially by distributing force along the entire length of the turbinate rather than just at one point. This step minimizes trauma while creating a larger space for the exit of tears from the valve of Hasner at the distal end of the nasolacrimal duct. The instillation of oxymetazoline (Afrin) into the inferior meatus before this maneuver reduces intraoperative and postoperative bleeding

Parents are instructed to use an antibiotic-steroid drop four times daily for the next week. The patient is seen in the office 2–3 weeks postoperatively. If one attempt at simple irrigation and probing is not successful, then the irrigation and probing can be repeated, including infracture of the inferior turbinate if this was not previously performed. Unless there is very rapid outflow on this repeat attempt with little resistance during irrigation, we usually proceed immediately to balloon dilation or silicone intubation of the nasolacrimal system.

Treatment for a Failed Probing

The patient who has persistent symptoms after an initial probing and irrigation procedure will likely require additional intervention to permanently cure their tearing. Ideally, this would be accomplished by only one more procedure under general anesthesia. The classic approach to a failed probing has been to simply repeat the same procedure [36, 37]. The main criticism to this approach, however, is the fact that it is not really introducing a new treatment method. An alternative to repeat probing is to surgically widen the nasolacrimal duct with either a balloon or probe with or without the placement of a stent that intubates the entire nasolacrimal outflow system. A more recent surgical approach that is becoming a readily adopted practice is to treat the nasolacrimal duct with a balloon or a stent as a primary procedure immediately after probing. The purpose is to avoid the risk of a reoperation [38, 39]. In this approach, a surgeon would consider probing a potential failure either because (1) there was an element of stenosis that would require stenting or (2) even with a simple membranous obstruction, the surgeon prefers to stent the system to prevent any membrane reepithelialization. Some authors prefer to use a canalicular endoscope to diagnose and treat CNLDO [41]. However, it is the opinion of the authors that while this is a helpful diagnostic tool, it is more invasive and ultimately unnecessary given the high success of stent placement and/or balloon dacryoplasty without this additional technique.

Balloon Dilation of the Nasolacrimal Duct

Becker et al. [40] and Hutcheson et al. [42] published their results using an inflatable balloon catheter as an alternative to silicone intubation in children who have failed previous lacrimal system probing or who presented at an older age of onset. The LacriCATH balloon lacrimal catheter (Atrium Medical Products, Birmingham, AL) is very similar to a classic balloon angioplasty device. It consists of a small polyurethane inflatable balloon on a semiflexible guide wire, which is inserted through the upper canaliculus through the nasolacrimal duct. The LacriCATH is then inflated to a pressure of 8 atm for 90 s. This is then repeated, without moving the catheter, for an additional 60 s. This device presumably dilates the nasolacrimal duct while it is inflated, thus enhancing the patency of the lower nasolacrimal system (Fig. 27.13).


Fig. 27.13
Balloon catheter . (a) Balloon catheter inflation apparatus with adjacent uninflated catheter. (b) A 2-mm balloon catheter inflated with saline, adjacent to uninflated catheter. (c) Gauge showing balloon catheter being inflated to 8 atm after being placed in the nasolacrimal duct

Previous studies of lacrimal balloon dilation with similar instruments have yielded success rates ranging from 56% to 97%. The variability in results may be due to the differences in perioperative management. For example, Becker et al. used postoperative oral steroids, whereas Hutcheson et al. did not. The use of this method as a primary procedure in effect is the same as an initial probing, which has a very high success rate. The use of this technique may have more proven value for failed DCR surgery, but our initial experience with this technique for failed probing or problematic cases has been approximately 90% which is comparable to our results with bicanalicular intubation, with slight improvement of results with the use of silicone intubation. Further controlled studies are needed to determine the efficacy and role of lacrimal duct balloon dilation with and without silicone intubation.

Silicone Intubation of the Nasolacrimal Duct

In the presence of nasolacrimal bony or mucosal stenosis, a simple probing and irrigation procedure is often not adequate to permanently cure the tearing child. Silicone stent placement is a minimally invasive procedure that can achieve lasting nasolacrimal patency once removed. The mechanism by which this stent is successful in treatment has not been proven. It is possible the stent prevents membrane reepithelialization or scar tissue formation due to intraductal inflammation. Alternatively, we suggest that a stent, if placed in a young growing child, may stimulate ductal bony growth. This has yet to be proven but can be postulated that younger children with a rapidly growing head may have better ductal growth stimulation with stent intubation [38, 39].

Intubation Materials

Silicone tubing #5941 with an external diameter of 0.025 mm is preferred for both pediatric and adult use, as was originally described by Quickert and Dryden [43]. The tubing can be stretched over a #0 tapered probe (Quickert 4220, Storz, St. Louis, MO). It can also be glued in place with silicone bonding glue before autoclaving if desired. Currently, a variety of packaged intubation sets (e.g., the Crawford probing set, 28–0185; retrieval hook, 28–0186, Jedmed Instrument, St. Louis, MO; or Ritleng system, FCI, Paris, France) are also available. They are more expensive but avoid the need to prepare the probes with tubing. The important features to consider in choosing a packaged set for nasolacrimal intubation are that the metal probe is malleable enough to minimize the trauma to the duct and the nasal structures and that the tubing is bonded sufficiently to the probes so that it will not slip off when pulled through the nasolacrimal system. For bicanalicular intubation, if a metal probe is used, the authors prefer the Crawford intubation set. Detachment of the silicone from the probe occurs most frequently when the junction of the tubing and the probe is pulled slowly through the punctum into the nasolacrimal system during retrieval from within the inferior meatus. Usually, detachment can be prevented by dilation of the punctum before insertion of the probe, application of an ointment for lubrication at the metal and silicone interface, and pulling the tubing rapidly through the system.

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Dec 19, 2017 | Posted by in OPHTHALMOLOGY | Comments Off on Initial Management of Pediatric Lower System Problems: Probing and Silicone Stents and Balloons

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