Retained stenting material: an unusual cause of dacryocystorhinostomy failure

Endoscopic and Radiologic Findings in Failed Dacryocystorhinostomy: Teaching Pearls for Success

Background

Although several studies have commented on causes of dacryocystorhinostomy (DCR) failure, detailed description of anatomical findings in such cases remains insufficient.

Objective

Our objective was primarily to analyze radiologic, endoscopic, and intraoperative findings in patients presenting with failed DCR and secondarily to assess the outcome of revision endoscopic DCR (endo-DCR) carried out at our institution.

Methods

Twenty-four failed DCRs presenting to our tertiary care center were retrospectively analyzed. Data collection included patients’ history, diagnostic, and management data, as well as thorough analysis of sinonasal CT scans, along with endoscopic and intraoperative findings. Outcome was also assessed in 21 cases with revision endo-DCR performed.

Results

The anterior part of uncinate process was not previously removed in 15 sides (62.5%), with unopened agger nasi in 13 sides (54.2%). The lacrimal bone was detected covering the posterior sac despite removal of the anterior ascending process of maxilla in 9 sides (37.5%). Rhinostoma was anterior to lacrimal sac in 2 sides (8.3%) and was below the sac in 7 sides (29.2%). Fibrous membrane covered the rhinostoma despite removal of all sac-overlying bones in 6 sides (25%). Other findings included intranasal adhesions, septal deviation, lateralized middle turbinate, granulation tissue, foreign body reaction, and chronic sinusitis. Nineteen of the 21 revision endo-DCRs were successful (90.5%).

Conclusion

This study provides a precise anatomical description of findings in cases of failed DCR. Such information is paramount in helping surgeons enhance their learning curve, refine the surgical technique, and improve patients’ outcome.

Post-external dacryocystorhinostomy lagophthalmos

To describe lagophthalmos and eyelid closure abnormality after external dacryocystorhinostomy (DCR). A retrospective review of medical records and postoperative photographs of 79 patients who underwent external DCR for nasolacrimal duct obstruction and developed eyelid closure abnormality and lagophthalmos with or without exposure keratopathy was conducted. Collected data included age, sex, indication for surgery, laterality, length and type of incision, length of follow-up duration, presence of punctate epithelial keratopathy, and time for resolution of eyelid closure abnormalities. Twenty-seven patients with 28 external dacryocystorhinostomy had postoperative eyelid closure abnormalities. Male to female ratio was 1:6. The mean age was 40.1 years (range 9-80 years). All surgeries were performed through diagonal skin incision. Lagophthalmos involving the medial third of the palpebral fissure was noticed in 28.6 % of cases. All patients had hypometric blink mainly of the upper eyelid. One patient had punctate epithelial keratopathy. Resolution of lagophthalmos was noticed over a period of 1-5 weeks with an average of 3 weeks. None of the patients continued to have residual hypometric blink or punctate keratopathy at the last follow-up time. The mean follow-up period was 4.2 months (range 3-6 months). Eyelid closure abnormality and lagophthalmos after external DCR are underestimated problems. Spontaneous resolution is seen in all cases weeks to months after surgery.

Nonsurgical retrieval of retained lacrimal stenting material

PURPOSE

The aim was to describe a novel technique to retrieve retained stenting material from the lacrimal system.

METHODS

In this consecutive case series, the authors reviewed charts of 4 children with retained silicone material in their lacrimal sac following intubation. In 2 children, the presence of the retained material was well documented. The other 2 children were examined for the following clinical triad: history of lacrimal intubation, obstructive symptoms characterized by mucopurulent discharge, and a patent nasolacrimal system on irrigation, highly suggesting retained stenting material in the lacrimal system. Retrieval of the foreign body is achieved by performing an intubation of the superior canaliculus with both arms of a Crawford silicone tube. This forms a loop of silicone tubing that can be retrieved from the nose. As the loop passes through the lacrimal sac and duct, the foreign body material is retrieved and extracted through the nose.

RESULTS

In the 4 children on whom this procedure was attempted, it was successful in retrieving the retained piece of silicone on every occasion. In all children, there was complete resolution of the epiphora and chronic dacryocystitis without need for dacryocystorhinostomy.

CONCLUSIONS

Retained stenting material can be responsible for persistent obstructive symptoms and chronic dacryocystitis. Patients examined for the clinical triad described should raise suspicion of the possibility of a foreign body in the lacrimal system. This technique should be considered in patients where a retained foreign body is known or suspected, prior to considering dacryocystorhinostomy. When successful, it will be both a diagnostic and therapeutic procedure, and will additionally serve to avoid unnecessary dacryocystorhinostomy.

Figure-of-eight vertical mattress suture technique for anterior flap suspension to overlying tissues in external dacryocystorhinostomy

PURPOSE

To describe figure-of-eight vertical mattress suture technique in external dacryocystorhinostomy for a combined one-step closure of anterior mucosal flaps and overlying wound tissues and to evaluate its effectiveness on surgical outcome.

DESIGN

A prospective, single surgeon, uncontrolled, interventional case series.

METHODS

A total of 112 consecutive lacrimal drainage systems of 106 patients (84 women, 22 men; 100 unilateral, six bilateral) from June 2002 to January 2006 with acquired nasolacrimal duct obstruction without canalicular disease underwent external dacryocystorhinostomy with this modified technique. Relief of epiphora and anatomic patency were defined as success. Operative time and success rate were evaluated and advantages were stressed and compared with our previous reports.

RESULTS

Mean age was 40.1 years (range, 6 to 75). The etiology was idiopathic in 109 patients and traumatic in three cases. Of 112 lacrimal drainage systems, epiphora was the presenting symptom in 88, combined epiphora and recurrent dacryocystitis in 15, and combined epiphora and mucocele in nine cases. Seven lacrimal drainage systems were revision cases. Mean follow-up was 26.3 months (range, 6 to 48). Success rate was 99.1% (111/112) and mean operative time was 38.2 minutes (range, 28 to 69).

CONCLUSIONS

Such a modified suture technique reveals a rapid and simultaneous one-step closure of two different layers that speeds up surgical procedure; simplifies closure process as the knots are tied completely outside the wound, avoiding the disadvantages of suture tying in a small and deep area; eliminates the dead space between anterior flaps and overlying wound tissues; keeps anterior mucosal flap complex away from posterior flaps that prevents collapse back onto the anastomosis and decreases the possibility of mucosal adhesions and, therefore, fibrotic band formation with underlying tissues that may also be useful in cases with small sacs or osseous openings and in revision cases where scarring is a large concern.

Posttraumatic obstruction of lacrimal pathways: a retrospective analysis of 58 consecutive naso-orbitoethmoid fractures

Posttraumatic dacryostenosis represent a troublesome sequela for patients who have sustained centrofacial trauma and can determine complexity in diagnosis and treatment. This article, based on a retrospective analysis of 58 patients with naso-orbitoethmoidal (NOE) trauma, reports the incidence of posttraumatic dacryostenosis and the evolution of such impairments in consideration of fracture type. Experience in diagnosis and treatment is illustrated, and surgical outcomes 6 months after external dacryocystorhinostomy (DCR) are reported. Posttraumatic epiphora was observed in 27 patients with NOE fractures (46.5%). In 10 cases, temporary epiphora was encountered and spontaneous recovery of lacrimal drainage within 5 months was observed. In the remaining 17 cases, permanent epiphora was registered and a frequent association with delayed treatment of facial fracture repair or bone loss in the lacrimal district was found. Surgical reconstruction of lacrimal pathways was performed 6 months after primary surgery, with external DCRs in all 17 patients with epiphora and the presence of nasolacrimal duct obstruction observed with dacryocystorhinography. External DCR with a large rhinostomy achieved a success rate of 94% in the reconstruction of lacrimal drainage. Such a technique proved to be effective in the treatment of posttraumatic dacryostenosis, although patients considered the temporary presence of external scars and stenting material to be a major problem.

Comparison of surgical outcomes in primary endoscopic dacryocystorhinostomy with and without silicone intubation

The surgical outcome of endoscopic endonasal dacryocystorhinostomy was analyzed in 30 cases of postsaccal stenosis. Intubation with silicone tubing was used in 14 cases (46.7%) and not used in 16 cases (53.3%). Surgical success was evaluated subjectively and objectively. The patients' complaints were improved in 85.7% of cases in the intubation group, and in 81.3% of the group in which no stent was used. Postoperative endoscopic examinations revealed that the rhinostomy opening was visible in 11 cases without intubation (68.8%) and 9 cases with intubation (64.3%). Six patients in the intubation group (42.9%) had granulation tissue at the rhinostomy site. Four patients (28.6%) had complaints regarding the intubation. Considering the similar surgical success rates, and the granulation formation, patient discomfort, and cost related to intubation, we recommend endoscopic dacryocystorhinostomy without intubation as the treatment of choice in cases of chronic epiphora due to postsaccal stenosis of the lacrimal canal.

Use of vinyl polysiloxane impression material to protect and identify the nasolacrimal sac in endonasal dacryocystorhinostomy

PURPOSE

To determine the role of vinyl polysiloxane impression material (trade name Reprosil) in endonasal dacryocystorhinostomy.

METHODS

Case series of 15 consecutive endonasal dacryocystorhinostomies in which vinyl polysiloxane material was used to mark and protect the nasolacrimal sac. Vinyl polysiloxane is mixed from two tubes, then immediately injected in the sac through a preplaced 21-gauge cannula. It is important to be sure the cannula is in the sac to avoid false injection and extravasation. We have found it best to inject a small amount, usually 0.2 to 0.3 mL.

RESULTS

A patent osteum was successfully created in 13 of the 15 cases (87%). Complications included two cases of retained vinyl polysiloxane that necessitated removal through an external excision.

CONCLUSIONS

Endonasal dacryocystorhinostomy has several advantages compared with the external approach. There is no external scar and the bruising and swelling are substantially reduced, allowing patients to return to work more quickly. In addition, the adjacent nasal anatomy is directly visualized, allowing for simultaneous treatment of any relevant nasal pathology and precise manipulation of the nasal tissues.