The Effects of Silicone Tube Intubation During Endoscopic Dacryocystorhinostomy in Patients With Acute Dacryocystitis With Acquired Skin Fistulization

Abstract

Objective:

This study aimed to determine the silicone tube intubation requirement for endoscopic dacryocystorhinostomy (En-DCR) in patients with acute dacryocystitis (AD) with acquired skin fistulization.

Methods:

Between September 2012 and October 2020, patients with AD and acquired skin fistulization undergoing En-DCR at the Eye Hospital of Wenzhou Medical University were randomized into treatment groups in which silicone tube intubation was carried out or not (groups A and B, respectively). All patients with skin fistulae present for 1+ months at En-DCR underwent fistulectomy. Operative success was assessed at 12 months post En-DCR in both treatment groups. Multiple logistic analyses were performed to assess for influencing factors on surgical success.

Results:

This study evaluated 94 patients for whom complete postoperative data were available, including 45 in group A and 44 in group B. Overall, 15 patients underwent fistulectomy and En-DCR simultaneously (8 from group A; 7 from group B ). At 12-month follow-up, anatomic and functional success rates were higher for patients in group A (93.3%, 86.7%) relative to those in group B (77.3%, 68.2%) (P<0.05). Intranasal ostium obstruction caused lacrimal passage reconstruction failure in group A. In contrast, intranasal ostium and canalicular obstruction caused it in patients in group B. No significant variations in operation success rates across groups were seen when group B cases with canalicular obstruction were eliminated from the analyses (P=0.070, >0.05). Multiple logistic regression analysis showed operative success was significantly influenced by fistulectomy (OR: 1.641, P<0.05) and intubation (OR: −1.559, P<0.05).

Conclusion:

These findings imply that in patients with AD with skin fistulization undergoing En-DCR, intraoperative intubation is linked with a lower incidence of canalicular obstruction and positive outcomes. Accordingly, intraoperative intubation should be performed when operating on patients with AD with skin fistulization.

Acute dacryocystitis (AD) is a form of acute inflammation secondary to nasolacrimal duct obstruction wherein patients experience rapid-onset pain, swelling, and erythema below the medial canthal tendon.¹ Endoscopic dacryocystorhinostomy (En-DCR) has recently emerged as a superior alternative to conservative AD patient management, given that the surgical decompression of a lacrimal abscess during the acute inflammatory phase can facilitate accelerated pain relief and infection resolution.² Success rates for En-DCR procedures reportedly range from 81.8% to 94.3%, and routine silicone intubation in patients with AD undergoing this procedure has not significantly impacted operative outcomes.³

In most studies performed to date, En-DCR is performed after the formation of a lacrimal abscess in patients with AD,^3–6 with some patients inevitably experiencing skin fistulization during the observation or treatment period before scheduled En-DCR,⁷ and some patients presenting to the hospital with AD-related fistulae. Some researchers have focused on performing En-DCR procedures in patients with AD without fistula-specific interventions.^8,9 At the same time, others had suggested that simultaneous fistulectomy should be performed on patients with fistulae that have been present for 1+ months.¹⁰ One study reported a 100% surgical success rate when patients simultaneously underwent fistula excision and silicone intubation with External DCR.¹¹ The En-DCR procedure success rates for patients with AD are often lower in cases with canaliculus or lacrimal sac cicatrization, rupture port epithelialization, and scar tissue formation secondary to the skin fistulization. However, silicone tube intubation has been suggested to mitigate these reductions.^10,12,13 The systematic studies examining the need for such intubation in patients with AD, affected by fistulization as a determinant of operative success rates in individuals undergoing fistulectomy and En-DCR, have yet to be established.

The current study sought to investigate the requirement for silicone tube intubation in patients with AD with skin fistulation following En-DCR.

METHODS

The Department of Orbital and Oculoplastic Surgery at Wenzhou Medical University’s Eye Hospital executed this prospective randomized controlled research from September 2012 to October 2020. Following the Helsinki Declaration, the Institutional Medical Ethics Committee (Wenzhou Medical University, Wenzhou, Zhejiang, China) approved this study effort. Participants of the study supplied written informed consent.

Patients 18 to 90 years old with AD, with skin fistulae before elective En-DCR operations, were recruited for this study, regardless of whether or not fistulae were present at the time of their arrival at the hospital (Fig. 1). Patients with a history of dacryocystorhinostomy, congenital fistulae of the lacrimal system, canalicular abnormalities, nasal trauma, severe nasal septum deviation, nasosinusitis, nasolacrimal neoplasms, or systemic bleeding disorders were excluded from this study. Clinical manifestations and high-resolution orbital computed tomography or magnetic resonance imaging were used to diagnose all the cases. Thirteen patients with AD took dacryocystography on orbital computed tomography with pain relief.

FIGURE 1.

Representative patients with AD exhibiting skin fistulation before hospitalization. (A) A patient with AD in group B showed fistulization 27 days before hospital admission. (B) The same patient upon follow-up evaluation and 1 week after surgical treatment. AD indicates acute dacryocystitis

In total, 94 eligible patients were assigned randomly into 2 treatment groups. Following the early intravenous administration of broad-spectrum antibiotics, participants underwent En-DCR under general anesthesia within 24 hours following admission as in prior reports.^3,6,13 After injecting 1 mL of 0.9% NaCl, the lateral nasal mucosa near the lacrimal sac fossa was cut and isolated. Then, a power drill was used to thin the maxilla and frontal process underneath, which were removed with a rongeur. The next step was to guide the incision and opening of the lacrimal sac using a probe. The maxilla was then covered by a nasal mucosal flap that was positioned correctly and cut. After that, a self-cross-linking HA hydrogel was used to fill the wound. A bicanalicular silicone tube was then placed in the superior and inferior puncta of the patients in group A, with its ends tied inside the nasal cavity. Patients in group B, on the other hand, underwent surgery without any intubation at all.

The patients in each group exhibiting acquired skin fistulae that had been present for 1+ months underwent simultaneous En-DCR and fistulectomy procedures. Briefly, fistulae were removed by incising along the fistula pathway, excising the fistular tract, and ligating and suturing the resultant stump using 6/0 polyglactine.¹¹

After surgery, all patients received methylprednisolone (20 mg/kg/d) and ceftriaxone (2.0 g/d) therapy for 3 days. They also received daily lacrimal syringes of dexamethasone and tobramycin for 3 days and twice-daily administration of intranasal Rhinocort Aqua Nasal Spray (Astra Zeneca) for 6 weeks.

Patient follow-up was performed at 1 week, 2 weeks, 1 month, 2 months, 3 months, 6 months, and 1 year post surgery. At each follow-up visit, patients were assessed for any evidence of acute external inflammation, underwent an endoscopic examination of ostium patency, and were assessed for lacrimal irrigation. Fistulectomy stitches were removed 1 week postoperatively.

Anatomic success was defined by relieving external acute symptoms, ostial patency, a lack of purulent secretions, and a customarily epithelized mucosa with free-flowing irrigation of the lacrimal system. Operational success was defined by the relief of external acute symptoms, the absence of postoperative purulent secretions or epiphora, positive nasal cavity dye test results during endoscopic evaluation, patency, and a normally epithelized mucosal layer covering the intranasal ostium, and free-flowing lacrimal system irrigation.

SPSS 17.0 was used for data analysis. While functional success rates were evaluated using Pearson χ² test or Fisher exact test, patient demographics were compared using Student t tests or χ² tests. The level of significance was P<0.05. Multivariate logistic regression analysis was adopted to assess the association between surgical success and patients’ demographic characteristics, intubation, and fistulectomy.

RESULTS

This study enrolled 94 patients with AD, in total, with skin fistulization who underwent En-DCR, including 48 and 46 patients in groups A and B, respectively. Intraoperative examination revealed that 1 patient in group A exhibited a lower canaliculus obstruction, while another patient experienced tube prolapse within 2 weeks. In total, 3 patients (1 from group A; and 2 from group B) failed to complete the postoperative follow-up evaluation. The remaining 89 patients (45 in group A; and 44 in group B) were enrolled in the final analyses for this study. The patient’s clinical and demographic characteristics are listed in Supplemental Digital Content, Table 1, http://links.lww.com/SCS/F717. There were no differences in age (P=0.24), laterality of involvement (P=0.343), or days from the onset of skin fistulation (P=0.773) between groups A and B. Similarly, the duration of the relief of pain, swelling, and erythema were comparable in group A and group B (14.51±5.58 d versus 13.41±5.94 d; P=0.369). Eight and 7 patients, respectively, from groups A and B, had skin fistulae for over 1 month. As a result, they received simultaneous En-DCR and fistulectomy.

At the 3-month follow-up time point, 100% of patients in group A (45/45) and 90.9% of patients in group B (40/44) showed successful surgical outcomes, with no significant differences in these rates between groups (P=0.056). At the 6-month follow-up time point, 3 additional cases of failure were observed (1 in group A; 2 in group B), with success rates falling to 97.8% (44/45) and 86.4% (38/44). At 12-month follow-up, 93.3% (42/45) and 77.3% (34/44) of patients in groups A and B were found to have achieved surgical success, with significant differences in anatomic success rates between these two groups (P<0.05). Despite apparent lacrimal duct patency during irrigation, 8 patients exhibited postoperative epiphora (3 in group A, 5 in group B). Overall functional success rates were 86.7% in group A (39/45) and 65.9% in group B (29/44) (P<0.05) (Fig. 2). Surgical success ratios for patients with skin fistulae present for 1+ months were 87.5% in group A (7/8) and 42.9% in group B (3/7). In contrast, the corresponding functional success rates were 87.5% in group A (7/8) and 14.3% in group B (1/7).

FIGURE 2.

Representative cases of anatomic and functional success. (A) A representative case of anatomic success for a patient in group A at a 6-month follow-up exhibiting ostial patency and a standard epithelized mucosal layer visible upon endonasal endoscopic examination. (B) Functional endoscopic dye test results for the same patient are shown in (A).

Overall, 13 patients experienced failed surgical lacrimal passage reconstruction. Primarily, the causes of failure included granulation tissue formation in 1 and 2 patients in groups A and B, respectively, whereas 2 patients in each group exhibited excessive fibrous tissue formation around the intranasal ostium (Fig. 3). Moreover, 4 and 2 patients in group B experienced operative failure due to common lacrimal duct and lower canalicular obstruction, respectively. When these canalicular obstruction cases were excluded from the overall analyses, the success rate for group B rose to 89.5%, with no significant differences in success rates between groups (P=0.07). Similarly, the surgical success rates turned to 94.6% (group A) and 83.8% (group B), with no significant differences between groups (P=0.261), while patients undergoing both En-DCR and fistulectomy were excluded from total cases (Supplemental Digital Content, Table 2, http://links.lww.com/SCS/F717).

FIGURE 3.

Representative instances of procedure failure in each group. (A) A failed case in group A exhibiting granulation tissue formation around the silicone tube positioned in the ostium. (B) A failed case in group B exhibited the occlusion of the lacrimal sac ostium by granulation tissue.

In the multiple logistic regression analysis of the total sample, 2 variables (intubation and fistulectomy) remained significantly associated with surgical success (Supplemental Digital Content, Table 3, http://links.lww.com/SCS/F717). Intubation (OR: −1.559, 95% CI: 0.049–0.906, P=0.036) indicted to be a protective factor while fistulectomy (OR: 1.641, 95% CI: 1.251–21.276, P=0.023) was a risk factor.

DISCUSSION

Due to suppurative and recurrent inflammation of the lacrimal sac, patients with AD appear with significant pain, medial canthus enlargement, lacrimal abscess development, and preseptal or orbital cellulitis.¹⁴ Endoscopic dacryocystorhinostomy has been established as the primary treatment for AD, enabling the rapid resolution of the underlying inflammation and associated symptoms by providing immediate and adequate lacrimal abscess drainage.

Skin fistulization in patients with AD often develops secondary to the delay or failure of treatment or in patients suffering from recurrent dacryocystitis following failed surgical repair.¹¹ Several prior reports have described En-DCR procedures performed in patients with AD who developed the skin fistulization of lacrimal abscesses despite antimicrobial therapy.^3,9,15 A study by Ali et al¹⁶ revealed that 5.6% of patients with AD developed fistulae, 83.3% of these cases being secondary to spontaneous lacrimal abscess rupture and the remaining 16.7% being secondary to incision and drainage. Systemic antibiotics cannot effectively penetrate the purulent lacrimal sac in patients with AD, thus explaining the high potential of spontaneous rupture of these resistant lacrimal abscesses.

In this operative context, persistent fistulae are characterized by abnormal passages between the lacrimal sac and the epithelial surface for 1+ months.¹⁰ As such, the timing of acquired skin fistula development in patients with AD was used as a secondary surgical criterion, with all enrolled patients with AD exhibiting fistulae present for < 1 month undergoing En-DCR alone, while all patients with fistulae present for 1+ months underwent simultaneous En-DCR and fistulectomy. In total, just 15 patients with persistent fistulization (8 from group A; and 7 from group B) were enrolled in this study. These low patient numbers may be attributable to patients seeking prompt medical care and increased awareness and advancement of the En-DCR procedure.⁸

Traditional treatments for acquired fistulae include conservative methods, an incision along the fistula pathway with concomitant fistular tract excision, and a combination of DCR and fistulectomy.¹⁷ In patients with AD, acquired lacrimal fistulae can quickly heal following En-DCR without needing intubation or fistulectomy, even when these fistulae were present for 4 months to 10 years.^8,9 Increased fluid egress through the nose during the En-DCR procedure may lead to the deprioritization of the narrow fistular tract so that it can close spontaneously following the cessation of fluid outflow. When excising persistent fistulae (present for 1+ months) during DCR, Barrett et al¹⁰ suggest that the delay of such treatment may result in persistent fistular tract epithelization, thus preventing the spontaneous closure of this passageway. Accordingly, simultaneous En-DCR and fistulectomy were performed for patients with persistent fistulization.

Our multivariate analysis of total patients indicated that fistulectomy was a risk factor for surgical success. Excluding patients who had undertaken both En-DCR and fistulectomy, there were no significant differences between group A and group B. Patients with AD with skin fistulae present for 1+ months were only 15 in total, 8 in group A and 7 in group B, with success rates of 87.5% and 42.9%, although there were too few patients in these subgroups to permit more detailed analyses. Further study of our team may be attempted in the future.

Silicone tube intubation offers a means of effectively maintaining and supporting nasolacrimal duct formation, and several prior reports have reported such intubation when performing En-DCR procedures for patients with AD.^15,18,19 Even so, silicone tube placement has been found to promote the development of granulation tissue and can be difficult to position correctly owing to AD-related cellulitis and edema.^5,19 When comparing patients who underwent En-DCR procedures with and without silicone tube intubation, no significant variations in operative success rates were identified in our earlier investigation of patients with AD free of skin fistulization and orbital cellulitis.³ Accordingly, routine AD patient intubation is not recommended when performing En-DCR surgical procedures.

Analyses of canalicular obstruction-related failures in the present study revealed that 5/6 of the affected patients in group B exhibited similar evidence of the formation of other abscesses connected to the initial lacrimal abscess based on the former fistula (Fig. 4). The incision of the lacrimal wall during the En-DCR procedure did not eliminate all of the pus in the lacrimal system unless squeezing or taking the incision to these other abscesses. In total, 4/5 of these patients underwent simultaneous En-DCR and fistulectomy such that the fistulous cavity was excised to the greatest extent possible. Fistulae in 4/5 of these patients were aligned with the medial canthus, while in the remaining patient, a fistula had formed 3 to 4 mm below the medial canthus. The contraction of the lacrimal sac wall as a consequence of incision, spontaneous rupture, or suturing has the potential to cause canalicular obstruction, with this risk increasing based on canalicular proximity. As such, the position of acquired skin fistulae is likely to be associated with operative success, although further large-scale validation will be necessary to test this hypothesis thoroughly.

FIGURE 4.

Dacryocystography on orbital CT for cases of fistulization with additional abscess formation. (A–C) CT images show the lacrimal sac as a high-density area (black arrow) with the formation of a different abscess as a sub-high–density area (white arrow). CT indicates computed tomography.

Common causes of reduced En-DCR procedure’s functional or surgical success in patients with AD include canalicular obstruction and stenosis.⁴ There were no substantial variations in the success rates between the two patient groups after excluding the 6 patients from group B who had postoperative canalicular blockages (4 common canalicular obstructions and 2 lower canalicular obstructions). In addition, 2 of the functional failures in group B occurred among patients who underwent fistulectomy, whereas none of the corresponding patients in group A experienced such loss. Owing to increased vulnerability to injury and scarring,²⁰ the highly edematous canalicular mucosa and suture-related tissue contraction in patients undergoing fistulectomy may contribute to the incidence of postoperative epiphora among patients with AD with acquired skin fistulization. However, silicone tube intubation can prevent canalicular cicatrization by minimizing connective tissue hyperplasia during postoperative recovery following En-DCR.⁴ It is consistent with our multivariate analysis that intubation was a protective factor of the success of patients with AD with acquired skin fistulization.

The current study has some limitations. First, this was a single-center analysis of Chinese patients and lacked patient diversity. Further study should explore the role of intubation in patients with AD with persistent acquired fistula, which is clinically uncommon in AD.

CONCLUSIONS

In summary, patients with AD and acquired skin fistulization who underwent En-DCR exhibited superior operative outcomes in silicone tube intubation due to reductions in the rate of canalicular obstruction. Intraoperative intubation should be routinely performed in patients with AD with skin fistulization.