Long-term Outcomes for Revision Endoscopic Dacryocystorhinostomy-The Effect of the Primary Approach

Classical vs. Retrograde Endoscopic Dacryocystorhinostomy: Analyses and Comparison of the Results

Background: In endoscopic dacryocystorhinostomy (DCR), surgical landmarks such as the maxillary line (ML) and the axilla of the middle turbinate (MT) guide the surgeon in identifying the lacrimal sac. The primary surgical risk associated with the classical technique, which involves directly opening the lacrimal sac, is the height of the bone drilling on the projection of the lateral wall of the nasal fossa. This poses a significant risk of damaging the orbit, the floor of the frontal sinus, and the anterior skull base. Furthermore, the anatomical variability in size and location of the lacrimal sac poses a risk for difficult and precise surgical identification. Recently, a 'retrograde' technique has been introduced to safely identify and expose the lacrimal sac. The aim of this study is to compare the results of retrograde DCR (rDCR) to a classic technique (clDCR), in terms of clinical recurrence and complications. Methods: A retrospective study on a cohort of 35 patients who underwent DCR at the ENT Department of the Modena University Hospital between January 2010 and October 2022 (18 clDCR and 17 rDCR) was performed. Minimum postoperative follow-up for inclusion was 12 months. We used the Fisher's exact test to compare the two techniques, comparing functional outcomes and clinical recurrence rates. Results: Clinical recurrence of nasolacrimal stenosis in clDCR patients was 50%, compared to 6% in those who underwent rDCR (p-value 0.005). Postoperative surgical complications were not significantly different between the two groups (p > 0.05). Conclusions: rDCR is a safe technique and has been shown to be a statistically more effective surgical technique than clDCR in reducing clinical recurrence rates.

Revision dacryocystorhinostomy: systematic review and meta-analysis

PURPOSE

The goal of this study is to determine if a certain revision DCR approach (external, endoscopic endonasal, laser transcanalicular) is superior to others. Additionally, this investigation evaluates the effect of the primary surgery on success of revision.

METHODS

This investigation is a systematic review and meta-analysis. All studies specifying type of primary DCR and revision DCR were included. Proportion of successes of each revision for every primary surgery was obtained from the included studies. Meta-analyses were performed to determine cumulative proportions of successes across studies.

OUTCOME MEASURES

Significant differences in the proportions yielded by meta-analysis of successes among different surgical approaches.

RESULTS

The type of primary surgery did not significantly influence overall revision success if the same procedure was used for the revision. Overall successes per each revision type were not significantly different. When performing subgroup analyses per each primary surgery, all methods of revisions were similar in efficacy with one exception: when the primary surgery was done using the laser transcanalicular approach, external revision outperformed repetition of the primary method.

CONCLUSIONS

Regarding success of re-operation, surgeons can use the method they are most comfortable with to perform DCR revisions. However, primary transcanalicular laser DCRs should be revised, if necessary, using the external approach.

Endoscopic and external dacryocystorhinostomy: A therapeutic proposal for distal acquired lacrimal obstructions

Endoscopic (END-DCR) and external dacryocystorhinostomies (EXT-DCR) are nowadays considered the gold standard techniques for non-oncologic distal acquired lacrimal disorders (DALO). However, no unanimous consensus has been achieved on which of these surgeries is the most suitable to the individual patient. Herein, we review the available literature of the last 30 years with the aim of defining a simple and reproduceable treatment algorithm to treat DALO. A search of PubMed, EMBASE, Scopus and Cochrane databases was last performed in December 2021 to examine evidence regarding the role of END-DCR and EXT-DCR in primary and revision surgeries. If considered primary surgeries, END-DCR should be preferred in case of intranasal comorbidities, given the possibility to directly visualize and treat potential intranasal pathologies. Conversely, EXT-DCR should be chosen in case of need/preference for local anesthesia, given the major historical experience and wider surgical field that helps to resolve intra-operatory complications (e.g., bleeding) in an uncollaborative patient. In the absence of the abovementioned conditions, the decision of one or other approach should be discussed with the patient. In recurrent cases, END-DCR should be considered the treatment of choice given the major likelihood to visualize the causes of primary failure and directly resolve it. In conclusion, END-DCR should be considered the treatment of choice in revision cases or in primary ones associated with intranasal pathologies, whereas EXT-DCR should be chosen if local anesthesia is needed. In the absence of these scenarios, it is still open to debate which of these two approaches should be used.

Multidisciplinary approach to lacrimal system diseases

Pathologies of the lacrimal drainage system range from benign to malignant lesions. However, independently of the etiological origin, the most common presenting symptom is represented by epiphora due to the dysfunction of the lacrimal system. Different diagnostic tools are now available, but for the most the first diagnostic approach is characterized by an ophthalmological visit, associated with nasal endoscopy, usually performed by an otolaryngologist. Frequently the diagnostic work-up is completed with a radiological exam (e.g. maxilla-facial CT or dacryocystography), whose role is still to be determined. Once a diagnosis has been made, different treatments are available in relation to the type of the disease, and commonly need close cooperation between an ENT and ophthalmic surgeon given the close anatomical structures involved. Taking into account all these aspects, the aim of this review is to highlight how a multidisciplinary approach to lacrimal pathologies is mandatory from diagnosis to treatment in order to offer the best clinical approach.

Long-term results of a balloon-assisted endoscopic approach in failed dacryocystorhinostomies

Purpose

Endoscopic endonasal balloon-assisted dacryoplasty is a minimally invasive surgical approach that can be applied after failure of dacryocystorhinostomy with recurrence of distal acquired lacrimal obstruction.

Methods

At the Department of Otolaryngology, San Raffaele Hospital, Milan (Italy), from December 2016 to October 2020, 14 patients underwent trans-nasal balloon-assisted dacryoplasty after a failed dacryocystorhinostomy (both external and endoscopic endonasal). The routinary pre-operative work-up included multidisciplinary study of the lacrimal disease, which consisted in primary ophthalmological and otorhinolaryngological visits associated with nasal endoscopy, in which a radiological exam was added if needed. The surgical approach includes pneumatic enlargement of the stenotic rhinostomy, created during the primary dacryocystorhinostomy, using a high-pressure trans-nasal balloon catheter. Anatomical success was considered when the ostium was patent upon irrigation, while functional success was considered as resolution of epiphora or free lacrimal flow on functional test.

Results

Among 14 patients included and after a mean follow-up of 19.5 months (range 13–51 months), anatomic success was achieved in 100% of patients and functional success was achieved in the 85.7% (12/14). Operative time ranged from 9 to 28 min (mean 18 min) and no complications were reported.

Conclusion

Trans-nasal balloon-assisted dacryoplasty is a mini-invasive surgical approach to treat failed dacryocystorhinostomies with reliable and stable outcomes in the long term. The absence of post-surgical complications, high success rate and short operative time are the main features of this innovative procedure.