Endoscopic and External Dacryocystorhinostomy: Long Term Result from a Tertiary Center in Portugal

Dacryocystorhinostomy is the gold-standard for distal lacrimal obstructions. This study aims to report the demography, clinical presentation, influence of agger nasi opening, uncinectomy and septoplasty, the use of silicone stent tubes, complications and success of endoscopic and external dacryocystorhinostomy over a period of 11 years. Retrospective review of clinical records, from January 2012 to December 2022, at a tertiary center in Portugal. A total of 249 procedures, 6 external and 243 endoscopic, were performed, including 39 revision cases. There was a female predominance (79.9%) with a mean age at diagnosis of 66.4 years. Recurrent acute dacryocystitis, reported by 33.3%, was associated with higher success (p = 0.053). Agger nasi opening, uncinectomy and septoplasty were performed in 17.7%, 6.0% and 15.3% respectively, although associated with higher success rates, no statistically significant difference was found. Minor complication rates for both external and endoscopic approach was 33.3% and 32.1% respectively. Functional and anatomical success was 100% and 83.3%, respectively, for external dacryocystorhinostomy, and 91.4% and 85.1%, respectively, for endoscopic dacryocystorhinostomy. Revision surgery was associated with a worse anatomical success (p = 0.05). Endoscopic dacryocystorhinostomy is an effective and safe alternative to the external approach. Minor procedures can increase the success rate, but multicentre studies need to be performed for a statistically significant result.

Outcomes of Endoscopic Endonasal Dacryocystorhinostomy in Glaucoma Patients

BACKGROUND

Anti-glaucoma eye drops have been investigated due to their production of fibrotic changes on the conjunctival surface, undermining the functioning of the upper lacrimal drainage system. We aimed to assess whether these effects may impair the effectiveness of endoscopic endonasal dacryocystorhinostomy (EE-DCR).

METHODS

This is a single-center observational retrospective study on EE-DCR via a posterior approach. Resolution of epiphora and dacryocystitis were analyzed after 1 (T1) and 6-months (T2) from surgery. Surgical success was defined as anatomical (patency at irrigation, no recurring dacryocystitis) or complete (zeroing of Munk score).

RESULTS

Twenty patients (32 sides) were enrolled. Preoperatively, 93.75% (n = 30/32) presented severe (Munk 3-4) epiphora and 68.75% (n = 22/32) recurrent dacryocystitis. At T1, 50.0% (n = 16/32) were referred with residual epiphora (Munk ≥ 1) and 18.75% (n = 6/32) dacryocystitis. At T2, 31.25% (n = 10/32) still complained of epiphora (Munk ≥ 1) and 6.25% (n = 2/32) dacryocystitis. Difference of outcomes at aggregate and paired timepoints (except for T1 versus T2) resulted in statistical significance (p < 0.05). At T2, 22 (68.75%) complete, 8 (25.0%) anatomical successes and 2 (6.25%) surgical failures were observed.

CONCLUSIONS

Despite the chronic uptake of anti-glaucoma eye drops, EE-DCR guaranteed high rates of clinical relief from epiphora and remarkable decreases in the rates of recurrent dacryocystitis.

Analysis of the safety and effectiveness of endoscopic nasal dacryocystorhinostomy in the remedy of chronic dacryocystitis

To estimate the safety and effectiveness of endoscopic nasal dacryocystorhinostomy in the remedy of chronic dacryocystitis. The clinical data of 105 subjects with chronic dacryocystitis enrolled into our hospital were analyzed retrospectively. The subjects were distinguished into nasal endoscopic group (endoscopic dacryocystorhinostomy; i.e., 51 cases) according to their surgical methods and external-route group (external-route dacryocystorhinostomy; i.e., 54 cases). The therapeutic effect, lacrimal gland secretion function, tear film stability, degree of epiphora, lacrimal passage patency, complications, and recurrence rate were contrasted between the 2 groups. The nasal endoscopic group exhibited a higher effective remedy rate (98.04%) compared with the external-route group (83.33%). Three months postoperation, both groups showed improvements in lacrimal gland secretion function and tear film stability, with the nasal endoscopic group demonstrating more significant enhancement in lacrimal gland secretion function than the external-route group. Six months postoperation, a reduction in the degree of epiphora was observed in both groups, with the nasal endoscopic group displaying a more pronounced decrease in epiphora severity and a higher lacrimal passage patency rate than the external-route group. Furthermore, the nasal endoscopic group experienced lower incidences of postoperative complications and recurrence rates. Endoscopic dacryocystorhinostomy is safe and effective in the remedy of chronic dacryocystitis.

Efficacy and Safety of Modified Seamless Endoscopic Dacryocystorhinostomy in Patients with Chronic Dacryocystitis

Objective

To evaluate the efficacy and safety of a modified seamless endoscopic dacryocystorhinostomy (EN-DCR) with chronic dacryocystitis.

Methods

This study included 54 patients (54 eyes) with chronic dacryocystitis treated in our hospital from 2019 to 2021, including 32 patients (32 eyes) who underwent modified and 22 patients (22 eyes) who underwent routine EN-DCR. In the modified EN-DCR, the nasal cavity was filled 30 min before the operation by injection of 1 mg/ml adrenaline hydrochloride and application of ephedrine hydrochloride and nitrofurazone nasal drops. Before the operation, the lacrimal passages were rinsed with a 1 : 2 mixture of dilute methylene blue and normal saline. The “I”-shaped incision was replaced by a ^“C^“-shaped incision near the lateral bone window. In place of suturing, a gelatin sponge was applied at the confluence of the lacrimal sac and nasal mucosa. After the end of the operation, the lacrimal sac was filled with tapered expansion sponge for 1 week. In routine EN-DCR, the nasal cavity was filled with 1 mg/ml epinephrine hydrochloride, and nitrofurazone nasal drops were provided for 5 minutes after the beginning of the operation; and a “I”-shaped incision was made in the nasal mucosa, with one stitch for each anterior and posterior flap. Operation time, intraoperative bleeding, and postoperative lacrimal duct irrigation were compared, with the curative effect evaluated after a follow-up of 6 months.

Results

Operation time was significantly shorter (41.3 ± 12.1 min vs. 65.4 ± 11.6 min; χ² = 7.312, P < 0.05) and intraoperative bleeding was significantly lower (12.5 ± 5.2 ml vs. 60.3 ± 8.9 ml; χ² = 24.883, P < 0.05) in the modified group than in the routine EN-DCR group. After follow-up for 6 months, the effective cure rate was significantly higher in the modified group than in the routine group (96.9% vs. 68.2%; χ² = 6.383, P < 0.05).

Conclusion

Compared with routine EN-DCR, modified seamless EN-DCR can achieve better surgical outcomes, shorten operation time, and reduce intraoperative bleeding.

[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.

Endoscopic and external dacryocystorhinostomy: A therapeutic proposal for distal acquired lacrimal obstructions

Endoscopic (END-DCR) and external dacryocystorhinostomies (EXT-DCR) are nowadays considered the gold standard techniques for non-oncologic distal acquired lacrimal disorders (DALO). However, no unanimous consensus has been achieved on which of these surgeries is the most suitable to the individual patient. Herein, we review the available literature of the last 30 years with the aim of defining a simple and reproduceable treatment algorithm to treat DALO. A search of PubMed, EMBASE, Scopus and Cochrane databases was last performed in December 2021 to examine evidence regarding the role of END-DCR and EXT-DCR in primary and revision surgeries. If considered primary surgeries, END-DCR should be preferred in case of intranasal comorbidities, given the possibility to directly visualize and treat potential intranasal pathologies. Conversely, EXT-DCR should be chosen in case of need/preference for local anesthesia, given the major historical experience and wider surgical field that helps to resolve intra-operatory complications (e.g., bleeding) in an uncollaborative patient. In the absence of the abovementioned conditions, the decision of one or other approach should be discussed with the patient. In recurrent cases, END-DCR should be considered the treatment of choice given the major likelihood to visualize the causes of primary failure and directly resolve it. In conclusion, END-DCR should be considered the treatment of choice in revision cases or in primary ones associated with intranasal pathologies, whereas EXT-DCR should be chosen if local anesthesia is needed. In the absence of these scenarios, it is still open to debate which of these two approaches should be used.

Clinical application of dexmedetomidine combined with dezocine in local anesthesia for endoscopic dacryocystorhinostomy

OBJECTIVE

To investigate the clinical effect of dexmedetomidine combined with dezocine in local anesthesia for endoscopic dacryocystorhinostomy (DCR).

METHODS

Ninety patients undergoing elective endoscopic DCR were randomly divided into two groups, local anesthesia group (LA group n = 45) and general anesthesia group (GA group, n = 45). These subjects were all American Society of Anesthesiologists (ASA)-Physical Status I-II patients. The changes of mean arterial pressure (MAP) and heart rate (HR) were observed and recorded before anesthesia (T0), after anesthesia (T1), at the beginning of surgery (T2), and at the end of surgery (T3). The visual analogue scale (VAS) score was observed and recorded immediately after awakening from anesthesia and at 1, 2, 6, and 12 h after surgery. Additionally, the occurrence of adverse reactions after surgery and the sedation-agitation scale (SAS) score after awakening were recorded.

RESULTS

Compared with the LA group, the MAP and HR of the GA group were significantly lower at T1 and T2, but significantly higher at T3. Local anesthesia was associated with lower VAS score immediately after awakening and at 1, 2, 6, and 12 h after surgery. Also, local anesthesia caused a lower incidence of postoperative agitation, nausea, and vomiting. The SAS score in the LA group was markedly higher than that in the GA group.

CONCLUSION

Local anesthesia with dexmedetomidine and dezocine as adjuvants in endoscopic DCR has more stable hemodynamics and reduces the stress response during perioperative period. Also, this anesthesia achieves better postoperative sedation and analgesia effects, reduces postoperative complications, and improves the quality of awakening from anesthesia. Collectively, local anesthesia is a comfortable and safe option for patients with high risks of general anesthesia and those unwilling to receive general anesthesia.

Maxillary Sinus Osteoma as a Support for Dental Implant Associated to Sinus Augmentation Procedure: A Case Report and Literature Review

Background: Maxillary sinus augmentation is a method extensively used to restore sufficient bone volume in the posterior maxilla to allow for the placement of fixtures. The purpose of the present case report was to describe a rare case of sinus osteoma used for implant support and to review the relevant literature. Materials and Methods: A 58-year-old man with a radiopaque intrasinusal lesion was referred for rehabilitation of the maxilla. The lesion was probably an osteoma and involved the nasal wall of the maxillary sinus. After discussing the options with the patient, he agreed to maintain the lesion and a sinus augmentation with a bone graft. A part of the osteoma was partially removed for histological analysis while avoiding perforation or tearing of the schneiderian membrane. After six months, 6 implants (Bone System Implant, Milano, Italy) were placed in the maxilla, two of which were inserted in the osteoma. Results: The two implants placed in the osteoma were perfectly osseointegrated. The graft material appeared well-integrated with no local signs of inflammation. No postoperative events or symptoms were reported after the surgery stages and at a 6-month follow-up. Regarding the two implants placed in the osteoma: article selection identified 9 case reports, 2 case series, and 1 retrospective study for a total of 58 subjects, 35 males and 25 females. The patients’ ages were heterogeneous and ranged between 12 and 79 years old. Conclusions: In the present case, we decided to leave the osteoma because it was asymptomatic and used as dental implant support. The effectiveness of the present investigation can provide useful guidance for surgeons and dentists in the management of similar clinical situations.

Lacrimal gland botulinum toxin injection for epiphora management

PURPOSE

Epiphora remains an often difficult to manage ocular complaint for ophthalmologists in all subspecialties. This review seeks to examine the safety and efficacy of botulinum toxin injection for management of chronic epiphora.

METHODS

The authors conducted a Pubmed search for studies on the use of lacrimal and transplanted salivary gland botulinum toxin injections for the management of epiphora within the past 20 years. Studies included had a minimum of four glandular injections.

RESULTS

The authors identified 14 studies and divided them by indication for injection; either functional epiphora, non-functional epiphora, or mixed studies. Seven studies examined injections for cases of functional epiphora, four for non-functional epiphora, and four for mixed cases. The number of glandular injections reported ranged from 4 to 65. Side effects reported were limited to diplopia, eyelid or lacrimal gland hematoma, papillary conjunctivitis, dry eye, ptosis, and bleeding.

CONCLUSIONS

Glandular botulinum toxin injection should be considered as a viable treatment strategy for both functional and nonfunctional epiphora. From the studies reviewed, botulinum toxin injection was shown to be effective in both children and adults. Injection can be performed in the outpatient setting, is minimally invasive, technically easy to administer, has a favorable side effect profile, and good efficacy. Furthermore, repeat injections can be performed with similar efficacy.

The importance of clinical presentation on long-term outcomes of external dacryocystorhinostomies: Our experience on 245 cases

PURPOSE

External dacryocystorhinostomy (EXT-DCR) is a surgical approach commonly used to treat post-canalicular acquired lacrimal obstruction whose success rate has been described, equally with endoscopic DCR, to be superior to other available treatments.

METHODS

At San Raffaele Hospital, Milan (Italy), from January 2008 to December 2020, 245 EXT-DCRs were performed. All patients underwent routine pre-operative work-up including Jones tests and probing and irrigation of the lacrimal pathway; when necessary, a multidisciplinary approach with nasal endoscopy was performed. The surgical approach was followed by positioning of a bicanalicular stent which was left in place for 6 months. Success was defined as resolution of clinical signs/symptoms and free lacrimal flow on functional test.

RESULTS

Of the cases enrolled, 26.9% were treated for recurrent epiphora (group 1), and 73.1% for epiphora associated with chronic dacryocystitis (group 2). After a median follow-up of 71 months, group 1 had success at T0 (1 month) and T1 (long-term) of 81.8% and 60.6%, respectively, compared to 93.8% and 77.7% in group 2. Statistical analysis showed a significant association with surgery both at T0 (p = 0.018) and T1 (p = 0.012) with group 2 showing better outcomes. Additionally, the cosmetic outcome of the external scar was defined as invisible in 91.8% of cases and slightly visible in 8.2%.

CONCLUSIONS

External dacryocystorhinostomy provides long-term reliable results particularly in case of chronic dacryocystitis. Moreover, the optimal esthetic outcome of the external scar should be no longer considered the only guiding principle of treatment modality, particularly in the elderly.

Longitudinal randomized study to evaluate the long-term outcome of endoscopic primary dacryocystorhinostomy with or without silicone tube

OBJECTIVE

Dacryocystorhinostomy (DCR) is indicated for the treatment of nasolacrimal obstruction with some authors suggesting the use of a silicone tube (stent) to maintain rhinostomy patency a long time. This study aims at comparing the results of endoscopic-DCR (En-DCR) with and without silicone stenting.

METHODS

A randomized prospective study was conducted from January 2013 to January 2018, following patients for up to 72 months. Sixty outbound patients suffering from chronic epiphora for primary acquired nasolacrimal duct obstruction were simply randomized and assigned to En-DCR with "silicone stent tube" (SST) or "no silicone stent tube" (NSST) group. Data about the results of the two procedures were collected using Munk' and Ali' assessments. The results were statistically compared to evaluate the differences.

RESULTS

30 patients were in the SST group and 30 in NSST. In the SST group, the tube remained in place for 3-6 months (4.1 ± 1.2 months). The follow-up period was 12-72 months (48.3 ± 6.2 months). Success rates (Junk and Javed Ali assessments) were, respectively, 97% in SST and 90% NSST group, with no statistical difference (Student's test). On a long-term follow-up, SST patients had an increased risk of re-stenosis by 14 months.

CONCLUSIONS

Our results showed there were not benefit in using tube, in the opposite it increased risk of re-stenosis. Despite preliminary results, our data confirmed comparing the two methods that silicone tube should not be used.

Multidisciplinary approach to lacrimal system diseases

Pathologies of the lacrimal drainage system range from benign to malignant lesions. However, independently of the etiological origin, the most common presenting symptom is represented by epiphora due to the dysfunction of the lacrimal system. Different diagnostic tools are now available, but for the most the first diagnostic approach is characterized by an ophthalmological visit, associated with nasal endoscopy, usually performed by an otolaryngologist. Frequently the diagnostic work-up is completed with a radiological exam (e.g. maxilla-facial CT or dacryocystography), whose role is still to be determined. Once a diagnosis has been made, different treatments are available in relation to the type of the disease, and commonly need close cooperation between an ENT and ophthalmic surgeon given the close anatomical structures involved. Taking into account all these aspects, the aim of this review is to highlight how a multidisciplinary approach to lacrimal pathologies is mandatory from diagnosis to treatment in order to offer the best clinical approach.

Role of anaesthesia in endoscopic and external dacryocystorhinostomy: A meta-analysis of 3282 cases

Distal acquired lacrimal obstruction is a common adulthood pathology whose primary treatment is represented by EXT-DCR and END-DCR. When considering their influencing factors, the role of the type of anaesthesia applied during these surgeries has a major role. The aim of this study is to systematically analyse the influence of general and local/regional anaesthesia on the final success rates of EXT-DCR and END-DCR. Primary EXT-DCR and END-DCR articles published later than 2000 with at least 50 single clinician procedures were selected. Exclusion criteria included acute dacryocystitis, tumours, studies focussing on revision surgeries, surgeries with adjunctive procedures, not clearly demarcated surgeons, mixed cohort study of acquired and congenital disorders. This systematic review was conducted in accordance with MOOSE guidelines; where feasible, a meta-analysis of the collected results was conducted. As a result, 11,445 articles were selected of which 2741 were examined after screening, and 16 included after full text review (0.6% of the initial papers). Among all papers included, the number of EXT-DCR was not enough to provide a solid analysis of the effect of anaesthesia; conversely, a significant difference of success rate was noted between local anaesthesia + sedation (85.1%, IC 77.8%-90.4%), and general anaesthesia (90.8%, IC 88.8%-92.4%) in END-DCR (p = 0.048). In conclusion, END-DCR performed with general anaesthesia should be considered as the solution of choice; however, local anaesthesia, eventually associated with a sedation, can be used as an alternative in selected cases. No meaningful conclusions could be drawn for EXT-DCR, due to the lack of data.

Long-term results of a balloon-assisted endoscopic approach in failed dacryocystorhinostomies

Purpose

Endoscopic endonasal balloon-assisted dacryoplasty is a minimally invasive surgical approach that can be applied after failure of dacryocystorhinostomy with recurrence of distal acquired lacrimal obstruction.

Methods

At the Department of Otolaryngology, San Raffaele Hospital, Milan (Italy), from December 2016 to October 2020, 14 patients underwent trans-nasal balloon-assisted dacryoplasty after a failed dacryocystorhinostomy (both external and endoscopic endonasal). The routinary pre-operative work-up included multidisciplinary study of the lacrimal disease, which consisted in primary ophthalmological and otorhinolaryngological visits associated with nasal endoscopy, in which a radiological exam was added if needed. The surgical approach includes pneumatic enlargement of the stenotic rhinostomy, created during the primary dacryocystorhinostomy, using a high-pressure trans-nasal balloon catheter. Anatomical success was considered when the ostium was patent upon irrigation, while functional success was considered as resolution of epiphora or free lacrimal flow on functional test.

Results

Among 14 patients included and after a mean follow-up of 19.5 months (range 13–51 months), anatomic success was achieved in 100% of patients and functional success was achieved in the 85.7% (12/14). Operative time ranged from 9 to 28 min (mean 18 min) and no complications were reported.

Conclusion

Trans-nasal balloon-assisted dacryoplasty is a mini-invasive surgical approach to treat failed dacryocystorhinostomies with reliable and stable outcomes in the long term. The absence of post-surgical complications, high success rate and short operative time are the main features of this innovative procedure.

Microbial Screening Reveals Oral Site-Specific Locations of the Periodontal Pathogen Selenomonas noxia

INTRODUCTION

Selenomonas noxia (SN) is an important periodontal pathogen, associated with gingivitis and periodontitis. Many studies have found associations between SN and indicators of poor health outcomes, such as smoking, low socioeconomic status and obesity. However, less is known about the prevalence of this organism and more specifically about other oral site-specific locations that may harbor this organism.

METHODS

Using an existing patient repository (n = 47) of DNA isolated from saliva and other oral sites (n = 235), including the dorsum of the tongue, lower lingual incisor, upper buccal molar and gingival crevicular fluid (GCF), molecular screening for SN was performed. Screening results were analyzed for associations between demographic variables (age, sex, race/ethnicity) and clinical information (body mass index or BMI, presence of orthodontic brackets, primary/mixed/permanent dentition).

RESULTS

qPCR screening revealed a total of n = 62/235 sites or 26.3% harboring SN with saliva and GCF (either alone or in combination with one or more sites) most often observed (Saliva, n = 23/27 or 85.18%, GCF, n = 14/27 or 51%). Analysis of site-specific data revealed most positive results were found among saliva and GCF alone or in combination, with fewer positive results observed among the tongue (33.3%), lower lingual incisor (29.6%), and upper buccal molar (25.9%). No significant associations were found between demographic or clinical variables and presence of SN at any site.

CONCLUSIONS

These results may be among the first to describe site-specific locations of S. noxia among various additional oral biofilm sites. These data may represent a significant advancement in our understanding of the sites and locations that harbor this organism, which may be important for our understanding of the prevalence and distribution of these organisms among patients of different ages undergoing different types of oral treatments, such as orthodontic treatment or therapy.

Melanoma of the lacrimal drainage system: A systematic review

Melanoma of the lacrimal drainage system (LDSM) is a rare and subtle condition that is frequently misdiagnosed. In the present work, we conducted a systematic review investigating the clinical features, management, and prognosis of LDSM. A structured search, according to PRISMA criteria, was performed in April 2020 and updated in February 2021 on Pubmed, EMBASE, Cochrane, and SCOPUS. The articles found underwent a double-reviewer selection and the main data were extracted. After complete screening, 30 articles reporting 38 cases were included. The time from the first symptom to medical contact ranged from 1 month to 4 years. Surgery was the treatment proposed to all patients, with a variable extension of resection. LDSM is a rare disease that is burdened by poor prognosis. Early diagnosis is crucial, even if difficult to achieve. Surgery and radiotherapy are standardized treatments, while targeted therapy and immunotherapy are attractive prospects.

The role of the rhinostomy ostium size on functional success in dacryocystorhinostomy

INTRODUCTION

Endonasal and external dacryocystorhinostomy procedures have both been used for the treatment of post-saccular obstruction of the lacrimal system. Functional success of these surgeries depends on several factors.

OBJECTIVE

To evaluate the status of the rhinostomy ostium with endonasal and external approaches in dacryocystorhinostomy operations and to determine the effect of ostium size on postoperative functional success.

METHODS

The charts of the patients operated in our hospital between May 2017 and January 2019 were analyzed retrospectively (ethical approval number: 2018-12.04). The patients that were operated in the ophthalmology and otolaryngology departments were included in the study. Endoscopic rhinostomy ostium measurements, punctum lavage findings and complications were recorded at 8 weeks postoperative at the earliest.

RESULTS

When the 64 patient charts were reviewed (76 operations), the mean ostium width was 1.85±1.11mm in the endonasal approach group and 3.60±2.24mm in the external approach group. The mean ostium areas in endonasal and external group were 14.61±16.66mm² and 56.05±60.41mm², respectively. The ostium was anatomically patent and punctum lavages were negative in 11 patients (6 patients in the endonasal approach group and 5 patients in the external approach group) and these cases were considered as functional failures. The rhinostomy ostium was significantly wider in the external approach group, but this was considered ineffective on functional outcomes.

CONCLUSION

Lacrimal duct stenosis can be successfully treated with endonasal and external methods. Tear drainage may be insufficient even in the presence of a patent ostium. Therefore, functional success should also be considered when evaluating the overall success of dacryocystorhinostomy. An anatomically patent ostium is definitely required, while it is believed that ostium size does not affect functional surgical success.

Incidence of Dacryocystorhinostomy (DCR) in France: A Nationwide Study over the 2010-2019 Period

BACKGROUND

To assess the annual incidence, surgical technique preferred (i.e. external versus endonasal) and the characteristics of patients undergoing a Dacryocystorhinostomy (DCR) in France over a 10-year-period.

METHODS

A national observational cohort study was conducted in France between January 2010 and December 2019. Data were collected from the national PMSI (Programme de Médicalisation des Sytèmes d'Information) database provided by the CNAM (Caisse Nationale de l'Assurance Maladie). All patients undergoing a DCR were included.

RESULTS

Twenty-one thousand one hundred ninety-nine patients, with a mean age of 70.4 years, were included. A female predominance (78%) was noted. The mean annual number of DCRs was 2481 (2366-2633), corresponding to a mean incidence of 3.8 per 100,000 person-years. This number remained stable over the study period (p = .966). Of the 24,808 DCRs, external DCRs were more prevalent compared to endonasal procedures (70.8% vs. 29.2%, p = .0001). Six hundred and fifteen (2.5%) associated acts were performed intraoperatively, mainly during endonasal DCR (96.3%). A total of 10,857 (43.8%) silicone stents were placed intraoperatively. Bicanalicular silicone stenting was preferred over the monocanalicular stenting. All the regions performed more likely external DCR except the Île-de-France area where endonasal DCR was performed in 75.6% of procedures. DCRs were mainly performed by an ophthalmologist (80%).

CONCLUSION

The mean annual incidence of external and endonasal DCRs remained stable over the study period. Endonasal DCR was more likely performed by the otorhinolaryngologists, emphasizing the need to develop personalized endonasal training in the ophthalmology residency program.

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.

A case of endonasal balloon-assisted dacryoplasty after failure of endonasal dacryocystorhinostomy

Endonasal balloon-assisted dacryoplasty is a minimally invasive technique that uses a high-pressure balloon catheter introduced into the lacrimal pathway through the nasal fossa into the neorhinostomy to treat recurrent epiphora after primary dacryocystorhinostomy. This procedure can be considered to be a reliable technique in patients unfit for general anesthesia.

Nasolacrimal duct stenosis-Surgery with a novel robotic endoscope positioning system

BACKGROUND

Distal nasolacrimal duct stenosis is usually treated by head and neck surgeons with transnasal endoscopic dacryocystorhinostomy (DCR). The presented clinical study discusses advantages and drawbacks of a robot-assisted endoscope positioning system, which allows for hands-free visualization of the surgical field.

MATERIAL AND METHODS

Two patients were treated by surgical DCR. The endoscopic positioning system (Medineering^® ) features a mechatronic holding arm with four segments and seven degrees of freedom. It is driven by using a foot pedal.

RESULTS

Visualization and instrumentation of the surgical field including the relevant anatomical landmarks were feasible. The endoscope position could be controlled with sufficient precision. The surgeon was able to maintain bimanual instrumentation.

CONCLUSION

The endoscope positioning system allows for two-handed surgery, which facilitates the essential steps of the surgical procedure. If the benefit of the system is sufficient for the use in clinical routine, it has to be evaluated in repeated applications.

Endoscopic endonasal balloon-dacryoplasty in failed dacryocystorhinostomy

OBJECTIVE

Endoscopic endonasal balloon-assisted dacryoplasty is a minimally-invasive surgical procedure that can be used in recurrent epiphora, a common pathology in both adulthood and childhood.

STUDY DESIGN/SETTINGS

We present a retrospective case series of eight patients who underwent trans-nasal balloon-assisted dacryoplasty after a failed external or endoscopic dacryocystorhinostomy, from March 2019 to January 2020, at the Department of Otolaryngology, San Raffaele Hospital, Milan, Italy.

SUBJECTS AND METHODS

All patients underwent routine preoperative work-up including fluorescein test (Jones test I-II), probing and irrigation of the lacrimal pathway and nasal endoscopy. Because of the recurrent nature of the pathology, pre-operatory computed tomography scan or dacryocystography was not performed. The surgical procedure was based on enlargement of the stenotic neorhinostomy created by primary dacryocystorhinostomy through the use of a high-pressure balloon catheter. Anatomical success was defined as a patent ostium on irrigation, whereas functional success was defined as free lacrimal flow on functional test and resolution of epiphora.

RESULTS

Anatomic and functional success was achieved in 100% of patients. Operative time ranged from 9 to 22 min (mean 16 min). No significant complications were reported.

CONCLUSION

Our results indicate that trans-nasal balloon-assisted dacryoplasty can be considered as a safe and reliable surgical approach after a failed primary dacryocystorhinostomy. The shorter surgical time and reduced post-operative complication rates are the main advantages of this procedure.

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.

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.