A comparative study of complete removal of medial wall of lacrimal sac against mucosal flap technique in endoscopic endonasal dacryocystorhinostomy

Ganesh D. Borewad; Samir V. Joshi

doi:10.18203/issn.2454-5929.ijohns20262380

Authors

Ganesh D. Borewad Department of ENT, BJ Medical College and Sasoon Hospital, Pune, Maharashtra, India
Samir V. Joshi Department of ENT, BJ Medical College and Sasoon Hospital, Pune, Maharashtra, India

DOI:

https://doi.org/10.18203/issn.2454-5929.ijohns20262380

Keywords:

Dacryocystorhinostomy, Endoscopic, Epiphora, Nasolacrimal duct obstruction, Mucosal flap

Abstract

Background: Dacryocystorhinostomy (DCR) is the standard surgical treatment for nasolacrimal duct obstruction (NLDO), creating a fistulous tract between the lacrimal sac and the nasal cavity to relieve epiphora. While considerable literature exists comparing external DCR with endoscopic endonasal DCR, there are few comparative studies evaluating the outcomes of endoscopic endonasal DCR with mucosal flap preservation versus complete removal of the medial wall of the lacrimal sac.

Methods: This was a single-center, prospective, comparative study conducted at the Department of ENT, BJMC and Sassoon Hospital, Pune, Maharashtra, India, from June 2019 to December 2020. Fifty patients with nasolacrimal duct obstruction were allocated into two groups of 25 each: Group A (complete removal of medial wall of lacrimal sac) and Group B (mucosal flap technique). Lacrimal system patency was assessed at three and six months postoperatively using the sac syringing technique.

Results: Surgical success at six months was 100% in Group B versus 92% in Group A, though this difference was not statistically significant (p=0.490). There was no significant difference in postoperative pain scores between the groups (p=0.810). Ostium size shrinkage was 21.3% in Group A and 15.8% in Group B (p=0.157). Early and late postoperative complications, including granulation tissue formation and synechiae, were relatively higher in Group A.

Conclusions: Mucosal flap technique and complete excision of the medial wall of the lacrimal sac in endoscopic endonasal DCR demonstrate comparable outcomes. Although statistically insignificant, the mucosal flap technique showed lower complication rates and less ostium shrinkage.

References

Thawley SE. The otolaryngologist-ophthalmologist relationship: an historic perspective. Otolaryngol Clin North Am. 2006;39(5):845-53.

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.

Burkat CN, Lucarelli MJ. The Lacrimal System: Diagnosis, Management and Surgery. In: Anatomy of the Lacrimal System. Springer Publications; 2006;3-17.

Kupper DS, Demarco RC, Resende R, Anselmo-Lima WT, Valera FC, Moribe I. Endoscopic nasal dacryocystorhinostomy: results and advantages over the external approach. Rev Bras Otorrinolaringol. 2005;71:356-60.

Wormald PJ. Powered endoscopic dacryocystorhinostomy. Laryngoscope. 2002;112:69-72.

Hartikainen J, Antila J, Varpula M. Prospective randomized comparison of endonasal endoscopic dacryocystorhinostomy and external dacryocystorhinostomy. Laryngoscope. 1998;108:1861-6.

Welham R, Wulc A. Management of unsuccessful lacrimal surgery. Br J Ophthalmol. 1987;71:152-7.

Caldwell G. Two new operations for obstruction of the nasal duct, with preservation of the canaliculi, and with an incidental description of a new lachrymal probe. Am J Ophthalmol. 1893;10:189-93.

Totti A. Nuovo metodo conservatore di cura radicale delle suppurazioni croniche del sacco lacrimale (dacriocistorhinostomia). Clin Mod (Firenze). 1904;10:385-89.

Cukurova I, Bulgurcu S, Arslan IB, Dikilitas B. Comparison of piezosurgery and hammer-chisel in endoscopic dacryocystorhinostomy. J Craniofac Surg. 2018;29:1612-3.

Selig YK, Biesman BS, Rebeiz EE. Topical application of mitomycin-C in endoscopic dacryocystorhinostomy. Am J Rhinol. 2000;14:205-7.

Cokkeser Y, Evereklioglu C, Tercan M, Hepsen IF. Hammer chisel technique in endoscopic dacryocystorhinostomy. Ann Otol Rhinol Laryngol. 2003;112:444-9.

Ovet G, Sakarya Y, Senturk M. A comparative study of transcanalicular diode laser supported endoscopic dacryocystorhinostomy and non-laser endoscopic dacryocystorhinostomy. Am J Otolaryngol. 2016;37:497-501.

Karim R, Ghabrial R, Lynch T, Tang B. A comparison of external and endoscopic endonasal dacryocystorhinostomy for acquired nasolacrimal duct obstruction. Clin Ophthalmol. 2011;5:979-89.

McDonogh M, Meiring JH. Endoscopic transnasal dacryocystorhinostomy. J Laryngol Otol. 1989;103(6):585-7.

Metson R. Endoscopic surgery for lacrimal obstruction. Otolaryngol Head Neck Surg. 1991;104(4):473-9.

Massaro BM, Gonnering RS, Harris GJ. Endonasal laser dacryocystorhinostomy: a new approach to nasolacrimal duct obstruction. Arch Ophthalmol. 1990;108(8):1172-6.

Wormald PJ, Kew J, Van Hasselt A. The intranasal anatomy of the nasolacrimal sac in endoscopic dacryocystorhinostomy. Otolaryngol Head Neck Surg. 2000;123(3):307-10.

Tsirbas A, Wormald PJ. Mechanical endonasal dacryocystorhinostomy with mucosal flaps. Otolaryngol Clin North Am. 2006;39(5):1019-36.

Trimarchi M, Giordano Resti A, Bellini C, Forti M, Bussi M. Anastomosis of nasal mucosal and lacrimal sac flaps in endoscopic dacryocystorhinostomy. Eur Arch Otorhinolaryngol. 2009;266:1747-52.

Kansu L, Aydin E, Avci S, Kal A, Gedik S. Comparison of surgical outcomes of endonasal dacryocystorhinostomy with or without mucosal flaps. Auris Nasus Larynx. 2009;36(5):555-9.

Singh M, Jain V, Gupta SC, Singh SP. Intranasal endoscopic DCR (END-DCR) in cases of dacryocystitis. Indian J Otolaryngol Head Neck Surg. 2004;56(3):177-83.

Cokkeser Y, Evereklioglu C, Er H. Comparative external versus endoscopic dacryocystorhinostomy: results in 115 patients (130 eyes). Otolaryngol Head Neck Surg. 2000;123(4):488-91.

Jyothi AC, Kumar A, Chiluveru P. Endoscopic dacryocystorhinostomy: our experience. Int J Otorhinolaryngol Head Neck Surg. 2016;2:254-7.

Pradeep KV, Ramesh S. Endoscopic dacryocystorhinostomy: our experience. IJCMR. 2018;5(11):K10-3.

Yigit O, Uzun H, Han T, Cakir BO. The effect of bicanalicular silicone tube implantation on the success rate of endoscopic dacryocystorhinostomy. Kulak Burun Bogaz Ihtis Derg. 2005;14:79-82.

Diggle FH. Lacrimal obstruction: its nasal origin and intranasal treatment. Br Med J. 1927;2(3489):933-5.

Reddy PS, Reddy B. Dacryocystitis: a clinico-pathological study. J Indian Med Assoc. 1955;24(11):413-6.

Chaudhary M, Bhattarai A, Adhikari SK, Bhatta DR. Bacteriology and antimicrobial susceptibility of adult chronic dacryocystitis. Nepal J Ophthalmol. 2010;2(2):105-13.

Sarkar I, Choudhury SK, Bandyopadhyay M, Sarkar K, Biswas J. A clinicobacteriological profile of chronic dacryocystitis in rural India. Int J Health Sci Res. 2015;5(7):82-7.

Deviprasad D, Mahesh SG, Pujary K, Pillai S, Mallick SA, Jain V. Endonasal endoscopic dacryocystorhinostomy: our experience. Indian J Otolaryngol Head Neck Surg. 2009;61(3):223-6.

Ramakrishnan VR, Hink EM, Durairaj VD, Kingdom TT. Outcomes after endoscopic dacryocystorhinostomy without mucosal flap preservation. Am J Rhinol. 2007;21(6):753-7.

Zloto O, Koval T, Yakirevich A, Ben Simon GJ, Weissman A, Ben Artsi E, et al. Endoscopic dacryocystorhinostomy with and without mucosal flap—is there any difference?. Eye (Lond). 2020;34(8):1449-53.

Garg R, Gupta P, Shakya DK, Varandani S, Uchainiya A. Clinico-microbiological profile in dacryocystitis: a prospective observational study. Int J Med Res Rev. 2018;6(4):210-7.

Hartikainen J, Lehtonen OP, Saari KM. Bacteriology of lacrimal duct obstruction in adults. Br J Ophthalmol. 1997;81:37-40.

Badhu B, Dulal S, Kumar S, Thakur SK, Sood A, Das H, et al. Epidemiology of chronic dacryocystitis and success rate of external dacryocystorhinostomy in Nepal. Orbit. 2005;24:79-82.

Tsirbas A, Wormald PJ. Mechanical endonasal dacryocystorhinostomy with mucosal flaps. Br J Ophthalmol. 2003;87(1):43-7.

Marcet MM, Kuk AK, Phelps PO. Evidence-based review of surgical practices in endoscopic endonasal dacryocystorhinostomy for primary acquired nasolacrimal duct obstruction and other new indications. Curr Opin Ophthalmol. 2014;25:443-8.

Green R, Gohil R, Ross P. Mucosal and lacrimal flaps for endonasal dacryocystorhinostomy: a systematic review. Clin Otolaryngol. 2017;42:514-20.

Khalifa MA, Ragab SM, Saafan ME, El-Guindy AS. Endoscopic dacryocystorhinostomy with double posteriorly based nasal and lacrimal flaps: a prospective randomized controlled trial. Otolaryngol Head Neck Surg. 2012;147:782-7.

Ji QS, Zhong JX, Tu YH, Wu WC. New mucosal flap modification for endonasal endoscopic dacryocystorhinostomy in Asians. Int J Ophthalmol. 2012;5:704-7.

Mahendran S, Stevens-King A, Yung MW. The viability of free mucosal grafts on exposed bone in lacrimal surgery: a prospective study. Clin Otolaryngol. 2006;31:324-7.

Zileliğlu G, Tekeli O, Uğurbaş SH. Results of endoscopic endonasal non-laser dacryocystorhinostomy. Doc Ophthalmol. 2002;105:57-62.