Outcomes of Endoscopic Powered Revision Dacryocystorhinostomy

External dacryocystorhinostomy: A critical overview of the current evidence

PURPOSE

External dacryocystorhinostomy (ext-DCR) is still considered the gold standard in the treatment of distal lacrimal duct obstruction. Despite an overall high success rate, some patients do relapse after surgery and the ideal perioperative management has not been identified yet. The purpose of this study is to critically discuss the published evidence in the last five years on the medical and surgical management of external dacryocystorhinostomy. Furthermore, the drawbacks of the available literature and the perspectives in this field will be also highlighted.

METHODS

Systematic review of the literature in the last 5 years by using PubMed and Google Scholar.

RESULTS

A total of 64 articles were included. Many technical modifications and surgical refinements have been proposed but a formal comparison among the various techniques is hampered by methodological heterogeneity. The use of local anesthesia, and the perioperative adjunctive techniques to reduce the risk of restenosis are also gaining popularity but the level of evidence remains weak.

CONCLUSION

Ext-DCR offers satisfactory clinical outcomes even though there are many gray areas that need to be addressed in future high-quality studies.

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.

Computed Tomography Morphology of Affected versus Unaffected Sides in Patients with Unilateral Primary Acquired Nasolacrimal Duct Obstruction

BACKGROUND

This study aimed to describe the anatomical details of the bony nasolacrimal duct (BNLD) and adjacent nasal structures by analyzing computed tomography (CT) images, and to investigate their effects on the development of primary acquired nasolacrimal duct obstruction (PANDO).

METHODS

A total of 50 patients with unilateral PANDO who underwent dacryocystorhinostomy, with a mean age of 57.96 years, were included. The preoperative CT images were reviewed to measure the anteroposterior and transverse diameters of the BNLD at the entrance and exit levels, as well as the minimum transverse diameter along the tract. The sagittal CT images were analyzed to classify the shape of the bony canals into columnar, funnel, flare, and hourglass. The associated paranasal abnormalities, including nasal septum deviation (NSD), sinusitis, angle between the bony inferior turbinate and medial wall of the maxillary sinus, and mucosal thickness of the inferior turbinate, were investigated.

RESULTS

Fifty CT images were analyzed, and all parameters measured on both sides of the BNLD were not significantly different between the PANDO and non-PANDO sides, except for the minimum transverse diameter, which was significantly smaller on the PANDO side (p = 0.002). Columnar-shaped BNLD was the most common on both sides. No significant difference was observed in the incidence of paranasal abnormalities between sides; however, deviation of the septum toward the non-PANDO side was more common (67.9%).

CONCLUSIONS

A small minimum transverse diameter of the BNLD may be a risk factor for PANDO. The association between nasal abnormalities and PANDO was not remarkable.

[Effect of endonasal endoscopic dacryocystorhinostomy combined with lacrimal duct drainage tube implantation in treating lacrimal duct obstruction]

Objective:To investigate the clinical effect of endonasal endoscopic dacryocystorhinostomy（EES-DCR） combined with lacrimal duct drainage tube implantation in treating the patients with lacrimal duct obstruction. Methods: 32 patients （37 eyes） with lacrimal duct obstruction were included into this study, including 1 patient （2 eyes） of functional nasal lacrimal duct obstruction,2 patients （2 eyes） of recurrence after EES-DCR,17 patients （19 eyes） of nasal lacrimal duct obstruction,6 patients （8 eyes） of small lacrimal sac, and 6 patients （6 eyes） of lacrimal duct obstruction. Intraoperative EES-DCR was performed, and lacrimal drainage tubes were implanted from the upper and lower lacrimal points. Septoplasty was performed in 3 patients with nasal septum deviation, and endoscopic sinus surgery was performed in 1 patient with chronic sinusitis.After operation, nasal hormone spraying was performed. During follow-up, the operation effect was evaluated according to the degree of symptom improvement, the patency of lacrimal passage irrigation and the opening state of dacryocystorhinostomy under nasal endoscope. Results:After 3-30 months of follow-up, 29 cases（34 eyes） were cured, 2 cases（2 eyes） were improved, and 1 case（1 eye） was ineffective. The total effective rate was 97.3%（36/37）. No intraorbital, intracranial or nasal complications occurred in all patients. Conclusion:EES-DCR combined with lacrimal duct drainage tube implantation is safe and effective in treating lacrimal duct obstruction. Implantation of lacrimal duct drainage tube can effectively avoid stoma blockage, prevent the adhesion of lacrimal duct, and significantly improve the success rate of surgery.

Efficacy of Hyaluronic Acid in Endoscopic Dacryocystorhinostomy: A Systematic Review and Meta-Analysis

Objective

The aim of this meta-analysis is to compare the surgical results of endoscopic dacryocystorhinostomy (Endo-DCR) for chronic dacryocystitis (CD) with and without intraoperative hyaluronic acid (HA) application.

Methods

An electronic literature search was performed using the PubMed, Embase, Cochrane Library, CNKI, and Wan Fang databases in April 1, 2022. Review Manager software version 5.4 was used for data synthesis and a forest plot was generated for each outcome measure.

Results

Seven randomized control trials (RCTs), which involved 739 eyes, were included in this meta-analysis. Overall, compared with the control group, intraoperative HA application significantly enhance the success rate (odds ratio [OR] = 3.27, 95% confidence interval [CI]: 2.15–4.98, P < .00001), promote re-epithelization (OR = 2.93, 95% CI: 1.83–4.68, P < .00001), reduce granulation (OR = 0.41, 95% CI: 0.21–0.80, P = .008), and scar (OR = 0.39, 95% CI: 0.22–0.68, P = .001) formation after Endo-DCR.

Conclusion

Intraoperative HA application seems to be a useful adjuvant that could enhance success rate by promoting re-epithelization and inhabiting granulation and scar formation around the ostium.

Factors involved in the success and failure of endoscopic dacryocystorhinostomy from our experience

INTRODUCTION

Chronic dacryocystitis is the condition secondary to permanent lacrimonasal duct stenosis (LNDS) that generates epiphora and recurrent conjunctivitis. Endoscopic dacryocystorhinostomy (EDCR) is a more natural route than the external route and offers higher success rates than the laser technique. We value this centre's experience in this procedure.

PATIENTS AND METHODS

A retrospective review was carried out in our centre of the medical records of adult patients undergoing EDCR due to LNDS between 1995 and 2019. The minimum follow-up period required after surgery was 6 months.

RESULTS

Over 297 months, 167 EDCR procedures were performed on 156 patients, with an average age of 65.7 ± 11.6 years and a male/female ratio of 1/1.98. The functional improvement was 86%, with an anatomical success rate of 87%. Lack of clinical improvement statistically significantly correlated with the age of the patient and the time since onset of the LNDS, the presence of concomitant systemic (especially diabetes mellitus) or ophthalmological disease, the intraoperative finding of a thickened tear sac and absence of drainage of the tear sac when marsupialised. Longer-term stent carriers in the rhinostomy had poorer outcomes. There were no postoperative complications of interest.

CONCLUSIONS

EDCR is an effective and safe technique, based on stable anatomical references. Failure rate seems to be multifactorial and should be considered in older, multipathological patients, with a long duration of the condition.

[Endonasal balloon dacryoplasty in partial and complete obstruction of dacryocystorhinostomy ostium]

Despite the success of dacryocystorhinostomy (DCR) in the treatment of lacrimal drainage system (LDS) obliteration and the use of medical and surgical methods to prevent its recurrence, the number of relapses reaches 37%. The main etiological factor leading to this pathology is partial (stenosis) or complete obstruction of the ostium.

PURPOSE

To study the effectiveness of endonasal balloon dacryoplasty in partial or complete obstruction of dacryocystorhinostomy ostium.

MATERIAL AND METHODS

The study involved 122 patients (127 cases) with relapse after endonasal endoscopic dacryocystorhinostomy performed 6 months to 3 years ago to treat partial or complete obstruction of lacrimal sac neck. Patients of the 1^st group (41 cases) underwent endonasal balloon dacryoplasty, patients of the 2^nd group (42 cases) underwent endonasal balloon dacryoplasty with bicanalicular silicone stenting, patients of the 3^rd group (44 cases) underwent revision endonasal endoscopic dacryocystorhinostomy with bicanalicular silicone stenting.

RESULTS

After 12 months follow-up, positive results were observed in 85.7% of cases with ostium stenosis and 80.0% of cases with complete obstruction of the ostium among group 1 patients; in 86.4% of cases with ostium stenosis and 85.0% of cases with complete obstruction of the ostium among group 2 patients; and in 81.0% of cases with ostium stenosis and 82.6% of cases with complete obstruction of the ostium among group 3 patients.

CONCLUSION

The obtained results give grounds to recommend inclusion of endonasal balloon dacryoplasty in the standards of treatment for patients with partial (stenosis) and complete obliteration of dacryocystorhinostomy ostium.

Infection After Endoscopic Dacryocystorhinostomy: Incidence and Implications

BACKGROUND

Endoscopic dacryocystorhinostomy (EN-DCR) is an increasingly common procedure performed by otolaryngologists. While EN-DCR has a high rate of success at relieving blockage of the lacrimal system, little is known regarding associated postoperative infection (POI) rates and risk factors.

OBJECTIVE

The purpose of this study was to identify factors associated with the occurrence of postoperative orbital and rhinologic infection in a large cohort of patients undergoing EN-DCR.

METHODS

A retrospective review of 582 patients who underwent EN-DCR was performed. All patients received antibiotic prophylaxis as a single intraoperative intravenous administration and a ten-day postoperative oral course. Clinical and demographic information was reviewed, including the occurrence of acute orbital or rhinologic infection within 30 days of surgery. Multivariable analysis was performed to identify risk factors associated with POI.

RESULTS

Fifteen of 582 patients (2.6%) developed POI following EN-DCR. The most common POI was acute rhinosinusitis (10/15, 66.7%), followed by acute dacryocystitis (2/15, 13.3%), preseptal cellulitis (2/15,13.3%), and acute bacterial conjunctivitis (1/15, 6.7%). The majority of patients (464/582, 79.7%) underwent concurrent endoscopic sinus surgery (ESS). In most cases (302/464, 65.1%), ESS was performed to address comorbid rhinosinusitis, whereas 7.8% (36/464) of patients underwent surgery to enhance surgical access to the lacrimal sac. Patients who underwent concurrent ESS were less likely to develop POI (OR: 0.17, CI: 0.04-0.80, p < 0.05). Evidence of mucopurulence at surgery increased the likelihood of POI (OR: 6.24, CI: 1.51-25.84, p < 0.05).

CONCLUSION

Mucopurulence at the time of surgery significantly increased the risk of POI, whereas concurrent ESS, performed most commonly to address comorbid rhinosinusitis, significantly decreased the risk of POI. Awareness of risk factors for POI and appropriate surgical management of concurrent rhinosinusitis can lead to reduced infectious complications after EN-DCR.

Relationship Between Primary Acquired Nasolacrimal Duct Obstruction, Paranasal Abnormalities and Nasal Septal Deviation

OBJECTIVES

This study aimed to investigate the relationship between nasal septal deviation and paranasal abnormalities in the etiology of primary acquired nasolacrimal duct obstruction (PANDO).

METHODS

A total of 37 (8 men, 29 women) patients (48 eyes with PANDO) between the ages 20 and 77 years (mean age, 52.8 ± 13.1 years) were included in the study. In the axial sections of paranasal sinus computed tomography, the transverse diameters at the most upper part and the most distal part of the nasolacrimal canal were separately measured. In addition, the relationships between PANDO and nasal septal deviation, inferior turbinate hypertrophy, agger nasi cells, paradoxical middle turbinate, concha bullosa, and the angle between the bony inferior turbinate and medial wall of the maxillary sinus were investigated.

RESULTS

A statistically significant relationship was found between PANDO and the axial location of septal deviation classification, axial angle of septal deviation classification, paradoxical middle turbinate, angle between the bony inferior turbinate and medial wall of the maxillary sinus and inferior meatus measure.

CONCLUSION

The authors concluded that the location and angle of the nasal septal deviation in the axial plane, width of the angle between the bony inferior turbinate and medial wall of the maxillary sinus, inferior meatus measure, and paradoxical middle turbinate may be effective factors in the etiology of PANDO.

Assessment of Long-Term Outcomes Associated With a Lobulated Pedicled Nasal Mucosa Flap Technique for Endoscopic Dacryocystorhinostomy Without Stenting

OBJECTIVE

This study describes a surgical approach wherein a lobulated pedicled nasal mucosa flap technique was employed for endoscopic dacryocystorhinostomy (EDCR) as a means of treating nasolacrimal duct obstructions. This study also assessed the long-term outcomes of this EDCR approach when implemented without stenting.

METHODS

This was a retrospective study of a total of 63 patients (67 eyes) treated for nasolacrimal duct obstructions between January 2011 and November 2016. All patients had undergone ophthalmic diagnosis followed by EDCR treatment using a lobulated pedicled nasal mucosa flap without stenting. Patients were then monitored for both anatomical patency and sustained symptom relief during the follow-up period in order to assess objective and subjective study outcomes.

RESULTS

Patients were followed for a mean of 25.3 ± 1.2 months (range: 24-28 months), with a 100% anatomical patency success rate (67/67) and a 94.03% symptomatic cure rate (63/67). There were no instances of complications.

CONCLUSIONS

The use of a lobulated pedicled nasal mucosa flap technique for EDCR without stenting is a straightforward, effective, and safe approach that keeps bone exposure to a minimum while offering a high rate of satisfactory outcomes, making it a procedure worthy of consideration as a means of treating patients suffering from nasolacrimal duct obstructions.

Relationship Between Lacrimal Bone Thickness and Lacrimal Sac in Chronic Dacryocystitis

BACKGROUND

Chronic inflammation in the lacrimal sac may lead to thickening of the surrounding bony tissues. This study aimed to assess the thickness of lacrimal bone surrounding the lacrimal sac, and the thickness of maxilla, based on the presence of purulent secretion in the lacrimal sac in patients who underwent EDCR.

MATERIAL AND METHODS

Lacrimal bone thickness and the maximum and midpoint maxillary bone thickness of 70 patients (mean age of 49.07 years) who underwent EDCR, were assessed along 3 planes (upper, middle, and lower) using CT of the paranasal sinus. The patients were divided into 2 groups: the 1 who had purulent secretion in the lacrimal sac during the intraoperative period (Group 1) and another who did not have purulent secretion (Group 2).

RESULTS

No significant difference was detected between the 2 groups in terms of maximum and midpoint maxillary bone thickness. The increase in the thickness of lacrimal bone in Group 1 was statistically significant in all the 3 planes as compared to that in Group 2. Cutoff values for the thickness of the upper, middle, and lower plane of lacrimal bone were detected to be 0.710 mm, 0.685 mm, and 0.675 mm, respectively.

CONCLUSION

The presence of purulent secretion in the lacrimal sac, along with the detected increase in the thickness of the lacrimal bone, as assessed by CT, offers an insight on the lacrimal sac before the surgery.