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Table of Contents
ORIGINAL ARTICLE
Year : 2018  |  Volume : 20  |  Issue : 2  |  Page : 46-48

Impact of Flab Technique Versus Non-Flap Techniques on Endoscopic Dacryocystorhinostomy


1 Department of Otolaryngology-Head & Neck Surgery, Faculty of Medicine, Jazan University, Jazan; Department of Otolaryngology-Head & Neck Surgery, King Abdullah Medical City, Makkah, Saudi Arabia
2 Department of Otolaryngology-Head & Neck Surgery, King Abdullah Medical City, Makkah, Saudi Arabia

Date of Web Publication23-Dec-2019

Correspondence Address:
MD Fahd Alharbi
Department of Otolaryngology-Head & Neck Surgery, Faculty of Medicine, Jazan University, Jazan; Department of Otolaryngology-Head & Neck Surgery, King Abdullah Medical City, Makkah
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-8491.273920

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  Abstract 


Objective: to compare the influence of flap versus non-flap technique on endoscopic dacryocystorhinostomy (EDCR).
Patients and Method: A prospective randomized trial in patients with bilateral nasolacrimal duct obstruction, comparing the two techniques to avoid inter-patient variability. We included all patients where bilateral epiphora, excluding unilateral, previously operated or recurrent cases.
Results: One hundred patients, fifty females and fifty males with bilateral epiphora due to naso-lacrimal duct obstruction were operated upon by EDCR with or without flap technique. Out of 100 EDCR procedures with flap technique, only 3 had recurrent epiphora with stenosis of the ostium on endoscopic examination and failed fluorescein dye test. In contrast, 4 procedures without flap failed as evident by recurrent epiphora, endoscopic and fluorescein dye test criteria.
Conclusion: There is no difference between DCR with flap preservation and flap removal in success rate but the preservation of both lacrimal and mucosal flaps aids in reducing the post-operative granuloma development.

Keywords: Epiphora; endoscopic dacrycystorhinostomy; (EDCR) flap; lacrimal sac.


How to cite this article:
Alharbi F, Kamel S, El-Zuraiqi B. Impact of Flab Technique Versus Non-Flap Techniques on Endoscopic Dacryocystorhinostomy. Saudi J Otorhinolaryngol Head Neck Surg 2018;20:46-8

How to cite this URL:
Alharbi F, Kamel S, El-Zuraiqi B. Impact of Flab Technique Versus Non-Flap Techniques on Endoscopic Dacryocystorhinostomy. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2018 [cited 2021 Apr 21];20:46-8. Available from: https://www.sjohns.org/text.asp?2018/20/2/46/273920




  Introduction Top


Bilateral epiphora is not uncommon clinical problem faced in rhinology and ophthalmology clinics. The gold standard solution for epiphora caused by lacrimal duct stenosis or obstruction is dacryocystorhinostomy. Dacryocystorhinostomy(DCR) is a commonly performed operation in which the lacrimal sac is directly connected to the nasal cavity via artificial fistula to alleviate epiphora caused by naso-lacrimal duct obstruction [1]. Toti is the father of DCR [2], who introduced the external DCR in 1904, which was the standard procedure to treat nasolacrimal duct obstruction (NLDO) for more than 80 years [3]. But with the improvement of endoscopic visualization, the endonasal approach of dacryocystorhinostomy has gained popularity. It was introduced in 1893 by Caldwell but because of poor endonasal visualization at that time and higher rate of complications, the procedure was discontinued [4]. The rapid innovation in endoscopic endonasal procedures in the last forty years and the better understanding of nasolacrimal anatomy with the introduction of the computed tomographic imaging re-illuminates the procedure to be the treatment of choice for NLDO [5]. The success rate reported in the early series of endonasal DCR was 60% to 84% [6]. Many techniques have been developed to improve the success rate and decrease the post-operative complication. The preservation and removal of lacrimal and mucosal flaps are proposed for better exposure and decrease the postoperative granuloma development. Our study focused on comparing these techniques but on the same patient.


  Patients and Methods Top


We conducted a prospective randomized trial in patients with bilateral nasolacrimal duct obstruction, comparing the two techniques to avoid inter-patient variability, and reported our results. After taking the ethical committee clearance we included all patients with bilateral epiphora, excluding unilateral, previously operated or recurrent cases.

We selected the side to operate with a random process. The randomly selected side was operated flap technique. We operated the contralateral side, at least 4 months after the first surgery, with no-flap technique.

Success was defined post operatively by relief of epiphora subjectively, and objectively by assessment of the ostium with the endoscope in the clinic. We also confirmed the patency of the ostium by using the fluorescein dye.


  Result: Top


One hundred patients, fifty females and fifty males with bilateral epiphora due to naso-lacrimal duct obstruction were operated upon by endoscopic DCR with or without flap technique. Their age ranged from 22 to 59 years (Median age = 41.5 year). The patients were followed up for at least 6 months following operative intervention. Out of 100 endoscopic DCR procedures with flap technique, only 3 had recurrent epiphora with stenosis of the ostium on endoscopic examination and failed fluorescein dye test. In contrast, 4 procedures without flap failed as evident by recurrent epiphora, endoscopic and fluorescein dye test criteria (Pearson’s χ2= 0.148, degrees of freedom: 1, p= 0.7)[Table 1]
Table 1: Chi Square Test

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  Discussion: Top


EDCR is recognized as a valid method for treating NLDO. This methods have shown EDCR to be safe and effective procedure when performed bilaterally and simultaneously. The authors of this article found no statistically significant differences between the two procedures. Many studies on endoscopic endonasal DCR with the variable techniques have been published in the last 25 years since the first paper published by with complete removal of both flaps after 6 months follow up. These success rates are comparable with reported success rates in both external DCR and endonasal powered DCR. Jin et al. reported success rate of 96% in their technique of endoscopic DCR with flap preservation and anastomosis [8]. In the other side, the reported success rate of external DCR is above 95% [6]. The external DCR was the treatment of choice for NLDO in the entire last century. But 10.8% of those undergoing Ext-DCR reported a cosmetically unacceptable result represented in external scar which is one of the withdrawal of the External DCR [9].

Tsirbres and Wormald divided the endonasal approaches into two main categories: Laser-assisted and mechanical. The mechanical approach is divided into powered and non-powered [10]. The best success rate achieved by powered technique was 91 % and it was varied with the other techniques between 77 – 89 %.[5],[9],[10],[11],[12].

In many studies the main cause of lower success rate in endoscopic endonasal approaches is related to many factors; the most common are size of endonasalostium at anastomosis and after the healing of endonasal fistula, the formation of granulation tissue post operatively and the location of osteotomy [13].

McDonough and Meiring in 1989, but few l were prospective studies.There is no study in the English literatures comparing the two different techniques in the same patient [7]. The aim of our study was to avoid the interpersonal variation in comparing the patient who underwent endoscopic mechanical dacryocystorhinostomy (EM-DCR) with preserving both the lacrimal and mucosal flap on one side and removal of both flaps in the other side of the same patient.

In our study we report a success rate of 97% in EM-DCR with preserving the flaps and 96% in counter side Linberg et al reported that the final size of the healed ostium was approximately 2% of the size of the surgical anastomosis. But he stated that the results fail to support the widely accepted principle that the larger the surgical anastomosis, the larger the resultant ostium, which in turn increases the rate of the procedure’s success [14]. Three patient had failures in both sides as reported above in our results [Table 1]. The failed cases are most likely due to patient factors like functional epiphora rather than mechanical obstruction. One patient got unilateral failure, in the side of removed flaps and this patient developed post-operative granuloma around the fistula and it healed with stenosis of the ostium. There were 20 cases developed post-operative granulation tissue around the fistula, 17 of them in the flaps removed side and 3 only in the flaps preservation side. All of these cases were treated using intranasal steroid spray and topical ocular steroids. Ali et al concluded in his series after reviewing 47 cases with granuloma development post dacryocystorhinostomy that early Detection of granulomas and appropriate management using intranasal and ocular steroids may aid in better outcomes [15].

The development of granuloma is less in the flap preservation side as notes in our series. Our techniques, one side involved the creation of a large bony ostium and incision in the middle of the medial sac wall, reflecting two flaps anteriorly and posteriorly and apposing with nasal mucosal flap. The other side of the same patient involved complete removal of the nasal mucosal and lacrimal flaps creating large opening in the medial wall of lacrimal sac.

Tsirbar and Wormald stated that the key to successful endoscopic DCR is to fully expose the lacrimal sac and marsupilise it into the lateral nasal wall, with the nasal and lacrimal mucosa in apposition allowing healing by primary intention rather than formation of granulation tissue, reducing the risk of closure of the sac opening into the nose [10].

Conclusion:

There is no difference between DCR with flap preservation and flap removal in success rate but the preservation of both lacrimal and mucosal flaps aids in reducing the post-operative granuloma development.

Conflict of Interest: The author declares that there is no conflict of interest.



 
  References Top

1.
Wormald PJ. Powered endoscopic dacryocystorhinostomy. Laryngoscope. 2002;112:69-72.  Back to cited text no. 1
    
2.
Toti A. Nuovametodoconservatore di curaradicaledellesuppurazionicroniche del saccolacrimale (dacriocistorinostomia). Clin Mod Firenze. 1904;10:365-387.  Back to cited text no. 2
    
3.
Chen D1, Ge J, Wang L, Gao Q, Ma P, Li N et al. A simple and evolutional approach proven to recanalise the nasolacrimal duct obstruction.Brit J Ophthalmol. 2009 Nov;93(11):1438-43.  Back to cited text no. 3
    
4.
Caldwell GW. Two new operations for obstruction of the nasal duct with preservation of the canaliculi. Am J Opthalmol. 1893;10:189-92.  Back to cited text no. 4
    
5.
Wormald PJ, Kew J, Van Hasselt A. Intranasal anatomy of the nasolacrimal sac in endoscopic dacryocystorhinostomy. Otolaryngol Head Neck Surg. 2000 Sep;123(3):307-10.  Back to cited text no. 5
    
6.
Huang J, Malek J, Chin D, Snidvongs K, Wilcsek G, Tumuluri K, et al. Systematic review and metanalysis on outcomes for endoscopic versus external dacryocystorhinostomy. Orbit. 2014 Apr;33(2):81-90.  Back to cited text no. 6
    
7.
McDonogh M, Meiring JH. Endoscopic transnasaldacryocystorhinostomy. J Laryngol Otol. 1989;103:585-7.  Back to cited text no. 7
    
8.
Jin, Hong-Ryul, Je-YeobYeon, Mi-Young Choi. “Endoscopic dacryocystorhinostomy: creation of a large marsupialized lacrimal sac.” J Korean Med Sci. 2006;21.4: 719-723.  Back to cited text no. 8
    
9.
Kinsely A, Harvey R, Sacks R. “Long-term outcomes in endoscopic dacryocystorhinostomy.” Current Opinion Otolaryngol Head Neck Surg. 2015;23: 53-58.  Back to cited text no. 9
    
10.
Tsirbas A, Wormald P J. “Endonasaldacryocystorhinostomy with mucosal flaps.” Am J Ophthalmol. 2003;135.1: 76-83.  Back to cited text no. 10
    
11.
Linberg JV, Anderson RL, Busted RM, Barreras R. Study of intranasal ostium external dacryocystorhinostomy. Arch Ophthalmol. 1982;100:1758-1762.  Back to cited text no. 11
    
12.
F Codère , l Denton P, C Jorge . “Endonasaldacryocystorhinostomy: a modified technique with preservation of the nasal and lacrimal mucosa.” Ophthal Plastic Reconstr Surg.2010; 26.3: 161-164.  Back to cited text no. 12
    
13.
Roithmann R1, Burman T, Wormald PJ. Endoscopic dacryocystorhinostomy. Braz J Otorhinolaryngol. 2012 Dec;78(6):113-21.  Back to cited text no. 13
    
14.
Linberg JV, Anderson RL, Busted RM, Barreras R. Study of intranasal ostium external dacryocystorhinostomy. Arch Ophthalmol. 1982;100:1758-1762.  Back to cited text no. 14
    
15.
Ali M J, Wormald P J, Psaltis A J. The DacryocystorhinostomyOstium Granulomas: Classification, Indications for Treatment, Management Modalities and Outcomes. Orbit. 2015;34, 1-6.  Back to cited text no. 15
    



 
 
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