Ostium Characteristics and Its Relevance in Successful Outcome Following Endoscopic Dacryocystorhinostomy

Study aims to assess the postoperative ostium shrinkage pattern and also attempted to evaluate various ostium parameters and their impact on surgical outcome by using DOS scoring system. Prospective study comprising 44 patients of NLD obstruction with 52 procedures performed during October 2016 to November 2018. Various dimensions of bony neo-ostium were recorded intraoperatively and during 1st, 3rd and 6th month follow up. Degree of ostium shrinkage and its correlation with anatomical and functional success was studied. DCR ostium (DOS) scoring system, comprised of ten various ostium parameters, was used to evaluate postoperative ostium. Intraoperative mean ostium height and width were 13.67 ± 2.76 mm and 7.0 ± 1.94 mm and surface area was 98.33 ± 38.46 mm2. Maximum ostium shrinkage (by 66.93%) occurred at 1 month and after which, average size of ostium was quite stable with little change. The anatomical and functional success rate was 94.23% and failure rate was 5.77%. DOS score was "excellent" in 40(75.92%), "good" in 9(17.31%) and "poor" in 3(5.77%) cases. Meticulous evaluation at regular intervals is important for surgeon to understand the characters of ostium during healing and also helps in early detection of pathologies and may facilitate early corrective intervention. We believe that DOS system provides an effective protocol to standardize the ostium evaluation. The ostium parameters with favourable surgical outcome are ostium location anterior to axilla of MT, circular/ oval shape with shallow base, size > 8 × 5 mm, clearly visualized and dynamic ICO, absence of ostium cicatrization, granulomas, synechiae and other pathologies.

Clinical Efficacy of Lacrimal Syringing under General Anesthesia

Purpose: To compare the results of lacrimal syringing performed in clinical practice and under general anesthesia, and the clinical efficacy of lacrimal syringing under general anesthesia before endoscopic dacryocystorhinostomy and dacryoscintigraphy.Methods: The study included 148 eyes of 82 patients who underwent endoscopic dacryocystorhinostomy and silicone tube intubation from August 2018 to April 2019. The patients were examined with lacrimal syringing in clinical practice and re‐examined under general anesthesia. Based on the change in lacrimal syringing, the patients were assigned to inconsistent and consistent groups. The inconsistent group was subclassified into complete (‘regurgitation’ of lacrimal syringing changes to a ‘passage’ pattern) and partial improvement groups (the degree of regurgitation improves under general anesthesia).Results: Twenty (13.5%) eyes showed inconsistent results of lacrimal syringing performed in clinical practice and under general anesthesia; all showed improved passage under general anesthesia. The surgical results did not differ significantly (p = 0.336) between the consistent and inconsistent groups, but did between the complete and partial improvement groups (p < 0.01). Conclusions: Lacrimal syringing under general anesthesia may enable an accurate preoperative diagnosis of the degree of obstruction. The combined results of dacryoscintigraphy and lacrimal syringing performed in clinical practice and under general anesthesia allow surgeons to evaluate the lacrimal drainage anatomy precisely and may be useful for predicting the functional success of endoscopic dacryocystorhinostomy.

Association between septoplasty, Lund-Mackay score and Lund-Kennedy score with endoscopic dacryocystorhinostomy results

PURPOSE

To compare endoscopic dacryocystorhinostomy (endo-DCR) + septoplasty with endo-DCR alone and determine the relationship between sinusitis and endo-DCR surgery results.

METHODS

Our study included 55 patients with nasolacrimal duct obstruction (NLDO) between June 2017 and June 2019. Patients were divided into two groups as endo-DCR alone and endo-DCR + septoplasty. Patients' symptoms were thoroughly evaluated and scored using the Lund-Mackay (LM) score and the Lund-Kennedy (LK) system. According to LK endoscopy scoring; those with a score of 0 were determined as group 1 (40 (58.8%) cases); and those with a score greater than 0 were determined as group 2 (28(41.2%) cases). According to LM CT scoring system, cases whose score was 0 were determined as group 1 (44(%66.2) cases); those greater than 0 were determined as group 2 (23(33.8%) cases).

RESULTS

A total of 68 endo-DCR surgeries, 42 unilateral and 13 bilateral, were performed. Forty one cases (60.3%) were managed with endo-DCR alone, and septoplasty surgery was performed in 27 (39.7%) cases in addition to endo-DCR due to septum deviation. There was no statistically significant difference in functional and anatomical success between the two groups in terms of surgery type (anatomical success p = .353, functional success p = .528); LK endoscopy scoring (anatomical success p = .956, functional success p = .925) and LM CT scoring system (anatomical success p = .202, functional success p = .172).

CONCLUSION

LK endoscopy and LM CT scores did not show any influence on functional and anatomic outcomes in endo-DCR cases.

Surgical outcomes of endoscopic dacryocystorhinostomy: analysis of age effect

There is limited evidence in literature determining age effect on outcomes of endoscopic dacryocystorhinostomy (EDCR) in adult patients with primary acquired nasolacrimal duct obstruction (NLDO). We aimed to analyze the outcomes of EDCR according to age in primary acquired NLDO. A retrospective study was performed on consecutive adult patients and patients were divided into two age groups; group 1 (aged to 61 years) and group 2 (aged 62 to 89 years) based on the average value. The minimum required follow-up period was 6 months. A total of 441 EDCRs performed in 342 patients were enrolled. The anatomical success rate was not significantly different between the two groups (91.8% and 88.2%, P = 0.209). However, the functional success rate was significantly lower in the group 2 (85.1% and 76.9%; P = 0.036). Functional failure was associated with old age and a history of diabetes mellitus (P  = 0.024 and P  = 0.008). In subgroup analysis of patients with anatomical success but functionally failed EDCR, group 2 had significantly more comorbid conditions such as eyelid laxity (P = 0.026). In conclusion, the comorbid conditions which increase with age may affect functional outcome, especially eyelid laxity, careful preoperative examination of the eyelid and conjunctiva should be emphasized to lacrimal surgeons before performing EDCR.

Does long-term success from endoscopic DCR correlate with early post-operative reduction in tearing?

PURPOSE

The purpose of the study was to determine the association between early post-operative improvement in tearing and the long-term success rate of endoscopic dacryocystorhinostomy (eDCR).

METHODS

A retrospective review of consecutive patients who underwent eDCR and were followed up for at least 6 months at our institution from January 2010 to December 2017 was performed.

RESULTS

47 cases(39 patients) of eDCR met the inclusion and exclusion criteria during this time period. Mean follow up after the surgery was 12.5 ± 8 months. In 45 out of 47 (96%) cases post-operative improvement in epiphora within 2 weeks of surgery, or lack thereof, correlated with long-term success or failure of the procedure. There were only 2 cases in which the patients felt improvement in tearing at the initial post-operative visit and the tearing recurred in the late post-operative period (>6 months).

CONCLUSIONS

There is a strong association between the early initial post-operative assessment of tearing resolution and the long-term result of eDCR.

A Systematic Review of Benefit of Silicone Intubation in Endoscopic Dacryocystorhinostomy

Objectives

Insertion of a silicone stent during endoscopic dacryocystorhinostomy (DCR) is the most common procedure to prevent rhinostomy closure. It has been claimed that silicone intubation improves the surgical outcomes of endoscopic DCR. However, many reports have documented an equally high success rate for surgery without silicone intubation. Accordingly, we conducted a systematic review and meta-analysis to clarify the outcomes of endoscopic DCR with and without silicone intubation and determine whether silicone intubation is actually beneficial for patients.

Methods

PubMed, Embase, and Cochrane Library databases were searched to identify relevant controlled trials evaluating endoscopic DCR with and without silicone intubation. The search was restricted to English articles published between January 2007 and December 2016. Relevant articles were reviewed to obtain information pertaining to interventions and outcomes. We also performed a meta-analysis of the relevant literature.

Results

In total, 1,216 patients included in 12 randomized controlled trials were pooled. A total of 1,239 endoscopic DCR procedures were performed, and silicone stents were used in 533 procedures. The overall success rate for endoscopic DCR was 91.9% (1,139/1,239), while the success rates with and without silicone intubation were 92.9% (495/533) and 91.2% (644/706), respectively. There was no statistically significant heterogeneity among the included studies. A meta-analysis using a fixed-effects models showed no significant difference in the success rate between endoscopic DCR with silicone intubation and that without silicone intubation (OR, 1.38; 95% CI, 0.89 to 2.12; P=0.148; z=1.45). Furthermore, there were no significant differences with regard to surgical complications such as synechia, granulation, and postoperative bleeding.

Conclusion

The findings of our meta-analysis suggest that the success rate and postoperative complication rate for endoscopic DCR is not influenced by the use of silicone intubation during the procedure.

An Italian multicentre experience in endoscopic endonasal treatment of congenital choanal atresia: Proposal for a novel classification system of surgical outcomes

OBJECTIVE

The purposes of this study were to report our experience with endoscopic treatment of choanal atresia (CA), to illustrate our surgical technique and analyse the different factors that may affect outcomes.

MATERIAL AND METHODS

A retrospective review was performed of patients affected by congenital CA and treated between June 1996 and November 2013 at three referral centres which follow a uniform policy.

RESULTS

Eighty-four patients with CA (55 unilateral and 29 bilateral), aged between one day and 76 years (mean, 13 years) were included. Associated malformations were present in 28 patients. The overall success rate was 93%, with 96.3% and 86.2% success rates for unilateral and bilateral CA respectively. Six patients (7%) required revision surgery for early symptomatic restenosis. Statistical analysis revealed that outcomes were not influenced by sex, previous surgeries, unilateral versus bilateral atresia or associated anomalies. However, age seemed to be a prognostic risk factor for patients under one year-old.

CONCLUSION

The endoscopic endonasal approach is safe and effective, with a very high success rate and low morbidity. The removal of the vomer and the use of mucoperiosteal flaps are the main keys to avoiding postoperative stenosis. The use of stents or Mitomycin C is therefore not mandatory.

[The Interdisciplinary Conference on Lacrimal System Disorders of ophthalmic and ENT surgeons at the University Hospital Halle : An analysis of present patient material]

BACKGROUND AND AIM

The lacrimal system (LS) crosses regions of ocular adnexa, the nose, and the paranasal sinuses. Surgery of disorders requires a targeted ophthalmologic and otolaryngologic examination. Since 2013, an Interdisciplinary Conference on Lacrimal System Disorders (ICLSD) has existed at the University Hospital Halle. First results of our experiences with this cooperation between ophthalmic and ENT surgeons are presented.

METHODS

In a retrospective study at the Department of Ophthalmology, University Hospital Halle, all patients aged 22-80 years (n = 43, 10 with bilateral manifestation; mean age 65.1 years) having had a consultation in ICLSD between February 2013 and May 2015 were analyzed. Thereby, 53 LS were included in the descriptive evaluation.

RESULTS

The main relevant pathology in terms of ophthalmologic manifestation was chronic dacryocystitis and its complications (n = 42), whereas nasal septum deviation (n = 11) and chronic rhinosinusitis (n = 10) were the most frequent otorhinolaryngologic pathologies. Prior to consultation, ENT (n = 34) and/or ophthalmic surgery (n = 40) had been performed. During ICLSD, an individualized therapeutic regime for each patient was developed. Surgery was required in 43 out of 53 LS. Of these, 32 were mainly ophthalmic, 11 mainly ENT interventions. At the time of evaluation (median 3 months; range 1 to 24 months), 29 out of 38 patients (76.3 %) were free of complaints.

CONCLUSION

Since 2013, competences of ophthalmic and ENT surgeons have been integrated in ICLSD for advanced diagnosis and therapy of lacrimal disorders at the University Hospital Halle. Encouraging functional results are shown in this study, as most patients have had a long and complicated history of lacrimal system disorders. ICLSD enables interdisciplinary patient care.

Anatomical and subjective success rates of endonasal dacryocystorhinostomy over a seven-year period

PurposeEndonasal dacryocystorhinostomy (END-DCR) is a relatively novel approach that has recently been shown in some studies to provide similar success rates to the more traditional external approach for the treatment of nasolacrimal duct obstruction (NLDO). However, a range of success rates using this approach are reported within the literature and the majority of oculoplastic surgeons are still favouring the external approach. The purpose of this study was to review the anatomical and subjective success rates of END-DCRs performed over a 7-year period.Patients and methodsWe provide a review of the success rates of 288 END-DCRs for the treatment of acquired NLDO performed over a 7-year period by a single oculoplastic surgeon in Sydney, Australia. We describe the operative technique used and define anatomical success as demonstrated patency of the nasolacrimal drainage system at 10 weeks postoperatively while subjective success is defined as complete resolution or significant improvement of symptoms as reported by patients at the same time point.ResultsIn our study, we were able to demonstrate that out of 288 END-DCRs, an average anatomical success rate of 89.6% and an average subjective success rate of 81.3% were achievable.ConclusionsWe conclude that the success rates using our endonasal approach remain similar to those obtained using the external approach, as reported within the literature, and may be considered as a primary treatment option for acquired NLDO.

Acute Dacryocystitis with Empyema of the Lacrimal Sac: Is Immediate Endoscopic Dacryocystorhinostomy Justified?

OBJECTIVES

To evaluate the efficacy of endoscopic dacryocystorhinostomy (Endo-DCR) in the treatment of acute dacryocystitis with lacrimal sac empyema (ADLSE).

DESIGN

Case series with chart review.

SETTING

Academic tertiary center.

PATIENTS

The study included 26 consecutive patients who underwent Endo-DCR for ADLSE between August 2005 and December 2013.

MAIN OUTCOME MEASURES

The success of the procedure was defined as complete complaint relief and DCR patency. Data on the time from referral to surgery, postoperative complications, and revision surgery are also reported.

RESULTS

The present patient series included 4 males (15.4%) and 22 females (84.6%) (mean age, 66 years). The mean time between referral and surgery was 0.88 days and the mean follow-up time was 29 months. All patients showed immediate relief from symptoms, with no ADLSE recurrences. Complete success was achieved in 25 (96.2%) cases; the only failure was in a patient who had previously undergone radioiodine treatment. In this case, revision Endo-DCR was not successful. The only perioperative complication (3.8%) was epistaxis in a patient who required revision surgery under general anesthesia. The definitive success rate was 96.2% after primary and revision surgery.

CONCLUSIONS

Endo-DCR enables rapid resolution of ADLSE with a very high success rate. Immediate surgery may reduce the risk of skin fistulization and/or orbital complications. DCR shrinkage and lacrimal obstruction are unlikely with Endo-DCR since the procedure is performed on an enlarged sac. The main advantage of Endo-DCR, compared with external DCR, is the absence of a skin incision in an inflamed and infected field.

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.