Outcome of primary endoscopic dacrocystorhinostomy with and without stent: a randomised prospective study

INTRODUCTION

Dacrocystorhinostomy (DCR) is a surgical procedure which involves diversion of lacrimal flow into nasal cavity by creating an opening at the level of lacrimal sac. DCR addresses the obstruction of lacrimal secretion at the level of lacrimal sac and nasolacrimal duct. There are several causes of obstruction, such as trauma, infections, neoplasms, or systemic diseases, although the vast majority of cases are due to idiopathic inflammation.¹ This operation can be performed by both external and intranasal approach. This was first described via an external approach by Toti in 1904.² The first intranasal DCR was described by Caldwell in 1983.³ In 1989, McDongh and Meiring described the endoscopic transnasal DCR.⁴ The introduction of endoscopes with different degrees of angulation for endoscopic sinus surgery led to widespread use of endoscopic endonasal DCR (EDCR). The results of EDCR are not only encouraging, but are associated with many other additional advantages e.g. avoidance of facial scar, preserves the pumping mechanism of orbicularis oculi muscle, better visualisation resulting in less intraoperative trauma and blood loss, reduced operative time, simultaneous nasal surgeries for other nasal pathologies are possible and revision DCR is easy.⁵ Lacrimal abscess in acute phase can be operated endoscopically. This is one of the most important advantages of endoscopic DCR. Many modifications like LASER assisted endoscopic DCR, use of silicon tube for stenting, mitomycin-C application etc. have been described. However, insertion of silicon stent in endonasal DCR is most commonly used procedure.⁶ Many surgeons claim that use of silicon stent improves success rate of endoscopic DCR. On the other hand, some studies indicate that silicon stent itself is a reason for surgical failure.⁷ The present study was done to compare surgical outcome and complication of endoscopic DCR with and without silicon stent.

METHODS

This study was conducted at Department of ENT, MRA Medical College, Ambedkar Nagar, UP from July 2015 to July 2016. Seventy cases were selected from outpatient department of ENT and ophthalmology who presented chronic epiphora regardless of age and gender. Out of 70 cases (49 female, 21 male) who underwent EDCR; of which 20 cases had undergone bilateral EDCR, so total 90 EDCR were performed. All patients were jointly evaluated by ophthalmologist and otolaryngologist. Pre-operative evaluation consisted of standard relevant eye and ear-nose-throat (ENT) examination, including regurgitation test, irrigation of lacrimal pathway and endoscopic examination of nasal cavities.

Inclusion criteria

Epiphora due to nasolacrimal duct obstruction and chronic dacryocystitis.

Exclusion criteria

Absent both upper and lower punctum, lid laxity leading to displacement of punctum, previous lacrimal surgery, traumatic or congenital bony deformity

Informed consent was obtained by all selected patients. Other causes of epiphora were excluded. The patients were divided into two groups. Group A included 40 patients (15 cases bilateral; so total 55 EDCR) in which intra-operative lacrimal stent was not inserted. Group B included 30 patients (5 bilateral; so total 35 EDCR) where intra-operatively silicon stent was inserted. All patients were operated under local anaesthesia except 5 cases (age <15 years) general anaesthesia were used.

Surgical technique

The surgical procedure was similar in all patients. All procedures were performed by the same surgeon. The nose was packed with 4% xylocaine 10 minutes before surgery. After de-congestion of nasal mucosa, nasal cavities were examined by 0⁰ rigid nasal endoscope attached to video camera. Those patients in which septal deformity was obstructing the view of operative site, endoscopic septoplasty was performed before starting DCR. 2% xylocaine with 1:100,000 adrenaline.was injected to the lacrimal sac area. A 'C' shaped incision was given with sickle knife on the lateral nasal wall along the maxillary line just anterior to the anterior end of middle turbinate. A posteriorly based mucosal flap was created using freer’s elevator and frontal process of maxilla and lacrimal bone identified. Kerrisson punch was used to remove the bone and lacrimal sac was visualised. Medial wall of sac incised with help of sickle knife and by using endoscopic scissor medial wall of sac was removed. A window is made the mucosal flap in the region of sac and rest of mucosa repositioned. Lacrimal probing was done in every case. A bicanalicular silicon stent was put in Group B patients. In Group A patients silicon stent was not used. Nasal packing was done in those cases in which bleeding were anticipated. Mean time of surgery was 30 minutes in one side. Patient was discharged on third day postoperative day after removing nasal pack if used. Syringing was done just prior to discharge and subsequently at every follow up. Postoperatively oral antibiotic (amxycillin-clavulanic acid) and analgesic were given for 05 days. Antibiotic eye drop (Ciplrofloxacin-Dexamethasone) and nasal saline drops for 04 weeks. The patients were followed at interval of 1 week, 2 week, 1 month, 3 months and 6 month post-operatively and data were entered, stored, and analyzed using SPSS statistical software (version 16) using the chi-square test. P<0.05 was considered significant.

RESULTS

Seventy patients (49 female and 21 male) had undergone endoscopic DCR in which 20 cases were bilateral (so total 90 EDCR). Group-A (55 EDCR, where silicon stent was not used) included 29 female, 11 male and 15 cases bilateral. Group-B (35 EDCR, where silicon stent was put) included 20 female, 10 male and 5 bilateral cases. The age range of all cases was from 8 to 65 years with mean age 35.2 years (Table 1).

Epiphora was the predominant complain in all cases (100%), swelling of lacrimal sac in 8 patients (11.4%) and mucopurulent discharge from medial canthus in 6 patients (8.5%). No significant intraoperative complication was observed. Intra operative haemorrhage occur in 12 cases (17.1%) which required nasal packing. Post operatively ecchymosis in 9 cases (12.8%), eyelid edema in 6 patients (8.5%) and nasal bleeding in 4 cases (5.7%) was observed and managed conservatively (Table 2).

Complete relief of epiphora was observed in 50 (90.9%) out of 55 EDCR in Group-A and 30 (85.7%) out of 35 EDCR in group-B. 5 EDCR (9.1%) in group-A and 5 EDCR (14.3%) in group-B has procedure failure (Table 3).

Common cause of failure was inadequate removal of upper part of ascending process of maxilla (60.0%), granuloma formation (20.0%) and fibrosis at neo-ostium (20.0%). All failed EDCR patients underwent repeat endoscopic surgery with silicon tube insertion but not included in study. Removal of crust and lacrimal syringing was done at every follow up. Silicon stent was removed on 3 month after surgery.

DISCUSSION

Majority (70%) of our cases were females. This trend is also noted in other studies.^5,8 Probable reason for this trend is narrow lumen of nasolacrimal duct.⁹ Fifty patients (71.4%), in our study, had unilateral symptoms whereas 20 (28.7%) had bilateral symptoms. Similar trends were observed in other studies.

Our diagnostic protocol included regurgitation test, irrigation of lacrimal system and endoscopic endonasal examination. Various studies employed dacryocystography and computed tomography (CT) scan imaging.^5,8 Although these investigations can provide additional information in few selected cases, but routine use of these investigations are not required in majority of cases. Irrigation of the lacrimal system can establish correct diagnosis in majority of cases, and it is also an easy, safe and low cost investigation. An overall success rate of EDCR recorded in our study was 88.9% after 6 months of follow up. Success rate of external DCR is reported in literature 75 to 99% while success rate of EDCR without use of laser and with use of laser, little lower i.e. 77 to 83%.^7,10

We found a success rate of 90.9% and 85.7% for group A and group B respectively. The statistic evaluation among these groups does not show any significant difference (p=0.445) which means that insertion of stent in cases of primary EDCR does not significantly change the surgical outcome. Review of relevant literature suggests that there is considerable controversy regarding the use of DCR tube. According to some authors, the best endonasal DCR results can be obtained with use of DCR tube.^8,11 Stent application, associated with topical antibiotic lavage, maintains the lacrimal system open and prevents infection, resulting in a successful outcome. Some authors do not favour use of silicon stent in primary EDCR because its use increase in occurrence of DCR stenosis, granulation tissue formation, patient discomfort and extra cost.^9,12 Many are of the opinion that use of stent does not affect the success of the procedure.^5,13 Success rate of different studies is summurised in Table 4.

Our study showed that use of silicon stent in primary EDCR does not change the surgical outcome like other study.^14,15

The optimal time for silicon tube extubation is another controversy. We planned to keep the DCR tube for 3 months after the surgery. We found premature extrusion of stent in one patient and adhesion of stent in flap in another patient which require endoscopic exploration and removal. In our study common causes of failure were inadequate removal of upper part of ascending process of maxilla (60.0%), granuloma formation (20.0%) and fibrosis at neo-ostium (20.0%). Other causes of failure of EDCR are failure to localise lacrimal sac, insufficient osteotomy, bone neogenesis and insufficient opening of lacrimal sac.

CONCLUSION

Endonasal DCR without silicon stent is consider as effective, safe and minimally invasive primary procedure for treatment of nasolacrimal duct obstruction. Role of using stent in primary EDCR is not very promising because it is not improving the outcome of surgery rather it has been found cause granulation formation, add costs to surgery, discomfort to patient and sometime removal is painful. Regular follow up are require to the process of wound healing and early detection of complication leading to failure of procedure.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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