Original Investigation
Outcomes of Endonasal Dacryocystorhinostomy Without Mucosal Flap Preservation Nickisa Hodgson, M.D. M.A.S.*, Emily Bratton, M.D.†, Katherine Whipple, M.D.*, Ayelet Priel, M.D.*, Sang-Rog Oh, M.D.*, Robert G. Fante, M.D. †‡, Don O. Kikkawa, M.D. F.A.C.S.*, and Bobby S. Korn, M.D. Ph.D. F.A.C.S.* *Division of Ophthalmic Plastic and Reconstructive Surgery, Shiley Eye Center, Department of Ophthalmology, University of California, San Diego; †Department of Ophthalmology, Rocky Mountain Lions Eye Institute, University of Colorado School of Medicine, Aurora; and ‡Fante Eye and Face Center, Denver, Colorado, U.S.A.
Purpose: Dacryocystorhinostomy (DCR) is the standard procedure for the treatment of acquired nasolacrimal duct obstruction (NLDO) that can be performed through an external or endonasal approach. Both techniques create a fistula from the lacrimal sac into the nasal cavity via a bony osteotomy. Historically, external DCR has been considered the gold standard; however, recent reports suggest endonasal DCR is an effective alternative. There are numerous variations of endonasal DCR described in the literature that report variable success rates. The purpose of this study is to describe the approach and success rate with endonasal DCR in which nasal mucosa, bone, and lacrimal sac mucosa are sequentially removed. Methods: The authors retrospectively reviewed cases of endonasal DCR from 2004 to 2011 from 2 institutions (the University of California, San Diego, California, and the Fante Eye and Face Center in Denver, Colorado, U.S.A.). Patients with a history of epiphora and NLDO confirmed with punctal irrigation were included. Exclusion criteria were the presence of canalicular obstruction, history of orbital trauma, and prior DCR surgery. Success was defined as subjective relief of epiphora and confirmation of ostium patency with irrigation. Results: A total of 324 patients (74 men, 250 women; mean age 59.3) encompassing 407 endonasal DCR cases were included in the study. The total case success rate was 92.2% with an average follow-up time of 91.5 days. Revision surgery was performed in 7 of the failed cases and resulted in success in 6 of these cases. Conclusions: Endonasal DCR is a simple and effective approach to surgically treat NLDO and offers success rates comparable with external DCR. (Ophthal Plast Reconstr Surg 2014;30:24–27)
D
acryocystorhinostomy (DCR) is the procedure of choice for definitive management of acquired nasolacrimal duct obstruction (NLDO). DCR creates a fistula between the lacrimal Accepted for publication July 18, 2013. Presented at the Academy of Ophthalmic Plastic and Reconstructive Surgery Meeting, October 2010, Chicago, IL. Supported by a grant from the Research to Prevent Blindness. The authors have no financial or conflicts of interest to disclose. Address correspondence and reprint requests to Bobby S. Korn, M.D. Ph.D. F.A.C.S., Department of Ophthalmology, Division of Ophthalmic Plastic and Reconstructive Surgery, Shiley Eye Center, University of California San Diego, 9500 Gilman Dr., No. 0946 La Jolla, CA 92093-0946. E-mail: [email protected] DOI: 10.1097/IOP.0b013e3182a7502e
24
sac and the nasal cavity to ameliorate symptomatic epiphora.1 The external, transcutaneous approach for DCR is still considered by many as the gold standard because of its efficacy. There are multiple published studies documenting the success rates of external DCR (Ext-DCR), which vary from 80% to 95%.2–4 With the improvement in nasal endoscopy, endonasal DCR has gained popularity. Many variations of endonasal DCR have been described since McDonogh and Meiring5 conducted one of the first clinical studies of endoscopic endonasal DCR in 1989. Variations include the use of adjunct equipment including retinal light pipes, laser,6 drills,7 and a nonendoscopic endonasal technique.8 Compared with the external approach, there is little consensus for the role of the nasal mucosal flap in endonasal DCR. Tsirbas9,10 addressed this question in his description of endonasal DCR with preservation of a nasal mucosal flap; however, not all surgeons routinely preserve nasal mucosal flaps during endonasal DCR. In this study, these clinical outcomes were reported retrospectively and describe a simplified endonasal approach in which the nasal mucosa, lacrimal bone, and lacrimal sac mucosa are sequentially removed without preservation of flaps. This technique also eliminates the need for adjunct instrumentation such as the retinal light pipe, laser, and surgical drills.
METHODS Medical records of patients were reviewed retrospectively who underwent primary endonasal DCR from 2004 to 2011 performed at University of California, San Diego, California, U.S.A., and the Fante Eye and Face Center in Denver, Colorado, U.S.A. Patients with symptomatic epiphora and NLDO confirmed by irrigation were included in the study. Patients with prior DCR surgery, history of orbital or nasal trauma, lacrimal system neoplasms, and canalicular stenosis were excluded. Institutional review board approval was obtained from the Human Research Protections Program at both institutions. Patients received a complete external and nasolacrimal system examination, including probing and irrigation. Patients were queried subjectively for severity of epiphora and symptoms of acute or chronic dacryocystitis. Three attending surgeons (B.S.K., D.O.K., R.G.F.) performed all operations. After surgery, each patient was assessed for subjective relief of epiphora, patency on nasal irrigation, and complications at 1 week, 1 month, 3 months, and 6 months postoperatively. If symptomatic relief of epiphora was obtained at the 3-month postoperative visit and irrigation proved patency, the stent was removed. Surgical Technique. Video 1 demonstrates this endonasal DCR technique. Endonasal DCR under general anesthesia was routinely performed. Nasal decongestion is achieved either intraoperatively with neurosurgical cottonoids soaked in a 50/50 mixture of 4% lidocaine
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FIG. 1. Endonasal view showing middle turbinate (white arrow) and Bowman probe through lacrimal bone (yellow arrow)
Outcomes of Endonasal Dacryocystorhinostomy
FIG. 3. Endonasal view showing exposure to the level of the internal common punctum (yellow arrow). lacrimal sac mucosa intact. Further removal of nasal mucosa and bone are extended vertically and laterally to exposure approximately 10 mm of the lacrimal sac (Fig. 2A,B). Bone is removed superiorly to the level of the internal common punctum that is confirmed on opening of the lacrimal sac (Fig. 3). In patients with thicker, more difficult to remove bone superiorly, an osteotome or 45° Kerrison rongeur can be used to facilitate bone removal. Once the lacrimal sac has been fully exposed, the lacrimal sac mucosa is then fenestrated using a disposable sickle knife (Surgistar, Vista, CA, U.S.A.) from its most superior to inferior position. Horizontal relaxing incisions are then performed, and the posterior aspect of the lacrimal sac is then removed in all patients (Video 2). The lacrimal sac mucosa is then sent for routine histopathology. Silicone stents are placed in the upper and lower puncta and retrieved through the bony osteotomy endonasally. In select cases where there is exuberant intraoperative bleeding and/or in patients taking anticoagulants, topical fibrin glue can be applied onto the osteotomy site for maximal hemostasis (Evicel, Ethicon Inc, Somerville, NJ, U.S.A.). In all cases, a gelfoam sponge is soaked in triamcinolone acetonide 40 mg/ml and placed at the osteotomy site. The stent is then secured to the lateral vestibule of the naris. Posteroperatively, patients are given topical antibiotic-steroid drops and steroid nasal spray for 2 weeks.
RESULTS
FIG. 2. A, Endonasal view showing bone and nasal mucosa removed as a single unit. B, Lacrimal sac as highlighted in yellow. and oxymetazoline or epinephrine 1:10,000 packed in the middle meatus. The initial osteotomy site is then infiltrated with local anesthetic (1% lidocaine with 1:200,000 epinephrine with 0.375% bupivacaine). Endoscopy is then performed using a 4-mm-wide 30° rigid endoscope (Stryker Surgical, Kalamazoo, MI, U.S.A.). The middle turbinate is used as a surgical landmark, as the lacrimal sac is located just anterior to the turbinate (Fig. 1, white arrow). In lieu of a retinal light pipe, a no. 1 Bowman probe can be passed from the superior canaliculus through the lacrimal bone to identify the region for initial bone removal (Figure1, yellow arrow). In patients with thicker lacrimal bone, a no. 4 Bowman probe can be utilized. A 4-mm Kerrison rongeur is used to create the initial osteotomy. The rongeur is used to remove nasal mucosa and bone overlying the lacrimal fossa piecemeal while leaving the
The charts of 324 patients (74 men, 250 women; mean age, 59.3, SD 17.1), who underwent 407 endonasal DCR surgeries, were reviewed. Demographics of the study population are summarized in Table 1. Two hundred ten surgeries were performed on the right side, 197 were performed on the left, and 83 cases were bilateral. Patients were evaluated postoperatively at 1 week, 1 month, and every 3 months thereafter. Silicone stent removal was considered on a case-by-case basis at 3 months after the operation with the average time to stent removal at 88 days (range 7–906 days, SD 74, interquartile range [IQR] 60–120) (Table 2). The average total postoperative followup time was 91.5 days (range 33–2130 days, SD 308.4, IQR 97–240). Surgery was considered successful if patients reported resolution of epiphora and had no evidence of reflux on nasolacrimal irrigation. Partial success was defined as improvement in tearing and/or partial patency on nasal irrigation. Failure was defined as persistent tearing and/or complete reflux on nasal irrigation postoperatively. Success rates are summarized in Table 2. Success was achieved in 375 cases (92.2%). Of the successful cases, 365 cases (89.7%) were complete successes, and 10 cases (2.5%) were partial successes. Only 32 cases (7.8%) were considered failures. Endonasal revision was performed in 7 failed cases, and 6 (85.7%) of these revisions were successful. In each case, fibrosis over the bony osteotomy was noted. Three of the 7 failures also contained strictures of the lateral nasal wall to a
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TABLE 1. Demographics of all 324 patients who underwent 407 endonasal dacryocystorhinostomy surgeries Age (y) (mean ± SD) Gender [N (%)] Male Female Medical history [N (%)] Acute dacryocystitis Chronic dacryocystitis Radioactive iodine Stent removal (days) (mean ± SD), IQR Follow-up time (days) (mean ± SD), IQR
59.3 ± 17.1 74 (22.8) 250 (77.2) 27 (8.3) 93 (28.7) 7 (2.1) 88 ± 74, 60–120 91.5 ± 308.4, 97–240
IQR, interquartile range; SD, standard deviation.
TABLE 2. Success rates of endoscopic dacryocystorhinostomy No. cases
407
Success [N (%)] Partial success [N (%)] Total success [N (%)] Failure [N (%)]
365 (89.7) 10 (2.5) 375 (92.2) 32 (7.8)
deviated nasal septum. Mucosal inflammation was not observed in any of the failures. In all revisions, residual bone removal was performed, and the osteotomy site was treated with topical 0.04% mitomycin-c for 2 minutes, and silicone stents were placed for a minimum of 6 months. Two patients developed complications, including 1 case of canaliculitis and 1 case of preseptal cellulitis, both of which resolved with antibiotics. There were no cases of postoperative retrobulbar hemorrhage, inadvertent orbital entry, or cerebrospinal fluid leak (CSF).
DISCUSSION In this study, the outcomes of endonasal DCR with sequential removal of nasal mucosa, bone and lacrimal mucosa is described. The success rate of this endonasal DCR approach was 92.2%, which is comparable to the published success rates of external and endonasal DCR.2–4,11,12,15 The advantages of endonasal DCR include the avoidance of a visible scar, minimal disruption of medial canthal structures, decreased operative time,13,14 potential for facial nerve injury, decreased blood loss, lower complication rate, shorter recovery times,15 and patient preference.8 The need for costly equipment and a steep technical learning curve6,16 have been cited as disadvantages of endonasal DCR. This approach is not the first endonasal DCR technique to sacrifice both nasal and lacrimal sac mucosa. Laser-assisted endonasal techniques have success rates ranging from 47% to greater than 90%,14,17 and similar to this mechanical approach, nasal mucosa, lacrimal bone, and lacrimal sac mucosa are removed in a sequential fashion from laser-assisted ablation. Although this is typically well tolerated intranasally, a recent report noted full thickness skin necrosis using the transcanalicular diode laser.18 Presumably, this is from the excessive thermal energy required to penetrate thicker bony and soft tissue structures. This mechanical, endonasal technique theoretically avoids this potential complication by using rongues, and there were no cases of full thickness skin necrosis in this study. Furthermore, surgeons uncomfortable elevating mucosal flaps with a sickle blade or periosteal elevator can apply this DCR technique without the need to elevate and preserve the nasal mucosa. This
26
simplified endonasal technique eliminates the need for mechanical drills, retinal light pipe, diode laser, and time-consuming complex intranasal surgical maneuvers, reducing operative costs. This large study validates the success and low complication rate of mechanical endonasal DCR with sequential nasal mucosa, bone, and lacrimal sac mucosal removal. One benefit of Ext-DCR is that the procedure can be performed under local anesthesia, and in select patients who are unfit for general anesthesia, the external approach should be considered. Less than 1% of all these cases of endonasal DCR were performed under local anesthesia. Although a drill or oscillating blade was not used during endonasal DCR, it was found that intranasal manipulation with the endoscope and ronguers is difficult to completely anesthetize with an ethmoidal block alone and thus, the endonasal DCR procedure is routinely performed under general anesthesia. In all study patients, silicone intubation was performed at the time of surgery. This study was not designed to assess efficacy of silicone stents on patency although this is a controversial subject. To address this, Chong et al.22 recently reported outcomes of endoscopic mechanical DCR with and without silicone intubation. In their study, a randomized clinical trial showed that there is no statistically significant difference between the 2 groups. Chong’s22 report can be used to extrapolate to this study group but a definitive answer would require a prospective study. Endonasal DCR has been criticized for the difficulty in obtaining lacrimal sac biopsy.9,10 Though lacrimal sac neoplasms are rare,19 biopsy is encouraged to rule out neoplasm, and endonasal DCR allows for lacrimal sac biopsy. A lacrimal sac tissue biopsy has been sent routine in virtually all cases of endonasal DCR since 2010. The incidence of complications of endonasal DCR is not high but have been reported to include infection, restenosis, hemorrhage, canalicular erosion, and lacrimal sump syndrome.2,20,21 Serious complications are rare and include CSF leak and damage to the lamina papyracea.19 Of the 324 patients in this study, 2 patients had postoperative infections that resolved with antibiotics. There were no cases of serious complications. This study is the largest to date reporting outcomes of endonasal DCR, reflecting the combination of 3 surgerson in 1 series. Each of the surgeons performed the same technique of endonasal DCR, and the high overall success rate in this study suggests that other surgeons can equally apply this technique. This study is, however, subject to the limitations of retrospective design. In addition, the success was measured at the last follow-up visit rather than at specified time intervals as can be done in a future study. Success was measured by subjective relief of epiphora and patency on irrigation. While patency was not confirmed with fluorescein nasal endoscopy, irrigation was performed on every patient to assess patency of the DCR. Both objectively and subjectively, this success rate included partial successes because these patients noted improvement in tearing after surgery and did not seek additional treatment. Reported success rates for endonasal DCR vary significantly.1 This review of 407 cases of endonasal DCR demonstrated a 92.2% success rate with minimal complications. In summary, endonasal DCR is an effective procedure for the definitive treatment of NLDO and should be considered as an alternative to the external technique.
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
Ophthal Plast Reconstr Surg, Vol. 30, No. 1, 2014
ACKNOWLEDGMENTS We thank Austin Kinney for assistance with data collection. This study was supported by a grant from the Research to Prevent Blindness.
REFERENCES 1. Karim R, Ghabrial R, Lynch T, et al. A comparison of external and endoscopic endonasal dacryocystorhinostomy for acquired nasolacrimal duct obstruction. Clin Ophthalmol 2011;5:979–89. 2. Tarbet KJ, Custer PL. External dacryocystorhinostomy. Surgical success, patient satisfaction, and economic cost. Ophthalmology 1995;102:1065–70. 3. Hanna IT, Powrie S, Rose GE. Open lacrimal surgery: a comparison of admission outcome and complications after planned day case or inpatient management. Br J Ophthalmol 1998;82:392–6. 4. Hartikainen J, Grenman R, Puukka P, et al. Prospective randomized comparison of external dacryocystorhinostomy and endonasal laser dacryocystorhinostomy. Ophthalmology 1998;105:1106–13. 5. McDonogh M, Meiring JH. Endoscopic transnasal dacryocystorhinostomy. J Laryngol Otol 1989;103:585–7. 6. Gonnering RS, Lyon DB, Fisher JC. Endoscopic laser-assisted lacrimal surgery. Am J Ophthalmol 1991;111:152–7. 7. Sham CL, van Hasselt CA. Endoscopic terminal dacryocystorhinostomy. Laryngoscope 2000;110:1045–9. 8. Dolman PJ. Comparison of external dacryocystorhinostomy with nonlaser endonasal dacryocystorhinostomy. Ophthalmology 2003;110:78–84. 9. Tsirbas A, Wormald PJ. Endonasal dacryocystorhinostomy with mucosal flaps. Am J Ophthalmol 2003;135:76–83. 10. Tsirbas A, Wormald PJ. Mechanical endonasal dacryocystorhinostomy with mucosal flaps. Br J Ophthalmol 2003;87:43–7. 11. Hii BW, McNab AA, Friebel JD. A comparison of external and endonasal dacryocystorhinostomy in regard to patient satisfaction and cost. Orbit 2012:31:67–76.
Outcomes of Endonasal Dacryocystorhinostomy
12. Durvasula VS, Gatland DJ. Endoscopic dacryocystorhinostomy: long-term results and evolution of surgical technique. J Laryngol Otol 2004;118:628–32. 13. Woog JJ, Kennedy RH, Custer PL, et al. Endonasal dacryocystorhinostomy: a report by the American Academy of Ophthalmology. Ophthalmology 2001;108:2369–77. 14. Codère F, Denton P, Corona J. Endonasal dacryocystorhinostomy: a modified technique with preservation of the nasal and lacrimal mucosa. Ophthal Plast Reconstr Surg 2010;26:161–4. 15. Hehar SS, Jones NS, Sadiq SA, et al. Endoscopic holmium:YAG laser dacryocystorhinostomy-safe and effective as a day-case procedure. J Laryngol Otol 1997;111:1056–9. 16. Onerci M, Orhan M, Ogretmenoğlu O, et al. Long-term results and reasons for failure of intranasal endoscopic dacryocystorhinostomy. Acta Otolaryngol 2000;120:319–22. 17. Leong SC, Macewen CJ, White PS. A systematic review of outcomes after dacryocystorhinostomy in adults. Am J Rhinol Allergy 2010;24:81–90. 18. Yeniad B, Bilgin LK, Cagatay A, et al. A rare complication after transcanalicular dacryocystorhinostomy: tissue necrosis and nasalcutaneous fistula. Ophthal Plast Reconstr Surg 2011;27:e112–3. 19. Altan-Yaycioglu R, Canan H, Sizmaz S, et al. Nasolacrimal duct obstruction: clinicopathologic analysis of 205 cases. Orbit 2010;29:254–8. 20. Sonkhya N, Mishra P. Endoscopic transnasal dacryocystorhinostomy with nasal mucosal and posterior lacrimal sac flap. J Laryngol Otol 2009;123:320–6. 21. Ben Simon GJ, Joseph J, Lee S, et al. External versus endoscopic dacryocystorhinostomy for acquired nasolacrimal duct obstruction in a tertiary referral center. Ophthalmology 2005;112:1463–8. 22. Chong KK, Lai FH, Ho M, Luk A, Wong BW, Young A. Randomized trial on silicone intubation in endoscopic mechanical dacryocystorhinostomy (send) for primary nasolacrimal duct obstruction. Ophthalmology, 2013;120:2139–45.
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Outcomes of Endonasal Dacryocystorhinostomy Without Mucosal Flap Preservation Nickisa Hodgson, M.D. M.A.S.*, Emily Bratton, M.D.†, Katherine Whipple, M.D.*, Ayelet Priel, M.D.*, Sang-Rog Oh, M.D.*, Robert G. Fante, M.D. †‡, Don O. Kikkawa, M.D. F.A.C.S.*, and Bobby S. Korn, M.D. Ph.D. F.A.C.S.* *Division of Ophthalmic Plastic and Reconstructive Surgery, Shiley Eye Center, Department of Ophthalmology, University of California, San Diego; †Department of Ophthalmology, Rocky Mountain Lions Eye Institute, University of Colorado School of Medicine, Aurora; and ‡Fante Eye and Face Center, Denver, Colorado, U.S.A.
Purpose: Dacryocystorhinostomy (DCR) is the standard procedure for the treatment of acquired nasolacrimal duct obstruction (NLDO) that can be performed through an external or endonasal approach. Both techniques create a fistula from the lacrimal sac into the nasal cavity via a bony osteotomy. Historically, external DCR has been considered the gold standard; however, recent reports suggest endonasal DCR is an effective alternative. There are numerous variations of endonasal DCR described in the literature that report variable success rates. The purpose of this study is to describe the approach and success rate with endonasal DCR in which nasal mucosa, bone, and lacrimal sac mucosa are sequentially removed. Methods: The authors retrospectively reviewed cases of endonasal DCR from 2004 to 2011 from 2 institutions (the University of California, San Diego, California, and the Fante Eye and Face Center in Denver, Colorado, U.S.A.). Patients with a history of epiphora and NLDO confirmed with punctal irrigation were included. Exclusion criteria were the presence of canalicular obstruction, history of orbital trauma, and prior DCR surgery. Success was defined as subjective relief of epiphora and confirmation of ostium patency with irrigation. Results: A total of 324 patients (74 men, 250 women; mean age 59.3) encompassing 407 endonasal DCR cases were included in the study. The total case success rate was 92.2% with an average follow-up time of 91.5 days. Revision surgery was performed in 7 of the failed cases and resulted in success in 6 of these cases. Conclusions: Endonasal DCR is a simple and effective approach to surgically treat NLDO and offers success rates comparable with external DCR. (Ophthal Plast Reconstr Surg 2014;30:24–27)
D
acryocystorhinostomy (DCR) is the procedure of choice for definitive management of acquired nasolacrimal duct obstruction (NLDO). DCR creates a fistula between the lacrimal Accepted for publication July 18, 2013. Presented at the Academy of Ophthalmic Plastic and Reconstructive Surgery Meeting, October 2010, Chicago, IL. Supported by a grant from the Research to Prevent Blindness. The authors have no financial or conflicts of interest to disclose. Address correspondence and reprint requests to Bobby S. Korn, M.D. Ph.D. F.A.C.S., Department of Ophthalmology, Division of Ophthalmic Plastic and Reconstructive Surgery, Shiley Eye Center, University of California San Diego, 9500 Gilman Dr., No. 0946 La Jolla, CA 92093-0946. E-mail: [email protected] DOI: 10.1097/IOP.0b013e3182a7502e
24
sac and the nasal cavity to ameliorate symptomatic epiphora.1 The external, transcutaneous approach for DCR is still considered by many as the gold standard because of its efficacy. There are multiple published studies documenting the success rates of external DCR (Ext-DCR), which vary from 80% to 95%.2–4 With the improvement in nasal endoscopy, endonasal DCR has gained popularity. Many variations of endonasal DCR have been described since McDonogh and Meiring5 conducted one of the first clinical studies of endoscopic endonasal DCR in 1989. Variations include the use of adjunct equipment including retinal light pipes, laser,6 drills,7 and a nonendoscopic endonasal technique.8 Compared with the external approach, there is little consensus for the role of the nasal mucosal flap in endonasal DCR. Tsirbas9,10 addressed this question in his description of endonasal DCR with preservation of a nasal mucosal flap; however, not all surgeons routinely preserve nasal mucosal flaps during endonasal DCR. In this study, these clinical outcomes were reported retrospectively and describe a simplified endonasal approach in which the nasal mucosa, lacrimal bone, and lacrimal sac mucosa are sequentially removed without preservation of flaps. This technique also eliminates the need for adjunct instrumentation such as the retinal light pipe, laser, and surgical drills.
METHODS Medical records of patients were reviewed retrospectively who underwent primary endonasal DCR from 2004 to 2011 performed at University of California, San Diego, California, U.S.A., and the Fante Eye and Face Center in Denver, Colorado, U.S.A. Patients with symptomatic epiphora and NLDO confirmed by irrigation were included in the study. Patients with prior DCR surgery, history of orbital or nasal trauma, lacrimal system neoplasms, and canalicular stenosis were excluded. Institutional review board approval was obtained from the Human Research Protections Program at both institutions. Patients received a complete external and nasolacrimal system examination, including probing and irrigation. Patients were queried subjectively for severity of epiphora and symptoms of acute or chronic dacryocystitis. Three attending surgeons (B.S.K., D.O.K., R.G.F.) performed all operations. After surgery, each patient was assessed for subjective relief of epiphora, patency on nasal irrigation, and complications at 1 week, 1 month, 3 months, and 6 months postoperatively. If symptomatic relief of epiphora was obtained at the 3-month postoperative visit and irrigation proved patency, the stent was removed. Surgical Technique. Video 1 demonstrates this endonasal DCR technique. Endonasal DCR under general anesthesia was routinely performed. Nasal decongestion is achieved either intraoperatively with neurosurgical cottonoids soaked in a 50/50 mixture of 4% lidocaine
Ophthal Plast Reconstr Surg, Vol. 30, No. 1, 2014
Ophthal Plast Reconstr Surg, Vol. 30, No. 1, 2014
FIG. 1. Endonasal view showing middle turbinate (white arrow) and Bowman probe through lacrimal bone (yellow arrow)
Outcomes of Endonasal Dacryocystorhinostomy
FIG. 3. Endonasal view showing exposure to the level of the internal common punctum (yellow arrow). lacrimal sac mucosa intact. Further removal of nasal mucosa and bone are extended vertically and laterally to exposure approximately 10 mm of the lacrimal sac (Fig. 2A,B). Bone is removed superiorly to the level of the internal common punctum that is confirmed on opening of the lacrimal sac (Fig. 3). In patients with thicker, more difficult to remove bone superiorly, an osteotome or 45° Kerrison rongeur can be used to facilitate bone removal. Once the lacrimal sac has been fully exposed, the lacrimal sac mucosa is then fenestrated using a disposable sickle knife (Surgistar, Vista, CA, U.S.A.) from its most superior to inferior position. Horizontal relaxing incisions are then performed, and the posterior aspect of the lacrimal sac is then removed in all patients (Video 2). The lacrimal sac mucosa is then sent for routine histopathology. Silicone stents are placed in the upper and lower puncta and retrieved through the bony osteotomy endonasally. In select cases where there is exuberant intraoperative bleeding and/or in patients taking anticoagulants, topical fibrin glue can be applied onto the osteotomy site for maximal hemostasis (Evicel, Ethicon Inc, Somerville, NJ, U.S.A.). In all cases, a gelfoam sponge is soaked in triamcinolone acetonide 40 mg/ml and placed at the osteotomy site. The stent is then secured to the lateral vestibule of the naris. Posteroperatively, patients are given topical antibiotic-steroid drops and steroid nasal spray for 2 weeks.
RESULTS
FIG. 2. A, Endonasal view showing bone and nasal mucosa removed as a single unit. B, Lacrimal sac as highlighted in yellow. and oxymetazoline or epinephrine 1:10,000 packed in the middle meatus. The initial osteotomy site is then infiltrated with local anesthetic (1% lidocaine with 1:200,000 epinephrine with 0.375% bupivacaine). Endoscopy is then performed using a 4-mm-wide 30° rigid endoscope (Stryker Surgical, Kalamazoo, MI, U.S.A.). The middle turbinate is used as a surgical landmark, as the lacrimal sac is located just anterior to the turbinate (Fig. 1, white arrow). In lieu of a retinal light pipe, a no. 1 Bowman probe can be passed from the superior canaliculus through the lacrimal bone to identify the region for initial bone removal (Figure1, yellow arrow). In patients with thicker lacrimal bone, a no. 4 Bowman probe can be utilized. A 4-mm Kerrison rongeur is used to create the initial osteotomy. The rongeur is used to remove nasal mucosa and bone overlying the lacrimal fossa piecemeal while leaving the
The charts of 324 patients (74 men, 250 women; mean age, 59.3, SD 17.1), who underwent 407 endonasal DCR surgeries, were reviewed. Demographics of the study population are summarized in Table 1. Two hundred ten surgeries were performed on the right side, 197 were performed on the left, and 83 cases were bilateral. Patients were evaluated postoperatively at 1 week, 1 month, and every 3 months thereafter. Silicone stent removal was considered on a case-by-case basis at 3 months after the operation with the average time to stent removal at 88 days (range 7–906 days, SD 74, interquartile range [IQR] 60–120) (Table 2). The average total postoperative followup time was 91.5 days (range 33–2130 days, SD 308.4, IQR 97–240). Surgery was considered successful if patients reported resolution of epiphora and had no evidence of reflux on nasolacrimal irrigation. Partial success was defined as improvement in tearing and/or partial patency on nasal irrigation. Failure was defined as persistent tearing and/or complete reflux on nasal irrigation postoperatively. Success rates are summarized in Table 2. Success was achieved in 375 cases (92.2%). Of the successful cases, 365 cases (89.7%) were complete successes, and 10 cases (2.5%) were partial successes. Only 32 cases (7.8%) were considered failures. Endonasal revision was performed in 7 failed cases, and 6 (85.7%) of these revisions were successful. In each case, fibrosis over the bony osteotomy was noted. Three of the 7 failures also contained strictures of the lateral nasal wall to a
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
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N. Hodgson et al.
TABLE 1. Demographics of all 324 patients who underwent 407 endonasal dacryocystorhinostomy surgeries Age (y) (mean ± SD) Gender [N (%)] Male Female Medical history [N (%)] Acute dacryocystitis Chronic dacryocystitis Radioactive iodine Stent removal (days) (mean ± SD), IQR Follow-up time (days) (mean ± SD), IQR
59.3 ± 17.1 74 (22.8) 250 (77.2) 27 (8.3) 93 (28.7) 7 (2.1) 88 ± 74, 60–120 91.5 ± 308.4, 97–240
IQR, interquartile range; SD, standard deviation.
TABLE 2. Success rates of endoscopic dacryocystorhinostomy No. cases
407
Success [N (%)] Partial success [N (%)] Total success [N (%)] Failure [N (%)]
365 (89.7) 10 (2.5) 375 (92.2) 32 (7.8)
deviated nasal septum. Mucosal inflammation was not observed in any of the failures. In all revisions, residual bone removal was performed, and the osteotomy site was treated with topical 0.04% mitomycin-c for 2 minutes, and silicone stents were placed for a minimum of 6 months. Two patients developed complications, including 1 case of canaliculitis and 1 case of preseptal cellulitis, both of which resolved with antibiotics. There were no cases of postoperative retrobulbar hemorrhage, inadvertent orbital entry, or cerebrospinal fluid leak (CSF).
DISCUSSION In this study, the outcomes of endonasal DCR with sequential removal of nasal mucosa, bone and lacrimal mucosa is described. The success rate of this endonasal DCR approach was 92.2%, which is comparable to the published success rates of external and endonasal DCR.2–4,11,12,15 The advantages of endonasal DCR include the avoidance of a visible scar, minimal disruption of medial canthal structures, decreased operative time,13,14 potential for facial nerve injury, decreased blood loss, lower complication rate, shorter recovery times,15 and patient preference.8 The need for costly equipment and a steep technical learning curve6,16 have been cited as disadvantages of endonasal DCR. This approach is not the first endonasal DCR technique to sacrifice both nasal and lacrimal sac mucosa. Laser-assisted endonasal techniques have success rates ranging from 47% to greater than 90%,14,17 and similar to this mechanical approach, nasal mucosa, lacrimal bone, and lacrimal sac mucosa are removed in a sequential fashion from laser-assisted ablation. Although this is typically well tolerated intranasally, a recent report noted full thickness skin necrosis using the transcanalicular diode laser.18 Presumably, this is from the excessive thermal energy required to penetrate thicker bony and soft tissue structures. This mechanical, endonasal technique theoretically avoids this potential complication by using rongues, and there were no cases of full thickness skin necrosis in this study. Furthermore, surgeons uncomfortable elevating mucosal flaps with a sickle blade or periosteal elevator can apply this DCR technique without the need to elevate and preserve the nasal mucosa. This
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simplified endonasal technique eliminates the need for mechanical drills, retinal light pipe, diode laser, and time-consuming complex intranasal surgical maneuvers, reducing operative costs. This large study validates the success and low complication rate of mechanical endonasal DCR with sequential nasal mucosa, bone, and lacrimal sac mucosal removal. One benefit of Ext-DCR is that the procedure can be performed under local anesthesia, and in select patients who are unfit for general anesthesia, the external approach should be considered. Less than 1% of all these cases of endonasal DCR were performed under local anesthesia. Although a drill or oscillating blade was not used during endonasal DCR, it was found that intranasal manipulation with the endoscope and ronguers is difficult to completely anesthetize with an ethmoidal block alone and thus, the endonasal DCR procedure is routinely performed under general anesthesia. In all study patients, silicone intubation was performed at the time of surgery. This study was not designed to assess efficacy of silicone stents on patency although this is a controversial subject. To address this, Chong et al.22 recently reported outcomes of endoscopic mechanical DCR with and without silicone intubation. In their study, a randomized clinical trial showed that there is no statistically significant difference between the 2 groups. Chong’s22 report can be used to extrapolate to this study group but a definitive answer would require a prospective study. Endonasal DCR has been criticized for the difficulty in obtaining lacrimal sac biopsy.9,10 Though lacrimal sac neoplasms are rare,19 biopsy is encouraged to rule out neoplasm, and endonasal DCR allows for lacrimal sac biopsy. A lacrimal sac tissue biopsy has been sent routine in virtually all cases of endonasal DCR since 2010. The incidence of complications of endonasal DCR is not high but have been reported to include infection, restenosis, hemorrhage, canalicular erosion, and lacrimal sump syndrome.2,20,21 Serious complications are rare and include CSF leak and damage to the lamina papyracea.19 Of the 324 patients in this study, 2 patients had postoperative infections that resolved with antibiotics. There were no cases of serious complications. This study is the largest to date reporting outcomes of endonasal DCR, reflecting the combination of 3 surgerson in 1 series. Each of the surgeons performed the same technique of endonasal DCR, and the high overall success rate in this study suggests that other surgeons can equally apply this technique. This study is, however, subject to the limitations of retrospective design. In addition, the success was measured at the last follow-up visit rather than at specified time intervals as can be done in a future study. Success was measured by subjective relief of epiphora and patency on irrigation. While patency was not confirmed with fluorescein nasal endoscopy, irrigation was performed on every patient to assess patency of the DCR. Both objectively and subjectively, this success rate included partial successes because these patients noted improvement in tearing after surgery and did not seek additional treatment. Reported success rates for endonasal DCR vary significantly.1 This review of 407 cases of endonasal DCR demonstrated a 92.2% success rate with minimal complications. In summary, endonasal DCR is an effective procedure for the definitive treatment of NLDO and should be considered as an alternative to the external technique.
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
Ophthal Plast Reconstr Surg, Vol. 30, No. 1, 2014
ACKNOWLEDGMENTS We thank Austin Kinney for assistance with data collection. This study was supported by a grant from the Research to Prevent Blindness.
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© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
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