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 Table of Contents  
Year : 2015  |  Volume : 108  |  Issue : 3  |  Page : 148-152

External versus endoscopic dacryocystorhinostomy for congenital nasolacrimal duct obstruction

1 Department of Ophthalmology, Sohag Faculty of Medicine, Sohag University, Sohag, Egypt
2 Department of ENT, Assiut Faculty of Medicine, Al-Azhar University, Assiut, Egypt

Date of Submission24-Apr-2015
Date of Acceptance15-May-2015
Date of Web Publication30-Oct-2015

Correspondence Address:
Mortada A Abozaid
Department of Ophthalmology, Sohag Faculty of Medicine, Sohag University, Sohag, 82524
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2090-0686.168718

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The aim of the study was to compare the success rates between external and endoscopic dacryocystorhinostomy (DCR) surgery performed for congenital nasolacrimal duct obstruction.
Materials and methods
Fifty patients with congenital nasolacrimal duct obstruction were recruited and divided into two groups. Group 1 underwent external DCR and group 2 underwent endoscopic DCR.
Relief from symptoms and endoscopic visualization of the patent stoma were considered indexes of success: 23 patients in group 1 (92%) and 22 patients in group 2 (90%) fulfilled these criteria after 6 months of follow-up.
Both approaches of pediatric DCR - that is, external and endoscopic - have comparable success rates, although the endoscopic approach has the advantages of avoidance of skin incision, preservation of the pump mechanism, and the ability to address other nasal pathologies at the time of surgery.

Keywords: External versus endoscopic, pediatric dacryocystorhinostomy, nasolacrimal duct obstruction

How to cite this article:
Abozaid MA, Othman Y. External versus endoscopic dacryocystorhinostomy for congenital nasolacrimal duct obstruction. J Egypt Ophthalmol Soc 2015;108:148-52

How to cite this URL:
Abozaid MA, Othman Y. External versus endoscopic dacryocystorhinostomy for congenital nasolacrimal duct obstruction. J Egypt Ophthalmol Soc [serial online] 2015 [cited 2022 Sep 28];108:148-52. Available from: http://www.jeos.eg.net/text.asp?2015/108/3/148/168718

  Introduction Top

Epiphora in infants is a very common condition, affecting upto 20% of all babies [1]. This usually results from a failure of canalization of the distal end of the nasolacrimal duct with persistence of a membranous web at the level of the Hasner valve. This is called a common congenital nasolacrimal duct obstruction (CNLDO). Fortunately, over 90% of these obstructions resolve spontaneously with little or no treatment during the first year of life [2].

Nasolacrimal massage with or without probing and dilatation helps to relieve most of the obstructions. The success rate of probing decreases with increasing age of the child. The success rate at age 12 months or less is 92%, whereas success rate at age 18 months or older is only 50%. Thus, it is generally avoided after 12 months of age [3].

Pediatric dacryocystorhinostomy (DCR) is not the first line of treatment for children with symptomatic common CNLDO. It is indicated in situations when a common CNLDO is unresponsive to previous therapy (probing, intubation, or balloon dacryoplasty), or is associated with a mucocele and when the child experiences recurrent dacryocystitis [4],[5].

Such refractory cases have been historically managed by external DCR. However, the endonasal approach has recently become widely used [6],[7].

The reported success for major lacrimal surgery in children has ranged from 78.9% [8] to 96% [9].

In this prospective comparative study, we assessed the success rate of pediatric DCR and compared the external versus endoscopic approaches.

  Materials and methods Top

A prospective comparative study was carried out at both the Department of Ophthalmology of Sohag University Hospital and the ENT Department of Sohag Alhelal Hospital between June 2012 and September 2014.

Fifty children with CNLDO were included in this study. Diagnosis of nasolacrimal duct obstruction depended on clinical examination in addition to nasolacrimal duct probing and sac syringing under general anesthesia.

Only patients younger than 16 years of age with lacrimal sac mucocele or failed previous probings for isolated primary nasolacrimal duct obstruction were included in this study [Figure 1].
Figure 1: A 2-year-old child with a positive regurge test and failed previous probings in the left eye.

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The exclusion criteria included cases with canalicular obstruction, patients with lacrimal fistula, and patients with previous DCR.

Written informed consent from the parents and institutional review board approval were obtained.

The patients were randomized into two groups: the first group (25 patients) underwent external DCR and the second group (25 patients) underwent endoscopic DCR.

Surgical technique

Hypotensive general anesthesia was used in all cases. The child was positioned supine with the nose and the affected eye in the operative field. The nasal cavity and middle meatus were packed with xylometazoline HCl 0.05% (Afrin) 10 min before surgery for adequate decongestion to achieve a bloodless field.

External DCR was performed by the first author (M.A.A.) through a small (2 cm) paranasal incision. A large osteotomy was created, silicone intubation was done, and a mucosal anastomosis was fashioned by suturing (using 6/0 polyglactin sutures) both the anterior and posterior mucosal flaps. Skin closure was typically performed with absorbable interrupted sutures [Figure 2].
Figure 2: A case of external dacryocystorhinostomy (DCR) with silicone tube in place.

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Endoscopic DCR was performed by the second author (Y.O.) at 0° and/or 30° with a 2.7-mm-diameter and/or 4-mm-diameter nasal endoscope.

The lateral wall of the nose just anterior to the attachment of the middle turbinate was injected submucosally with 2% lidocaine HCl with epinephrine 1 : 100 000. A mucosal incision was made using a sickle knife starting turbinate on the lateral nasal wall (the axilla of the middle turbinate). This incision was brought anterior to the axilla for ∼1 cm. The incision was extended inferiorly and posteriorly to the insertion of the uncinate process. A Freer elevator was used to lift the mucosal flap to expose the lacrimal bone and part of the frontal process of the maxilla (covering the sac). This bone covering the lacrimal sac was removed using a drill that fashioned a 1.0-1.5-cm bony window exposing the entire medial wall of the lacrimal sac. The most important step is the identification of the medial wall of the sac. The position of the lacrimal sac was confirmed by pressing the sac area externally, which caused bulging of the lacrimal sac into the nasal cavity, or by passing a Bowman lacrimal probe into the sac, which caused tenting of the sac into the nasal cavity. A sickle knife was used to incise the lacrimal sac. The medial wall of the sac was then removed using Blakesley forceps making as wide an opening as possible. Patency of the stoma was checked by sac syringing and confirming the free flow of the irrigating fluid by the endoscope. Silicone intubation was then performed. Only adequate amounts of nasal mucosa was removed so as to expose the sac in order to avoid granulation tissue formation as much as possible. No packing (except in two cases) was used. The patient was discharged the following day after nasal suction [Figure 3],[Figure 4] and [Figure 5].
Figure 3: Insertion of the silicone tube during an endoscopic dacryocystorhinostomy (DCR) in a 3-year-old child.

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Figure 4: Endoscopic view showing the passage of the silicone tube into the nasal cavity.

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Figure 5: Tying the silicone tube into the nose.

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Postoperative care and follow-up

A steroid-antibiotic eyedrop was prescribed for approximately 10-14 days after surgery and nasal wash was prescribed for patients who had undergone endoscopic DCR. Preoperative symptoms and signs and their degree of resolution were assessed from parental observation and clinical examination appropriate for the age group.

The patients were followed up every month for 6 months. Successful outcome was defined as patients' relief from symptoms in addition to endoscopic visualization of the patent stoma. A failed procedure was reviewed at 3 months and assessed for its cause and revision surgery. Any underlying cause for the failure was treated first and then the revision surgery was performed; the patients were followed up in a similar way.

  Results Top

Fifty children with CNLDO (19 boys and 31 girls) underwent DCR surgery (25 external and 25 endoscopic). The mean age was 4.9 years and the age range was 9 months to 14.5 years, with the maximum incidence in the age group of 4-8 years.

Along with watering of eyes 23 patients had an external swelling due to mucocele/pyocele formation, and 33 had discharge.

The 50 patients were randomly divided into two groups: group 1 included 25 patients who underwent external DCR and group 2 included the other 25 patients who underwent endoscopic DCR.

There was no significant intraoperative complication, apart from one case of profuse bleeding in group 1, which required a temporary tamponade before surgery could be continued further. Two patients had minimal orbital emphysema, which subsided within 24 h with local treatment.

All patients were followed up for 6 months. Relief of symptoms and endoscopic visualization of the patent stoma made into the lacrimal sac with sac syringing determined a successful outcome: 23 patients in group 1 (92%) and 22 patients in group 2 (90%) fulfilled both criteria.

Of the five failed cases, anatomic obstruction at the fistula site, diagnosed by inability to irrigate fluid to the nose, and scar visualization by nasal endoscopy were seen in three cases (60% of failed cases): one in group 1 and two in group 2; functional failure with no evidence of obstruction was found in two cases (40%), one in each group.

Endoscopic revision was performed in the three cases with anatomic obstruction with silicone intubation, which was successful in two cases, whereas the third case experienced success only after a second endoscopic revision.

Hence, overall success after DCR and revision was 96%.

Postoperative complications were seen in one patient in group 1, who had nose bleeding on the first postoperative day (the bleeding resolved with nasal packing for 24 h), and in one patient in group 2, who had pyogenic granuloma, which was treated with cauterization. No cases of sump syndrome, cerebrospinal fluid leak, orbital tissue damage, or uncontrolled bleeding occurred.

  Discussion Top

Nasolacrimal duct obstruction is a common cause of epiphora and matting of the eyelashes in infants and young children. It has a spontaneous remission rate of 85-96% by the age of 1 year [10],[11].

Comparing the published success rates of lacrimal surgery is a difficult task because different studies use different criteria. Guidelines [12] published by the Royal College of Ophthalmologists suggest that lack of tearing 3 months after surgery is a good indicator of successful surgery. Many investigators advocate monitoring the rhinostomy using postoperative endoscopy [13],[14].

Success rate following the performance of external DCR in children is reported to be in the range of 83-96% [15],[16],[17].

The reported primary surgical failure rate of 10% in children is similar to that reported in adults [18].

Advantages of endoscopic DCR include absence of skin incision with possible related complications, preservation of the pump mechanism of the orbicularis oculi muscle [19], less bleeding, the ability to address nasal or paranasal sinus abnormality at the same time [20], limitation of injury to tissue at the osteotomy site, and faster rehabilitation. Drawbacks include longer operative time, technical difficulties, and specific instrumentation [21],[22],[23].

External DCR is technically easier, with an unimpaired view of the surgical area [24],[25] and well-defined landmarks allowing the creation of a wide bony window and the use of mucosal flaps to obtain an epithelialized DCR tract [24].

Success depends upon the creation of a wide osteotomy and preservation of mucosa around the lacrimal window to reduce the chance of postoperative scarring and stenosis [26]. Longer follow-up may be associated with decreased success [27].

Potential complications of external DCR include bruising, wound infection, cerebrospinal fluid leaking, punctual eversion, and inadvertent incision of the periorbita. Endonasal DCR complications include damage to the nasal mucosa with scar formation, perirhinostomy granuloma, orbital fat prolapse, transient damage to the medial rectus muscle with diplopia, secondary canalicular stenosis, canalicular cheese-wiring by the silicone stent, sump syndrome, recurrence of lacrimal mucocele, and adhesions between the ostium and the septum [24],[28].

The limitations of our study include a relatively short postoperative follow-up. A longer follow-up would have reduced our reported success rate. Postoperative nasal endoscopy with dye application would have been a more accurate means of estimating functional outcome. Also there was no standardization of blockage site or osteotomy size in either the endoscopic or the external approach. Future studies should take into consideration standardization of blockage site and osteotomy size and strict definitions of improvement and failure, preferably by functional endoscopic dye test, to evaluate more accurately this longstanding controversy.

  Conclusion Top

Our experience suggests that endoscopic DCR offers the same success rates for primary surgery as external DCR in children with CNLDO. Moreover, it has the advantages of absence of skin incision, preservation of the pump mechanism of the orbicularis oculi muscle, and the ability to address nasal or paranasal sinus abnormality at the same time.

  Acknowledgements Top

Conflicts of interest

None declared.

  References Top

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Kamel R, El-Deen HG, El-Deen YS, El-Hamshary M, Assal A, Farid M, et al. Manometric measurement of lacrimal sac pressure after endoscopic and external dacryocystorhinostomy. Acta Otolaryngol 2003; 123 :325-329.  Back to cited text no. 19
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Woog JJ, Kennedy RH, Custer PL, Kaltreider SA, Meyer DR, Camara JG Endonasal dacryocystorhinostomy: a report by the American Academy of Ophthalmology. Ophthalmology 2001; 108 :2369-2377.  Back to cited text no. 23
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


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