External Versus Endoscopic Dacryocystorhinostomy: A Retrospective Study

Abstract

IntroductionN ormal drainage of tear from the conjunctival sac into the nose is dependent on patency of the naso lacrimal passage that includes the lacrimal puncta, the lacrimal canaliculi, the common canaliculus, the lacrimal sac and the nasolacrimal duct, which opens into the inferior meatus of the nose. Blockage of any portion this passage, from puncti down to the nasolacrimal duct, by inflammation and scarring, trauma, stone or neoplasm results in epiphora. In cases of obstruction of the nasolacrimal duct dacryocystorhinostomy (DCR) has been the standard surgical recourse. This operation is designed to drain the tears and the infected secretion from lacrimal sac into the middle meatus of the nose through an ostium in the lacrimal bone and the nasal mucosa. Toti originally described dacryocystorhinostomy (DCR) in 1904 [1]. Since then DCR surgery through an external approach has been the gold standard for the treatment of nasolacrimal duct obstruction with a success rate of over 90% [2]. Endoscopic dacryocystorhinostomy (endoscopic DCR), performed through an intranasal route was first described by McDonogh in 1989 [3]. Since then various workers [4,5] have published their experiences with endoscopic DCR from time to time. We share our experience with external and the endoscopic DCR in a retrospective study. Material and MethodsA retrospective study was conducted on a total of 103 cases of nasolacrimal duct obstruction treated by us. A total of 51 cases (55 sacs) treated by external DCR and 52 cases (54 sacs) treated by endoscopic DCR were included. Patients having epiphora due to chronic nasolacrimal duct obstruction resulting from chronic dacryocystitis with or without mucocoele were included in the study.Cases of canalicular or common canalicular obstruction, lid laxity, previous lacrimal surgery, cases with suspicion of malignancy, previous radiation therapy, posttraumatic lids / bony deformity were excluded from the study. A record of complete ophthalmic and rhinological examination was considered.External DCR: All surgeries were performed under local anaesthesia by infiltration of the area around the lacrimal sac with 2% xylocaine with adrenaline 1 in 100,000. Nasal packing was done with gauze socked in 4% xylocaine and 1 in 100,000 adrenaline. In all the cases both the anterior and posterior lacrimal sac flaps were sutured with the nasal mucosa. The External Versus Endoscopic

Comparison of external and endoscopic endonasal dacryocysto-rhinostomy: a hospital based retrospective study

“…Premature spontaneous tube extrusion, and granulation tissue formation around the ostium is a common phenomenon following STI-implantation, as reported by several studies, and believed to be one of the major reason of failure in DCR surgeries. 9 In our study, mean duration of STI removal in all cases was 3.4±0.2 months, which corresponds to the other studies as well, where authors reported that, STI placement for more or less than 3 months, can act as either nidus for infection and granuloma formation, or may lead to failure of surgery, respectively. 18 Although, we have found STI an exceptionally valuable tool especially in revision cases, but simultaneously we believe that it adds extra cost to the surgery and increases surgical failure chance by of forming granulation tissue around the rhinostomy site, hence we emphasize this should be used judiciously in selected cases only.…”

“…[5][6][7] It is heartening that, surgical success after revision DCR surgeries following failed primary surgeries (total n=8; Ex-DCR n=3, En-DCR n=5) in our series was 100% in both the groups, although reported success rates varies into a large extent in this regard, ranging from 75 to 97%. 9,10 The reason for such discrepancy may be because of larger cohort of revision cases and differing study design, as compared to us.…”

“…9,13 We kept our maximum follow up time up to 6 months, as literature reports most While performing En-DCR, along with additional surgeries in patients with additional intranasal disease (n=18) or in the opposite side in patients with bilateral NLDO (n=5), simultaneously in the same sitting, we had a feeling of its advantage over Ex-DCR in reducing the cost, duration of hospital stay, risk of anesthesia, and saving the time for the patient by minimizing follow up visits, as agreed by several authors. 8,14 Special operative steps adopted by us during Ex-DCR by preserving MCT and suturing of anterior flaps alone, which were aimed to prevent iatrogenic telecanthus and to save the total operative time, respectively does not have any impact in attainment of final reasonably good surgical success (94.54%), which is corroborative to the findings by several authors.…”

Endoscopic Dacryocystorhinostomy with Flap Suturing

“…In effect any new technique must compare favourably to external DCR which having been present for 100 years must be regarded as the gold standard. The reported success rate of external DCR have varied but have often been reported as over 90% in many specialist lacrimal units [8,9].…”

Comparison of balloon dacryocystorhinostomy with conventional endonasal endoscopic dacryocystorhinostomy for relief of acquired distal nasolacrimal drainage obstruction and its impact on quality of life: A prospective, randomized, controlled study

“…The external approach of DCR (Ext DCR) described by Toti in 1904 had been the gold standard in the past, but with improvements in the endoscopes, now endoscopic endonasal approaches are becoming popular; especially among ENT surgeons due to shorter operative time, low complications, an absence of visible scar and high success rate which has been quoted as 95-100% in previous studies. 2,3 The conventional technique of endoscopic endonasal DCR (End DCR) 4,5 has undergone many modifications. These include the use of stents, newer flaps, and mucosal preservation methods, local application of mitomycin C (MMC), use of powered instruments like drills and micro-debriders, use of lasers, radiofrequency, composite technique and balloons.…”