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Table of Contents
ORIGINAL ARTICLE
Year : 2016  |  Volume : 18  |  Issue : 2  |  Page : 58-61

The added value of endoscopic dacrocystorhinostomy performed by the otolaryngologist: A tertiary care experience


Department of Ophthalmology & Otolaryngology, Head and Neck Surgery, Umm Al-Qura University; The Director of the Head and Neck and Skull Base Center King Abdullah Medical City (KAMC), Makkah, Saudi Arabia

Date of Web Publication6-Jan-2020

Correspondence Address:
MD, FRCSC Osama A Marglani
Head of the Department of Ophthalmology and Otolaryngology Head and Neck Surgery Umm Al-Qura University; Director of the Head and Neck and Skull Base Center, King Abdullah Medical City
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-8491.275265

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  Abstract 


Introduction: Dacryocystorhinostomy (DCR) is the preferred treatment for lacrimal duct blockage. Endoscopic DCR has been practiced increasingly in recent years as it avoids a facial scar and can be performed as a day procedure. Recent improvements in endonasal surgical technique led to success rates of up to 90 per cent. However, the endonasal approach often requires concomitant procedures along with DCR for optimal outcome. This includes procedures like septoplasty, turbinoplasty etc.
Aims and Objective: The aim was to assess the added value of endoscopic DCR performed by otolarygologist surgeons in terms of simultaneous intranasal procedures for optimal outcome which cannot be performed by oculoplastic surgeons.
Design of Study: Retrospective tertiary care study.
Materials and Methods: we retrospectively studied the demographic, clinical, and surgical data of 87 endoscopic DCR cases performed over the last 3 years. Complication rates in the patients who had simultaneous procedures were documented.
Results: The rates of simultaneous nasal procedures (septoplasty, turbinectomy, and polypectomy) were 21.8%. No complications were noted.
Conclusions: A significant proportion of patients undergoing endoscopic DCR may req uire ancillary endonasal procedures that is performed by the otolaryngologist at the same operative setting with minimal complications for optimal outcome and to decrease the recurrences

Keywords: endocopic, endonasal, dacryocystorhinostomy, septoplasty, turbinoplasty, recurrences


How to cite this article:
Marglani OA. The added value of endoscopic dacrocystorhinostomy performed by the otolaryngologist: A tertiary care experience. Saudi J Otorhinolaryngol Head Neck Surg 2016;18:58-61

How to cite this URL:
Marglani OA. The added value of endoscopic dacrocystorhinostomy performed by the otolaryngologist: A tertiary care experience. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2016 [cited 2021 May 5];18:58-61. Available from: https://www.sjohns.org/text.asp?2016/18/2/58/275265




  Introduction Top


Dacryocystorhinostomy (DCR) is a procedure done for the surgical cure of epiphora due to anatomic nasola- crimal duct obstruction (NLDO) and has been described more than 100 years ago. Since the first descriptions of DCR by Caldwell in 1893 by the external approach [1] and then Tito [2] in 1904, operative technique and technical approaches have evolved with varied success rates. It has been performed by either otolaryngologist or orbital surgeon. Although in many centers it is becoming a multidisciplinary team approach which we support.

DCR is generally a very well tolerated and a successful intervention for those with NLDO. Two approaches to DCR are currently in practice: external DCR (Ext- DCR) and endoscopic DCR (END-DCR). While the endoscopic approach is gaining popularity, the otolaryngologists are incorporating it in their practice as evidence points out that EM-DCR compares favorably with Ext-DCR, both in primary and revision cases with added cosmetic advantages. There have been multiple cohorts and a randomized controlled trial that supported comparable efficacy. Additionally, EM-DCR avoids external scar. The endoscopic surgical technique described by otolaryngologist has enabled them to excel in this anatomical region particularly and has added additional value to the patients by performing many ancillary endoscopic endonasal procedures like septoplasty, functional endoscopic sinus surgery, turbinoplasty and adenoidectomy at the same operative session. In addition to their ability for treating post operative complication like bleeding and synechia release, aiding in the overall concurrent patient satisfaction with minimal complications.

The endoscopic dacryocystorhinostomy (endo DCR) may require concomitant nasal procedures to enable adequate access to marsupialize the entire lacrimal sac. It has also been suggested that anatomical failure of both external and endo DCRs may be related to severe septal deviation, a large concha, or nasal polyps [3],[4]. The aim of this study was to assess the added value of endoscopic DCR performed by otolaryngologist surgeons in terms of simultaneous intranasal procedures for optimal outcome which cannot be performed by oculoplastic surgeons.


  Materials and Methods Top


We retrospectively studied the demographic, clinical, and surgical data of 87 endoscopic DCR cases performed over the last 3 years. The rates of simultaneous nasal procedures (septoplasty, turbinectomy, and polypectomy) and complication rates in the patients who had simultaneous procedures were documented. All patients operated for ENDO-DCR were included in this study at King Abdullah Medical City, Makkah, Saudi Arabia which is a tertiary care referral hospital.

The pre-operative evaluation

All cases in our center had a combined evaluation by both the rhinologist and the oculoplastic surgeon to achieve a full lacrimal assessment, nasal endoscopy and syringing. Dacryocystograms and lacrimal scintillograms were performed if there was doubt as to the level of obstruction following the clinical examination. Preoperative nasal endoscopy was performed to assess nasal pathologic findings such as a deviated nasal septum, middle turbinate hypertrophy, concha bullosa, or nasal polyps that would hinder access to the lacrimal sac. All patients underwent CT scan of the paranasal sinuses to further assess them in terms of pathologies that can compromise the lacrimal system like inflammatory disease such as allergic fungal sinusitis or tumors that can subsequently change the management significantly.

The surgical technique

All procedures were performed under general anesthesia. The endo-DCR and postoperative care were carried out as previously described [5],[6].

The post operative period

The patients were given post operative oral antibiotics and topical ophthalmic antibiotics eye drops with steroids and a follow-up visit in 6 days to report earlier if any complications arose. Then every 2 weeks for 2 months then monthly afterward.

We routinely used the endoscope to suction any blood or mucus around the surgical endonasal site and from the sinuses if FESS was performed. Additionally if septoplasty was performed splints removal was done on the first follow-up visit.

Data collected from patient’s records included patient demographics, site of lacrimal drainage obstruction, details of the operation, complications, and any additional ancillary procedures. The main outcome measure was the rates of ancillary endonasal procedures performed during endoDCR to improve surgical access to the lacrimal sac. The secondary outcome measure was the presence of complications following ancillary procedures.


  Results Top


In our series of 96 endoscopic DCRs were performed on 87 consecutive patients. No patients were excluded. The mean age at surgery was 46 years. The male to female ratio was 1:3. Sixty-nine patients underwent unilateral DCR and 9 patients, bilateral DCR.

Adjunctive nasal procedures were performed in 19 of the patients (21.8%). Twelve of our patients (13.7) required a septoplasty, non required turbinoplasty nor turbinectomy. One had adenoidectomy, and one had choanal atresia repair. We had no post operative bleeding needing intervention nor development of synechia.


  Discussion Top


We have a specialized rhinology clinic where all patients referred for management of their epiphora undergo a full combined assessment in addition to their lacrimal evaluation. We focus strongly on sinus pathology as well as sinonasal anatomical variants which are managed at the same time as the DCR. Due to the rhinologists expertise at performing endoscopic procedures it does not add morbidity to the overall procedure. Better visualization and access to the lacrimal sac may indeed improve the speed of an endoscopic DCR and may ultimately translate into higher success rates if done by experienced endoscopic surgeons. These added values are summarized in [Table 1].
Table 1: Summary of the added value of otolaryngologist performing ENDO-DCR

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Previous DCR studies examining the role of adjunctive sinonasal endoscopic procedures have found DCR success rates to be comparable between patients undergoing and not undergoing such additional procedures [7],[8].

However, another study of 19 patients who failed primary ENDO-DCR in a tertiary center reported an adjunctive middle turbinectomy rate of 53% and anterior ethmoidectomy rate of 21%, and the authors suggested that all oculoplastic surgeons who performed the ENDO-DCR should be familiar with those techniques [9]. This practically needs special endoscopic training and is better handled by an experienced otolaryngologist especially when dealing with anatomical variants and dangerous nearby structures like dehiscent exposed anterior ethmoid artery as described in the CT scan of [Figure 1], and if not recognized this can lead to devastating bleeding and orbital heamatoma.
Figure 1: A case of bilateral epiphora and Chronic sinusitis, note the agger nasi cell (circle) and the Anterior ethmoid artery (Arrow)

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Adjunctive nasal procedures were performed in 19 of the patients (21.8%) which is comparable to previous studies that ranged from 14.1% to 46% as shown in [Table 2]. Twelve of our patients (13.7) required a septoplasty, non required turbinoplasty nor turbinectomy. The rate of septoplasty from previous reports have been variable from 10% to 40% and turbinectomy rates of <4% during ENDO-DCR [10],[11],[12]. Sinus surgery was performed in 5 patients. One other patient had adenoidectomy, and another had choanal atresia repair. We had no post operative bleeding needing intervention nor development of synechia.
Table 2: Studies showing the rate of ancillary procedures

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Although the prevalence of concha bullosa ranges between 14–53% [13], we found intra-operatively that it is rarely necessary to resect this concha to achieve an adequate access as the lacrimal region is anterior to the middle turbinate.


  Conclusion Top


We are great proponents of the multidisciplinary combined team work with our oculo-plastic colleagues. Our results indicate a significant number of our patients needed ancillary procedures during ENDO-DCR and therefore the expertise of the otolaryngologist dealing with the paranasal sinus and lacrimal region is crucial. This has the potential to improve the overall benefit of the patient’s outcome by enhancing the endonasal airway and function, and decreasing morbidity.

Acknowledgments

The author would like to thank Dr Ahmed Sheikh for his help in writing this paper, Dr Omar Abu Suliman for developing the data base registry, Dr Yousef Zeeshan, Dr Bassam Alruzaiqi and Dr Abdul Aziz Neazy for the data collection and for their efforts in this study, Mr Maher Alhazmi for the data registry and analysis.



 
  References Top

1.
Caldwell GW. Two new operations for obstruction of the nasal duct with preservation of the canaliculi and an incidental description of a new lacrimal probe. NY Med J. 1893; 57: 581.  Back to cited text no. 1
    
2.
Griffiths JD. Nasal catheter use in dacryocystorhinostomy. Ophthal Plast Reconstr Surg. 1991; 7: 177-186.  Back to cited text no. 2
    
3.
Elmorsy SM, Fayk HM. Nasal endoscopic assessment of failure after external dacryocystorhinostomy. Orbit. 2010;29:197-201.  Back to cited text no. 3
    
4.
Demarco R, Strose A, Araújo M, et al. Endoscopic revision of external dacryocystorhinostomy. Otolaryngol Head Neck Surg.. 2007;137:497-9.  Back to cited text no. 4
    
5.
Wormald PJ. Powered endonasal dacryocystorhinostomy. Laryngoscope. 2002; 112:69-71.  Back to cited text no. 5
    
6.
Tsirbas A, Wormald PJ. Endonasal dacryocystorhinostomy with mucosal flaps. Am J Ophthalmol. 2003; 135:7678.  Back to cited text no. 6
    
7.
Figueira E, Abbadi ZA, Malhotra R, et al. Frequency of simultaneous nasal procedures in endoscopic dacryocystorhinostomy. Ophthal Plast Reconstr Surg. 2014; 30:40-43.  Back to cited text no. 7
    
8.
Nussbaumer M, Schreiber S, Yung MW. Concomitant nasal procedures in endoscopic dacryocystorhinostomy. J Laryngol Otol. 2004; 118:267-269.  Back to cited text no. 8
    
9.
Hull S, Lalchan S-A, Olver JM. Success rates in powered endonasal revision surgery for failed dacryocystorhinostomy in a tertiary referral center. Ophthal Plast Reconstr Surg. 2013; 29:267-271.  Back to cited text no. 9
    
10.
Tsirbas A, Wormald PJ. Mechanical endonasal dacryocystorhinostomy with mucosal flaps. Otolaryngol Clin North Am. 2006; 39:1019-36, viii.  Back to cited text no. 10
    
11.
Nussbaumer M, Schreiber S, Yung MW. Concomitant nasal procedures in endoscopic dacryocystorhinostomy. J Laryngol Otol. 2004;118:267-9.  Back to cited text no. 11
    
12.
Weidenbecher M, Hosemann W, Buhr W. Endoscopic endonasal dacryocystorhinostomy: results in 56 patients. Ann Otol Rhinol Laryngol. 1994; 103(5 pt 1):363-7.  Back to cited text no. 12
    
13.
Stallman JS, Lobo JN, Som PM. The incidence of concha bullosa and its relationship to nasal septal deviation and paranasal sinus disease. Am J Neuroradiol. 2004;25:1613-1618.  Back to cited text no. 13
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2]



 

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Abstract
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