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Endo-DCR is a safe, quick, less traumatic, with minimal blood loss and post-operative discomfort and last but not the least, avoids external scar. It has high success rate in both primary and secondary cases. Fifty two cases of chronic dacryocystitis were treated by the endoscopic technique including 33 females and 19 males in mean age group 35.8 year, 29 left eye and 23 right eye with 8 patients cannulated with nasolacrimal tube with very good results and few complications.
[J Indian Med Assoc 2008; 106: 228-31]
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Key words : Endo-DCR, external DCR, chronic dacryocystitis.
Endoscopic endonasal dacryocystorhinostomy (Endo-
DCR) is gaining popularity as the procedure leaves no external facial scar and it can be performed even in cases of lacrimal abscess1. This procedure is performed to connect the lacrimal sac to nasal cavity when the nasolacrimal duct or lacrimal sac is obstructed. It is an alternative approach to conventional external DCR, because of close anatomical relationship of lacrimal sac and lateral wall of nasal cavity2. Although a high success rate of conventional DCR in the range of 85-90% is reported, however, it has several disadvantages like cutaneous scar formation, potential injury to adjacent medial canthal structure (eg, medial canthal tendon), immediate post-operative morbidity (eg, peri orbital ecchymosis and epistaxis) and delayed post-operative morbidity (eg, intranasal scarring with obstruction of DCR and/or sinus ostia leading onto recurrent lacrimal obstruction or sinusitis or both)3,4. The search for an alternative to external approach is motivated by the desire to improve DCR success rates with better cosmetic results.
Material and Method
This study was conducted in fifty two cases of chronic dacryocystitis which were referred by eye surgeon between 2000-2005. Endo-DCR was performed in patients of nasolacrimal duct blockage, who were refractory to conservative medical treatment. A detailed history was taken about persistent watering and recurrent muco purulent discharge, recurrent pain in medial aspect of eyes and swelling over lacrimal sac area, congestion of eye ball, regurgitation on pressure over sac area and facial trauma.
Examination
General physical, eye and ENT examination was done to arrive at tentative diagnosis of nasolacrimal pathway obstruction. Systemic disorders like hypertension, tuberculosis and diabetes were ruled out. The diseases which are known to cause lacrimal system blockage like lacrimal sac malignancy, severe bony deformity of lacrimal fossa (post-traumatic), acute infections of conjunctiva and fossa (post-traumatic), acute infections of conjunctiva and sac and lacrimal sac tuberculosis were excluded from the study.
Diagnosis
Diagnosis was confirmed after syringing and irrigation of lacrimal canaliculi with a 23/26 gauge, lacrimal cannula.
Operative Technique
In all patients endo-DCR, was done under local anaesthesia after premedication with pethidine 50 mg and phenargan 25 mg intramascular half an hour prior to surgery. General anaesthesia was given in three children. Nasal cavity was anaesthetised with cottonoid soaked in 4% lignocaine with xylometazline HCI O.1% for about 15-20 minutes. This gave easy access, mucosal anaesthesia and bloodless field.
Proper Lying Position
of the Patient
The patient was made to lie down in supine position with head end elevated by 10-15 degree to reduce the venous pressure. External aspect of nose was cleaned with full concentration (5%) povidone- iodine solution and 1:10 dilution of the same solution was instilled in the eye (two drops every minutes for five minutes). Head was tilted towards the surgeon.
Steps of Operation
Under direct endoscopic vision the anterior end of middle turbinate and the area of lateral nasal wall just anterior and superior to it was infiltrated with 2% xylocaine solution with adrenaline (1: 30000) submucosally till blanching of the area occurred.
Incision
Incision in mucosa of the wall just anterosuperior to anterior attachment of middle turbinate on lateral wall was made with sickle knife and carried down to the bone, in-U-shaped manner and piece of mucosa 1 cm x 1.5 cm was removed. The bone that came into view was the frontal process of maxilla which was drilled out with the help of burr and lacrimal sac was widely exposed.
Topical Anaesthesia
Topical 2% lignocaine drops was instilled in the eye. Lower punctum was dilated with the help of punctum dilater and a lacrimal probe was passed through the lower punctum into the sac directed medially into obstructed lacrimal sac, which made a tent on the lateral nasal wall. Two parallel vertical incisions were made with sickle knife on the medial wall of the lacrimal sac, and the area between the two incisions was removed. Syringing was done on the table using normal saline fortified with amikacin solution (500 mg in 20 ml), to confirm the patency. In failed cases a silastic tube was put into upper and lower canliculi into nasal cavity and was tied in fashion of multiple knots. The operated nasal cavity was filled with medicated pack which was removed after 24 hours. Post-operatively, patients were instructed to put amikacin eye drops to facilitate drainage. The nasal cavity was examined and cleaned off crusts if any. Nasal irrigation with saline was started on the next day. Patients were asked not to blow their nose for 4-5 days after the surgery.
Post-operative Evaluation
Post-operative evaluation was done at 2 weeks, 1,2,4 and 6 months after the surgery and on each visit syringing with antibiotic and cleaning of nasal cavity for any crusts was done
Observations
Out of fifty two patients, there were 33 females and 19 males. The mean age was 35.8 (range 11-64 years). Mean duration of epiphora was 1.6 year (2 months-6 years), 29 being on left and 23 on right side. The silicon-stent (silastic tube) was introduced in 8 patients and kept in situ for 2 months. In all patients post-operatively syringing revealed patent DCR except one, who had a lower canaliculi blockage where upper canaliculi was cannulated with lacrimal cannula for 3 months and epiphora cleared. Three cases developed ecchymosis which subsided after 10 days.
Discussions
External DCR is practised by eye surgeons, since its description by Toti in 1904. DCR consists of making a passage between lacrimal sac and middle meatus of the nose, to re-establish tear flow from lacrimal sac to nasal cavity. Caldwell also described the endonasal DCR in which a portion of inferior turbinate bone was removed and nasolacrimal canal was followed to lacrimal sac5. Endoscopic endonasal DCR was first reported by Rice (1990) in cadavers6. MacDonagh and Meiring (1989) studied anatomical relationship of lacrimal sac and nasolacrimal duct to lateral wall of nose2. They also described the relation of superior border of lacrimal sac above the middle turbinate, anterior attachment lateral to agar nasi cells. There are many causes of naso lacrimal duct system blockage like chronic dacryocystitis, lacrimal abscess, mucocele and failed external DCR7-8. The success rate of external DCR has been reported at 90-97% depending upon the surgeon’s experience1. Many workers conducted studies on endo DCR with different success rates which ranged from 82 – 86% 9. The authors' success rate of endo-DCR was 100% although it is small study. Some workers also published the study on success rate of endo-DCR in failed external DCR and used YAG laser in endo-DCR and reported superior results10. It is much better in revision cases. Endo-DCR is known for many advantages like safety ease of performance, economy, no facial scar, no injury to medial canthal tendon, no peri-orbital ecchymosis and epistaxis11. Post-operative care like meticulous clearing of the debris and early repeated irrigation with sodium bicarbonate is mandatory for good results. Anti meta bolitic agents like 5-FU and mitomycin-C are known to inhibit human tenon’s capsule fibroblast proliferation, hence a single intraoperative application of 5-FU has been used with good outcome, however, the authors didn’t use 5-FU in any case. The results of endo-DCR reflect the effect of a learning curve associated with the introduction of a new procedure, hence there is difference in the success rate of earlier studies as compared to latter one. In patients with failed endo-DCR, a revision endo-DCR can be done by just removal of fibrotic tissue from operated area. In the authors' study only one case who complained of recurrent discharge post-operatively was also cured after cannulation through upper punctum as also reported by others1,11. External DCR has a failure rate ranging from 3-15% and revision surgery has a very poor success rate, however, revision faces the dilemma of reopening of external incision and attempt is to create lacrimal drainage through an already scarred surgical field3. Revision endo- DCR was found to have good success rate in literature2-3. There are many advantages of Endo-DCR, but certain limitations like the need of sophisticated equipments including endoscopes and sometimes intra operative intranasal bleeding may make this procedure difficult. This technique should be attempted only by those with extensive experience with endoscopic nasal surgeries11. Minor reported complications include injury to anterior nares by the drill shaft, synechia formation and ecchymosis of eye. References
1 David S, Raju R, Job A and Richard J — A comparative study of external and endoscopic endonasal dacryocystorhinostomy - a preliminary report. Indian J Otolaryngol Head Neck Surg 1999; 52: 37-9.
2 Mcdonagh M and Meiring JH — Endoscopic transnasal dacryocystorhinostomy. J Laryngol Otol 1989; 103: 585-7.
3 Metson R — The endoscopic approach for revision dacryocystorhinostomy. Laryngoscope 1990; 100: 1344-7.
4 Shunshin GA and Thurairajan G. External dacryocystorhinostomy and end of an era? Br J Ophthalmol South Asia 1998; 1: 11-2.
5 Cunningham MJ and Woog JJ — Endonasal endoscopic dacryocystorhinostomy in children. Arch Otolaryngol Head Neck Surg 1998; 124: 328-33.
6 Rice DH — Endoscopic intransal dacryocystorhinostomy, results in four patients. Arch Otololaryngol Head Neck Surg 1990; 116: 1061.
7 Sprekelsen MB, Barberan MT — Endoscopic dacryocystorhinostomy : surgical technique and results. Laryngoscope 1996; 106: 187-9.
8 Linberg JV and McCormick SA — Primary acquired nasolacrimal duct obstruction. A clinicopathologic report and biopsy technique. Ophthalmology 1986; 93: 1055-63.
9 Jokinen K, Karja J — Endonasal dacryocystorhinostomy. Arch Otolaryngol 1974; 100: 41-4.
10 Hehar SS, Jones NS, Sadiq SA and Downes RN — Endoscopic holmiun: YAG laser dacryocystorhinostomy - safe and effective as a day case procedure. J Laryngol Otol 1997; 111: 1056-9.
11 Nayak et al — Endoscopic dacryocystorhinostomy and retrograde nasolacrimal duct dilation with cannulation: our experience. Indian J Otolaryngol Head & Neck Surg 1999; 52: 23-7.
Bharat ENT & Endoscopy Hospital, Haryana 127021
*MS (Otorhinolaryngol), Director
**MS (Otorhinolaryngol), Associate Professor, Pt BD Sharma Postgraduate Institute of Medical Sciences, Haryana 124001
***MS (Ophthalmol), Medical Officer
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