Endonasal Dacryocystorhinostomy Surgery Research Articles

Comparison of success between external and endonasal dacryocystorhinostomy in primary acquired nasolacrimal duct obstruction in South India population

Background: Dacryocystorhinostomy (DCR) has been the standard procedure for primary acquired nasolacrimal duct obstruction (PANDO) for many years. This process can be performed either using an endoscopic or external approach. Aims and Objectives: The aim is to evaluate the results and recurrence rates of external DCR (ExDCR) and endonasal DCR (EDCR) surgery in patients with PANDO in the South Indian population. Materials and Methods: Medical records were reviewed in all patients who underwent surgery for PANDO between December 2021 and August 2023 at Government Medical College Mahabubabad. Results: This study was conducted in 92 patients; 34 males (36.96%) and 58 females (63.04%) were the gender split. ExDCR was used in 52 (56.52%) of the cases, and EDCR was used in 40 (43.487%) of the cases. Operation success rates of these data revealed that 50 (54.34%) cases were recorded as successful, 24 (26.10%) of the cases were accepted as partially successful, and 18 (19.56%) of the cases were deemed unsuccessful. There was no statistically significant difference between success rates and recurrences in both groups (P>0.05). Conclusion: Endoscopic DCR produced simple, minimally invasive, and preferable results compared to ExDCR in the South Indian population. Although the success of ExDCR is higher and the recurrence is lower than endoscopic DCR, with the outcomes of this study, endoscopic DCR can be tried as the first choice to protect the patient from major surgery and anesthesia in PANDO.

A comparative study of conventional endoscopic and powered endoscopic dacryocystorhinostomy in a tertiary hospital of Rohtas district, Bihar, India

<p class="abstract"><strong>Background:</strong> Dacryocystorhinostomy (DCR) consists of creating an alternative lacrimal drainage pathway to the nasal cavity to restore permanent drainage of the previously obstructed excreting system. The opening is normally made at the level of lacrimal bone. Introduction of the nasal endoscope, interest in endo-nasal DCR increased. The objective of this study was to compare the result and advantage of both conventional endo-nasal and powered endo-nasal DCR regarding patency rate, patient compliance intra-operative and postoperative complications.</p><p class="abstract"><strong>Methods:</strong> In this comparative study of 60 cases for conventional endo-nasal dacrocystorhinostomy and 100 cases of powered endo-nasal dacrocystorhinostomy was performed in the period of May 2017 to March 2018 in the Department of Ophthalmology in conjunction with Department of Otorhinolaryngology, Narayan medical college and hospital Jamuhar Sasaram, Bihar. Level of blockage was diagnosed by lacrimal syringing and probing, Jones dye test and dacrocystography. Surgery was done under local anesthesia except in children and uncooperative patients where general anesthesia was used. For endo-nasal DCR 0 and 30-degree rigid endoscope was used for surgery. </p><p class="abstract"><strong>Results:</strong> Functional success and symptomatic relief were more in powered DCR. Powered endo-nasal DCR surgery was found to be quicker to perform than conventional endo-nasal DCR surgery. Patient satisfaction was significantly higher in the powered endo-nasal DCR group. Complication of powered endoscopic DCR was low.</p><p class="abstract"><strong>Conclusions:</strong> Powered endo-nasal DCR surgery offers a very attractive alternative to the well-established technique than conventional Endo-nasal DCR for the treatment of primary acquired nasolacrimal duct obstruction with better success rates, shorter surgical time and higher patient satisfaction.</p><p class="abstract"> </p>

Bicanalicular Silicone Stents in Endonasal Dacryocystorhinostomy: Results of a Randomized Clinical Trial

To assess whether the use of silicone lacrimal stents affects the long-term success of endonasal dacryocystorhinostomy (EN-DCR). Prospective, randomized, controlled, interventional trial. The subjects were adult patients older than 16 years undergoing primary EN-DCR for nasolacrimal duct obstruction who gave fully informed consent and who had no lid malpositions or canalicular pathology. In cases with bilateral surgery, only the right eyes were studied. Participants were randomized to receive stents (control group) or not (study group). Standardized nonendoscopic EN-DCR was performed by the senior author in all cases. When the ostium was completed, the randomization code was revealed as to whether a lacrimal stent was placed or not. Follow-up assessments were made at 3, 6, 9, and 12 months. Stents were removed at 3months. The primary end point was symptoms of epiphora at 12 months, reported to the surgical booking clerk as (a) resolved, (b) significantly improved, (c) partially improved, or (d) no change or worse. The secondary end point was anatomic patency based on nasolacrimal syringing and categorized as (a) fully patent, minimal, or no reflux; (b) >50% patent but some reflux; (c) some patency but >50% reflux; or (d) nonpatent, 100% reflux. Complete success was defined as having resolved or significantly improved symptoms of watering and minimal or no reflux on nasolacrimal syringing. Partial success was defined as symptoms partially improved with a combination of patency and reflux on syringing. Failure was categorized as no change or worse symptoms of watering and 50% to 100% reflux on syringing. A total of 300 patients completed 12 months of follow-up. A total of 152 patients received tubes, and 148 patients did not. Overall success both subjectively and objectively was 94.7% in the stented group and 87.8% in the nonstented group (P= 0.034, Pearson chi-square 1-tailed test). The most common complications of stents included canalicular cheese-wiring and tube prolapse in approximately 4% each. There is a statistically significantly higher success rate in EN-DCR surgery with tubes compared with no tubes. The failure rate in this study was more than twice as high when tubes were not used (12.2% vs. 5.3%).

Cause and Management of Patients With Failed Endonasal Dacryocystorhinostomy.

ObjectivesEndonasal dacryocystorhinostomy (DCR) is a well-established treatment method in patients with nasolacrimal duct obstruction. However, there are a few reports about the overall management of failed endonasal DCR. We investigated the causes and management strategies of failed endonasal DCR.MethodsThis retrospective review included 61 patients (61 eyes) who had undergone revision surgery by the same surgeon after failed endonasal DCR between January 2008 and December 2012. The appropriate revision method was determined after analysis of the etiology of failure by the fluorescein dye disappearance test, nasal endoscopy, lacrimal irrigation, and probing. The criteria for success of the revision surgery were defined by the passage of fluid without resistance upon lacrimal irrigation and normalization of the tear meniscus height.ResultsThe mean duration between the primary endonasal DCR and revision surgery was 15.3 months. The average follow-up period after revision surgery was 12.2 months. The most common cause of endoscopic revision surgery was membranous obstruction. Endoscopic revision surgery was performed in 48 patients, while lacrimal silicone tube intubation under endoscopy was performed in 13 patients. The most common indication for lacrimal silicone tube intubation was functional epiphora. The overall success rate of the revision surgery was 89%.ConclusionThe most common cause of failed endonasal DCR was membranous obstruction. When patients with failed endonasal DCR presented at the clinic, it is important to identify the cause of the failure. Revision surgery could increase the final success rate of endonasal DCR.

Anatomical landmarks of the lateral nasal wall: implications for endonasal lacrimal surgery.

An accurate understanding of the anatomy of the lateral nasal wall is key to achieving complete exposure of the lacrimal sac during endonasal dacryocystorhinostomy (EnDCR) and the avoidance of complications such as basal skull fracture and orbital fat prolapse. This review provides a comprehensive summary of the clinical and cadaveric anatomical studies of the lateral nasal wall to date and their application to endonasal lacrimal surgery. The maxillary line and the axilla of the middle turbinate are the major landmarks commonly utilized by lacrimal surgeons to localize the lacrimal sac. Numerous clinical, cadaveric and radiologic studies have attempted to define the relationship of these and other important anatomical landmarks, closely related to the lacrimal sac and routinely encountered during endonasal surgery, such as the frontal process of the maxilla, the agger nasi air cell and the uncinate process. A greater understanding of the relevant endonasal anatomy over time has led to safer and more effective surgical techniques. Greater insights into the precise anatomical relationship of the lacrimal sac to other structures on the lateral nasal wall has enabled lacrimal surgeons to perform EnDCR surgery in a more accurate, efficient and well tolerated manner, matching its success to that of the external approach.

External versus endonasal dacryocystorhinostomy in a specialized lacrimal surgery center

PurposeTo study the duration of surgery, outcomes, adverse events and success rates of external versus endonasal dacryocystorhinostomy (DCR) surgery in a specialized lacrimal surgery center. MethodsProspective, interventional case series. Standard external DCR technique was performed. Mechanical endonasal DCR was performed with enlargement of the ostium and full length opening of the lacrimal sac. Surgical time, duration of intubation, incidence of hemorrhage, infection, wound dehiscence; follow-up duration and functional success at the end of follow up were recorded. ResultsFunctional success and symptomatic relief were equivalent in both procedures. Endonasal DCR surgery was found to be quicker to perform than external DCR surgery. The follow-up duration was comparable in both groups (mean 9months). Patient satisfaction was significantly higher in the endonasal DCR group (9.3 versus 8.6). ConclusionEndonasal DCR surgery offers a very attractive alternative to the well established technique of external DCR surgery for the treatment of primary acquired nasolacrimal duct obstruction with equivalent success rates, shorter surgical time and higher patient satisfaction.

Success Rates in Powered Endonasal Revision Surgery for Failed Dacryocystorhinostomy in a Tertiary Referral Center

To evaluate the causes of failed dacryocystorhinostomy (DCR) surgery, recommend specific endoscopic endonasal techniques in revision DCR, and report postoperative success rates. Retrospective case series in a tertiary referral center of 19 consecutive, endonasal revision DCR surgeries in 17 adult patients with previous failed DCR. All cases were revised endonasally by 1 surgeon. Analysis of etiology of failure and techniques of surgery were supplemented by review of surgical video and medical records. Surgical outcomes were measured functionally by resolution of epiphora and anatomically by patency of nasolacrimal duct system on syringing and positive functional endoscopic dye test. The most common cause for failed DCR was a blocked ostium due to membranous scarring (74%). Multiple causes for failure were found in 9 of 19 cases. Adjunctive procedures during revision surgery included partial middle turbinectomy (53%) and anterior ethmoidectomy (21%). The serrated oscillating blade was required in 89% cases, the high-speed diamond bur in 26%. Mean follow up was 15 months (range 7-26 months). All 19 cases had an anatomically successfully outcome. Fifteen of 19 cases (79%) had a functionally successful outcome. In this study, the most frequent cause of failed DCR was a scarred ostium, which is optimally visualized endonasally and precisely managed with the oscillating blade. Using the abovementioned specific endonasal techniques, the authors have demonstrated a high success rate in endonasal revision DCR surgery.

A comparison of external and endoscopic endonasal dacryocystorhinostomy for acquired nasolacrimal duct obstruction.

PurposeTo compare success rates of external dacryocystorhinostomy (DCR) and endoscopic endonasal DCR for acquired nasolacrimal duct obstruction (NLDO).DesignHistorical cohort study.Participants100 patients who underwent external DCR and 105 patients who underwent endoscopic endonasal DCR.MethodsA retrospective review of medical records of patients with acquired NLDO who underwent DCR from 2004–2010 was performed. Data regarding the lacrimal drainage system, eye examination, surgical outcomes, patient symptom control, and postoperative care were analyzed.Main outcome measuresSurgical success was defined by patient’s resolution of symptoms with patency on irrigation. Surgical failure was defined as no symptomatic reduction in epiphora and/or an inability to irrigate the lacrimal system postoperatively.ResultsA total of 205 patients underwent surgeries for acquired NLDO. The average age was 69 years, and 62.4% of subjects were female. Pooled results showed that both surgical approaches had similar success rates (endoscopic endonasal DCR 82.4% versus external DCR 81.6%; P = 0.895). Complication rates were low in both types of surgery. This included three patients with postoperative hemorrhage (two who had endonasal DCR surgery and one having external DCR surgery). This resolved with conservative treatment. Postoperative problems with lacrimal patency (including canalicular obstruction) occurred to 6.8% of endoscopic patients and 9% of those with the external DCR surgery. Of the 14 patients who had their silicone tubes fall out before the 2-month assessment, 10 were classified as failures (71%), in contrast to only a failure rate of 13.9% of those whose tubes were present for the recommended time. This difference was statistically significant (P < 0.01).ConclusionThe success rate of DCR for acquired NLDO in our group of patients was high overall with a low complication rate between the two types of surgery. There was no statistically significant difference between endoscopic and external DCR. Endoscopic surgery may have a benefit of preserving the lacrimal pump system and leaving no surgical scar. Patient preference and availability of each service should direct management. Hence endoscopic endonasal DCR surgery should be considered for primary treatment of nasolacrimal duct obstruction.

The Agger Nasi cell and uncinate process, the keys to proper access to the nasolacrimal drainage system

Background: Profound knowledge of the surgical anatomy is required to perform any dacryo-cysto-rhinostomy (DCR) procedure. In endoscopic endonasal DCR surgery, the uncinate process (UP) and/or agger nasi (AN) cell are frequently found to obstruct access to the lacrimal fossa. The aim of this study was to analyse the radiological anatomy of the UP and the AN cell in relation to the lacrimal sac. Methods: Preoperative computed tomography (CT) scans of patients undergoing DCR and other endoscopic sinus surgeries were analysed regarding their anatomical variations concerning the UP and the AN cell at the level of the common canaliculus. The covering of the lacrimal fossa by the UP was graded and a surgically relevant AN cell was sought after. Results: CT datasets of 60 sides were included. Analysis showed an AN cell overlying the upper parts of the lacrimal sac in 55% of patients. An anteriorly attaching UP covering at least 50% of the lacrimal fossa was found in 63% of individuals. Conclusion: In this study more than 80% of all patients presented with either a very anteriorly attached UP or an AN cell that would have to be removed to perform effective endoscopic DCR. The AN cell and the UP need to be included in the endonasal surgical concept.

The Agger Nasi cell and uncinate process, the keys to proper access to the nasolacrimal drainage system

Profound knowledge of the surgical anatomy is required to perform any dacryo-cysto-rhinostomy (DCR) procedure. In endoscopic endonasal DCR surgery, the uncinate process (UP) and/or agger nasi (AN) cell are frequently found to obstruct access to the lacrimal fossa. The aim of this study was to analyse the radiological anatomy of the UP and the AN cell in relation to the lacrimal sac. Preoperative computed tomography (CT) scans of patients undergoing DCR and other endoscopic sinus surgeries were analysed regarding their anatomical variations concerning the UP and the AN cell at the level of the common canaliculus. The covering of the lacrimal fossa by the UP was graded and a surgically relevant AN cell was sought after. CT datasets of 60 sides were included. Analysis showed an AN cell overlying the upper parts of the lacrimal sac in 55% of patients. An anteriorly attaching UP covering at least 50% of the lacrimal fossa was found in 63% of individuals. In this study more than 80% of all patients presented with either a very anteriorly attached UP or an AN cell that would have to be removed to perform effective endoscopic DCR. The AN cell and the UP need to be included in the endonasal surgical concept.

Topical Mitomycin C as a Postoperative Adjunct to Endonasal Dacryocystorhinostomy in Patients with Anatomical Endonasal Variants

ABSTRACTPurpose: Unusual intranasal conditions may increase the rate of complications and affect success rate of endonasal dacryocystorhinostomy (DCR) surgery. The purpose of this study was to find the influence of endonasal abnormalities on outcome of endonasal DCR surgery and to find the role of topical mitomycin C (MMC) as a postoperative adjunct to endonasal dacryocystorhinostomy in these patients. Methods: A total of 23 patients (19 males and 4 females) of bilateral chronic dacryocystitis in the age range of 18–60 years, having endonasal anatomical variants were included in this study. After endonasal DCR, the right side of nasal cavity was packed with 0.05% MMC nasal pack and left side of nasal cavity was packed with normal saline pack for 48 hours. During postoperative visits, the patients were checked for improvement in clinical symptoms and watched for complications including formation of adhesions and/or synechaie. The statistical association between endonasal pathologies and 3 dichotomous outcome variables (clinical features, adhesions, synechaie) was assessed by applying Fisher's Exact Test. Results: Postoperative retention of nasal packs for 48 hours after endonasal DCR, did not cause any side effect in our patients. An improvement in clinical symptoms (23/23 = 100%) was seen in all the patients on side with 0.05% MMC soaked nasal pack, while 10/23 i.e., 43.47% patients did not show improvement in symptoms on side of saline nasal pack. Postoperatively, the MMC nasal pack side nasal cavity had a healthy nasal mucosa during the entire follow up, while the saline nasal pack side nasal cavity had synechiae in 15/23 (65.2%) patients and adhesions in 15/23 (65.2%) patients. In our study, none of the anatomical endonasal variants had a statistically significant association with either formation of adhesion or formation of synechiae, as the p-value was > 0.05 in all these instances. Conclusions: The patients with endonasal anatomical variants have a higher incidence of complications like formation of adhesions and synechaie after endonasal DCR than other patients. Topical MMC is safe and effective agent to decrease the rate of complications when used as an adjunct in endonasal DCR in patients with endonasal anatomical variants.

Endonasal dacryocystorhinostomy with mucosal flaps

PurposeTo describe a new endonasal dacryocystorhinostomy (DCR) technique and assess its efficacy. DesignProspective nonrandomized interventional case series. MethodsA prospective series of 44 consecutive endonasal DCRs performed from January 1999 to December 2000 was entered into the study. The new technique involved creation of a large bony ostium and mucosal flaps to create an anastamosis between the lacrimal sac mucosa and nasal mucosa. Patients presenting with naso-lacrimal duct obstruction based on symptomatic, clinical, and radiologic grounds were included in the study. Patients who had undergone previous lacrimal surgery were excluded. Surgery was performed by two surgeons (A.T., P.J.W.) using a standardized operative technique. Patient demographics, presentation, examination findings, surgical and anesthetic data, postoperative success, complications, and follow-up were evaluated. Success was defined as anatomic patency as well as relief of symptoms as assessed by fluorescein flow on nasendoscopy, lacrimal syringing, and patient examination. Intubation of the lacrimal apparatus was performed in all operations and the tubes usually removed at 4 to 6 weeks postoperatively. After removal of the tubes follow-up was 13 months (mean, 12.9 months; range, 9–28 months; standard deviation [SD], 6.1 months). ResultsThere were 36 patients (12 male/24 female) who underwent 44 endonasal DCRs. The average age of the patients was 62.9 years old (range, 15–86 years old; SD, 19.1 years) and the main presentation was with epiphora (93%) and/or mucocoele (33%). In 13 operations (30%) a septoplasty was required at the time of surgery, and in 10 operations (23%) further endoscopic sinus surgery was performed in conjunction with the DCR. Anatomic success with a patent nasolacrimal system was achieved in 40 of 44 operations (91%). Symptomatic and anatomic success was seen in 39 of 44 operations (89%). Five of the DCRs were classified as failures. In one DCR the patient was symptomatic despite a patent nasolacrimal system and well-healed ostium. In two DCRs preoperative medial canalicular problems were noted. In two DCRs scarring and fibrosis of ostium were noted. ConclusionsThis new technique of endonasal DCR involves creation of a large ostium and construction of nasal and lacrimal sac mucosal flaps. Its anatomic success rate (91% or 40 of 44 DCRs) compares favorably with the success rate of other techniques for endonasal DCR and is also similar to the success of external DCR. Experience in endoscopic nasal surgery is important in endonasal DCR surgery, as other ancillary procedures may be required within the nose at the time of surgery.