CLINICAL RESEARCH, Endoscopic Radiofrequency-Assisted Dacryocystorhinostomy with Double Stent: A Personal Experience

Postoperative Bioresorbable Chitosan-Based Dressing for Endoscopic Middle Meatal Dacryocystorhinostomy With Balloon Dilation

PURPOSE

To evaluate the improvement in epiphora and need for surgical revision in patients with acquired nasolacrimal duct obstruction following balloon-assisted, middle meatal endoscopic dacryocystorhinostomy with chitosan-based dressing versus bioresorbable polyurethane packing versus no packing.

PATIENTS AND METHODS

This was a retrospective study of consecutive adult patients seen from 2015 to 2018 with follow-up evaluation of epiphora at least 3 months after balloon-assisted, middle meatal endoscopic dacryocystorhinostomy. Patients with a history of prior punctoplasty, septoplasty, sinus surgery, or dacryocystorhinostomy of any kind were excluded. Those meeting criteria were stratified by postoperative hemostatic intervention: no packing, bioresorbable packing, and chitosan-based dressing (groups 1, 2, and 3, respectively). Procedural outcomes were graded as successes or failures based on subjective report and anatomical findings at most recent visit within an 18-month postoperative window. Instances of recommendation for revision surgery were also recorded.

RESULTS

Forty-three cases (36 patients) met the abovementioned criteria. Groups 1, 2, and 3 comprised 12, 17, and 14 cases each, respectively. Average patient age was 55.3 years old, and average duration of follow-up was 6.7 months. Significant variation in outcomes was detected across the 3 groups (P = .0495), particularly between groups 1 and 3 (P = .033). Use of chitosan-based dressing trended toward reduced rates of recommendation for surgical revision (P = .203, P = .113).

CONCLUSIONS

Use of chitosan-based dressing after endoscopic dacryocystorhinostomy was associated with improved subjective and anatomical outcomes. It may also contribute to less frequent need for revision surgery. Further study in a larger prospective trial is recommended.

Comparison of balloon dacryocystorhinostomy with conventional endonasal endoscopic dacryocystorhinostomy for relief of acquired distal nasolacrimal drainage obstruction and its impact on quality of life: A prospective, randomized, controlled study

Background

We compared balloon dacryocystorhinostomy with conventional endoscopic dacryocystorhinostomy for the management of acquired distal nasolacrimal obstruction and the quality of life post procedure.

Methods

98 patients, aged 10-73 years, were recruited and randomized into 2 groups of 49 each who underwent conventional endoscopic dacryocystorhinostomy (group 1) and 9 mm balloon assisted endoscopic dacryocystorhinostomy (group 2). Follow-up sessions were conducted at 3, 6 and 12 months post-op.

Results

Group 2 showed significantly shorter mean operative time (25.10 min versus 29.82; p < 0.001), lesser pain in the post-op evening (mean 2.12 versus 2.9 on NRS-11 pain scale; p < 0.001) as well as on first post-op day (mean 1.08 versus 1.73; p < 0.001). Success was achieved in 89.79% in group 1 and 93.87% in group 2 at 3 months (p = 0.46) which declined due to recurrences to 85.71% and 87.75% respectively at 12 months (p = 0.76). Complications occurred in 14 cases in group 1 and in 10 cases in group 2 (p = 0.34). All were minor. Mean GBI scores (for quality of life assessment) at 12 months follow-up were 27.20 and 28.38 respectively (p = 0.08).

Conclusion

The efficacy, safety and quality of life of balloon dacryocystorhinostomy and conventional endoscopic dacryocystorhinostomy were comparable. In addition, balloon dacryocystorhinostomy had significantly shorter operative time and lesser post-op pain.

Recurrent dacryocystitis and lacrimocutaneous fistula caused by a retained Griffiths' collar button stent

A 42-year-old man presented with a white plastic-like material exposed in the left medial canthal area, with a fistula and purulent discharge. He had undergone endonasal dacryocystorhinostomy 7 years earlier for left eye epiphora; he had persistent postoperative epiphora and recurrent dacryocystitis despite multiple drainage attempts and antibiotics elsewhere. Computed tomography showed bilateral enlarged cystic lacrimal sacs, with a well-defined contoured tunnel-like hole at the center of the left sac. Treatment included excision of the foreign body, which was a Griffiths' collar button nasolacrimal stent, excision of the fistula tract, and revision dacryocystorhinostomy with implantation of bicanalicular silicone stent. He recovered with no further symptoms or complications. This case highlights the importance of follow-up for removal of an implanted Griffiths' stent after dacryocystorhinostomy. Patients with recurrent dacryocystitis may benefit from a detailed history of previous surgery, careful examination, and imaging to evaluate for endogenous and exogenous foreign bodies such as lacrimal sac calculi, and retained lacrimal sac stents.

Esthetic removal of head and neck nevi and lesions with 4.0-MHz radio-wave surgery: a 30-year experience

PURPOSE

The cosmetic removal of facial nevi and related lesions is a frequent patient request of cosmetic surgeons. Many patients live with esthetically bothersome lesions, unaware that scar-free or minimal scar treatment modalities are available.

MATERIALS AND METHODS

The author has used a protocol of treating thousands of nevi and related benign lesions with 4.0-MHz radio-wave ablation during the past 30 years. A review of this technique is presented with substantiation by before and after images. Indications, diagnosis, and complications also are reviewed.

RESULTS

Conservative ablation of nevi and benign lesions of the face and neck can be predictably removed with minimal and frequently imperceptible scarring.

CONCLUSION

Facial surgeons see multiple patients on a daily basis requesting the removal of nevi and other benign lesions of the face and neck. Many patients are misinformed by experienced practitioners that the resulting scar will be worse than the lesion. This unfortunate dictum has been disproved hundreds of times by the author's treatment using 4.0-MHz radio-wave surgery to ablate benign lesions of the face and neck, with excellent cosmetic results. Even if practitioners do not offer this treatment, they should be aware that it exists and offer patients exposure to this modality.

Randomized trial on silicone intubation in endoscopic mechanical dacryocystorhinostomy (SEND) for primary nasolacrimal duct obstruction

PURPOSE

To study the effect of bicanalicular silicone intubation on endonasal endoscopic mechanical dacryocystorhinostomy (EEM-DCR) for primary acquired nasolacrimal duct obstruction (PANDO).

DESIGN

Randomized clinical trial.

PARTICIPANTS

A total of 120 consecutive adults (103 females) with a presenting age of 64 ± 13.7 years (range, 39-92 years) underwent EEM-DCR for PANDO from November 2005 to May 2009 in a lacrimal referral center.

METHODS

The EEM-DCR was performed by 2 lacrimal surgeons using standard techniques. Patients were randomly assigned to receive or not receive bicanalicular silicone intubation for 8 weeks. No antimetabolite was used. All patients received a course of oral antibiotics during nonabsorbable nasal packing for flaps tamponade, which was removed at the first postoperative visit. Patients were assessed at 1, 3, 6, 12, 26, and 52 weeks after the operation.

MAIN OUTCOME MEASURES

Surgical success was defined by symptomatic relief of epiphora, reestablishment of nasolacrimal drainage confirmed by irrigation by 1 masked observer, and positive functional endoscopic dye test by the operative surgeon at 12 months postoperatively. Intraoperative and postoperative complications were recorded.

RESULTS

A total of 118 of the 120 randomized cases completed 12 months of follow-up. Two patients died of unrelated medical illnesses during follow-up. At 12 months postoperatively, there was no statistical difference in the success rate between patients with (96.3%) and without (95.3%) intubation (P=0.79). The odds ratio of failure without silicone intubation was 1.28 (95% confidence interval, 0.21-7.95). There was no difference in the incidence (P=0.97) or the time to develop (P=0.12) granulation tissue between the 2 groups. No significant difference was found between successful and failed cases in terms of age (P=0.21), sex (P=0.37), laterality (P=0.46), mode of anesthesia (P=0.14), surgeon (P=0.26), use of stent (P=0.79), or presence of granulation tissue postoperatively (P=0.39).

CONCLUSIONS

The current study design provided 90% statistical power to detect more than 21% difference in surgical outcome, and no such difference was found whether intubation was used or not used in EEM-DCR for PANDO at the 12-month follow-up.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Management of traumatic dacryocystitis and failed dacryocystorhinostomy using silicone lacrimal intubation set

The aim of this work is to study the management and success rate of traumatic dacryocystitis and failed dacryocystorhinostomy (DCR) using Silicone lacrimal intubation set. A prospective study was conducted at a tertiary eye care hospital, India from February 2006 to January 2008. This study material comprised 50 patients of traumatic dacryocystitis and failed dacryocystorhinostomy. Anterior single flap external dacryocystorhinostomy with Silicon intubation was performed in all the patients. The patients were followed up at weekly intervals for 1 month and thereafter every 2 months for 1 year post operatively. Criteria determining success were based on resolution of epiphora and patency on syringing. In traumatic dacryocystitis, 21(91.3%) cases fulfilled these criteria while 23(85.2%) cases of failed DCR were successful. The overall success rate (88%) was determined with an average follow-up of 1 year. Globally, the technique was effective in 85% of cases. The results were comparable with other similar studies. This study concludes that performing a DCR in traumatic dacryocystitis and failed DCR taking into consideration the complications and chances of failure is a challenge for the surgeon. We opine that External dacryocystorhinostomy with Silicon Intubation is one of the most effective modality in dealing with such cases.

Efficacy of endoscopic lacrimal duct recanalization using microendoscope

PURPOSE

To describe a new endoscopic procedure to restore the passage of tears in an obstructed lacrimal drainage system and to compare its efficacy with the standard external dacryocystorhinostomy (SE-DCR).

METHODS

Patients with complete and partial primary acquired nasolacrimal duct obstruction (PANDO) were randomly allocated to 2 treatment groups using completely randomized design. The first group was treated using endoscopic lacrimal duct recanalization (ELDR), while the second group was treated using SE-DCR. Follow-up was conducted for at least 6 months and evaluated for anatomical and functional patency. Complications were also noted for both groups.

RESULTS

A total of 86 patients underwent ELDR, 60 of whom had complete PANDO, while 26 patients had partial PANDO. Eighty patients underwent SE-DCR; 58 had complete PANDO, and 22 had partial PANDO. The combined success rate in terms of anatomical patency for ELDR was 93.02% (95% confidence interval [CI], 0.88-98) compared with 93.75% (95% CI, 0.87-90) for SE-DCR (p = 0.85). Meanwhile, the combined success rate (functional patency) for ELDR is 84.88% (95% CI, 0.77-93) versus 90.00% (95% CI, 0.83-97) for SE-DCR (p = 0.32).

CONCLUSIONS

ELDR using microendoscope is as efficacious as SE-DCR, without its associated major complications.

Sleeve technique to maintain a large mucosal ostium during endoscopic dacryocystorhinostomy

Currently, many surgeons use bicanalicular silicone tubes as a stent to keep the intranasal mucosal ostium patent when they perform endoscopic dacryocystorhinostomy. The authors describe the sleeve technique using bicanalicular silicone tubes. After inserting the bicanalicular silicone tube, a sleeve is passed over it. The sleeve prevents the nasal mucosa from obstructing the intranasal mucosal ostium and enlarges the mucosal ostium. In primary acquired nasolacrimal duct obstruction, the sleeve technique was applied to 61 cases (group 1); the other 75 cases (group 2) were intubated by bicanalicular silicone tube only. The overall success rate was 95.1% in group 1 and 90.7% in group 2 (P = .51), and the average mucosal ostium at 6 months postoperatively was 3.2 ± 1.1 and 1.9 ± 1.0 mm (P = .04), respectively. The authors believe that the sleeve technique has the advantage of maintaining a larger intranasal mucosal ostium.

Prevention and management of lacrimal duct injury

Due to the proximity of the lacrimal duct and sac to the uncinate process, occult injury to the lacrimal drainage system is common during uncinectomy and maxillary antrostomy. Fortunately, these injuries do not often progress to develop clinical symptoms as most either heal on their own, or drain into the middle meatus. In the event that injury to the lacrimal drainage system does become clinical evident, symptoms will present within the first two weeks following surgery. These symptoms may resolve over the ensuing weeks as the intranasal inflammation resolves. In cases of persistent epiphora, determination of the level of obstruction is critical for proper intervention. This can be achieved with several office-based studies as well as radiographic studies. If the obstruction is in the lacrimal duct, dacryocystorhinostomy is a highly successful surgical procedure. However, complications do occur with inadvertent violation of the orbit and cranial vault the subject of substantial publications while lacrimal duct injury (LDI) following FESS has been relatively neglected.

Acquired nasolacrimal duct obstruction

Acquired nasolacrimal duct obstruction is a common problem. Although tearing is the usual complaint, the clinical presentation can range from a patient having no symptoms to one with a life-threatening infection. Despite many studies providing useful clues, the exact pathophysiology of the obstructive process is incompletely understood. The clinician must be able to accurately make the diagnosis, which is often a clinical one, because many treatments with excellent success are available.

Endoscopic Dacryocystorhinostomy and Conjunctivodacryocystorhinostomy

Intranasal approaches to the correction of lacrimal outflow obstruction initially were described more than 100 years ago, but they have gained renewed popularity with the recent development of the field of endoscopic sinus surgery. Endoscopic dacryocystorhinostomy (EDCR) surgery may be considered in many patients who have lacrimal outflow obstruction. It may be particularly advantageous in patients who have concomitant sinonasal disease, patients with a history of radiation therapy, pediatric patients, and in revision procedures. Advantages of the endoscopic technique include excellent visualization, the ability to evaluate the location and size of the rhinostomy site thoroughly, and the avoidance of a facial scar. Recent studies suggest that the success rates of EDCR are comparable to those achieved through traditional external dacryocystorhinostomy.