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ORIGINAL PAPERS

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ORIGINAL PAPERS Adv Clin Exp Med 2009, 18, 5, 501–506 ISSN 1230−025X

© Copyright by Wroclaw Medical University

PIOTR WÓJCICKI 1, 2, IRENEUSZ SIEWIERA2

External Dacryocystorhinostomy in the Treatment of Congenital and Acquired Lacrimal Duct Stenoses Dakryocystorynostomia zewnętrzna w leczeniu wrodzonej i nabytej niedrożności dróg łzowych 1 2

Plastic Surgery Clinic, Wroclaw Medical University, Poland Department of Plastic Surgery, Specialistic Medical Centre, Polanica Zdrój, Poland

Abstract Background. The surgical treatment of lacrimal duct stenosis consists of the formation of a fistula between the lacrimal sac and the nasal passage, which facilitates the outflow of tears. Objectives. The aim of the study was to evaluate the efficacy of dacryocystorhinostomy (DCR) with the external approach depending on the etiology of the defect. Material and Methods. Fifty−four patients 3–70 years of age with lacrimal duct obstruction were treated at the Clinic of Plastic Surgery in Polanica Zdrój. In 19 patients the lactimal duct defect was congenital and in 35 it was a consequence of injury or tumor. A total of 65 dacryocystorhinostomies with the external approach were per− formed. Results. The efficacy of dacryocystorhinostomy was 83.3%. In the patients with a congenital etiology it was 84.2% and in the group with an acquired defect 82.9%. Conclusions. External dacryocystorhinostomy appears a highly safe and effective method. In combination with other reconstruction methods, it has advantageous over endoscopic methods especially in cases of an acquired defect (Adv Clin Exp Med 2009, 18, 5, 501–506). Key words: dacryocystorhinostomy, DCR, lacrimal duct stenoses.

Streszczenie Wprowadzenie. Chirurgiczne leczenie niedrożności dróg łzowych polega na wytworzeniu przetoki między wo− reczkiem łzowym a przewodem nosowym umożliwiającej odpływ łez. Cel pracy. Ocena skuteczności zabiegów dakryocystorynostomii (DCR) z dostępu zewnętrznego w zależności od etiologii schorzenia. Materiał i metody. W Klinice Chirurgii Plastycznej w Polanicy Zdroju leczono 54 pacjentów z niedrożnością dróg łzowych w wieku 3–70 lat. U 19 chorych przyczyną niedrożności dróg łzowych były wady wrodzone, a u 35 cho− rych następstwa urazów i chorób nowotworowych. Wykonano 65 zabiegów DCR z dostępu zewnętrznego. Wyniki. Skuteczność dakryocystorynostomii wyniosła ogółem 83,3%, w tym w grupie o etiologii wrodzonej 84,2%, a w grupie o etiologii nabytej 82,8%. Wnioski. Dakryocystorynostomia z dostępu zewnętrznego jest zabiegiem skutecznym i bezpiecznym. W połącze− niu z innymi metodami rekonstrukcyjnymi ma niewątpliwą przewagę nad metodami endoskopowymi, zwłaszcza w przypadkach o etiologii nabytej (Adv Clin Exp Med 2009, 18, 5, 501–506). Słowa kluczowe: dakryocystorynostomia zewnętrzna, DCR, niedrożność dróg łzowych.

Lacrimal duct stenosis is a pathology which manifests mainly with excess overflow of tears, called by the Greek word epiphora. It was described in the Talmud and in ancient Egyptian papyruses and was also mentioned in the works of Celsius and Avicenna [1]. Surgical procedures

aimed at restoring lacrimal duct patency by form− ing a fistula between the tear sac and nasolacrimal duct were performed at the turn of the 19th and 20th centuries by Caldwell. In 1904, an Italian ophthal− mologist, Addeo Toti, was the first to present the external approach [2]. In 1911, West proposed the

502

P. WÓJCICKI, I. SIEWIERA

lacrimal gland (gruczoł łzowy) punctum (punkt łzowy) upper canaliculus (kanalik łzowy górny) lacrimal sac (woreczek łzowy) lower canaliculus (kanalik łzowy dolny) nasolacrimal duct (przewód nosowo−łzowy) Drawing: I. Siewiera

Fig. 1. Lacrimal tract anatomy Ryc 1. Schemat budowy dróg łzowych

nasal approach; however, the method did not find many followers due to lack of adequate instru− ments. In 1920, Dupuy−Dutemps and Borguet [3] described a modified method of the external approach consisting of combining flaps of nasal mucosa and the lacrimal sac. In 1974, Casper pro− posed his own method of suturing the lacrimal sac with the nasolacrimal duct without the necessity of using mucosal flaps [4]. Subsequent studies by Becker [5] and Burns [6] confirmed the high effec− tiveness of this method. Progress in technology and a tendency to limit invasiveness by the use of endoscopic methods with fiberoptics and laser tools found their application in the treatment of lacrimal duct stenosis. The first dacryocystorhi− nostomy (DCR) with the use of a Nd:YAG laser with the nasal approach, without skin scarring, was described in 1997 [7]. The lacrimal ducts consist of the lacrimal puncta, lacrimal canals, lacrimal sac, and naso− lacrimal canal (Fig. 1). Nasolacrimal drainage stenosis may be congenital or acquired. The con− genital form is rare. It may occur as an isolated defect or may be associated with craniofacial abnormalities. Obliteration of the lumen or a trans− verse obstacle occurs most commonly at the junc− tion of the nasolacrimal canal and nasal mucosa. Dacryocystocele (or timo cyst) may be one of the forms of congenital lacrimal canal obstruction. The acquired form may originate as a consequence of injury (car accident, a blow) (Fig. 2), inflamma− tion, mechanical obstruction caused by dacry− olithiasis, a foreign body, benign tumor (lacrimal sac cyst), or malignant tumor originating from the maxillary or ethmoid sinus. Purulent inflammation of the lacrimal canal usu− ally involves the upper canal. The symptoms include swelling, pain, and redness over the lacrimal canal. It is caused by streptococci, pneumococci, Pseudo− monas aeruginosa, or fungi (Fig. 3). The diagnosis is based on ophthalmological examination evaluat− ing the dynamics of the production and outflow of

Fig. 2. Craniofacial injury – medial canthus recon− struction and DCR Ryc 2. Stan po urazie części twarzowej czaszki – korekcja kąta przyśrodkowego i DCR

tears. The Jones test with fluorescein, dacryocystog− raphy, scintigraphy, and taste tests are used. CT and MR scanning are useful in cases of bone deformity caused by injury. Intubation and probation of the lacrimal ducts prior to surgery may confirm the diag− nosis and determine the level of obstruction. Surgical treatment of lacrimal duct obstruction is contraindicated in cases of dry eye syndrome and disturbances in bleeding and blood clotting.

Material and Methods Sixty−five external dacryocystorhinostomies were performed at the Hospital of Plastic Surgery and then SCM Clinic and Department of Plastic Surgery in Polanica Zdrój in the years 1985–2008. Fifty−four patients aged 3–70 years (mean age: 27 years), were treated. Children up to 16 years of age constituted 33.3% (n = 18) of the patients. The investigated group included 32 males and 22 fe− males. Twenty−three patients had nasolacrimal obstruction on the right side, 27 on the left side, and 4 had bilateral obstruction. In 19 patients the nasolacrimal obstruction was due to congenital abnormalities and in 35 patients it was a conse− quence of an injury or tumor (Table 1). The majority of the surgeries (83.3%) were performed under general anesthesia. The surgeries

503

Dacryocystorhinostomy

were performed under local anesthesia in adult patients (n = 9). All the surgeries were performed with the external approach. Following infiltration of the site with an anesthetic, a 15−mm incision was made in the region of the medial canthus. Then the tissues were prepared to expose the lacrimal sac, which was separated from the lacrimal bone and cut with a fraise or a gouge to form an opening with a diameter of about 7 mm. The nasal mucosa and lacrimal sac were incised several times and sutured with resorbable sutures. Thus a fistula was formed above the obstructed site. In the majority of cases a bridge was formed between the lacrimal ducts and the nasal canal without connecting the mucosal flaps, in accor− dance with the Casper technique. The lacrimal ducts were intubated with drains inserted through the lacrimal sac and the orifice formed in the lat− eral bony wall of the nose. The drain ends were tied and fixed in the nasal cavity (Fig. 4). The skin wound was closed in layers. In two cases the inci− sions were made along scars on the ciliary margin resulting from previous surgery, and in one child along a scar on the nose from surgery for hyper− telorism. In most cases the dacryocystorhinostomy was associated with medial canthus reconstruction and shortening of the medial ligament. In two cases the DCR procedure was associated with medial canthus Z−plasty (Fig. 5). Follow−up examinations associated with the removal of drains were performed about six

Fig. 3. Lacrimal sac abscess – state after DCR Ryc 3. Ropień woreczka łzowego – stan po DCR

Table 1. Etiology of the lacrimal duct stenoses of the patients treated by DCR Tabela 1. Etiologia niedrożności dróg łzowych pacjentów poddanych DCR Congenital form (Postać wrodzona)

Acquired form (Postać nabyta)

Congenital isolated form (Wrodzona izolowana niedrożność dróg łzowych)

5

craniofacial trauma 27 (uraz ze złamaniem kości części twarzowej czaszki)

(Multiple craniofacial abnormalities (Mnogie wady części twarzowej czaszki)

3

soft tissue trauma (uraz tkanek miękkich)

4

Unilateral cleft lip and palate (Wada rozszczepowa jednostronna)

3

animal bite (rana kąsana)

2

Bilateral cleft lip and palate (Wada rozszczepowa obustronna)

3

burns (oparzenie)

1

Hypertelorism, nasal cleft (Hyperteloryzm, środkowy rozszczep nosa)

2

excision of carcinoma (stan po resekcji zmiany nowotworowej)

1

Dacryocystocele (Skośny rozszczep twarzy)

1

Ectodermal dysplasia (Dysplazaja ektodermalna)

1

Total (Razem)

19

total (razem)

35

504

P. WÓJCICKI, I. SIEWIERA

months after the surgery. Cessation of tearing and maintenance of normal nasolacrimal drainage were considered a good therapy outcome. site of DCR ostium (otwór w kości łzowej) silicone tubing (dren silikonowy)

Results Drawing: I. Siewiera

Fig. 4. Scheme of DCR Ryc 4. Schemat DCR

Fig. 5. Craniofacial injury – medial canthus Z−plasty and DCR

Patients with post−traumatic injury to the naso− lacrimal duct prevailed in this material. In such cases the DCR procedure was one of the stages of reconstructive therapy. The effectiveness of dacry− ocystorhnostomy was 83.3% in the total group of patients; in patients with congenital abnormality it was 84.2% and in those with an acquired defect it was 82.8%. This is a good outcome, comparable to those achieved in other centers worldwide (Table 2). Dacryocystorhinostomy may be associated with early complications, such as bleeding and local inflammation. The silicone drain fell out too early in one patient and two patients developed lacrimal sac abscess in the postoperative course. Permanent obstruction is considered a poor outcome of treat− ment. Failure to restore nasolacrimal duct patency was observed in 9 patients, three with a congenital abnormality and 6 with an acquired defect; these patients were qualified for another surgery. Despite reoperation, 2 patients did not achieve satisfactory outcome. The relapse of tearing was usually due to scarring and inflammatory condition. Dilatation of the bone orifice in the lateral nasal wall was per− formed during reoperation in one case.

Discussion

Ryc. 5. Stan po urazie części twarzowej czaszki – wykonano Z−plastykę kąta przyśrodkowego oka i DCR

Restoration of the patency of the lacrimal ducts is performed by specialists in otolaryngolo−

Table 2. Outcomes achieved in other centers Tabela 2. Wyniki uzyskane w innych ośrodkach Author (Autor)

Approach (Dostęp operacyjny)

Number of patients (Liczba pacjentów)

Efficacy (Skuteczność) %

Failures (Powikłania) %

Seider N 2007 Sieśkiewicz 2008 Emmerlich KH Kominek P 2005 Tarbet KJ 1995

external endoscopic external endoscopic external

162 16 1014 34 169

81 87.5 85 82.3 95

Warren JF 2005 Beigi B 1998 Erdol H 2005 Delaney YM 2002 Struck HG 2001 Barnes EA 2002 Kashkouli MB 2003 Horix D 2004

external external external external external external external external

9 12.5 – – 3.9 bleeding 2.6 scarring – – – – – 3 – –

128/150 242 437 50 72 121 274 146

93 83.5 91.5 90 90.4 96 89.1 80.1

Dacryocystorhinostomy

Fig. 6. Palpebral reconstruction and DCR after burn injury of the face Ryc. 6. Stan po rekonstrukcji powiek po oparzeniu twarzy i DCR

gy, ophthalmology, and reconstructive surgery. In view of the various evaluation criteria and selec− tion of patients, it is not easy to compare the out− comes of lacrimal reconstructive surgery on the basis of data from the literature. According to the criteria of the Royal College of Ophthalmologists of 1999, relief from symptoms of excessive tearing for 3 months is considered a satisfactory outcome (Fig. 6). The treatment of lacrimal duct obstruction due to trauma, often accompanied by bone injury and altered anatomical relations, is more difficult and brings less advantageous outcomes. This has been confirmed by other authors [8], who addi− tionally point to a significant prognostic factor, i.e. the time from the onset of symptoms and the dura− tion of inflammation [9]. In post−traumatic cases, dacryocystorhinostomy is often a successive oper− ation performed in the stage following the primary management of fractures and soft tissue injury. The surgery should be combined with shortening of the medial ligament, as correction of the posi− tion of the medial canthus and restoration of the anatomical position of the lacrimal puncti are indispensable for normal drainage of tears. Increasing attention has been paid recently to new endoscopic methods with or without the use of a laser. Both modalities have their advantages and disadvantages. Dolman compared the external and the endoscopic method without the use of laser on a large body of material of 349 cases. He demonstrated almost identical effectiveness of the two therapeutic modalities. Shorter time of surgery

505 in the case of the endoscopic method and the opin− ions of patients with a bilateral defect in whom both techniques were used indicate that the endo− scopic method is more advantageous [10]. Hartikainen demonstrated a statistically significant advantage of the procedure with the external approach, the success rate being 91% for the con− ventional surgery and 63% for the intranasal approach with the use of a laser [11]. The duration of the surgery with the nasal approach using a Holmium: YAG laser is shorter. However, taking into account the low effectiveness of this method (70%) and the necessity to repeat the procedure, Malhorta et al. [12] advocate the use of both meth− ods depending on the indications in particular cases of lacrimal duct obstruction. Considering the economic aspect of the therapy, the endoscopic procedure is cheaper. However, considering the real costs of equipment and training, only large centers can afford it. In the present authors’ opinion, the external approach is favorable for another reason: it gives a detailed insight into the pathology underlying the lacrimal duct obstruction. This method is effective in practically every case of lacrimal duct obstruc− tion and does not require any expensive or com− plicated equipment. Only 2 patients (3.1%) failed to achieve a complete cure. The scar remaining after the external approach is not a problem for the majority of patients [13]. According to Tarbet et al., the appearance of a scar was satisfactory for about 97% of patients [14]. In post−traumatic cases the incision is usually made to follow a preexisting scar. Otolaryngologists often prefer the intranasal approach as the method of choice, reserving the procedure with the external approach for recurrent cases [15]. The use of an endoscope with a diame− ter of 4 mm enables operations on children even before 1 year of age [16]. However, in such cases the therapy should resort to conservative and least traumatic methods (washing the canals, massage, intubation, and ballooning). When this manage− ment proves ineffective, the surgical reconstruc− tion should be postponed until the child is one year old. On the other hand, lower risk of damaging the medial canthus is an advantage of the endoscopic method [17]. The majority of the procedures were performed under general anesthesia, although according to some authors local anesthesia may suffice, especially in uncomplicated cases [18]. The postsurgical management also arouses a lot of discussion. Most authors recommend removing the silicone drains 3–6 months after the surgery. Maintaining the drains for too long a time may result in a poorer functional effect. Removal of the drain is a simple procedure performed on an

506

P. WÓJCICKI, I. SIEWIERA

out−patient basis during a follow−up visit. Smirnow G et al. compared two groups of patients who had had endoscopic dacryocystorhinostomy with and without silicone drains. The efficiency rate was 89% in the group with drains and 75% in the patients in whom drains were not inserted [19]. Some authors advocate additional washing of the lacrimal ducts with steroids and others the local intraoperative administration of mitomycin C [20].

The authors concluded that external dacry− ocystorhinostomy is a highly effective and safe procedure. In association with other reconstructive methods it has an advantage over endoscopic methods especially in cases with an acquired defect, post−traumatic or neoplastic. Dacryocy− storhinostomy may be successfully performed even in small hospitals in view of the modest instrumental requirements.

References [1] Hirschberg J: The History of Ophtalmology. Vol. 1 Blodi FC trans. Bonn, Germany, JP Wayenborgh 1982. [2] Toti A: Nuovo metodo conservatore di cura radicale delle suppurazioni croniche del sacco lacrimale (Dacriocistorinostomia). Clin Mod Firenze 1904, 10, 385. [3] Dupuy−Dutemps MM, Bourguet ET: Note preliminare sur un prodede de dacrocystorhinostomie. Ann Ocul (Paris) 1920, 157, 445–447. [4] Casper TC, Sergent RA, Smith B: Dacryocystorhinostomy: The Casper operation. Ann Ophthalmol 1974, 6, 1333. [5] Becker BB: Dacryocystorhinostomy without flaps. Ophthalmic Surg 19, 419, 1988. [6] Burns JA, Cahill KV: Modified Kinosian dacryocystorhinostomy: A review of 122 cases. Ophthalmic Surg 1985, 16, 710. [7] Pearlman SJ, Michalos P, Leib ML: Translacrimal transnasal laser assisted dacryocystorhinostomy. Laryngo− scope 1997 107(10), 1362–1365. [8] Seider N, Kaplan N, Gilboa M: Effect of timing of external dacryocystorhinostomy on surgical outcome. Ophthal Plast Reconstr Surg 2007, 23(3), 183–186. [9] Kashkouli MB, Parvaresh M, Modarreszadech M: Factors affecting the success of external dacryocystorhi− nostomy. Orbit 2003, 22(4), 247–255. [10] Dolman PJ: Comparison of external dacryocystorhinostomy with nonlaser endonasal dacryocystorhinostomy. Ophtalmology 2003, 110, 78–84. [11] Haratikainen J, Grenman R, Puukka P: Prospective randomized comparison of external dacryocystorhinosto− my and endonasal laser dacrocystorhinostomy. Ophtalmology 1998, 105(6), 1106–1113. [12] Malhotra R, Wright M, Olver JM: A consideration of the time taken to do dacryocystorhinostomy (DCR) surgery. Eye 2003, 17(6), 691–696. [13] Dewoto MH, Zaffaroni MC, Bernardyni FP: Postoperative evaluation of skin incision in external dacryocys− torhinostomy. Ophthal Plast Reconstr Surg 2004, 20(5), 358–361. [14] Tarbet KJ, Custer PL: External dacryocystorhinostomy. Surgical success, patent satisfaction, and economic cost. Ophtalmology 1995, 102, 1065–1070. [15] Mirza S, Al.−Barmani A, Douglas SA et al.: WSP retrospective comparison of endonasal KTP laser dacryocys− torhinostomy versus external dacryocystorhinostomy. Clin Otolaryngol Allied Sci 2002, 27(5), 347–351. [16] Kominek P: Pediatric endonasal dacryocystorhinostomy: a report of 34 cases. Laryngoscope 2005, 115, 1800–1803. [17] Vagefi MR, Winn BJ, Lin CC et al.: Facial Nerve Injury during External Dacryocystorhinostomy. Ophthal− mology 2009, 116(3), 585–590. [18] McNab AA, Sigmie RJ: Effectiveness of local anesthesia for external dacryocystorhinostomy. Clin Experiment Ophtalmol 2002, 30(4), 270–272. [19] Smirnow G, Tuomilehto H, Terasvirta M et al.: Silicone Tubing after endoscopic dacryocystorhinostomy: is it necessary? Am J Rhinol 2006 20(6), 600–602. [20] Kao SC, Liao CL, Tseng JH: Dacryocystorhinostomy with intraoperative mitomycin C. Ophthalmology 1997, 104(1), 86–91.

Address for correspondence: Piotr Wójcicki Wojska Polskiego 23b 57−320 Polanica Zdrój Poland E−mail: [email protected] Conflict of interest: None declared Received: 22.06.2009 Revised: 3.07.2009 Accepted: 7.09.2009

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ORIGINAL PAPERS

ORIGINAL PAPERS Adv Clin Exp Med 2009, 18, 5, 501–506 ISSN 1230−025X © Copyright by Wroclaw Medical University PIOTR WÓJCICKI 1, 2, IRENEUSZ SIEWIER...

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