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ORIGINAL ARTICLE
Results of 12 years of endoscopic dacryocystorhinostomy Antonio Martínez Ruiz-Coello,* Beatriz Arellano Rodríguez, Cristina Martín González, Cristóbal López-Cortijo Gómez de Salazar, David Laguna Ortega, José Ramón García-Berrocal, Mayte Pinilla Urraca, Rafael Ramírez-Camacho Servicio de Otorrinolaringología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain Received April 21, 2010; accepted September 3, 2010 KEYWORDS Dacryocystorhinostomy; Dacryocystitis; Lacrimal duct obstruction; Epiphore; Nasal endoscopic surgery
Abstract Introduction: Chronic inflammation of nasolacrimal duct determines obstruction of the lacrimal flow and is called chronic dacryocystitis. Endoscopic dacryocystorhinostomy (DCR) can solve this obstruction by opening the lacrimal sac directly to the nasal cavity, avoiding external scars in a simple, safe way. Material and method: We reviewed all cases operated using this technique between January 1996 and June 2008. We focused on demographic characteristics as well as the results obtained (subjective and objective improvements). Results: We reviewed 76 Endoscopic DCR that were performed during aforementioned period of time. Of these cases, 75% were females; mean age was 52.4 years old. Improvement in symptoms was reported by 80.3% of the patients. These data are similar to the results seen in other studies. Conclusions: Endoscopic dacryocystorhinostomy is a simple, safe technique for treating chronic dacryocystitis, which provides similar or even better rates of improvement than other techniques used for this condition. In our patients, the results are not different from those observed in other studies. Our outcomes are comparable to those observed in other studies. © 2010 Elsevier España, S.L. All rights reserved.
PALABRAS CLAVE Dacriocistorrinostomía; Dacriocistitis crónica; Obstrucción de vía lacrimal; Epífora; Cirugía endoscópica nasal
Resultados de 12 años de dacriocistorrinostomía endoscópica Resumen Introducción y objetivos: La inflamación crónica del conducto lacrimonasal con la consiguiente obstrucción del flujo de la lágrima es llamada dacriocistitis crónica. Mediante la dacriocistorrinostomía por vía endoscópica, es posible resolver esta obstrucción poniendo en comunicación el saco lacrimal directamente con la luz de la fosa nasal, sin cicatrices externas y de una forma relativamente sencilla y segura. Métodos: Se realiza una revisión de los casos intervenidos mediante esta técnica entre enero de 1996 y junio de 2008. Se estudian las características epidemiológicas de los pacientes, así como
*Corresponding author. E-mail address:
[email protected],
[email protected] (A. Martínez Ruiz-Coello). 0001-6519/$ - see front matter © 2010 Elsevier España, S.L. All rights reserved.
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Results of 12 years of endoscopic dacryocystorhinostomy
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los resultados obtenidos, tanto en mejoría sintomática (subjetiva) como en mejoría del drenaje comprobada por el cirujano a la exploración (objetiva). Resultados: Un total de 76 dacriocistorrinostomías fueron realizadas en este período. De ellas, el 75% se trataba de pacientes mujeres. La edad media fue de 52,4 años. En un 80,3% de las intervenciones el paciente refería mejoría (total o parcial) de los síntomas, lo que se asemeja a los resultados arrojados por otras series. Conclusiones: La dacriocistorrinostomía realizada por vía endoscópica endonasal constituye una técnica sencilla y segura para el tratamiento de la dacriocistitis crónica, aportando unas tasas de curación/mejoría similares o superiores a las de otras técnicas. Las tasas de mejoría observadas en nuestra serie coinciden con las observadas en otros estudios. © 2010 Elsevier España, S.L. Todos los derechos reservados.
Introduction Chronic dacryocystitis is a state of permanent obstruction of the nasolacrimal duct that is manifested through constant dripping of tears because the natural evacuation route for tears is blocked. The usual causes of stenosis of the nasolacrimal drainage system are chronic or acute inflammation, traumatisms and congenital malformations.1,2 The initial symptoms include chronic epiphora, lacrimal sac inflammation and recurrent conjunctivitis.1,2 This pathology is more frequent in women in the fifth or sixth decade of life.1 Although the obstruction can occur in any part of the route, it is most frequently located in the union between the sac and the nasolacrimal duct.1 The only effective treatment, when other measures, such as unblocking through probes or a local massage over the lacrimal sac area have failed, is surgery. The classic treatment for this chronic obstruction of the lacrimal duct has been external dacryocystorhinostomy, performed by the Ophthalmology Service.1,3 Described for the first time by Toti (a rhinologist from Florence) in 1904,3-5 this procedure consists in the removal of the inner wall of the lacrimal sac as well as the bone portion of the lacrimal fossa and the adjacent nasal mucosa, through an external approach. The first reference to an endonasal approach was made by Caldwell in 1893.2,4,6,7 Lacrimal sac fenestration, as performed today, is based on the technique described by Westen in 1911.4,7 The use of optics for endonasal surgery was described by Herrmann (1958), Prades (1970) and Rouvier (1981).3,7 In 1958, Herrmann described the technique of endonasal approach and microsurgery through the use of a binocular microscope, preserving the bone architecture supporting the lacrimal canaliculi by avoiding an external approach. The first reference to the use of endoscopes in DCR was made by Rice (1988) and McDonogh in 1989.4,7 With the emergence of endoscopic systems in the late 1970s, Hopkins created interest in endoscopic sinonasal techniques; consequently, the possible surgical uses and fields of action increased, the technical material improved and endoscopic sinonasal surgery was established at most Otolaryngology Services throughout the world. Endoscopic DCR represented a new indication for endoscopic nasal surgery, since its endonasal approach
is more natural and avoids the sequelae of an external approach, with less surgical trauma, fewer postoperative complications and better anatomical accesibility,2,3,5-7 and in most cases, a reduced surgical period and hospital stay. The disadvantages of this technique compared to the external approach are related to the use of specific instruments and to the technical difficulties of the endonasal route.6 Adding lacrimal duct surgery to the field of endoscopic sinonasal surgery required specific training in the new anatomic region, and a significant learning curve was observed in surgeons.6 Although at first the presence of an ophthalmologist may be necessary to help in channelling lacrimal canaliculi, any ORL specialist can perform the complete technique. The most important surgical difficulties with this technique are haemorrhage and nasal anatomical anomalies, which if present can be corrected in the same operation with the endoscopic technique. Among the most frequent difficulties are nasal polyposis, middle turbinate hypertrophy and septal deviation. Although a slight deviation of the septum is present in almost 20% of the population, the need for septoplasty prior to DCR varies from 0.3% to 30% in recent medical literature6 (Table). Many authors have suggested different techniques using drills or laser, with the consequent advantages and disadvantages.8,9 Different techniques have been described with the common objective of approaching the lacrimal sac through an endonasal route to make permanent drainage towards the nasal fossae possible. This is how lacrimal bone wall drilling through an endonasal route, osteotomy with a chisel, laser vaporisation, etc. are performed, with constant endoscopic control or in some cases even microscopic control. Others perform a more complex surgery involving flaps, of either nasal or sac mucosa, surrounding the osteotomy.3,8 The results, as far as resolution of symptoms and the costbenefit ratio, are similar among the various techniques, oscillating between 75% and 96%, with a certain disadvantage for laser-based surgeries.2,3,5,7,9 A retrospective study was performed to assess the results of endoscopic surgery at our hospital. This study covered patients who underwent an endoscopic dacryocystorhinostomy at our Otolaryngology Service between January 1996 and June 2008.
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A. Martínez Ruiz-Coello et al
Table Advantages and disadvantages of endoscopic DCR Advantages Technical difficulties Less surgical trauma Haemorrhage Shorter surgical time and postoperative stay Endoscopic dcr Middle turbinate hypertrophy Better anatomical accessibility Very anterior ethmoid cells Correction of other pathologies or anatomical Mucocele anomalies in the same operation Narrow nasal fossa DCR indicates dacryocystorhinostomy.
Material and methods A review of all surgeries between January 1996 and June 2008 was performed, including all those patients who underwent dacryocystorhinostomy through unilateral or bilateral endoscopic route. All patients included were attended by the ORL service, having been referred by the Ophthalmology Service with the diagnosis of chronic dacryocystitis. Surgical treatment was suggested for patients who presented symptoms of lacrimal route obstruction (epiphora, repeated acute dacryocystitis), who did not respond to medical treatment and who suffered from a lacrimal duct obstruction distal to the sac as confirmed by ophthalmologic exploration and dacryocystography, as well as permeability of the lacrimal canaliculi. The surgical procedure was performed under general anaesthesia employing topical vasoconstriction with a guided endoscopic endonasal approach using rigid 0º (Ref.: Endoview SN16827) and 30º (Ref.: Endoview SN38797) endoscopes. All these interventions were performed by a formal technique, although with small individual variations, consisting of approaching the lacrimal sac by the lateral nasal wall (Figure 1), through the insertion of a pedicled U-shaped flap. Subsequently, the lacrimal bone was extracted, usually with a chisel, reserving the use of drills for those cases in which a complete resection of the
bone was not possible. The upper and lower canaliculi were channelled with Bowman probes after being dilated (Figure 2) and the sac was opened to the nasal cavity (Figure 3). Lastly, a bicanalicular silicone probe was inserted with its ends tied inside the cavity (Figure 4) and the flap was repositioned, cutting a band from the uppermost area, so as to not obstruct the region of the open sac. The probe was maintained in place after surgery for a period ranging from 2 to 3 months. Standard monitoring was carried out in the ORL clinic, with a first review by the same surgeon 10-15 days after surgery, a second one after 4-6 weeks, the next after 3 months and the last after 6 months. This final review took place approximately one year after surgery. Epidemiological data was collected during this study, including gender, age at the time of intervention, need for secondary surgery, time elapsed till such secondary surgery, period the lacrimal probes were maintained after surgery and pathology resolution results. Results were assessed based on 2 criteria. The first was the patient’s subjective perception with regard to improvement in symptoms, such as decrease of the epiphora and reduction of inflammation crises, classifying patients into 3 groups: total improvement (no episodes of epiphora no inflammation of the lacrimal duct), partial improvement (decrease in tearing and less inflammation, although without complete
Figure 1 Mucosal U-shaped flap in the lateral nasal wall.
Figure 2 Probing the lacrimal canaliculi.
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Results of 12 years of endoscopic dacryocystorhinostomy
Figure 3 Exposure of the left lacrimal sac. Lacrimal probe within the sac prior to its opening (arrow).
disappearance) and no improvement. The second criterion was based on the surgeon’s perception of the degree of lacrimal sac opening to the nasal cavity (or lack thereof) in reviews done after surgery, dividing patients into “complete opening or complete closing of lacrimal sac”.
Results A total of 71 patients were intervened during the time period studied, with the loss of two patients who were not monitored after surgery and who could not be contacted by telephone. Of the remaining 69 patients, 7 of them required a bilateral intervention, only one of which was performed during the same operation, with the other 6 taking place at a later time. The total number of dacryocystorhinostomies performed by the endoscopic route during this period was 76. This represents an annual average of 5 patients/year undergoing surgery using this technique. When referring to statistical
Figure 4 Probe ends knotted in the nasal fossa.
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analysis in this article, it is always with respect to the total number of surgeries (76) and not to the number of patients (69). A total of 57 DCRs were performed on female patients, which represents 75% of the total. The remaining interventions, 25% (19), were performed on males. In 51.3% the intervened side was the left, and in 48.7% it was the right. The mean age of patients at the time of surgery was 52.4 years. The ages ranged from 22 to 80 years. The decades of life with the highest incidence rates were the sixth and the seventh, with over half of patients being included in that group. The mean period of maintenance of the lacrimal probes after surgery was of 3.5 months. The range was from 1 month (the probe fell out accidentally) to 12 months (the patient did not turn up for postoperative revisions). One important fact to take into account before analysing the results is that, in 13 of the DCRs performed, the patient had already received some type of previous treatment. In this case they were secondary interventions which, according to other studies published in the literature, usually have a significantly worse result. Out of these 13 previously intervened patients, 8 had been treated by the Interventional Radiology service with the insertion of a lacrimal prosthesis. Subsequently, they presented an obstruction, thus requiring new treatment. Another 4 had undergone external DCR, without success. Lastly, one patient had undergone both treatments (prosthesis and external DCR). With respect to the analysis of surgery results, it should be noted that the classification of patients into the 3 possible groups (total improvement, partial improvement or no improvement) was carried out after the complete follow-up period, that is, once they were discharged, in cases of improvement as well as in cases where symptoms persisted, or once another surgical intervention was programmed. While analysing the subjective criterion of patientperceived improvement, we found that 80.3% of patients reported an improvement in their symptoms after surgery (64.5% reported total improvement and 15.8% reported partial improvement), while the remaining 19.7% of patients did not improve after surgery. Out of that 19.7% (15 patients), 10 underwent a new intervention. Of these 10 secondary operations, 4 underwent another endoscopic DCR, with success in only 1 patient; in 6 cases, a lacrimal prosthesis was inserted or an external technique was used, with improvements reported by 5 of the 6 patients and without any further data on their subsequent evolution. If we analyse objective improvement as reported by the surgeon during the reviews, the results are slightly different. In this case, global improvement figures were 77.6%, with 22.4% of patients still presenting an absence of lacrimal sac opening to the nasal cavity and without tear drainage through it when the surgeon pressed the sac region during exploration. The complications found were limited to a few cases of bruising of the inner canthus of the eye in the lacrimal bone removal area, with complete remission within a few days.
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Discussion Endoscopic dacryocystorhinostomy is a safe surgical technique, yielding improvements in lacrimal obstruction symptoms (epiphora, local inflammation) that vary from 75% to 96% depending on the studies.1-3,5,7. Compared to other techniques, such as that carried out by an external approach, it presents similar results with regard to symptomatic improvement, involving less surgical traumatism and shorter surgery time and postoperative hospital stay. In our series, 64.5% presented a total symptomatic improvement, and this figure rises to 80.3% if both total and partial improvement categories are included. In the case of direct observation by the surgeon, the rate of improvement was 77.6%. These results match those published in other series. This small discrepancy between patient-reported symptoms and the assessment by the surgeon during exploration has been described by various authors. It is not uncommon for the patient to report an improvement in symptoms after surgery, although the duct may still not appear permeable according to the exploration. It can also occur that the sac appears well open to the nasal cavity, with correct tear drainage, but the patient does not report any symptomatic improvement, although this is less frequent. There are various possible explanations for these differences in results. The improvement in exploration without improvement in symptoms could be due to a faulty indication in cases where stenosis at the level of the canaliculi was responsible for the pathology. On the other hand, this stenosis could be caused iatrogenically by aggressive catheterisation during surgery. In the opposite case, it could be that the duct is permeable after surgery, although it is not possible to appreciate this under endoscopic exploration. Among the secondary operations for cases with no improvement after the first intervention, a greater rate of symptomatic resolution was found when an external technique or a lacrimal prosthesis was used (improvement: no improvement ratio being 5:1), than among those who underwent a new endoscopic DCR (1:3). In spite of an initially good result with the insertion of a lacrimal prosthesis, this result will probably not remain for long, as this has been observed in many studies with this type of prosthesis. In recent years, advances with laser techniques have given way to a debate over whether using a laser in this pathology is better than the classical technique we have described here. The rates of improvement published in various series are similar to or only slightly lower than those known for endoscopic DCR.3,4 The ease of the surgical technique involving the use of laser and the possibility of performing it under local anaesthesia makes us think that laser (through
A. Martínez Ruiz-Coello et al
a transcanalicular approach) could be an alternative to the endonasal technique.
Conclusions Endoscopic dacryocystorhinostomy is a safe technique for the treatment of chronic dacryocystitis, with variable results ranging from 75% to 95% according to the different published series. In our series, studied from January 1996 to June 2008, the rate of improvement with this technique was 80.3%. Data published in other studies using laser DCR show similar results or only slightly worse than those we have observed with our endoscopic technique. The possibility of performing this technique under local anaesthesia, without needing to drill the lacrimal bone, constitutes an advantage over the classical endoscopic technique.
Conflict of interest The authors declare no conflict of interest.
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