Eur Arch Otorhinolaryngol (2008) 265:1071–1074 DOI 10.1007/s00405-008-0612-1
RHINOLOGY
Lacrimal sac removal made easy by methylene blue in endoscopic dacrocystorhinostomy Devrim Bektas · Nurettin Akyol · Hidayet Erdol · Mehmet Imamoglu · ReWk Caylan
Received: 1 November 2007 / Accepted: 8 February 2008 / Published online: 26 February 2008 © Springer-Verlag 2008
Abstract Endonasal dacrocystorhinostomy (DCR) has gained interest in the last decade. Especially when a novice surgeon is performing the surgery, diYculty in identiWcation of the lacrimal apparatus may complicate the procedure. We investigated the eYcacy of methylene blue (MB) solution as a marker for lacrimal sac (LS) in endoscopic DCR. A total of 24 endoscopic DCR cases were performed (16 primary and 8 revision cases). During surgery, LS was irrigated with MB solution. Following lacrimal bone removal, medial wall of the LS is seen with a bluish hue. When the sac is dissected, the epithelium of the LS, which is heavily stained with MB contrasts with the surrounding nasal mucosa and therefore tailoring of the extent of the LS mucosa removal is facilitated. The follow-up period of the patients was 23 § 7.5 months. Of the 24 cases operated, only one case needed a re-operation. Use of MB solution is eVective in both identifying LS and distinguishing it from surrounding nasal mucosa in DCR. Keywords Method · Treatment outcome · Surgical procedure · Dacrocystorhinostomy · Methylene blue
D. Bektas · M. Imamoglu · R. Caylan Department of Otolaryngology, Karadeniz Technical University, School of Medicine, Trabzon, Turkey N. Akyol · H. Erdol Department of Ophthalmology, Karadeniz Technical University, School of Medicine, Trabzon, Turkey D. Bektas (&) KTU Tip Fak, KBB ABD, Trabzon, Turkey e-mail:
[email protected]
Introduction The external dacrocystorhinostomy (DCR) is considered the mainstay of the surgical treatment in chronic dacriocystistis and in more than 90% of cases the surgical outcome is successful [1]. However, this procedure is not without drawbacks such as external scar formation, injury to the medial canthal ligament and periorbital ecchymosis that are overcome by the alternative endoscopic method [2]. The endonasal DCR was initially described by Caldwell and carried out by West and regained interest in the last two decades [2]. For the occasional surgeon or the beginner, it may be troublesome to identify the lacrimal sac (LS), which is a vital step of the surgical procedure in order to avoid unwanted entry into the orbit [3]. Additionally, the success of the surgery has generally been related to the size of the surgically created ostium, which must be adequately wide [4]. This calls for deWning the proper limits of the secondary opening made in the surgery. We have used methylene blue (MB) solution for identiWcation of the LS and appreciation of the surgically created new ostium. The postoperative results in these patients are also evaluated.
Materials and methods A retrospective review of the medical charts of the patients that underwent endoscopic DCR was performed. Endoscopic DCR’s were performed on patients for the relief of lacrimal obstruction at the departments of Otolaryngology and Opthalmology. All patients underwent an initial ophthalmologic evaluation including lacrimal irrigation and dacryocystography with Lipiodol®. Patients with small LSs were excluded. Preoperative nasal endoscopy was performed in order to identify any existing intranasal
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pathologies such as deviated nasal septum, malposition of uncinate process or variations in the middle turbinate.
Eur Arch Otorhinolaryngol (2008) 265:1071–1074
5–10 ml is suYcient) the freely Xowing dye is appreciated. Surgery is terminated after hemostasis. Nasal packing is generally unnecessary unless active epistaxis is present.
Surgical technique Revision surgery The surgical technique is described elsewhere in detail by Metson [5]. The surgery is performed by the otolaryngologist performing the intranasal surgery and the ophthalmologist irrigating and probing the LS for better identiWcation. The surgery is performed with a video camera attached to a nasal endoscope so that the opthalmologist can simultaneously observe the endoscopic manipulations on the monitor. Primary surgery The surgical procedure is performed under local or general anesthesia. Local anesthesia consists of submucosal injection of 1% lidocain hydrochloride with 1:100.000 epinephrine into the junction of middle turbinate and lateral nasal wall and the proposed mucosal area overlying the sac. In order to promote patients’ comfort during punctual manipulation and lacrimal irrigation, supratrochlear and infratrochlear nerve blockages are also performed. Epinephrine soaked cotton pledges are introduced into the nasal cavity for vasoconstriction. Anterior to the attachment of middle turbinate, nasal mucosa is incised with the help of a sickle knife to open a lateral mucosal window sizing approximately 5 £ 10 mm. Removal of the mucosa reveals the lacrimal bone overlying the LS. Using a 2 mm chisel, the bone is widely removed exposing the soft tissues. Before irrigation a punctal dilator was used to create a larger opening. After insertion of dilator vertically, lower eyelid is pulled laterally to line up the vertical and horizontal canaliculi. Then the dilator is positioned to a horizontal position and moved further. Irrigation of the sac with diluted MB (1% solution in saline) was performed with a 5-cc syringe and a #23 lacrimal cannula, using the same technique as with the dilator. Irrigation with small amount of MB (less than 0.5 ml) immediately contrasts the sac with the surrounding red colored nasal mucosa. If the sac wall is very thick preventing reXection of any color changes, lacrimal probe helps in tenting the medial wall of the sac, facilitating its identiWcation. Incision of the sac wall with a sickle knife reveals the dark blue color of MB escaping out of the sac. Using the 3 mm ear cup forceps, the medial wall of the sac is removed piecemeal. The internal epithelial lining of the sac is whitish in color and is very easily and heavily stained with MB contrasting the surrounding mucosa and the thick Wbrous wall of the LS. This enables exact appreciation of the size of the resection of the medial wall during creating a surgical neo-ostium. The ostium is widened to a Wnal size of 6–7 £ 10 mm and following irrigation with MB (usually
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Initially, the anastomotic area is appreciated with the endoscope and lacrimal irrigation with MB is performed to conWrm the ineYciency of the lacrimal drainage. After irrigation with MB, the sac is identiWed. Bony defect region is palpated to judge the suYciency of the size of prior bone removal, which generally should be approximately 7–8 mm in size. The ideal bony opening should extend from the anterior margin of the sac to the posterior margin revealing completely the medial surface of the sac. The granulation tissue, crusts or scarring in the area is removed with the help of sickle knife and ear cup-forceps caring to cause minimal trauma to the mucosa of the lateral nasal wall and the middle turbinate. In the postoperative period the patient is discharged the same or the next day and receives daily lacrimal irrigation for the next Wve days. Twice weekly active lacrimal irrigation is continued for 8 weeks which is decreased to once weekly for the next 6 months.
Results There were 4 men and 20 women ranging in age from 16 to 73 years. Presenting symptoms were epiphora in 11 patients and chronic dacriocystitis in 13 patients. The lacrimal obstruction was due to maxillofacial trauma in one patient presenting with epiphora. Local anesthesia was used for 22 patients and general anesthesia was used in 2 patients. There were eight patients with prior external DCR’s performed at the Department of Opthalmology that required revision. The causes of failure were related to nasal septal deviation in four cases, posttraumatic dacriocystitis in two cases and uncinate process malformation in one case. In 16 patients we performed primary endoscopic DCRs. Decriptives of the patients and additional surgical procedures applied are demonstrated in Table 1. The follow-up period was 23 § 7.5 months. Only one case, who failed at the second month of the operation, needed a revision surgery.
Discussion The introduction of the endoscopic DCR has not received the deserved attention for years partly due to its relatively lower rates of surgical success compared to its external counterpart and partly due to its other drawbacks. Endoscopic
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Table 1 Patient demographics and additional surgeries performed Primary surgery
Revision surgery
Gender m/f
3/13
1/7
Age
47.5 § 16.8
41.6 § 15.1
Middle turbinate resection (partial)
–
1
Partial anterior ethmoidectomy
1
–
Agger nasi cell
–
1
Nasal septoplasty
2
4
Uncinectomy
–
1
Descriptive characteristics
Additional Surgeries
DCR allows the LS to be opened into the nasal cavity via intranasal approach eliminating the need of external skin incision. The main factors inXuencing the outcome of surgery for endoscopic surgery reported in the literature are; diYculty in identiWcation of the lacrimal apparatus, insuYcient size of the surgically created ostium, poor visualization due to excessive bleeding, formation of postoperative Wbrous adhesions and granulation tissue in the region of the neo-ostium [2, 5]. These unfavorable conditions have all been blamed for the poor surgical results and following the introduction of more sophisticated instruments and equipment the outcome in endoscopic surgery is becoming comparable to the results of its external counterpart. One of the major drawbacks of this technique is poor visualization of the LS. Poor visualization in endoscopic DCR may be due to more than one reason. For the inexperienced surgeon in facial fracture cases with LS damage and cases with excessive intraoperative bleeding it may be diYcult to locate the sac [2]. Localization of the sac has been reported to be facilitated by the use of retinal light pipe [2], Xuorescein dye [6], middle turbinate excision [7] and turbinate infracture [8]. In our endoscopic DCR experience to overcome such drawbacks and to improve our postoperative results we used an alternative method that we found both cost eVective and eYcient for two main reasons. Diluted MB facilitated identiWcation of the LS by contrasting the blue colored sac wall with the red colored surrounding tissues. This enabled us to dissect out the medial wall of the sac precisely without injuring the neighboring structures, which may have inXuenced our high rate of success. Secondly, fenestration of the LS revealed the blue colored epithelium that lines the inner surface of the sac outlining its limits (Fig. 1). This resulted in a more precise removal of both the epithelium and the soft tissues of the LS avoiding unnecessary trauma to the surrounding nasal mucosa. We think that MB is a better identiWcation marker than previously used Xuorescein dye [6] because it has a better contrasting blue color with the nasal mucosa and additional
Fig. 1 Following LC incision epithelium of the sac is heavily stained can easily be diVerentiated from the surrounding nasal mucosa
epithelium staining eVect. Although not studied in this report, the well-known antiseptic feature of the MB may have also had a positive eVect on the elimination of pathogenic microorganisms present in the lumen of the sac or in the surrounding tissues. The postoperative results in our patients are seemingly high and promising which may further be attributed to other reasons. The mean follow-up period of 23 months is considerably long when 6 months is generally considered adequate in the literature [2]. Postoperatively we chose not to insert any silicone tubing or stents due to the controversies about their use in this type of surgery [4]. Continued lacrimal lavage in the long run and prolonged use of antibiotic 4£ eye drops were considered suYcient in preserving the opening of the surgical ostium. Another possible factor was the teamwork of the specialties of otolaryngology and opthalmology, which have improved the success rate. Thus as an alternative to other adjunctive methods we advocate the methlylene blue dye as both simple and cost-eVective method for intraoperative identiWcation of the LS and estimating the size of the surgical neo-ostium
References 1. Erdol H, Akyol N, Imamoglu HI, Sozen E (2005) Long-term follow-up of external dacryocystorhinostomy and the factors aVecting its success. Orbit 24:99–102 2. Watkins LM, Janfaza P, Rubin PA (2003) The evolution of endonasal dacryocystorhinostomy. Surv Ophthalmol 48:73–84 3. Cokkeser Y, Evereklioglu C, Tercan M, Hepsen IF (2003) Hammerchisel technique in endoscopic dacryocystorhinostomy. Ann Otol Rhinol Laryngol 112:444–449 4. Unlu HH, Ozturk F, Mutlu C, Ilker SS, Tarhan S (2000) Endoscopic dacryocystorhinostomy without stents. Auris Nasus Larynx 27:65– 71 5. Metson R (1991) Endoscopic surgery for lacrimal obstruction. Otolaryngol Head Neck Surg 104:473–479
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1074 6. Kong YT, Kim TI, Kong BW (1994) A report of 131 cases of endoscopic laser lacrimal surgery. Ophthalmology 101:1793–1800 7. Sprekelsen MB, Barberan MT (1996) Endoscopic dacryocystorhinostomy: surgical technique and results. Laryngoscope 106:187– 189
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Eur Arch Otorhinolaryngol (2008) 265:1071–1074 8. Boush GA, Lemke BN, Dortzbach RK (1994) Results of endonasal laser-assisted dacryocystorhinostomy. Ophthalmology 101:955– 959
