Endoscopic surgery for lacrimal obstruction RALPH MelSON. MD. Boston. Massachusetts
Intranasal access to the lacrimal drainage system has been greatly enhanced with the advent of endoscopic nasal surgery. This technique has been used for the treatment of recurrent lacrimal obstNctlon after failed extemal dacryocystorhinostomy (DCRI In 12 patients. Improved Intranasal visualization with the endoscope allOWed easy Iden· tlflcatlon and opening of the lacrimal sac. with no need for a skin Incision. ObstNctlng Intranasal pathology, Including adhesions from previous DCR, an enlarged middle turbinate, and ethmoid sinusdisease, was readily Identified and corrected. Therewere no Intraoperative complications. Lacrimal obstNctlon was completely relieved In nine of 12 patients (75%), With a followup of 7 to 25 months. Endoscopic revision OCR should be considered In patients with recurrent epiphora after external OCR. (OTOLARVNGOL HEAD NECK SURG 1991;104:473.)
Since Toti'sl original description of the dacryocystorhinostomy (OCR) in 1904, most surgery for relief of lacrimal obstruction has been performed through an external incision. Intranasal approaches to the lacrimal sac that avoid a skin incision are inherently limited by poor visibility within the narrow confines of the superior nasal cavity. Even Mosher," who first described an intranasal approach for lacrimal obstruction in 1921, eventually abandoned this procedure in favor of a combined external and intranasal approach. Surgical access throughout the nasal cavity has been greatly enhanced by the development of endoscopic nasal surgery. Small-diameter endoscopes with angled fields of view provide excellent intranasal visualization, enabling the surgeon to identify and open the lacrimal sac with relative ease from inside the nasal cavity. This report describes recent experiences with endoscopic nasal instrumentation for the treatment of lacrimal obstruction.
METHODS AND MATERIAU Lacrimal obstruction was the indication for surgery in 20 of the first 200 patients on whom I performed endoscopic intranasal surgery between April 1987 and August 1990. A total of 24 separate procedures (Table
From the Department of Otology and Laryngology. Harvard Medical School. and the Massachusetts Eye and Ear Infirmary. Presented at the Annual Meeting of the American Academy of Otolaryngology-Head and Neck Surgery, San Diego, Calif., Sept. 9-13. 1990. Received for publication Sept. II. 1990; accepted Nov. 14. 1990. Reprint requests: Ralph Merson, MD. Zero Emerson Place. Boston. MA02114.
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I) for relief of lacrimal obstruction were performed on these patients, including 15 revision DCRs, six con. junctivodacryocystorhinostomies (COCRs) with Jones tube placement, two primary DCRs, and one anterior ethmoidectomy. This report details the results of the first 13 endoscopic revision OCRs, which were performed on the 12 patients who have had a minimum 9-month followup. There were nine women and three men, ranging in age from 28 to 79 years. All patients were diagnosed as having lacrimal obstruction distal to the common canaliculus by their referring ophthalmologist. Presenting symptoms were epiphora in nine patients and recurrent dacryocystitis in three. These symptoms had not been relieved by at least one previous external OCR in all patients. Five patients had two or more unsuccessful external OCRs on the affected eye. The length of time between the last external OCR and the endoscopic OCR ranged from 3 months to 4 years. Thirteen secondary procedures were performed at the time of endoscopic revision OCR in order to enhance surgical exposure of the sac, remove accompanying sinus disease, or decrease the likelihood of postoperative adhesions (Table 2). The middle turbinate was resected when it was enlarged or the lacrimal sac extended beneath the anterior edge of turbinate (Fig. I). Septoplasty was performed to correct a deviation that precluded adequate endoscopic visualization of the lateral nasal wall. Such a deviation usually involved the perpendicular plate of ethmoid bone. A straight septum also allowed for easier examination and cleaning of the surgical site postoperatively. Anterior ethmoidectomy was performed to remove middle meatus adhesions from previous surgery and open agger nasi cells located in the region of the lacrimal sac. In one patient with
473
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Fig. 1. View of the right lateral nasal wall demonstrates the relationship of the lacrimal sac and nasolacrimal duct to the turbinates. Note how a portion of the sac may extend beneath the middle turbinate, requiring turbinate resection for adequate exposure.
Table 1. Endoscopic procedures performed for relief of lacrimal obstruction in 20 patients Procedure
N
extensive sinusitis, a posterior ethmoidectomy and middle meatus maxillary antrostomy were also performed.
Revision OCR COCR with Jones tube Primary OCR Anterior ethmoidectomy
15
Operative Procedure
6 2 1
OCR. Dacryocystorhinostomy; CoCR. conjunctivodacryocystorhinoslamias.
Table 2. secondary procedures performed during 13 endoscopic revision DCRs Procedure
N
Middle turbinate resection Septoplasty Anterior ethmoidectomy Posterior ethmoidectomy Maxillary antrostomy
7 4
3 1 1
The technique of endoscopic revision OCR surgery has been described in detail elsewhere.' The surgery is performed as a team effort, using skills of both the otolaryngologist, who performs the endoscopic intranasal procedure, and the ophthalmologist, who passes the lacrimal probes through the canaliculi into the sac to direct tissue removal. The entire procedure is performed with a video camera attached to a nasal endoscope, so that both surgeons can simultaneously observe intranasal manipulations on a video monitor. The lacrimal sac is located along the superior aspect of the lateral nasal wall, just anterior to the middle turbinate (Fig. I). A lacrimal probe is passed through a canaliculus and directed medially into the obstructed sac, where it is seen to tent the mucosa of the nasal
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Endoscopic surgery for lacrimal obstruction
Fig. 2. Endoscopic view of left nasal cavHy demonstrates a pair of slilcone rubber catheters passing through the lateral nasal wall (o"ow) Into the lacrimal sac. These catheters are Introduced through the canaliculi (see Fig. 3) to serve as a stent during the healing period. The nasal septum (5) and remaining posterior portion of resected middle turbinate (T) are also shown. Fig. 3. The extranasal course of the silicone rubber catheters shown In Fig. 2 is demonstrated In this photograph of the left eye at the same patient. The tub ing (o"ow). wh ich serves as a stent during the healing pe riod. posses from the canaliculi through the lacrimal sac and Into nasal cavity. where it Is tied to form a continuous loop. Fig. 4. Endoscop ic view of same patient as shown In Fig, 2 after silicone rubber catheters have been removed, Yellow color along lateral nasal wall demonstrates free-flow of fluorescein dye from eye into nose through healed ostium ianow). AIl opening Into the ethmoid sinus is seen In the center of the field. just lateral to the middle turbinate remnant (Photograph reprint with permission from Laryngoscope 1990;100:cover).
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FIg. 5. Endoscopic view of right lateral nasal wall shows ftow of ftuoresceln dye through the surgical ostium (offOWS) Into the nose. The varlatton In sizes of healed ostia Is demonstrated by comparison of this relatively large lacrimal opening with the small one shown In Fig. 4. Prominent structures seen In the center of the figure are openings Into the ethmoid sinusesIn this patient. who has undergone an ethmoldectomy and middle turbinate resection. Nasal septum (5). FIg. 6. View of left nasal cavity demonstrates flow of ftuoresceln dye through ostium (Offow) onto lateral nasal wall and turbinate. The anterior aspect of turbinate has been resected. A hole Is seen, which leads to an air cell within the turbinate (concha bullosa). Nasal septum (5).
wall. Using a 0- or 30-degree nasal endoscope for visualization, a sickle knife is used to make a curvilinear incision in the nasal mucosa, approximately I-em anterior to the underlying probe tip. A mucosal flap is elevated posteriorly and removed with a straight Blakesley forceps. Frequently, there is additional scar tissue that needs to be removed to enter the sac interior. Once the sac has been entered, the lacrimal probe will be exposed. The intranasal opening is deepened with an angled Blakesley forceps (Karl Storz Endoscopy, Culver City, Calif.) directed laterally. The surgeon must be careful to remove only tissue immediately surrounding the probe. Direct visualization into the sac can often be achieved at this point with a 70-degree endoscope. Once the intranasal opening has been sufficiently enlarged to a diameter of approximately 10 mm, the lacrimal probes should pass freely into the nose from both the superior and inferior canaliculi. The lacrimal probe is then replaced by silicone rubber tubing that has its ends stented over a rigid wire (Guibor Canaliculus Intubation Set, Concept Inc., Largo, Fla.). The ends of the tubing are grasped with a forceps and guided out of the nose. They are tied and trimmed so
that the knot lies within the nasal cavity. The tubing thus forms a continuous loop, which passes through the intranasal ostium and is unlikely to become dislodged until it is removed in 2 to 6 months (Figs. 2 and 3). Unless bleeding is a problem or a septoplasty has been performed, no nasal packing is used. RESULTS
Endoscopic revision OCR successfully relieved all symptoms of lacrimal obstruction in nine of 12 patients (75%), with a followup ranging from 7 to 25 months. There were no intraoperative complications. Lacrimal tract patency was verified by endoscopic visualization of fluorescein dye flowing from the eye into the nose through the newly created internal ostium (Figs. 4, 5, and 6). The first of three surgical failures involved a 40-yearold man who had undergone three previous unsuccessful external DCRs for recurrent dacryocystitis. The endoscopic revision OCR resulted in new adhesions between the lateral nasal wall and turbinate, with a recurrence of the dacryocystitis. A second endoscopic revision DCR was performed 9 months later, which included
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middle turbinate resection and septoplasty to correct an ipsilateral septal deviation. Three months after surgery, endoscopic examination revealed a patent internal ostium, with flow of fluorescein dye around the silicone rubber stents and no new adhesions. He has no symptoms of epiphora or dacryocystitis. The second patient to have unsuccessful endoscopic revision OCR was a 66-year-old woman in whom recurrent epiphora developed 2 months after an external OCR. Endoscopic examination revealed a dense scar band extending from the middle turbinate to the lateral nasal wall. She underwent an endoscopic revision OCR with lysis of adhesions. Endoscopic examinations revealed gradual closure of the internal ostium from an initial diameter of 10 mm to a tight stenosis around the silicone rubber tubing. Epiphora had returned within 2 months. Complete closure of the ostium occurred soon after the tubing was removed. The last surgical failure occurred in a 62-year-old woman who had two previous external OCRs, with subsequent return of her epiphora. Four months after her last procedure she underwent an endoscopic revision OCR, with lysis of adhesions between the nasal septum and lateral nasal wall. She had relief of her epiphora for only 22 days. New intranasal adhesions were visible with the endoscope. The internal ostium closed 3 weeks after removal of the silicone rubber stents. Eight months later, she underwent a second endoscopic revision OCR. Middle turbinate resection and septoplasty were performed concurrently. No new adhesions were noted; however, epiphora returned within 2 weeks as the OCR drainage site quickly stenosed. The silicone rubber stents were removed after 4 months and the small internal ostium closed. Postoperative complications other than recurrent lacrimal obstruction involved one patient with epistaxis from a bleeding site along the cut edge of resected middle turbinate and another with a canalicular laceration from the silicone rubber tubing having been tied too tightly within the nose. The epistaxis occurred on the fifth postoperative day and was controlled with anterior nasal packing. The laceration was noted 3 weeks after surgery and healed once the tubing was removed. Both patients obtained complete relief of their epiphora from the endoscopic OCR.
DISCUSSION The advent of endoscopic nasal surgery has greatly enhanced intranasal access to paranasal structures, including the sinuses and lacrimal sac. Endoscopic revision OCR enables the sac to be safely reopened under direct visualization, even in the presence of fibrosis from previous surgery. Intranasal pathology contribut-
ing to OCR failure, such as postoperative adhesions or an enlarged middle turbinate, can be readily identified and corrected with the endoscopic instrumentation. This approach also avoids a skin incision in a patient who has already been subjected to an external approach that has failed. There were no intraoperative complications in 13 surgical procedures performed on 12 patients. Postoperative complications included epistaxis from an edge of resected turbinate in one patient and a canalicular laceration from an overly tight silicone rubber stent in another. Both conditions were easily remedied and did not interfere with the successful surgical outcomes. Endoscopic revision OCR led to complete relief of lacrimal obstruction in nine of 12 patients, for a success rate of 75%. These results are comparable to those of Welham and Henderson," who reported an 83% success rate for revision OCRs performed through a repeat external approach. The first of three surgical failures was considered the result of obstructing postoperative adhesions. A second endoscopic procedure with middle turbinate resection and septoplasty has led to a resolution of symptoms, although followup has been only 3 months. Inadvertent damage to the mucosa of the turbinate or adjacent deviated nasal septum during previous OCR surgery appeared to be the cause of obstructing adhesions in six of the 12 patients undergoing endoscopic revision DCR. These findings are consistent with reports showing the most frequent cause of external OCR failure to be membranous occlusion of the surgical internal ostium created between the lacrimal sac and nasal cavity.t" Middle turbinate resection is considered an important step in the prevention of postoperative adhesions. Its resection is recommended whenever the surgical ostium into the sac extends beneath the turbinate or the turbinate is enlarged, such as from mucosal hypertrophy or a concha bullosa (air cell within the turbinate bone). It is critical to remove enough turbinate to provide good exposure to the sac and ensure that the edges of sac mucosa are not in proximity to the edges of resected turbinate. Similarly, a septoplasty may be necessary to prevent obstructing postoperative adhesions between the opened sac and damaged mucosa overlying a deviated nasal septum. The other two patients who failed endoscopic revision surgery also had membranous obstruction of the surgical ostium, although not by adhesions. In these cases, re-epithelialization and fibrosis within the ostia and sac led to closure of the mucosal opening around the silicone rubber stents. When the stents were removed, the ostia closed completely. One patient underwent a second endoscopic revision DCR that also failed sim-
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ilarly. A possible explanation for surgical failure in these two cases in unrecognized canalicular obstruction. In a series of 21 external DCRs, Van Deenen et al.? found that five of the six failures occurred in patients with obstruction at the common canaliculus. Postoperative nasal endoscopy demonstrated an ostium that was closed or hardly identifiable. They concluded that sufficient tearftow through the OCR site is necessary to keep the ostium patent. These two patients whose external and intranasal OCRs were both unsuccessful are now considered candidates for CDCR with Jones tube placement, which is also done with the endoscope to ensure proper intranasal positioning of the tube. Silicone rubber tubing, placed at the time of surgery in all 12 patients, was intended to stent the lacrimal system and assure a minimum diameter aperture between the sac and nasal cavity. There is some evidence that silicone rubber tubing increases the incidence of OCR failure by inciting granulomatous inflammation at the internal ostium.! Such a cause of failure in the cases described is unlikely. On the other hand, adverse reaction to the silicone rubber tubing was clearly evident in another patient in whom epiphora recurred 4 weeks after surgery. Nasal endoscopy revealed granulation tissue surrounding the silicone rubber tubing at the internal ostium. Symptoms did not improve with the use of oral and topical steriods. The tubing was removed 6 weeks postoperatively and epiphora permanently resolved. Despite the best efforts to create and maintain patency of a large intranasal opening into the lacrimal sac, this ostium tends to close through either fibrosis or the natural healing process of granulation tissue formation and re-epithelialization. In a review of 22 successful external OCRs, Bumsted et a1. 9 found no statistical correlation between the size of the surgical anastomosis and the size of the final size of the healed intranasal ostium. The mean diameter of the healed ostium was 1.8 mm, representing an area only 2% that of the initial anastomosis. In the group of patients who underwent endoscopic revision OCR presented in this report, there was a wide variation in the diameter of the healed ostia (Figs. 4, 5, and 6), ranging from approximately I to 4 mm. The exact location of the smallest openings in the lateral nasal wall were often not apparent until fluorescein dye was instilled in the eye. However, even the smallest ostia-once healed and patent-have continued to provide good lacrimal drainage. The described technique for endoscopic revision OCR does not incorporate mucosal flaps, a technique commonly used for external OCR. Suturing of adjacent flaps of lacrimal and nasal mucosa should theoretically
provide a patent epithelial-lined tract for tear drainage. In practice, the importance of such flaps is doubtful, as indicated by Becker, 10 who reported a 92.5% success rate for series of 41 external DCRs performed using stents without mucosal flaps. These results are comparable to the reported success rates of 85% to 97% for the traditional external OCR using flaps.6.11.12 Other intranasal approaches have recently been described for the treatment of lacrimal obstruction, including endoscopic primary OCR 13 and microscopic primary DCR. 14 Unlike the endoscope, the operating microscope allows for binocular vision and the use of both hands for operative manipulations; however, visualization around corners, such as into the sac interior, is not possible. Microscopic OCR appears to be a successful technique for those surgeons who use the microscope routinely for intranasal sinus surgery. For the larger numbers of surgeons who are trained in the techniques of endoscopic sinus surgery, though, the endoscopic approach to the lacrimal sac is probably more applicable. A disadvantage of endoscopic revision DCR, compared to external OCR, is the need for meticulous hemostasis. As with all endoscopic nasal surgery, bleeding obscures the surgeon's view through the endoscope and makes the procedure substantially more difficult. Furthermore, such surgery requires specialized training and instrumentation. It is interesting to note that one of the most common complications of endoscopic sinus surgery may be inadvertent injury to the nasolacrimal duct. 15 The endoscopist who is skilled in lacrimal surgery should be better able to treat this complication if it does arise. In conclusion, endoscopic revision OCR appears to be a safe, effective treatment for the difficult patient who manifests recurrent lacrimal obstruction after externalOCR.
REFERENCES I. Toli A. Nuovo metoda conservatore di cura radicale delle supporazioni chroniche del sacco lacrimale. Clin Med 1904;10: 385-9. 2. Mosher HP. Mosher-Toti operation on the lacrimal sac. Laryngoscope 1921;31 :284. 3. Metson R. The endoscopic approach for revision dacryocystorhinostomy (OCR). Laryngoscope 1990;100:1344-7. 4. Welham RAN, Henderson PH. Results of dacryocystorhinostomy: analysis of causes for failure. Trans Ophthalmol Soc U K
1913;93:601-9. 5. Allen KM. Berlin Al, Levine HL. Intranasal endoscopic analysis of dacryocystorhinostomy failure. Ophthalmic Plast Reconstr Surg 1988;4:143-5.
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6. Pico G. A modified technique of external dacryocystorhinostomy. Am J Ophthalmol 1971;72:679-90. 7. Van Deenen WL. Lamers WPMA. Pasmans-Woudstra TC. Berg JP. An unconventional view of dacryocystorhinostomy. Documenta Ophthalmol 1989;72:225-33. 8. Allen K. Berlin AJ. Dacryocystorhinostomy failure: association with nasolacrimal silastic intubation. Ophthalmic Surg 1989;20: 486-9. 9. Bumsted RM, Linberg JV. Anderson RL. Barreras R. External dacryocystorhinostomy: a prospective study comparing the size of the operative and healed ostium. Arch Otolaryngol 1982; 108:407-10. 10. Becker BB. Dacryocystorhinostomy without flaps. Ophthalmic Surg 1988;19:419-27.
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II. McLachlan DL. Shannon GM. Flanagan JC. Results of dacryocystorhinostomy: analysis of reoperations. Ophthalmic Surg 1980;II :427-30. 12. Welham RA. Wulc AE. Management of unsuccessful lacrimal surgery. Br J Ophthalmol 1987;71:152-7. 13. McDonagh M. Meiring JH. Endoscopic transnasal dacryocystorhinostomy. J Laryngol Otol 1989;103:585-7. 14. Heermann J. Neues D. Intranasal microsurgery of all paranasal sinuses. the septum. and the lacrimal sac with hypotensive anesthesia. Ann Otol Rhinol Laryngol 1986;95:631-8. 15. Serdahl CL. Berris CEoChole RA. Nasolacrimal duct obstruction after endoscopic sinus surgery. Arch Ophthalmol 1990;108: 391-2.
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Intranasal access to the lacrimal drainage system has been greatly enhanced with the advent of endoscopic nasal surgery. This technique has been used for the treatment of recurrent lacrimal obstNctlon after failed extemal dacryocystorhinostomy (DCRI In 12 patients. Improved Intranasal visualization with the endoscope allOWed easy Iden· tlflcatlon and opening of the lacrimal sac. with no need for a skin Incision. ObstNctlng Intranasal pathology, Including adhesions from previous DCR, an enlarged middle turbinate, and ethmoid sinusdisease, was readily Identified and corrected. Therewere no Intraoperative complications. Lacrimal obstNctlon was completely relieved In nine of 12 patients (75%), With a followup of 7 to 25 months. Endoscopic revision OCR should be considered In patients with recurrent epiphora after external OCR. (OTOLARVNGOL HEAD NECK SURG 1991;104:473.)
Since Toti'sl original description of the dacryocystorhinostomy (OCR) in 1904, most surgery for relief of lacrimal obstruction has been performed through an external incision. Intranasal approaches to the lacrimal sac that avoid a skin incision are inherently limited by poor visibility within the narrow confines of the superior nasal cavity. Even Mosher," who first described an intranasal approach for lacrimal obstruction in 1921, eventually abandoned this procedure in favor of a combined external and intranasal approach. Surgical access throughout the nasal cavity has been greatly enhanced by the development of endoscopic nasal surgery. Small-diameter endoscopes with angled fields of view provide excellent intranasal visualization, enabling the surgeon to identify and open the lacrimal sac with relative ease from inside the nasal cavity. This report describes recent experiences with endoscopic nasal instrumentation for the treatment of lacrimal obstruction.
METHODS AND MATERIAU Lacrimal obstruction was the indication for surgery in 20 of the first 200 patients on whom I performed endoscopic intranasal surgery between April 1987 and August 1990. A total of 24 separate procedures (Table
From the Department of Otology and Laryngology. Harvard Medical School. and the Massachusetts Eye and Ear Infirmary. Presented at the Annual Meeting of the American Academy of Otolaryngology-Head and Neck Surgery, San Diego, Calif., Sept. 9-13. 1990. Received for publication Sept. II. 1990; accepted Nov. 14. 1990. Reprint requests: Ralph Merson, MD. Zero Emerson Place. Boston. MA02114.
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I) for relief of lacrimal obstruction were performed on these patients, including 15 revision DCRs, six con. junctivodacryocystorhinostomies (COCRs) with Jones tube placement, two primary DCRs, and one anterior ethmoidectomy. This report details the results of the first 13 endoscopic revision OCRs, which were performed on the 12 patients who have had a minimum 9-month followup. There were nine women and three men, ranging in age from 28 to 79 years. All patients were diagnosed as having lacrimal obstruction distal to the common canaliculus by their referring ophthalmologist. Presenting symptoms were epiphora in nine patients and recurrent dacryocystitis in three. These symptoms had not been relieved by at least one previous external OCR in all patients. Five patients had two or more unsuccessful external OCRs on the affected eye. The length of time between the last external OCR and the endoscopic OCR ranged from 3 months to 4 years. Thirteen secondary procedures were performed at the time of endoscopic revision OCR in order to enhance surgical exposure of the sac, remove accompanying sinus disease, or decrease the likelihood of postoperative adhesions (Table 2). The middle turbinate was resected when it was enlarged or the lacrimal sac extended beneath the anterior edge of turbinate (Fig. I). Septoplasty was performed to correct a deviation that precluded adequate endoscopic visualization of the lateral nasal wall. Such a deviation usually involved the perpendicular plate of ethmoid bone. A straight septum also allowed for easier examination and cleaning of the surgical site postoperatively. Anterior ethmoidectomy was performed to remove middle meatus adhesions from previous surgery and open agger nasi cells located in the region of the lacrimal sac. In one patient with
473
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474 MElSON
Fig. 1. View of the right lateral nasal wall demonstrates the relationship of the lacrimal sac and nasolacrimal duct to the turbinates. Note how a portion of the sac may extend beneath the middle turbinate, requiring turbinate resection for adequate exposure.
Table 1. Endoscopic procedures performed for relief of lacrimal obstruction in 20 patients Procedure
N
extensive sinusitis, a posterior ethmoidectomy and middle meatus maxillary antrostomy were also performed.
Revision OCR COCR with Jones tube Primary OCR Anterior ethmoidectomy
15
Operative Procedure
6 2 1
OCR. Dacryocystorhinostomy; CoCR. conjunctivodacryocystorhinoslamias.
Table 2. secondary procedures performed during 13 endoscopic revision DCRs Procedure
N
Middle turbinate resection Septoplasty Anterior ethmoidectomy Posterior ethmoidectomy Maxillary antrostomy
7 4
3 1 1
The technique of endoscopic revision OCR surgery has been described in detail elsewhere.' The surgery is performed as a team effort, using skills of both the otolaryngologist, who performs the endoscopic intranasal procedure, and the ophthalmologist, who passes the lacrimal probes through the canaliculi into the sac to direct tissue removal. The entire procedure is performed with a video camera attached to a nasal endoscope, so that both surgeons can simultaneously observe intranasal manipulations on a video monitor. The lacrimal sac is located along the superior aspect of the lateral nasal wall, just anterior to the middle turbinate (Fig. I). A lacrimal probe is passed through a canaliculus and directed medially into the obstructed sac, where it is seen to tent the mucosa of the nasal
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Volume 104 Number 4 April 1991
Endoscopic surgery for lacrimal obstruction
Fig. 2. Endoscopic view of left nasal cavHy demonstrates a pair of slilcone rubber catheters passing through the lateral nasal wall (o"ow) Into the lacrimal sac. These catheters are Introduced through the canaliculi (see Fig. 3) to serve as a stent during the healing period. The nasal septum (5) and remaining posterior portion of resected middle turbinate (T) are also shown. Fig. 3. The extranasal course of the silicone rubber catheters shown In Fig. 2 is demonstrated In this photograph of the left eye at the same patient. The tub ing (o"ow). wh ich serves as a stent during the healing pe riod. posses from the canaliculi through the lacrimal sac and Into nasal cavity. where it Is tied to form a continuous loop. Fig. 4. Endoscop ic view of same patient as shown In Fig, 2 after silicone rubber catheters have been removed, Yellow color along lateral nasal wall demonstrates free-flow of fluorescein dye from eye into nose through healed ostium ianow). AIl opening Into the ethmoid sinus is seen In the center of the field. just lateral to the middle turbinate remnant (Photograph reprint with permission from Laryngoscope 1990;100:cover).
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FIg. 5. Endoscopic view of right lateral nasal wall shows ftow of ftuoresceln dye through the surgical ostium (offOWS) Into the nose. The varlatton In sizes of healed ostia Is demonstrated by comparison of this relatively large lacrimal opening with the small one shown In Fig. 4. Prominent structures seen In the center of the figure are openings Into the ethmoid sinusesIn this patient. who has undergone an ethmoldectomy and middle turbinate resection. Nasal septum (5). FIg. 6. View of left nasal cavity demonstrates flow of ftuoresceln dye through ostium (Offow) onto lateral nasal wall and turbinate. The anterior aspect of turbinate has been resected. A hole Is seen, which leads to an air cell within the turbinate (concha bullosa). Nasal septum (5).
wall. Using a 0- or 30-degree nasal endoscope for visualization, a sickle knife is used to make a curvilinear incision in the nasal mucosa, approximately I-em anterior to the underlying probe tip. A mucosal flap is elevated posteriorly and removed with a straight Blakesley forceps. Frequently, there is additional scar tissue that needs to be removed to enter the sac interior. Once the sac has been entered, the lacrimal probe will be exposed. The intranasal opening is deepened with an angled Blakesley forceps (Karl Storz Endoscopy, Culver City, Calif.) directed laterally. The surgeon must be careful to remove only tissue immediately surrounding the probe. Direct visualization into the sac can often be achieved at this point with a 70-degree endoscope. Once the intranasal opening has been sufficiently enlarged to a diameter of approximately 10 mm, the lacrimal probes should pass freely into the nose from both the superior and inferior canaliculi. The lacrimal probe is then replaced by silicone rubber tubing that has its ends stented over a rigid wire (Guibor Canaliculus Intubation Set, Concept Inc., Largo, Fla.). The ends of the tubing are grasped with a forceps and guided out of the nose. They are tied and trimmed so
that the knot lies within the nasal cavity. The tubing thus forms a continuous loop, which passes through the intranasal ostium and is unlikely to become dislodged until it is removed in 2 to 6 months (Figs. 2 and 3). Unless bleeding is a problem or a septoplasty has been performed, no nasal packing is used. RESULTS
Endoscopic revision OCR successfully relieved all symptoms of lacrimal obstruction in nine of 12 patients (75%), with a followup ranging from 7 to 25 months. There were no intraoperative complications. Lacrimal tract patency was verified by endoscopic visualization of fluorescein dye flowing from the eye into the nose through the newly created internal ostium (Figs. 4, 5, and 6). The first of three surgical failures involved a 40-yearold man who had undergone three previous unsuccessful external DCRs for recurrent dacryocystitis. The endoscopic revision OCR resulted in new adhesions between the lateral nasal wall and turbinate, with a recurrence of the dacryocystitis. A second endoscopic revision DCR was performed 9 months later, which included
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middle turbinate resection and septoplasty to correct an ipsilateral septal deviation. Three months after surgery, endoscopic examination revealed a patent internal ostium, with flow of fluorescein dye around the silicone rubber stents and no new adhesions. He has no symptoms of epiphora or dacryocystitis. The second patient to have unsuccessful endoscopic revision OCR was a 66-year-old woman in whom recurrent epiphora developed 2 months after an external OCR. Endoscopic examination revealed a dense scar band extending from the middle turbinate to the lateral nasal wall. She underwent an endoscopic revision OCR with lysis of adhesions. Endoscopic examinations revealed gradual closure of the internal ostium from an initial diameter of 10 mm to a tight stenosis around the silicone rubber tubing. Epiphora had returned within 2 months. Complete closure of the ostium occurred soon after the tubing was removed. The last surgical failure occurred in a 62-year-old woman who had two previous external OCRs, with subsequent return of her epiphora. Four months after her last procedure she underwent an endoscopic revision OCR, with lysis of adhesions between the nasal septum and lateral nasal wall. She had relief of her epiphora for only 22 days. New intranasal adhesions were visible with the endoscope. The internal ostium closed 3 weeks after removal of the silicone rubber stents. Eight months later, she underwent a second endoscopic revision OCR. Middle turbinate resection and septoplasty were performed concurrently. No new adhesions were noted; however, epiphora returned within 2 weeks as the OCR drainage site quickly stenosed. The silicone rubber stents were removed after 4 months and the small internal ostium closed. Postoperative complications other than recurrent lacrimal obstruction involved one patient with epistaxis from a bleeding site along the cut edge of resected middle turbinate and another with a canalicular laceration from the silicone rubber tubing having been tied too tightly within the nose. The epistaxis occurred on the fifth postoperative day and was controlled with anterior nasal packing. The laceration was noted 3 weeks after surgery and healed once the tubing was removed. Both patients obtained complete relief of their epiphora from the endoscopic OCR.
DISCUSSION The advent of endoscopic nasal surgery has greatly enhanced intranasal access to paranasal structures, including the sinuses and lacrimal sac. Endoscopic revision OCR enables the sac to be safely reopened under direct visualization, even in the presence of fibrosis from previous surgery. Intranasal pathology contribut-
ing to OCR failure, such as postoperative adhesions or an enlarged middle turbinate, can be readily identified and corrected with the endoscopic instrumentation. This approach also avoids a skin incision in a patient who has already been subjected to an external approach that has failed. There were no intraoperative complications in 13 surgical procedures performed on 12 patients. Postoperative complications included epistaxis from an edge of resected turbinate in one patient and a canalicular laceration from an overly tight silicone rubber stent in another. Both conditions were easily remedied and did not interfere with the successful surgical outcomes. Endoscopic revision OCR led to complete relief of lacrimal obstruction in nine of 12 patients, for a success rate of 75%. These results are comparable to those of Welham and Henderson," who reported an 83% success rate for revision OCRs performed through a repeat external approach. The first of three surgical failures was considered the result of obstructing postoperative adhesions. A second endoscopic procedure with middle turbinate resection and septoplasty has led to a resolution of symptoms, although followup has been only 3 months. Inadvertent damage to the mucosa of the turbinate or adjacent deviated nasal septum during previous OCR surgery appeared to be the cause of obstructing adhesions in six of the 12 patients undergoing endoscopic revision DCR. These findings are consistent with reports showing the most frequent cause of external OCR failure to be membranous occlusion of the surgical internal ostium created between the lacrimal sac and nasal cavity.t" Middle turbinate resection is considered an important step in the prevention of postoperative adhesions. Its resection is recommended whenever the surgical ostium into the sac extends beneath the turbinate or the turbinate is enlarged, such as from mucosal hypertrophy or a concha bullosa (air cell within the turbinate bone). It is critical to remove enough turbinate to provide good exposure to the sac and ensure that the edges of sac mucosa are not in proximity to the edges of resected turbinate. Similarly, a septoplasty may be necessary to prevent obstructing postoperative adhesions between the opened sac and damaged mucosa overlying a deviated nasal septum. The other two patients who failed endoscopic revision surgery also had membranous obstruction of the surgical ostium, although not by adhesions. In these cases, re-epithelialization and fibrosis within the ostia and sac led to closure of the mucosal opening around the silicone rubber stents. When the stents were removed, the ostia closed completely. One patient underwent a second endoscopic revision DCR that also failed sim-
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OtolaryngologyHead and Neck Surgery
METSON
ilarly. A possible explanation for surgical failure in these two cases in unrecognized canalicular obstruction. In a series of 21 external DCRs, Van Deenen et al.? found that five of the six failures occurred in patients with obstruction at the common canaliculus. Postoperative nasal endoscopy demonstrated an ostium that was closed or hardly identifiable. They concluded that sufficient tearftow through the OCR site is necessary to keep the ostium patent. These two patients whose external and intranasal OCRs were both unsuccessful are now considered candidates for CDCR with Jones tube placement, which is also done with the endoscope to ensure proper intranasal positioning of the tube. Silicone rubber tubing, placed at the time of surgery in all 12 patients, was intended to stent the lacrimal system and assure a minimum diameter aperture between the sac and nasal cavity. There is some evidence that silicone rubber tubing increases the incidence of OCR failure by inciting granulomatous inflammation at the internal ostium.! Such a cause of failure in the cases described is unlikely. On the other hand, adverse reaction to the silicone rubber tubing was clearly evident in another patient in whom epiphora recurred 4 weeks after surgery. Nasal endoscopy revealed granulation tissue surrounding the silicone rubber tubing at the internal ostium. Symptoms did not improve with the use of oral and topical steriods. The tubing was removed 6 weeks postoperatively and epiphora permanently resolved. Despite the best efforts to create and maintain patency of a large intranasal opening into the lacrimal sac, this ostium tends to close through either fibrosis or the natural healing process of granulation tissue formation and re-epithelialization. In a review of 22 successful external OCRs, Bumsted et a1. 9 found no statistical correlation between the size of the surgical anastomosis and the size of the final size of the healed intranasal ostium. The mean diameter of the healed ostium was 1.8 mm, representing an area only 2% that of the initial anastomosis. In the group of patients who underwent endoscopic revision OCR presented in this report, there was a wide variation in the diameter of the healed ostia (Figs. 4, 5, and 6), ranging from approximately I to 4 mm. The exact location of the smallest openings in the lateral nasal wall were often not apparent until fluorescein dye was instilled in the eye. However, even the smallest ostia-once healed and patent-have continued to provide good lacrimal drainage. The described technique for endoscopic revision OCR does not incorporate mucosal flaps, a technique commonly used for external OCR. Suturing of adjacent flaps of lacrimal and nasal mucosa should theoretically
provide a patent epithelial-lined tract for tear drainage. In practice, the importance of such flaps is doubtful, as indicated by Becker, 10 who reported a 92.5% success rate for series of 41 external DCRs performed using stents without mucosal flaps. These results are comparable to the reported success rates of 85% to 97% for the traditional external OCR using flaps.6.11.12 Other intranasal approaches have recently been described for the treatment of lacrimal obstruction, including endoscopic primary OCR 13 and microscopic primary DCR. 14 Unlike the endoscope, the operating microscope allows for binocular vision and the use of both hands for operative manipulations; however, visualization around corners, such as into the sac interior, is not possible. Microscopic OCR appears to be a successful technique for those surgeons who use the microscope routinely for intranasal sinus surgery. For the larger numbers of surgeons who are trained in the techniques of endoscopic sinus surgery, though, the endoscopic approach to the lacrimal sac is probably more applicable. A disadvantage of endoscopic revision DCR, compared to external OCR, is the need for meticulous hemostasis. As with all endoscopic nasal surgery, bleeding obscures the surgeon's view through the endoscope and makes the procedure substantially more difficult. Furthermore, such surgery requires specialized training and instrumentation. It is interesting to note that one of the most common complications of endoscopic sinus surgery may be inadvertent injury to the nasolacrimal duct. 15 The endoscopist who is skilled in lacrimal surgery should be better able to treat this complication if it does arise. In conclusion, endoscopic revision OCR appears to be a safe, effective treatment for the difficult patient who manifests recurrent lacrimal obstruction after externalOCR.
REFERENCES I. Toli A. Nuovo metoda conservatore di cura radicale delle supporazioni chroniche del sacco lacrimale. Clin Med 1904;10: 385-9. 2. Mosher HP. Mosher-Toti operation on the lacrimal sac. Laryngoscope 1921;31 :284. 3. Metson R. The endoscopic approach for revision dacryocystorhinostomy (OCR). Laryngoscope 1990;100:1344-7. 4. Welham RAN, Henderson PH. Results of dacryocystorhinostomy: analysis of causes for failure. Trans Ophthalmol Soc U K
1913;93:601-9. 5. Allen KM. Berlin Al, Levine HL. Intranasal endoscopic analysis of dacryocystorhinostomy failure. Ophthalmic Plast Reconstr Surg 1988;4:143-5.
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Volume 104 Number 4 April 1991
Endoscopic surgery for lacrimal obstruction
6. Pico G. A modified technique of external dacryocystorhinostomy. Am J Ophthalmol 1971;72:679-90. 7. Van Deenen WL. Lamers WPMA. Pasmans-Woudstra TC. Berg JP. An unconventional view of dacryocystorhinostomy. Documenta Ophthalmol 1989;72:225-33. 8. Allen K. Berlin AJ. Dacryocystorhinostomy failure: association with nasolacrimal silastic intubation. Ophthalmic Surg 1989;20: 486-9. 9. Bumsted RM, Linberg JV. Anderson RL. Barreras R. External dacryocystorhinostomy: a prospective study comparing the size of the operative and healed ostium. Arch Otolaryngol 1982; 108:407-10. 10. Becker BB. Dacryocystorhinostomy without flaps. Ophthalmic Surg 1988;19:419-27.
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II. McLachlan DL. Shannon GM. Flanagan JC. Results of dacryocystorhinostomy: analysis of reoperations. Ophthalmic Surg 1980;II :427-30. 12. Welham RA. Wulc AE. Management of unsuccessful lacrimal surgery. Br J Ophthalmol 1987;71:152-7. 13. McDonagh M. Meiring JH. Endoscopic transnasal dacryocystorhinostomy. J Laryngol Otol 1989;103:585-7. 14. Heermann J. Neues D. Intranasal microsurgery of all paranasal sinuses. the septum. and the lacrimal sac with hypotensive anesthesia. Ann Otol Rhinol Laryngol 1986;95:631-8. 15. Serdahl CL. Berris CEoChole RA. Nasolacrimal duct obstruction after endoscopic sinus surgery. Arch Ophthalmol 1990;108: 391-2.
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