Endoscopic and External Dacryocystorhinostomy: Long Term Result from a Tertiary Center in Portugal

Abstract

Dacryocystorhinostomy is the gold-standard for distal lacrimal obstructions. This study aims to report the demography, clinical presentation, influence of agger nasi opening, uncinectomy and septoplasty, the use of silicone stent tubes, complications and success of endoscopic and external dacryocystorhinostomy over a period of 11 years. Retrospective review of clinical records, from January 2012 to December 2022, at a tertiary center in Portugal. A total of 249 procedures, 6 external and 243 endoscopic, were performed, including 39 revision cases. There was a female predominance (79.9%) with a mean age at diagnosis of 66.4 years. Recurrent acute dacryocystitis, reported by 33.3%, was associated with higher success (p = 0.053). Agger nasi opening, uncinectomy and septoplasty were performed in 17.7%, 6.0% and 15.3% respectively, although associated with higher success rates, no statistically significant difference was found. Minor complication rates for both external and endoscopic approach was 33.3% and 32.1% respectively. Functional and anatomical success was 100% and 83.3%, respectively, for external dacryocystorhinostomy, and 91.4% and 85.1%, respectively, for endoscopic dacryocystorhinostomy. Revision surgery was associated with a worse anatomical success (p = 0.05). Endoscopic dacryocystorhinostomy is an effective and safe alternative to the external approach. Minor procedures can increase the success rate, but multicentre studies need to be performed for a statistically significant result.

Introduction

Dacryocystorhinostomy (DCR) is the gold standard treatment for symptomatic distal lacrimal obstructions, allowing the direct drainage of tears via a surgically made fistulous bypass between the lacrimal sac and nasal cavity [1, 2].

External DCR (EXT-DCR) technique was initially described in 1904 [3] and later modified by Dupuy-Dutemps with the introduction of suturing of the nasal and lacrimal mucosal flaps [4]. The advent of rigid fiberoptic endoscopes and endoscopic instrumentation played a critical role in establishing endoscopic DCR (END-DCR) as a treatment for nasolacrimal duct obstructions [5, 6]. Over the past years, endoscopic DCR has become a well-established technique with a safety profile and efficacy equivalent or even better than the traditional external approach and with several advantages [7, 8].

The aim of this study is to report our 11-year experience performing endoscopic and external DCR, discussing the outcomes of both procedures and the role of adjunctive procedures. To our knowledge this is the largest Portuguese DCR retrospective case series published in the literature.

Methods

This retrospective study was conducted at the Department of Otorhinolaryngology of the Centro Hospital de Lisboa Ocidental, Lisbon, Portugal.

The clinical records of patients submitted to DCR were retrospectively reviewed. We included all patients submitted to END-DCR and EXT-DCR over a 11-year period, from January 2012 to December 2022. Patients submitted to DCR due to malignant disease or with no clinical records of follow-up were excluded. Patients’ records were reviewed for demographic data, clinical presentation, epiphora etiology, level of obstruction in dacryocystography, adjunctive procedures, use of silicone stent tubes, complications and success rates at the last follow-up. In terms of etiology, we considered a mechanical cause when there was an obstruction identified in dacryocystography, whereas a functional cause was considered in case of absence of obstruction. Proximal obstructions were defined in dacryocystography as the contrast filling of the nasolacrimal pathway proximal to the lacrimal sac (between the puncta and the distal end of the common canaliculus), while distal obstructions were considered when contrast was detected up to a point distal to this boundary (between lacrimal sac and valve of hasner) (Fig. 1).

Fig. 1.

Representation of proximal (green arrow) and distal (blue arrow) obstructions

A detailed clinical history and physical examination was performed for all patients, including lacrimal probing, irrigation, functional fluorescein test and nasal endoscopy. As part of the clinical workup, computed tomography (CT) scan of the paranasal sinus with dacryocystography was performed in most cases.

Anatomical success was defined as a patent ostium on irrigation. Functional success was subdivided as complete (total resolution of symptoms, evidenced by no tearing, discharge or recurrent episodes of acute dacryocystitis), partial (minor intermittent symptoms with significant improvement compared to preoperative status), or absent (no improvement compared to preoperative status). The functional success was finally defined as complete success plus partial success.

Statistical analysis was performed with SPSS 24.0 for windows (SPSS Inc., Chicago, IL, USA).

Surgical Technique for Endoscopic DCR In our centre endoscopic DCR was performed according to the technique described by Wormald et al. [9–12]. At the beginning, nasal mucosa was decongested with neuro patties soaked in a solution of 2–4 vials of adrenaline (1:100,000) with nasal saline (10–20 mL) for 10 min. The axilla of middle turbinate was injected with 2% lidocaine with 1:80,000 adrenaline. In brief, the technique described by Wormald et al. starts by mucosal incisions. The first incision is made horizontally 8–10 mm above the axilla of the middle turbinate and is continued anteriorly approximately 10 mm onto the frontal process of the maxilla. A vertical incision is continued inferiorly until about two-thirds of the vertical height of the middle turbinate, followed by a horizontal inferior incision started at the insertion of the uncinate process and brought forward until the vertical incision (Fig. 2A). A suction freer elevator is used to raise the posteriorly pediculated mucosal flap (Fig. 2B), with subsequent exposure of the frontal process of the maxilla and its junction with lacrimal bone. The bone is removed with a Hajek Koeffler puch (Fig. 2C) until it becomes thick and not amenable to punch removal. At this point, a curved 25° high-speed diamond DCR burr is used to complete the bone removal, in order to fully expose the lacrimal sac (Fig. 2D). During this process, the agger nasi is exposed. Next the inferior punctum is dilated with a punctum dilator and a Bowman’s lacrimal probe tents the medial sac wall, which is incised vertically along its entire length with a DCR spear knife (Fig. 2E). Horizontal cuts superiorly and inferiorly in the lacrimal sac anterior and posterior flaps are performed to allow the flaps to be reflected in the lateral nasal wall in an open book fashion (Fig. 2F). The initial nasal mucosal flap is refashioned and reflected back to cover the superior and inferior exposed bone. O´Donoghue tubes are placed through the upper and lower puncta and retrieved endonasally. A silastic spacer is placed over the tubes and ligar clips are used to secure the stents. A gelfoam patch is used to keep the flaps in position in early postoperative period. In the postoperative period all patients received oral and topic antibiotics and were instructed to perform regular saline douching.

Fig. 2.

A Intraoperative image of right nasal cavity showing the two horizontal incisions and the vertical incision. B Intraoperative image of right nasal cavity showing the elevation of the posteriorly pediculated mucosal flap with freer elevator. C Intraoperative image of left nasal cavity showing bone removal with a Hajek Koeffler puch. D Intraoperative image of left nasal cavity showing complete exposure of the lacrimal sac (*) after bone removal. E Intraoperative image of left nasal cavity showing the vertical incision in the medial sac wall along its entire length with a DCR spear knife. F Intraoperative image of left nasal cavity showing the horizontal cut inferiorly in the lacrimal sac anterior flap with backbiter

Some surgeons performed an anterior uncinectomy and/or agger nasi opening in order to ensure the proper exposition of the lacrimal sac and correct positioning of the posterior sac flap.

In patients with proximal obstructions, we attempt to overcome it with punctum dilator. If we are unable to overcome the obstruction, we create a false tract. All the remaining surgical technique is similar to distal obstructions described above. In the post operative period, O'Donoghue tubes are maintained for 6–12 months to prevent contracture and also to provide scaffolding to direct proper epithelialization. In case of surgical failure, we propose these patients to conjunctivodacryocystorhinostomy with Lester Jones tube.

Results

A total of 249 procedures were performed in 189 patients. Of these procedures, 243 were endoscopic and 6 were external approaches. The mean age was 66.45 ± 0.947 years (range 3–94 years) and there was a female gender predominance (79.9%). Epiphora was the most common symptom, present in all patients, followed by purulent discharge (54.62%) (Table 1).

Table 1.

Characteristics and clinical presentation of the patients included

Characteristics	n = 249 procedures (189 patients)
Mean age (years) ± SD (range)	66.45 ± 0.947 (3–94 years)
Female (%)	79.9%
Clinical presentation (n, %)
Epiphora	249 (100%)
Purulent discharge	136 (54.62%)
Recurrent acute dacryocystitis	65 (26.1%)
Recurrent acute dacryocystitis w/complication	18 (7.23%)
Cutaneous fistula	2 (0.86%)

Aetiology was subdivided into congenital (2 cases, 0.80%), mechanical acquired (228 cases, 91.57%) and functional acquired (10 cases, 4.02%). In terms of level of obstruction in dacryocystography, distal obstructions were more frequent (150 cases, 60.24%), with predominance for the valve of Krause (135 cases, 54.22%) (Table 2).

Table 2.

Level of obstruction in dacryocystography

Level of obstruction	Number (%)
Proximal
Canaliculi	11 (4.42%)
Valve of Rosenmüller	35 (14.06%)
Distal
Lacrimal sac	9 (3.61%)
Valve of Krause	135 (54.22%)
Nasolacrimal duct	5 (2.0%)
Valve of Hasner	1 (0.4%)
Proximal + distal
Puncta + valve of Krause	2 (0.8%)
Canaliculi + valve of Krause	2 (0.8%)
No obstruction	10 (4.02%)
No information	39 (15.66%)

Agger nasi opening was performed in 41 cases (16.47%), uncinectomy in 14 cases (5.62%) and septoplasty in 38 cases (15.3%). An O’Donoghue silicone stent tube was used in 98.8% of cases, with a mean duration of 7.32 ± 0.355 weeks.

Considering all END-DCRs (243), 206 (84.77%) were primary surgeries and 37 (15.23%) were revision surgeries. At last follow-up, final anatomic success was achieved in 86.41% cases in primary DCR and in 75.68% in revision surgery, whereas functional success was obtained in 92.72% in primary and 83.78% in revision DCRs (Table 3). Globally, anatomic success for END-DCR was 85.1% and functional success was 91.4% (Fig. 1).

Table 3.

Endoscopic DCR success rate

Endoscopic DCR	Primary surgery (n, %)	Revision surgery (n, %)
No. procedures	206 (84.77%)	37 (15.23%)
Anatomic success	178 (86.41%)	28 (75.68%)
Functional success	191 (92.72%)	31 (83.78%)

EXT-DCRs were performed in 6 cases, of which 4 (66.67%) were primary surgeries and 2 (33.33%) were revision surgeries. In this group, final anatomic success was 100% in primary and 50% in revision DCRs, while functional success was 100% for both primary and revision surgeries (Table 4). Globally, anatomic success for EXT-DCR was 83.3% and functional success was 100% (Fig. 3).

Table 4.

External DCR success rate

External DCR	Primary surgery (n, %)	Revision surgery (n, %)
No. procedures	4 (66.67%)	2 (33.33%)
Anatomic success	4 (100%)	1 (50%)
Functional success	4 (100%)	2 (100%)

Fig. 3.

Global anatomic and functional success for END-DCR and EXT-DCR.

Postoperative complications for END-DCR occurred in 10.7% cases and for EXT-DCR in 16.7% cases. All reported complications were minor and included synechia (6.16%), epistaxis (1.2%), stent extrusion (1.2%), periorbital ecchymosis (0.93%), ostium granuloma (0.93%), postoperative infection (0.8%), lid edema (0.67%) and stent dislocation (0.13%).

Mean follow-up of patients was 21.16 ± 1.406 months (range 2–124 months).

In terms of factors with impact in success, clinical presentation was associated with functional success (p = 0.053), being the recurrent episodes of acute dacryocystitis the symptom with higher correlation. Although agger nasi opening, uncinectomy and septoplasty were associated with higher success, this result was not statistically significant (p > 0.05). There was no statistically significant difference between endoscopic and external DCR concerning success rate and postoperative complications (p > 0.05). Revision surgery was statistically associated with worse anatomical success (p = 0.05).

Discussion

Over the past 40 years, multiple studies showed that END-DCR yields comparable results to EXT-DCR with several advantages such as absence of a cutaneous incision, less disruption of the lacrimal pumping mechanism, reduced operative time and postoperative morbidity, early recovery, ability to address concomitant nasal abnormalities and to identify etiological factors of failure [2, 13–15]. We found equivalent results between these two approaches, regarding success rate and complications.

Success rates for END-DCR reported in the literatures ranges from 75 to 96% [5, 8, 13, 16, 17]. Our results are in agreement with the literature, since we documented an anatomic success rate of 86.41% in primary DCR and 75.68% in revision surgery, with a functional success of 92.72% and 83.78% in primary and revision surgery, respectively. Literature also states that revision surgery results are worse than primary surgery, which is also in accordance with our study.

In 2022 Vinciguerra et al. [18] performed a review in order to propose an algorithm to treat distal acquired lacrimal disorders. According to this review, in primary surgeries END-DCR should be preferred in case of concomitant intranasal comorbidities, due to the possibility to directly treat it, whereas EXR-DCR should be elected in case of need or preference for local anesthesia. In the absence of these conditions, the surgeon should discuss the advantages and disadvantages of both approaches with the patient. In revision cases, END-DCR should be chosen due to the major probability to directly visualize and solve the causes of primary failure. In our retrospective case series, all external approaches were performed in patients unfit for general anesthesia. Actually, in our centre we advocate END-DCR due to all of its advantages, which can be seen by the discrepancy between endoscopic and external approaches.

For successful long-term outcomes in endoscopic DCR, there are some critical issues that need to be taken into account, which include the accurate localization of lacrimal sac, a large osteotomy sufficient to expose the entire lacrimal sac, complete sac marsupialization and a perfect lacrimal sac mucosa to nasal mucosa apposition [5]. To address these critical issues, it is important that a proper access to the lacrimal fossa is achieved. Soyka et al. [19] defend that the uncinate process and the agger nasi cell form a key point for a successful endonasal approach to the lacrimal sac. These authors found that more than 60% of the patients showed an obstructing uncinate process of not less than 50% of the lacrimal fossa and that in 55% of the individuals an agger nasi cell was found at a level that could be troublesome for the surgeon. Therefore, these authors concluded that in most cases either an overlying agger nasi cell or a covering uncinate process needs to be removed to gain a proper access to the lacrimal and maxillary bone in DCR (Fig. 4A, B).

Fig. 4.

A Axial CT-scan showing the lacrimal sac (arrow) is fully covered by the uncinate process (dots); B Axial CT-scan showing agger nasi cell covering the lacrimal sac; adapted from Soyka et al.

In addition, several studies in the literature suggest that a concomitant septoplasty should be considered when indicated to improve surgical access and that not addressing a deviated septum at time of primary DCR may increase the failure rate [20]. In our series, in 16.47% of cases the agger nasi was opened, in 15.3% a concomitant septoplasty was performed and in 5.62% a partial uncinectomy was done. All these procedures showed a trend to increase the success rates, but the result was not significant.

The main limitations of this review include its retrospective nature and the sample asymmetry between END and EXT-DCR.

Conclusion

In conclusion, this retrospective case series supports that END-DCR is an effective and safe alternative to the external approach. An appropriate knowledge of the intranasal anatomy allied to a lower threshold for performing concomitant endonasal procedures, such as agger nasi opening, uncinectomy or septoplasty, can increase the success rate, but multicentre studies need to be performed.

Declarations

Conflict of interest

The authors did not receive support from any organization for the submitted work.The authors have no relevant financial or non-financial interests to disclose.

Human and animals rights

Considering this is a non-interventional study where data was retrospectively obtained, analysed and anonymized, the need for ethics committee approval was waived.

Informed consent

Considering this is a non-interventional study where data was retrospectively obtained, analysed and anonymized, the need for informed consent was waived.