Abstract
Objective
To evaluate the ultrasonic bone aspirator versus traditional powered drill technique for use in endoscopic dacryocystorhinostomy.
Study design
Retrospective chart review.
Setting
Academic institution.
Subjects and methods
A retrospective chart review of all patients undergoing endoscopic dacryocystorhinostomy from June 2010 through May 2014 was performed. Data were collected from 63 eyes of 63 patients. Recorded data points include: age, gender, etiology of epiphora, procedure type, success rate, need for septoplasty, and length of follow-up. Surgical failure was defined as no improvement in epiphora, postoperative dacryocystitis, or inability to irrigate the lacrimal system post-operatively.
Results
Sixty three consecutive patients underwent endonasal endoscopic dacryocystorhinostomy. Twenty nine patients underwent powered microdrill DCR (pDCR); 34 patients underwent ultrasonic bone aspirator DCR (uDCR). There was no statistically significant difference between groups in terms of age or gender. The success rates were: pDCR 86.2% and uDCR 94.1% (p = 0.4). Concurrent septoplasty was performed in 48% of pDCR patients and 21% of uDCR patients (p = 0.03) There was no significant difference in surgical success when septoplasty was controlled for (p = 0.39).
Conclusion
Ultrasonic bone aspirator dacryocystorhinostomy has a similar success rate to traditional powered microdrill dacryocystorhinostomy.
1
Introduction
The standard surgical treatment for epiphora is dacryocystorhinostomy, either by an external or endonasal approach. The endonasal approach has gained popularity over the past two decades. Advantages include avoidance of an external incision, ability to evaluate intranasal anatomy, the potential for shorter operative/recovery times, and avoiding disruption of the medial canthus or orbicularis oculi muscle . Multiple surgical techniques have been described for bone removal during endonasal dacryocystorhinostomy including bone ronguers, lasers, radiofrequency devices, and drills . Each of these techniques offers unique advantages and disadvantages. The ultrasonic bone aspirator is a comparatively new tool for endonasal dacryocystorhinostomy and there are relatively few reports in the literature. This study was designed to compare the ultrasonic bone aspirator technique to the traditional microdrill technique.
2
Patients and methods
Institutional review board approval was obtained through the University of California Davis (IRB# 630264) and a retrospective review was performed. All patients undergoing endonasal dacryocystorhinostomy between June 2010 and May 2014 were included. The exclusion criteria were patients younger than age 18, patients with a history of previous dacryocystorhinostomy, and patients without a minimum of 6 weeks of follow up. Sixty-three consecutive patients were included. All patients underwent a pre-operative head and neck examination including irrigation of the lacrimal system. Surgery with either the ultrasonic bone aspirator (Sonopet; Stryker, Kalamazoo, MI) ( Fig. 1 ) or powered microdrill (Medtronic, Minneapolis, MN) ( Fig. 2 ) was performed by the senior author in all cases. Twenty-nine consecutive patients underwent microdrill dacryocystorhinostomy followed by thirty-four consecutive ultrasonic bone aspirator assisted dacryocystorhinostomies. The decision to perform septoplasty was based upon access to the lacrimal sac and ability to remove the frontal process of the maxilla without traumatizing surrounding mucosal surfaces. Data points collected on each patient included: age, gender, etiology of epiphora, procedure type, success rate, adjunctive septoplasties, and length of follow-up. At each post-operative visit, patients were assessed for presence or absence of epiphora and nasal endoscopy was performed to evaluate the neo-ostium. Lacrimal irrigation was performed in all patients with persistent complaints of epiphora. Surgical failure was defined as no improvement in epiphora, any episode of postoperative dacryocystitis, or inability to irrigate the lacrimal system.
2
Patients and methods
Institutional review board approval was obtained through the University of California Davis (IRB# 630264) and a retrospective review was performed. All patients undergoing endonasal dacryocystorhinostomy between June 2010 and May 2014 were included. The exclusion criteria were patients younger than age 18, patients with a history of previous dacryocystorhinostomy, and patients without a minimum of 6 weeks of follow up. Sixty-three consecutive patients were included. All patients underwent a pre-operative head and neck examination including irrigation of the lacrimal system. Surgery with either the ultrasonic bone aspirator (Sonopet; Stryker, Kalamazoo, MI) ( Fig. 1 ) or powered microdrill (Medtronic, Minneapolis, MN) ( Fig. 2 ) was performed by the senior author in all cases. Twenty-nine consecutive patients underwent microdrill dacryocystorhinostomy followed by thirty-four consecutive ultrasonic bone aspirator assisted dacryocystorhinostomies. The decision to perform septoplasty was based upon access to the lacrimal sac and ability to remove the frontal process of the maxilla without traumatizing surrounding mucosal surfaces. Data points collected on each patient included: age, gender, etiology of epiphora, procedure type, success rate, adjunctive septoplasties, and length of follow-up. At each post-operative visit, patients were assessed for presence or absence of epiphora and nasal endoscopy was performed to evaluate the neo-ostium. Lacrimal irrigation was performed in all patients with persistent complaints of epiphora. Surgical failure was defined as no improvement in epiphora, any episode of postoperative dacryocystitis, or inability to irrigate the lacrimal system.
3
Surgical technique
All endoscopic dacryocystorhinostomies were performed under general anesthesia. Following induction, cottonoid pledgets with 1:1000 epinephrine were placed intranasally for decongestion. Local anesthetic (1% lidocaine with 1:100,000 epinephrine) was injected submucosally at the attachment of the middle turbinate and inferiorly along the frontal process of the maxilla. Epinephrine soaked pledgets were then replaced while both puncta were dilated and the lacrimal system was probed to confirm normal anatomy. Monopolar cautery was then used to make an incision beginning 7–8 mm superior to axilla of the middle turbinate, and extending 8–10 mm anteriorly. A parallel incision is made at the midpoint of the middle turbinate and carried 6–8 mm anteriorly from the insertion of the uncinated process. A vertical incision was placed to join the two horizontal incisions ( Fig. 3 ). The mucosal flap was then elevated and removed with a Blaksely forcep, exposing the maxillary and lacrimal bones. To minimize the risk of post-operative scarring, the leading 4 mm of the middle turbinate (medial to the length of the lacrimal sac) was trimmed away. A Kerrison ronguer was used to remove the inferior portion of the frontal process of the maxilla, exposing the inferior lacrimal sac. The ultrasonic bone aspirator or microdrill was then used to remove the remaining frontal process to a level approximately 8 mm above the axilla. Care was used to assure that the non-cutting surface of the ultrasonic bone aspirator was turned laterally to avoid injury to the sac ( Fig. 4 ). For patients undergoing bone removal with the microdrill, caution was also used to minimize trauma to the sac or the septum with the drill. After adequate bone removal, a lacrimal stent was passed through the upper punctum and used to tent the sac medially. A right angled Beaver blade (Beaver Surgical Instrument Company, Waltham, MA) was used to make a vertical incision along the entire length of the sac. Horizontal relaxing incisions were made at the superior and inferior edges of the flaps. The mucosal edges were then trimmed and the entirety of the lacrimal sac was marsupialized. The lacrimal stent was then passed through the lacrimal system and out of the nostril. The second stent was placed through the lower punctum, the common canaliculus, and out the nostril ( Fig. 5 ). The stents were then placed side by side and passed through a 1.5 × 1.5 mm square of compressed Gelfoam (Pharmacia and Upjohn Company, Kalamazoo, MI). The Gelfoam was passed up the stents to cover the marsupialized sac. A 5 mm length of silastic tubing was then passed up the stents in a similar fashion to maintain appropriate stent position/tension at the medial canthus. The stent was fixated by application of surgical clips across the silastic tubing. Finally the stents were clipped to appropriate length within the nose. Initial postoperative follow up visits occurred at 1 and 6 weeks, with removal of the stents at the second visit.
