Dr.Roopa
Introduction
Dacryocystorhinostomy (DCR) is a surgical procedure performed for the relief of nasolacrimal duct obstruction (NLDO) of either anatomical or functional cause.
Endoscopic DCR, when compared to external techniques, has always had guarded acceptance primarily due to inconsistent success rates.Several techniques and modifications have been suggested by various authors over the years since the first introduction of endoscopic endonasal DCR. With the newer techniques and advancements, the success rates have become comparable or even higher than external DCR.The use of powered instruments with mucosal flap preservation has been shown to be highly successful. The creation and preservation of mucosal flap with trimming of the medial wall of the lacrimal fossa using Diamond burr produces a large and stable ostium aiding in long term patency. Synechiae formation at the site of neo-ostium is another common cause of failure. The objective of our study was to evaluate the outcome of endoscopic endonasal DCR with mucosal flap preservation, powered removal of the medial wall of the lacrimal sac
A total of 42 cases of epiphora due to NLD obstruction (confirmed clinically by lacrimal syringing) were operated by the same surgeon using endonasal DCR technique with removal of medial wall of the lacrimal fossa and the anterior end of middle turbinate using Diamond burr . The outcome and long term patency of the cases were evaluated.
Inclusion Criteria
Patients above 12 years of age
Primary DCR
Epiphora due to NLD obstruction
Exclusion Criteria
Secondary DCR
Canalicular obstruction
Primary nasal pathology (atrophic rhinitis, sinonasal polyposis, nasal mass etc.)
Surgical Technique
All cases were performed under local anaesthesia using45° 4 mm nasal endoscope. Nasal cavities were packed with ribbon gauze soaked in decongestant solution (5 ampoules of inj. adrenaline mixed with 30 ml of 4 % lignocaine solution) for a period of about 5–7 min. Local infiltration of 2 % lignocaine with 1 in 100,000 adrenaline was given along the lateral wall of the nose. Now the incision is taken with inferior base ,first incision starting 10mm above the axilla of the middle turbinate extending till inferior turbinate . Second vertical incision is 10 mm in front of the first , then the two incision are joined superiorly .this mucosal flap is reflected over inferior turbinate. The bone over the frontal process of maxilla is removed, initially starting with a Kerrisons punch and then with a 2mm diamond burr, almost up to the axilla of the middle turbinate . This provides a wide exposure of the lacrimal sac. Once the bone is removed, the medial wall of the nasolacrimal sac is identified and confirmed by applying pressure externally over the nasolacrimal sac region.
Lacrimal probing is done at this stage to determine the level of the common canaliculus. The lacrimal sac is opened above downwards and further incisions are made to create anterior and posterior based flaps. Then the inferior based flap is reflected back on the bare bone. Light nasal packing was done which was removed after 24 h. The patients were discharged on the next day with antibiotic coverage and saline nasal sprays.Lacrimal syringing was done on the first post-operative day and weekly thereafter for 6 weeks, following which they were followed-up twice monthly for minimum of 8 months. At each follow-up visit, lacrimal syringing with nasal endoscopy was done to visualise the patent ostium.
Results
Operative and postoperative data were retrospectively collected on 42 patients (15 men and 27women; mean age, 62.4 y; range 14–91 y) who presented to a lacrimal clinic with epiphora and obstruction of the nasolacrimal system and who consecutively underwent either primary or revision powered endoscopic DCR.
The only surgical complication was one case of sub cutaneous emphysema. 40 of the 42 DCRs were patent after a mean follow‐up of 11 months (standard deviation = 5 mo), yielding a success rate of 95.7%. One of the 42 DCRs was a failure because of improper use of medications. Two patients with a patent ostium and positive results on fluorescein
Discussion
DCR is an accepted standard procedure of choice for the treatment of NLDO.The extent of lacrimal sac exposure and the size of the ostium are important factors that determine long term patency. The importance of mucosal flap preservation is still under debate [1]. The idea of mucosal apposition is healing by primary intention and avoidance of granulation tissue formation. This has shown to have excellent functional outcome [2]
In our technic use of diamond burr increases the success rate of endonasal DCR.Utilization of diamond burr helps to make a large ostium. Drilling the bone helps to have a good grip of the bone to punch it.
Neil C Tan et al., in their study, concluded that surgical outcome depends on the ostium size and that significant shrinkage of the DCR ostium occurs in the first 4 weeks post-operatively [3]. Hence, it is not just the creation of a wide sac ostium which is important; the first few weeks of healing also plays a big role in determining long term patency.
P J Wormald (2012) in his study said that adequate exposure of the lacrimal sac requires exposure above the level of the axilla of middle turbinate using a drill. This was found to be important to ensure success of the procedure [4].
The overall success rate (94.6 %) of our new technique is comparable to the previous studies and further validation of this new method requires larger randomised control trials.
Endoscopic DCR has many advantages as compared to external DCR—avoidance of facial scaring, non-division of medical canthal ligament, performed as a day care procedure, limited tissue damage and preservation of the pump action of the lacrimal sac of the orbicularis oculi muscle [5,6,].
Conclusion
Powered endoscopic DCR which meets the with full sac exposure and primary mucosal apposition has a success rate comparable to that achieved with external DCR.
- Ramakrishnan VR, Hink EM, Durairaj VD, Kingdom TT. Outcome after endoscopic dacryocystorhinostomy without mucosal flap preservatio
- Mann BS, Wormald PJ. Endoscopic assessment of the dacryocystorhinostomy ostium after endoscopic surgery. Laryngoscope. 2006;116:1172–1174.
- Tan Neil C, Rajapaksa Suresh P, Gaynor James, Nair Salil B. Mechanical endonasal dacryocystorhinostomy—a reproducible technique. Rhinology. 2009;47:310–315.
- Tsirbas A, Wormald PJ. Mechanical endonasal dacryocystorhinostomy with mucosal flaps. Br J Ophthalmol. 2003;87:43–47.
- Weidenbecher M, Hasemeenn W, Buhr W. Endoscopic endonasal dacryocystorhinostomy: results in 56 patients. Ann OtolRhinolLaryngol. 1994;103:363–367.
- Hartikainen J, Gernman R, Puukka P, Seppa H. Prospective randomised comparison of external dacryocystorhinostomy. Ophthalmology.
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