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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 20  |  Issue : 2  |  Page : 135-137

A comparative study of the results of endoscopic dacryocystorhinostomy with and without stent placement


1 Department of ENT, INHS Kalyani, Visakhapatnam, Andhra Pradesh, India
2 Department of ENT, INHS Asvini, Mumbai, Maharashtra, India

Date of Submission02-Jun-2018
Date of Acceptance06-Sep-2018
Date of Web Publication10-Jan-2019

Correspondence Address:
Surg Cdr Rahul Naga
Department of ENT, INHS Asvini, Mumbai - 400 005, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmms.jmms_31_18

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  Abstract 

Background: Nasolacrimal duct (NLD) obstruction is a common clinical entity encountered both by ophthalmologists as well as otorhinolaryngologists. Endoscopic dacryocystorhinostomy (DCR) has emerged as a gold standard surgery for treatment of this disorder. Silicone stents are often promoted as agents to maintain patency of surgically created fistula during postoperative period in this surgery. Aim: The aim of this study is to evaluate and compare the outcomes of endoscopic DCR with and without silicone stenting. Materials and Methods: A prospective observational study was conducted. Totally 50 patients with acquired NLD obstruction were enrolled in the study and were randomly assigned to two groups: Group I underwent the surgery with silicone stent placement while the Group II underwent the surgery without stent placement. The patients were evaluated in terms of relief of symptoms and postoperative complications. Results: The overall success rate for endoscopic DCR in this study was 90% which is comparable with the reports in the literature. Success rate for patients with placement of stent was 92% and without stenting was 88%. However, there was no significant statistical difference between the two groups. Conclusion: Use of silicone stents does not influence results of Endoscopic DCR.

Keywords: Endoscopic dacryocystorhinostomy, nasolacrimal duct obstruction, silicone stent


How to cite this article:
Raghav MG, Naga R, Raghavan D. A comparative study of the results of endoscopic dacryocystorhinostomy with and without stent placement. J Mar Med Soc 2018;20:135-7

How to cite this URL:
Raghav MG, Naga R, Raghavan D. A comparative study of the results of endoscopic dacryocystorhinostomy with and without stent placement. J Mar Med Soc [serial online] 2018 [cited 2019 Mar 25];20:135-7. Available from: http://www.marinemedicalsociety.in/text.asp?2018/20/2/135/249760


  Introduction Top


Inflammation of nasolacrimal drainage system is common disorder leading eventually to obstruction of the drainage pathway. With the development of nasal endoscopes, and better illumination sources endoscopic dacryocystorhinostomy (DCR) has become a popular and well-established procedure for patients with obstruction of the lacrimal system.[1] The major advantage of endoscopic DCR is avoidance of scar and maintenance of pump mechanism of orbicularis muscle.[2] The literature reports success rates of this surgery ranging from 50% to 97% and the results have been influenced by technique and use of silicone stents.[3],[4] Causes of failure of endoscopic DCR are mainly due to stenosis of the neo-ostium as a result of scarring or fibrosis at mucosal/submucosal level. To enhance the success rate of DCR, many intraoperative adjuncts have been employed. These included intraoperative use of nasolacrimal silastic stents to maintain the patency of canaliculi and neo-ostium by preventing postoperative synechiae.[5],[6] The use of silicone stents is, however, mired in controversy. Some studies suggest that these stents may themselves lead to granulations, postoperative infections, and failure of surgery.[7],[8],[9] The aim of this study was to evaluate the effectiveness of silicone stents in endoscopic DCR and to ascertain that whether it increases the success rate of surgery and avoid revisions.


  Materials and Methods Top


50 patients with acquired nasolacrimal duct (NLD) obstruction and epiphora visiting the outpatient department of our tertiary care hospital were enrolled for this study. Patients with symptomatic chronic dacryocystitis and objective evidence of NLD obstruction were included in the study. Patients with fibrosed puncta, common canalicular blockage, lid laxity, and any suspicion of underlying malignancy were excluded from the study. All patients underwent complete ocular examination by ophthalmologist to rule out associated ocular pathology. They also underwent anterior rhinoscopy followed by endoscopic nasal examination to exclude any local nasal pathology such as chronic rhinosinusitis, nasal polyposis, and gross DNS to assess the adequacy of space for endoscopic surgery.

Sac syringing was done in all cases to confirm the level of obstruction in nasolacrimal system. A blunt lacrimal needle (25 gauge) was introduced from inferior punctum and saline was injected and regurgitation of saline mixed with mucoid or mucopurulent discharge through upper punctum with a slight delay denoted NLD obstruction. This was done to exclude those patients with common canalicular block. All the patients were offered surgical line of management by endoscopic route. They were randomly assigned into two groups: Group I – with stenting and Group II – without stenting. Experienced surgeons performed all the surgeries [Figure 1]. Totally 7 surgeries were done under general anesthesia and 43 surgeries were performed under local anesthesia (LA).
Figure 1: Type of surgery

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The standard surgical technique of endoscopic DCR was adopted. Nasal decongestion with infiltration of LA 2% and 1:100,000 adrenaline and neuro-patties soaked in 4% lignocaine with 1:10,000 adrenaline was done in lateral nasal wall just superior and anterior to the attachment of middle turbinate. A 4 mm 0° or 30° nasal endoscope with CCD camera and Xenon light source was used.

Using number 15 blade, mucosal incision was made. The first horizontal incision made 8–10 mm above axilla of the middle turbinate starting about 3 mm posterior to axilla and brought about 10 mm anterior to axilla onto the frontal process of maxilla. The incision turned vertically to about 2/3rd of the vertical height of middle turbinate stopping just above the insertion of inferior turbinate into the lateral nasal wall. The incision was then continued horizontally and posteriorly till the insertion of uncinate process. The mucosal flap was raised posteriorly and elevated backward off the maxillary bone up to uncinate process. In the middle meatus, the lacrimal bone was exposed; a round knife was used to elevate the lacrimal bone off the thin posterior inferior region of the sac. The thick bone of frontal process of maxilla was removed with Kerrison Rongeur to the extent of approximately 1.0 cm × 1.5 cm and lacrimal sac was exposed. A 2.5 mm diamond burr was also used in 15 patients to remove the bone where it was found to be too thick for removal with rongeurs.

A punctum dilator was used to dilate the lower punctum and a Bowman's lacrimal probe was placed through the inferior canaliculus into the lacrimal sac. The sac wall was indented against it. Once the sac was identified and confirmed, it was incised with a number 12 blade or a sickle and the presence of mucopurulent material within sac and escaping into the nasal cavity was confirmatory of chronic dacryocystitis. The incision was extended to the top of the sac till the probe was seen coming through the common canaliculus. A large flap was made and rotated onto the frontal process of the maxilla. The original mucosal flap that was raised was trimmed and adjusted in size to cover the denuded bone surrounding the opened sac. The lacrimal sac flaps were incised, everted, and adjusted to accurately appose the nasal mucosa.

Patients in Group I underwent bicanalicular Silastic tube stenting. The silastic stent was passed through upper and lower lacrimal punctum into the sac and grasped with straight Blakesley–Wilde forceps endoscopically. The parts of the stent within the eye were kept a little loose so as to prevent damage to lacrimal puncta and the medial caruncle (preventing cheese writing). The stent was kept for a minimum of 6 weeks duration. This procedure was employed in 25 patients assigned to undergo nasolacrimal intubation. In patients assigned to Group II, sac syringing was done to confirm the flow of normal saline into the nasal cavity through the neo-ostium.

All patients were followed up to 6 months postoperatively. Sac syringing was done at regular intervals in patients who were not stented, weekly for 1 month then once after every 2 weeks for 2nd month after surgery. Sac syringing was performed during every visit to verify the patency of ostium along with nasal endoscopy to remove crusts and debris from ostium gently. Tear meniscus level was measured using a slit lamp by the ophthalmologist. In patients undergoing stenting, stent was removed after 6 weeks and sac syringing was done to confirm the patency. The surgical outcome was evaluated both subjectively and objectively. In subjective assessment, patients were asked to grade the degree of epiphora relief on a scale described by Munk et al.[10]


  Results Top


In objective assessment, sac syringing was performed with simultaneous nasal endoscopy and saline dropping into nasal cavity was observed. Tear meniscus level was measured using slit lamp. The results were documented and studied. Postoperative patency of sac [Table 1] and level of tear meniscus on slit lamp [Table 2] were used to analyze the success of surgery. The results were analyzed using Chi-square test on the two groups. The success rate in 25 cases that had undergone endoscopic intranasal DCR with stent placement was 92%; only two patients had failure [Table 1]. Totally 25 patients undergoing DCR without stent had 88% success rate [Table 1]. Three patients had surgery failure. Few minor complications were noted in both groups which resolved with conservative measures [Table 3].
Table 1: Patency percentage of sac in both groups

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Table 2: Level of tear meniscus on slit lamp

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Table 3: Postoperative complications

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  Discussion Top


There was no significant statistical difference in both groups. The overall success rate for endoscopic DCR in this study was 90% which is comparable with the reports in the literature. Our study had limitations of relatively small sample size and involvement of multiple surgeons. The strength of this study was the standardized surgical protocol which was followed in all cases without any deviation. Based on our findings and results, it is reasonable to conclude that the endoscopic procedure of doing DCR is definitely a viable alternative in treating this condition, catering even to the need of cosmesis for the patient. This study concluded that endoscopic DCR with or without stent is a safe and effective surgery with good outcomes. Use of silicone stents was not found to have additional advantage as it increased surgery duration, increased postoperative care, and overall cost of surgery. Our study revealed that there was no significant difference in the surgical complication rate between the two groups suggesting that the use of silicone stents does not increase the risk of synechia, granulation tissue formation, and postoperative bleeding. However, at the same time, silicone stent does not seem to increase the success rate in the primary surgery.


  Conclusion Top


This study concludes that use of Silicone stents for primary Endoscopic DCR does not influence the long term outcomes, however it does lead to a significant increase in the cost of this procedure.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Unlu HH, Toprak B, Aslan A, Guler C. Comparison of surgical outcomes in primary endoscopic dacryocystorhinostomy with and without silicone intubation. Ann Otol Rhinol Laryngol 2002;111:704-9.  Back to cited text no. 1
    
2.
Leong SC, Macewen CJ, White PS. A systematic review of outcomes after dacryocystorhinostomy in adults. Am J Rhinol Allergy 2010;24:81-90.  Back to cited text no. 2
    
3.
Feng YF, Cai JQ, Zhang JY, Han XH. A meta-analysis of primary dacryocystorhinostomy with and without silicone intubation. Can J Ophthalmol 2011;46:521-7.  Back to cited text no. 3
    
4.
Callejas CA, Tewfik MA, Wormald PJ. Powered endoscopic dacryocystorhinostomy with selective stenting. Laryngoscope 2010;120:1449-52.  Back to cited text no. 4
    
5.
Gu Z, Cao Z. Silicone intubation and endoscopic dacryocystorhinostomy: A meta-analysis. J Otolaryngol Head Neck Surg 2010;39:710-3.  Back to cited text no. 5
    
6.
Okuyucu S, Gorur H, Oksuz H, Akoglu E. Endoscopic dacryocystorhinostomy with silicone, polypropylene, and T-tube stents; Randomized controlled trial of efficacy and safety. Am J Rhinol Allergy 2015;29:63-8.  Back to cited text no. 6
    
7.
Saeed BM. Endoscopic DCR without stents: Clinical guidelines and procedure. Eur Arch Otorhinolaryngol 2012;269:545-9.  Back to cited text no. 7
    
8.
Unlu HH, Gunhan K, Baser EF, Songu M. Long-term results in endoscopic dacryocystorhinostomy: Is intubation really required? Otolaryngol Head Neck Surg 2009;140:589-95.  Back to cited text no. 8
    
9.
Al-Qahtani AS. Primary endoscopic dacryocystorhinostomy with or without silicone tubing: A prospective randomized study. Am J Rhinol Allergy 2012;26:332-4.  Back to cited text no. 9
    
10.
Munk PL, Lin DT, Morris DC. Epiphora: Treatment by means of dacryocystoplasty with balloon dilation of the nasolacrimal drainage apparatus. Radiology 1990;177:687-90.  Back to cited text no. 10
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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