Rhinostomies: an open and shut case?

The clinical effectiveness of transcanalicular diode laser-assisted revision surgery for failed endoscopic endonasal dacryocystorhinostomy

AIMS

We report the results and clinical effectiveness of transcanalicular diode laser-assisted revision surgery for failed endoscopic endonasal dacryocystorhinostomy (EDCR).

METHODS

We reviewed electronic charts of 53 eyes in 51 revision surgery patients, with anatomical failure after primary EDCR.

RESULTS

The major cause of failed EDCR was membranous obstruction of the rhinostomy site (36/53 eyes, 67.9%). The second most common cause of failure was granulomatous obstruction (13/53 eyes, 24.5%). The overall success rate of the first revision surgery was 83.0% (44/53 eyes). Revision surgery for membranous obstruction (36 eyes) showed a 100% success rate, while a 50% success rate was achieved in granulomatous obstruction (13 eyes). 2 patients with synechial obstruction also showed good results (100%). Sump syndrome (two eyes) showed a 100% failure rate after revision surgery. When granuloma was the main cause of obstruction (13 eyes), the size of the granuloma was correlated with the success of revision surgery. Granuloma size was larger in failed revision surgery (p=0.002).

CONCLUSIONS

A diode laser can achieve effective tissue dissection with minimal damage and is a good alternative technique for patients with membranous obstruction who had a failed EDCR. However, it may not be appropriate for large granulomatous obstruction and sump syndrome.

Anastomosis of both posterior and anterior flaps or only anterior flaps in external dacryocystorhinostomy

PURPOSE

To evaluate the outcomes of external dacryocystorhinostomy (DCR) by using two different patterns of flap anastomosis; one only with anterior flap anastomosis and the other with both anterior and posterior flap anastomosis.

METHODS

One hundred and sixty-four patients were enrolled in the study. Patients were then randomly divided into two groups as follows: those who underwent DCR with both anterior and posterior flap anastomosis (Group 1) and those who underwent DCR with only anterior flap anastomosis (Group 2). Surgical success was defined as patient satisfaction, disappearance of epiphora and lacrimal patency up to 12 months after surgery.

RESULTS

After 12 months, the DCR with both anterior and posterior flap anastomosis had a success rate of 89.8% (71/79), while the DCR with only anterior flap anastomosis had a success rate of 89.4% (76/85). There was no statistically significant difference between the two groups (p < 0.05).

CONCLUSION

Anastomosis of posterior flaps does not seem to affect success rate of external DCR. Creating only the anterior anastomosis is technically simpler and does not seem to negatively influence the outcome of DCR surgery.

Inferior flap anastomosis in external dacryocystorhinostomy

PURPOSE

To describe the inferior flap design as a modification in external dacryocystorhinostomy (DCR) and to evaluate the effectiveness on surgical outcome.

METHODS

This prospective study enrolled 33 consecutive patients with acquired nasolacrimal duct obstruction who underwent external DCR with this modified flap design from February 2007 to April 2008. Success was defined as amelioration of epiphora and anatomic patency. Operative outcomes and success of the procedure were evaluated.

RESULTS

The mean age was 45 years (range, 12-65 years). The mean follow-up time was 15.6 months (range, 10-23 months). None of the patients had signs or symptoms of epiphora at the end of the follow-up period.

CONCLUSIONS

The inferior flap design simplifies the surgical procedure and produces success rates comparable with those found in conventional DCR. Further studies with larger numbers of patients are necessary.

A comparison of endonasal with external dacryocystorhinostomy in revision cases

The objective is to compare the success rates of revision endonasal dacryocystorhinostomy (END-DCR) with revision external dacryocystorhinostomy (EXT-DCR). The present retrospective study was conducted between January 2002 and July 2009. Seventy-four consecutive patients (17 males, 57 females) who had epiphora or recurrent dacryocystitis after a previous failed EXT-DCR procedure were enrolled in the study. The END-DCR group consisted of 43 patients (10 males, 33 females) who underwent 44 END-DCRs, whereas the EXT-DCR group included 31 patients (7 males, 24 females) who underwent 31 dacryocystorhinostomies (DCRs). Successful DCR was defined as relief of symptoms as demonstrated by saline irrigation at the last post-operative visit. Further nasal surgery was performed in 18 (40.9%) eyes in the END-DCR group. The average follow-up time for the END-DCR and EXT-DCR groups was 11 and 9 months, respectively. The success rate was 77.4% (24/31 DCRs) in the END-DCR group, and 84.1% (37/44 DCRs) in the EXT-DCR group. There was no significant difference between the groups regarding overall success (p = 0.465). END-DCR is as safe and efficient technique as external approach with low complication rates in revision cases. END-DCR yields good esthetic and functional results and has a success rate similar to that of the external approach.

Transcanalicular-endonasal semiconductor diode laser-assisted revision surgery for failed external dacryocystorhinostomy

PURPOSE

To report the results of transcanalicular-endonasal revision dacryocystorhinostomy (DCR) with a semiconductor diode laser in cases of failed external DCR.

DESIGN

Prospective, nonrandomized, interventional case series.

METHODS

Fifteen cases in 13 patients with failed external DCR underwent transcanalicular-endonasal DCR with a semiconductor diode laser. A functional successful outcome was defined as a patent nasolacrimal drainage system in nasolacrimal irrigation and a resolution of the symptomatic epiphora and/or mucoid discharge.

RESULTS

The patients were followed for a mean postoperative period of 27.3 months (range, nine to 54 months). The mean duration of the surgery was 19.6 minutes. After the initial revision transcanalicular-endonasal DCR surgery, patency to irrigation was obtained in 12 cases (80%), and 15 cases (100%) after a second revision treatment. Three cases required repeated revision surgery, and three other cases were considered to be functional failures in spite of a patent lacrimal system after the final revision surgery. The overall functional success rate was 80% (12 cases) at the final examination (mean, 27.3 months after surgery), and there were no intraoperative and postoperative complications. The presence of a canalicular obstruction or granulation tissue was not significantly related to the success rates of the revision surgery. The length of time between the primary and revision surgery, gender, age, the duration of the first revision surgery, and the timing of stent removal were also not significantly related to the failed cases.

CONCLUSION

Transcanalicular-endonasal DCR is a minimally invasive procedure and is recommended for patients as an alternative procedure for failed external DCR.

The role of larger osteotomy in long term success in external dacryocystorhinostomy

AIM

This study aims to investigate whether it is possible to create a critical size bone defect in external dacryocystorhinostomy (DCR), and also at what size a defect can be considered as being critical for a successful surgical outcome.

METHODS

Eighteen patients undergoing 19 external dacryocystorhinostomies, with the creation of wide osteotomies, were enrolled in this retrospective study. A 2 x 2 cm bone defect, which was considered as the critical size, was created. The postoperative structure of the bone gap was evaluated by computed tomography in axial and coronal planes at least two years after surgery. Functional patency of the ostium was confirmed with irrigation and nasal endoscopic examination.

RESULTS

Thirteen female (72.2%) and five male (27.8%) patients underwent DCR. The patients were aged between 18 and 72 years old (mean+/-S.D.: 45.3+/-13.9). The follow-up time was between 24 and 48 months (mean 30.4 months). The areas of the gaps were between 1.21 and 4 cm(2) (mean+/-S.D.: 2.26+/-0.19).

CONCLUSION

The critical size bone defect (2 x 2 cm) might prevent restenosis in long term follow ups.

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.