Mucosal and lacrimal flaps for endonasal dacryocystorhinostomy: a systematic review

Medial lacrimal sac excision versus conventional H-shaped lacrimal sac opening in external dacryocystorhinostomy: a comparative cohort study

PURPOSE

The external dacryocystorhinostomy (Ex-DCR) is a reliable but surgically challenging procedure to overcome a nasolacrimal duct obstruction (NLDO). The aim of this study is to describe the outcomes of a modified technique of lacrimal sac opening and to compare it with the conventional Ex-DCR.

METHODS

This comparative cohort study included adult patients undergoing Ex-DCR for primary acquired NLDO by or under supervision of one surgeon. Group 1 (conventional Ex-DCR including H-shaped incision, anastomosis of the anterior mucosal flap to nasal mucosal flap and resection of the posterior sac flap) was compared with Group 2 (modified Ex-DCR including excision of the medial lacrimal sac and anastomosis of remaining anterior sac flap to nasal mucosal flap). Outcome measures included the success rate (defined as complete symptom relief or patent irrigation after three months), reoperation rate, redo-free survival within five years, and occurrence of postoperative bleeding and postoperative infection.

RESULTS

138 patients were included. The success rates were 94.7% (54/57 cases) for Group 1 and 96.3% (78/81) for Group 2 (p-value = 0.658). The redo-rate was 5.3% (3/75) in Group 1 and 2.5% (2/81) in Group 2 (p = 0.331). Two-year redo-free survival probability estimates were 89.8% for Group 1 and 96.3% for Group 2, respectively. No complications occurred in Group 2, whereas in Group 1, one patient (1.8%) suffered from postoperative bleeding and one (1.8%) from postoperative infection.

CONCLUSIONS

This study showed that our modified Ex-DCR technique is equally efficacious compared with the conventional Ex-DCR technique in adult patients with NLDO.

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.

Influence of Surgical Techniques on Endoscopic Dacryocystorhinostomy: A Systematic Review and Meta-analysis

Objective

Endoscopic endonasal dacryocystorhinostomy (END-DCR) has increased as a valid alternative to the classic external approach to treat distal lacrimal obstruction. Different surgical varieties of the END-DCR approach have been proposed with no clear understanding of the best surgical technique.

Data Source

A comprehensive research was performed in PubMed, Embase, SCOPUS, and Cochrane databases with a final search on March 2020.

Review Methods

The aim of this search was to identify relevant END-DCR procedures performed with mechanical (Mecn-END-DCR) and powered (Pow-END-DCR) approaches to compare their functional success rate. In addition, the influence of mucosal flaps was evaluated. Articles were selected only if they were published later than 2000 and had at least 50 single-clinician surgical procedures performed. Excluded articles included acute infections, cancers, mixed cohort study, and revision cases.

Results

A total of 11,445 publications were identified and 2741 reviewed after screening; 15 articles were included after full-text review (0.6% of the initial articles reviewed). The mean success rate was 91.34% (95% CI, 87.1%-94.3%) for Pow-END-DCR and 89.5% (95% CI, 86.5%-91.9%) for Mecn-END-DCR with no significant difference between the surgical approaches ( P = .43). For mucosal flaps performed during END-DCR, the mean success rate was 89% (95% CI, 86%-91%) if mucosal flaps were used and 92% (95% CI, 88%-95%) if they were not used, with no statistical difference present ( P = .14).

Conclusions

Our analyses suggest that there are no differences in outcomes between mechanical and powered approaches in END-DCR and that mucosal flap preservation is not essential to achieve a superior END-DCR outcome.

Methodological Quality of Systematic Reviews and Meta-analyses Published in High-Impact Otolaryngology Journals

OBJECTIVE

To assess the methodological quality of intervention-focused systematic reviews (SRs) and meta-analyses (MAs) published in high-impact otolaryngology journals.

DATA SOURCES

Ovid Medline, Embase, and Cochrane Library.

REVIEW METHODS

A comprehensive search was performed for SR and MA citations from 2012 to 2017 in the 10 highest impact factor otolaryngology journals. Abstracts were screened to identify published manuscripts in which the authors indicated clearly that they were performing an SR or MA. Applying a modified typology of reviews, 4 reviewers characterized the review type as SR, MA, or another review type. A simplified version of the AMSTAR 2 (A MeaSurement Tool to Assess systematic Reviews 2) tool was used to assess the reporting and methodological quality of the SRs and MAs that were focused on interventions.

RESULTS

Search and abstract screening generated 499 manuscripts that identified themselves as performing an SR or MA. A substantial number (85/499, 17%) were review types other than SRs or MAs, including 34 (7%) that were literature reviews. In total, 236 SRs and MAs focused on interventions. Over 50% of these SRs and MAs had weaknesses in at least 3 of the 16 items in the AMSTAR 2, and over 40% had weaknesses in at least 2 of the 7 critical domains. Ninety-nine percent of SRs and MAs provided critically low confidence in the results of the reviews.

CONCLUSION

Intervention-focused SRs and MAs published in high-impact otolaryngology journals have important methodological limitations that diminish confidence in the results of these reviews.

Endoscopic dacryocystorhinostomy: A comparison of double-flap and single-flap techniques

Background

Dacryocystorhinostomy (DCR) is a procedure to restore the flow of tears into the nose from the lacrimal sac when the nasolacrimal duct obstructed. This study aimed to compare the success rates of two different techniques in endonasal endoscopic DCR; namely single and double mucosal flap techniques.

Material and methods

A nonequivalent quasi-experiment design was used in this study. Retrospectively, patients underwent endoscopic DCR for primary nasolacrimal duct (NLD) obstruction were included. Patients were divided into the single-flap technique and the double-flap technique groups. Success was defined as the achievement of patency of the NLD throughout the period of follow-up with significant improvement in epiphora.

Results

Overall, 77 cases were included in the final analysis. Mean age was 41 years and 60% were female. Forty-six cases underwent the single-flap technique and 31 cases underwent the double-flap technique. Recurrence of NLD obstruction occurred in 11 (23.9%) cases in the single-flap group and in only one case (3.2%) in the double-flap group.

Conclusion

The modified double-flap technique for primary NLD obstruction resulted in less recurrence compared to the single-flap technique. Creating double flaps to cover any exposed lacrimal bone may reduce the rate of postoperative adhesions over the nasolacrimal duct ostium.

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DCR is used to restore the tears into the nose from the obstructed lacrimal sac.

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Single and double mucosal flap techniques can be used.

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Double-flap technique for primary NLD obstruction resulted in less recurrence.

Endoscopic dacryocystorhinostomy with and without mucosal flap-is there any difference?

BACKGROUND

The nasal mucosa is sacrificed in conventional endoscopic dacryocystorhinostomies (EDCRs). Some surgeons, however, modify the technique by elevating a mucosal flap prior to creating the osteotomy with the aim of preserving the mucosa. To our knowledge, no clear-cut benefit of a mucosal flap has been established. The aim of this study is to examine the differences in surgical techniques and success rates of EDCRs with and without mucosal flap preservation.

METHODS

We carried out a medical record review of all patients who underwent primary EDCR at the Goldschleger Eye Institute from October 2009 to October 2017. The following data were retrieved from the medical database and analyzed: patient demographics (age at diagnosis and gender), medical history, examination findings, surgical details, postoperative success, complications, and follow-up.

RESULTS

A total of 107 patients who underwent 117 EDCRs participated in the study. Fifty-one patients comprised the group without a mucosal flap and 56 patients comprised the group with mucosal flap preservation. The medical history, presenting complaints, and preoperative examination findings were similar for both groups. The surgical success rate was not significantly different between the groups (82.1% without flap vs. 86.8% with flap, P = 0.478, Chi-square).

CONCLUSION

The findings of this comparison of EDCRs with and without mucosal flap preservation in a large patient population revealed no differences in surgical success or complications rates between the two procedures and, therefore, no benefit for adding flap preservation to conventional EDCRs.

The Fibrin Glue Application Enhances Surgical Success Rate in Endonasal Endoscopic Dacryocystorhinostomy With Lacrimal Sac Preservation

The purpose of this study to compare lacrimal sac flap preserving techniques with or without fibrin glue in patients undergoing endoscopic endonasal dacryocystorhinostomy. A retrospective study included 132 patients who underwent unilateral endonasal dacryocystorhinostomy between February 2011 and March 2016. Patients were divided into 2 groups: the nonfibrin glue group (n = 66) and fibrin glue anastomosis group (n = 66). Surgical success was defined as the patients' subjective report of relief of epiphora and objective endoscopic confirmation of ostium patency confirmed by a positive functional dye test. These parameters were compared between the 2 groups. Both groups were similar, in terms of demographic and clinical characteristics. The surgical success rate was significantly higher in the fibrin glue anastomosis group (95.5%) than in the nonfibrin glue group (84.8%; P = .041). Complication rate was 6.1% in the nonfibrin glue group, whereas in the fibrin glue anastomosis group, it was 4.5%. The complication rate was similar in both groups (P = .99). Creation of an anastomosis between the lacrimal sac flaps and the nasal mucosa using fibrin glue improves the outcome of endonasal endoscopic dacryocystorhinostomy.

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.