Endonasal dacryocystorhinostomy: a modified technique with preservation of the nasal and lacrimal mucosa

Abstract

Purpose: In the last 15 years, endonasal dacryocystorhinostomy (End-DCR) has become an alternative to external dacryocystorhinostomy. In most series reported, it appears that End-DCR had a higher failure rate than Ext-DCR. Uncontrolled epithelialization of the surgical site as compared with the fashioning of mucosal flaps may explain the somewhat lower success rate. The purpose of our study is to validate a modification of a new technique described by Tsirbas and Wormald in which the nasal mucosa is preserved and brought in contact with the lacrimal mucosa during End-DCR, leaving an epithelialized surgical site at the end of the operation.

Methods: A retrospective study was performed from November 2001 to January 2003. Patients with epiphora and or chronic or recurrent dacryocystitis were evaluated. Patients with symptomatic nasolacrimal duct obstruction (NLDO) and who met the criteria for End-DCR were selected. NLDO was diagnosed based on symptoms, along with a blocked irrigation or an abnormal bone substract dacryocystogram. The surgical procedure involved a manual osteotomy of the frontal process of the maxilla and removal of the lacrimal bone with the creation of posteriorly hinged lacrimal sac and nasal mucosal flaps.

Results: Forty-five patients underwent End-DCR with preservation of the lacrimal and nasal mucosa. Five patients had bilateral surgery. A total of 50 surgeries were performed. Twenty-four surgeries were performed on the right side and 26 on the left. Patients were evaluated at 1 week, 1 month, and 3 months after surgery. Evaluation included asking about subjective symptoms of epiphora, lacrimal irrigation on the 3 visits, and endoscopic evaluation of the surgical site at 3 months. Surgery was considered successful when patients did have relief of their epiphora and had a patent system with irrigation. Forty-nine patients (98%) were asymptomatic at 1 month and at 3 months with both a patent system tested with irrigation and a patent ostium evaluated with the endoscope. One patient who had undergone bilateral surgery had blockage of the fistula on the left side at 3 months. The patient underwent endoscopic revision surgery and was patent 1 year afterward. A phone survey was performed from January to May 2008. Thirty-four patients (75%) were reached. Two patients were still tearing and were brought for reassessment. One had an open lacrimal system and one was blocked.

Conclusions: This study validates the concept of preserving the lacrimal and nasal mucosa through an endoscopic approach to treat NLDO. Early and controlled lining of the fistula with mucosal flaps appears to prevent closure of the ostium and leads to a high success rate comparable with that of external dacryocystorhinostomy. This can be accomplished successfully with a manual osteotomy thus avoiding the use of power drills and burrs.