Experience with bicanalicular intubation of the lacrimal drainage apparatus combined with conventional external dacryocystorhinostomy

Journal of Cranio-Maxillofacial Surgery (2003) 31, 187–190 r 2003 European Association for Cranio-Maxillofacial Surgery. doi:10.1016/S1010-5182(03)00020-9, available online at http://www.sciencedirect.com

Experience with bicanalicular intubation of the lacrimal drainage apparatus combined with conventional external dacryocystorhinostomy Punita Kumari Sodhi1, Ravindra M. Pandey2, K.P.S. Malik1 1

Department of Ophthalmology, Safdarjung Hospital, New Delhi, India; 2 Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India SUMMARY. Aim: The aim of this study was to assess the success rate of bicanalicular intubation of lacrimal

drainage apparatus in chronic dacryocystitis patients who were at high risk of failure of surgery of dacryocystorhinostomy. Material and methods: A total of 24 patients with chronic dacryocystitis (25 eyes) including 11 males and 13 females (age range 3–80 years) having high risk factors of failure of dacryocystorhinostomy were enrolled. Factors such as previous attacks of acute dacryocystitis, trauma in lacrimal sac region, previously failed dacryocystorhinostomies, formation of false passages in the lacrimal drainage apparatus were considered. Conventional dacryocystorhinostomy followed by bicanalicular intubation of the lacrimal drainage apparatus with Jain metal silicone the lacrimal intubation tube (20–23 gauge) was performed in all these patients. The patients were followed up at weekly intervals for two months, at 6 months and at 1 year post surgery. Results: A total of 25 eyes in 24 patients (including 11 males and 3 females) were operated upon using the technique of bicanalicular intubation of lacrimal drainage apparatus with conventional external dacryocystorhinostomy. The procedure was successfully performed in 22 out of the 25 eyes. Perioperative complications included punctual damage due to recurrent attempts at passing these probes in 2 patients and mild damage to nasal mucosa in 5 patients. The majority of patients did not experience any untoward symptoms from these silicone tubes. However, in three eyes there was felt a mild foreign body sensation and two patients had chronic conjunctival erythema. The tubes could not be retained in two of these three eyes. Additionally, in one eye there was spontaneous extrusion of tubes whilst sneezing 3 months after surgery. All these three eyes had a recurrence of symptoms due to non-retention of the tubes and needed re-operation.On average the tubes were retained for a period of six months before they were spontaneously extruded or removed. Fifteen patients retained the silicone tubes for more than 1 year. The procedure gave a success rate of 76% (19/25 eyes) and these were the eyes in which the tubes had been retained for more than 6 months. The success was not influenced by the age or sex of patient, laterality of eye, aetiology of chronic dacryocystitis, or evidence of bony deformity or abnormality of the sac. Conclusions: Bicanalicular intubation for lacrimal drainage system is a simple, inexpensive and straight forward adjunct to conventional external dacryocystorhinostomy. The procedure is strongly indicated for patients with chronic dacryocystitis who are at high risk of surgical failure. Carefully performed, it gives a 76% success rate and is not influenced by the different variables examined. r 2003 European Association for Cranio-Maxillofacial Surgery. Keywords: Bicanalicular intubation; Dacryocystorhinostomy; Failed dacryocystorhinostomy

lacrimal drainage passage for such patients was first described by Keith in 1968. From that time onwards, materials like silk sutures (Crawford, 1977), silver wires (Crawford, 1977; Quickert and Dryden, 1970), polyethylene tubes (Crawford, 1977), nylon (Shannon and Hamdi, 1966), and polyurethane stents have been used to intubate the lacrimal drainage system. These materials serve to maintain the patency and dimension of the lacrimal system and the intranasal ostium until epithelialization is complete (Crawford, 1977; Quickert and Dryden, 1970; Kraft and Crawford, 1982). The disadvantages of previous materials were that these were very rigid (Crawford, 1977) and tissue cutting (Crawford, 1977). The intubation with silicone tubes attached to metal probes was first described by Gibbs (1967). The silicone tubes are non-irritating (Kraft and Crawford, 1982), well-tolerated (Crawford, 1977; Quickert and Dryden, 1970; Hausler and

INTRODUCTION Dacrocystorhinostomy involves formation of an alternative (bypass) channel from the lacrimal sac to the middle meatus of the nose for drainage of lacrimal secretions. The reported success rate of conventional external dacryocystorhinostomy is 90–95% (Mannor and Millman, 1992; Muellner et al., 2000). The reasons for surgical failure include incorrect identification of the lacrimal sac, failure to make an adequate osteotomy, fall back of lacrimal sac flaps and fibrosis of the bony osteotomy. Previously, re-operation using conventional techniques (Muellner et al., 2000), with Nd-YAG laser (Patel et al., 1997) or endoscopic intranasal dacryocystorhinostomy (Mannor and Millman, 1992) had been recommended for patients with a failed dacryocystorhinostomy. The technique of intubation of 187

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Caversaccio, 1998), flexible (Kraft and Crawford, 1982), easy to knot (Kraft and Crawford, 1982) and can be retained for even as long as 3 years (Hausler and Caversaccio, 1998). In this study 24 patients (25 eyes) were evaluated who were at high risk of failure of dacryocystorhinostomy. The conventional dacryocystorhinostomy in these patients was followed by bicanalicular silicone intubation of lacrimal drainage system. MATERIAL AND METHODS A total of 24 chronic dacryocystitis patients (11 males, 13 females) between the ages of 3 and 80 years were evaluated. These patients presented with complaints of epiphora and pressure regurgitation of fluid from the lacrimal sac. After a proper ophthalmic examination to rule out other causes of epiphora (adnexal, corneal, conjunctival etc.), probing (with a lubricated probe) and syringing was performed to confirm the diagnosis. An ear, nose and throat examination was performed for all patients; investigation included radiographs of orbits and paranasal sinuses, blood sugar; urine sugar and albumin; bleeding and clotting times. Informed consent of all patients was taken. A conventional external dacryocystorhinostomy with bicanalicular silicone intubation using Jain metal silicone intubation tubes (20–23 gauge) was performed in all patients. Prefabricated silicone intubation sets available in 21–23 gauge with 11.5 cm long probes were used for this study.

the lacrimal sac. The nasal pack was removed. These probes are already bent at an angle of 301 at about one third length from the end where the silicone tubes were attached. The two probes were manipulated through the nasal ostium behind the anterior nasal flap and passed out of the nasal cavity. On occasions, curved artery forceps had to be used to extract the probes out of the nasal cavity. A drinking straw was found to be useful in guiding the probes out of the nose (Fig. 1). The two probes were cut away from the silicone tubes. While exerting downwards traction on these tubes three knots were used to tie them together. As soon as the tubes were left loose, they retracted into the upper nasal cavity, two steps which have not been described before. The nasal cavity was then repacked superficially up to the inferior turbinate and middle turbinate, i.e. the portion which was easily approachable without disturbing the silicone tubes. The lacrimal sac flaps were then sutured to the nasal flaps using 6.0 Vicryls. The orbicularis muscle was also sutured with interrupted 6.0 Vicryls sutures. The skin incision was closed using subcuticular sutures with 6.0 silk. After applying antibiotic ointment to the wound and conjunctival sac, the eye was padded and bandaged. The overall operating

SURGICAL TECHNIQUE Ribbon gauze soaked in 2% xylocaine with adrenalin 1:10,000 was used as a nasal pack up to the middle turbinate. About 10 cm3 of local anaesthetic (5 cm3 of 2% xylocaine and 5 cm3 of 4% sensorcaine) was injected into the lacrimal sac region blocking the infraorbital, supraorbital and lacrimal nerves, and, 25 mg of phenergan was administered intramuscularly for sedation. Patients were positioned with the head raised and after preparation, an incision through skin and orbicularis muscle starting about 3 mm above and 3 mm medial to the medial canthus and extending 5 mm caudally was made. The anterior lacrimal crest was exposed. The periosteum incised, and the lacrimal sac was separated from the lacrimal fossa. After retracting the lacrimal sac with a lens spatula, the lamina papyracea was fractured and a nasal ostium 12 mm  12 mm was prepared in the region of middle meatus using Citelli’s bone punch. The lacrimal probe was guided into the lacrimal sac through the lower canaliculus and while tenting the sac upwards, the lacrimal sac flaps were prepared. This was followed by formation of nasal flaps. The posterior flaps were excised. Jain metal silicone tubes (11.5 cm long) similar to those described by Hausler and Caversaccio (1998) were lubricated and passed through both the upper and lower canaliculus into

Fig. 1 – Drinking straw used for introduction of lacrimal silicone intubation tubes.

Experience with bicanalicular intubation of the lacrimal drainage 189

time was about 1 hour and 15 minutes. The procedure took longer in patients with orbital trauma or in case of increased bleeding, difficult tissue plane dissection, difficult probing, formation of false passages and those with deformed sac anatomy and nasal mucosa. If the silicone loop running between the upper and lower canaliculus was accidentally pulled out, it could be returned using a forceps (Patel et al., 1997). The tubes can be easily removed by cutting the upper end between the puncta (Patel et al., 1997; Kraft and Crawford, 1982) and blowing the nose forcibly while occluding the other nostril (Mannor and Millman, 1992; Patel et al., 1997). Follow-up visits were performed weekly for 1 month, and monthly for 6 months and finally at one year postoperatively. At all these visits the patients were examined for retention of tubes, any erythema or allergic reaction to tubes, or any signs of infection.

RESULTS Table 1 shows the distribution of case characteristics and the outcome of surgery. The risk factors for failure of surgery in these patients included reoperation (6 eyes), trauma (5 eyes), recurrent acute attacks (11 eyes) and canalicular damage (3 eyes). The factors observed perioperatively were thick nasal bone (3 eyes), bony deformity (4 eyes), dilated atonic sac (8 eyes), fragile sac (5 eyes), on thick sac (2 eyes) while 3 eyes had a normal sac. The procedure of bicanalicular intubation with dacryocystorhinostomy was successful in 22 out of 25 eyes. Problems including haemorrhage, adhesions, difficult probing, false passage formation and

Table 1 – Case characteristics and outcome of surgery Variables

Age (years) Sex M:F Laterality Right eye Left eye Both eyes Indication Traumaa Recurrent acute attacks Operative finding Bony abnormalityb Sac abnormalityc a

Outcome of surgery

p-value

Success n=18(75%)

Failure n=6(25%)

34712.88

34.5720.52

p>0.5

8:10

3:3

p>0.5

7 10 1

3 3 0

p>0.5

11

3

7

3

p>0.5

4 14

2 4

p>0.5

Trauma refers to insults from previous surgery, interventional procedures like syringing and probing, and accidental causes. b Bony abnormality refers to bony thickening, fracture or fibrosis of previous osteotomy sites. c Sac abnormality includes any fibrosis, contracture, or atony of sac.

deformed sac or deformed nasal mucosal anatomy were encountered more frequently than following other operations. There was punctal damage in 2 patients and mild damage to nasal mucosa in 5 others due to recurrent intubation attempts. The procedure could not be performed in three patients due to the formation of false passages while probing (1/3); success in passing only a single tube through one of the canaliculi (1/3); or separation of the silicone tube from the probe while passing through the canaliculi (1/3). The silicone tubes were generally well tolerated in these patients. Three eyes had a mild foreign body sensation and two had chronic conjunctival erythema. In two of these three the tubes could not be retained for more than 3 weeks. In another case, there was spontaneous extrusion of tubes on sneezing three months after surgery. All these three eyes had a recurrence of symptoms following loss of the tubes and needed re-operation later. On average, the tubes were retained for a period of 6 months before being spontaneously extruded or removed. Fifteen patients retained the silicone intubation tubes for more than a year. The success rate was 100% in patients in whom the tubes could be retained for more than 6 months (19/25 eyes). The success was not influenced by age or sex, laterality of eye, aetiology of chronic dacryocystitis, or deformity of bone or abnormality of the sac. DISCUSSION Bicanalicular intubation of lacrimal drainage apparatus has been previously performed in patients with traumatic or inflammatory damage to the sac, nasolacrimal duct or canaliculi (Muellner et al., 2000; Kraft and Crawford, 1982; Crawford, 1977). When undertaken as an isolated procedure (Kraft and Crawford, 1982; Crawford, 1977; Fulcher et al., 1998), it has a low success rate (Muellner et al., 2000; Kraft and Crawford, 1982; Fulcher et al., 1998; Beigi and O’Keefe, 1993; Pashby and Rathbun, 1979; Mannor and Millman, 1992). Although the additional procedure of dacryocystorhinostomy significantly raises the success rate (Quickert and Dryden, 1970; Zapala et al., 1992), it has been infrequently performed at the same time as lacrimal intubation (Crawford, 1977). Whilst earlier surgeons have accomplished the procedure of lacrimal intubation in patients ranging in age from 6 months to 83 years (Kraft and Crawford, 1982; Fulcher et al., 1998), unlike previous studies, we included only those patients who had an anticipated poor outcome with DCR. Hence, we encountered perioperative difficulties like haemorrhage, tissue plane adhesions, difficult probing and false passage formation more frequently. In order to decrease damage to the nasal mucosa (Beigi and O’Keefe, 1993), various aids such as a grooved director (Quickert and Dryden, 1970; Gibbs, 1967; Fulcher et al., 1998), Crawford hook (Hausler and

190 Journal of Cranio-Maxillofacial Surgery

Caversaccio, 1998), stainless steel grooved hook (Crawford, 1977; Kraft and Crawford, 1982), and nasal endoscope (Beigi and O’Keefe, 1993) were used for retrieving the tubes. We also used drinking straws to direct these probes in some of our patients. While earlier workers tied the two lower ends of silicone tubes together (Crawford, 1977) or fixed the tubes inside the nasal cavity (Hausler and Caversaccio, 1998), we allowed the lower tied ends of the tubes to retract freely into the nasal cavity. Previous workers have encountered post-operative complications including local inflammatory reactions (Hausler and Caversaccio, 1998), formation of small mucosal polyps at the lacrimal puncta (Hausler and Caversaccio, 1998); and sometimes corneal complications (Hausler and Caversaccio, 1998). Other authors have reported a success rate ranging from 56.25% (Kraft and Crawford, 1982) to 80.3–100% (Crawford, 1977; Kraft and Crawford, 1982; Hausler and Caversaccio, 1998; Beigi and O’Keefe, 1993; Dortzbach et al., 1982) with lower success rate in patients with a history of trauma. In our patients the procedure was successful in all those who retained the tubes for more than 6 months. CONCLUSION Bicanalicular intubation of the lacrimal drainage apparatus with dacryocystorhinostomy is simple, inexpensive and fairly quick. It is indicated for patients with chronic dacryocystitis who are at high risk of surgical failure. The silicone tubes are atraumatic and cosmetically acceptable. Providing trauma during the passage of tubes is avoided, and these are retained for a period longer than six months, the procedure has a high success rate (76%).

Crawford JS: Intubation of obstruction in the lacrimal system. Can J Ophthalmol 12: 289–292, 1977 Dortzbach RK, France TD, Kushner BJ, Gonnering RS: Silicone intubation for obstruction of the naso-lacrimal duct in children. Am J Ophthalmol 94: 585–590, 1982 Fulcher T, O’Connor M, Moriarty P: Nasolacrimal intubation in adults. Br J Ophthalmol 82: 1039–1041, 1998 Gibbs DC: New probe for the intubation of lacrimal canaliculi with silicone rubber tubing. Br J Ophthalmol 51: 198, 1967 Hausler R, Caversaccio M: Microsurgical endonasal dacryocystorhinostomy with long term insertion of bicanalicular silicone tubes. Arch Otolaryngol Head Neck Surg 124: 188–192, 1998 Keith CG: Intubation of the lacrimal passages. Am J Ophthalmol 68: 70–74, 1968 Kraft SP, Crawford JS: Silicone tube intubation in disorders of the lacrimal system in children. Am J Ophthalmol 94: 290–299, 1982 Mannor GE, Millman AL: The prognostic value of preoperative dacryocystography in endoscopic intranasal dacryocystorhinostomy. Am J Ophthalmol 113: 134–137, 1992 Muellner K, Bodner E, Mannor GE, Wolf G, Hofmann T, Luxenberger W: Endolacrimal laser assisted lacrimal surgery. Br J Ophthalmol 84: 16–18, 2000 Pashby RC, Rathbun JE: Silicone tube intubation of the lacrimal drainage system. Arch Ophthalmol 97: 1318–1322, 1979 Patel BC, Phillips B, Mclush WM, McLeish WM, Flaharty P, Anderson RL: Transcanalicular Nd-YAG laser for revision of dacryocystorhinostomy. Ophthalmology 104: 1191–1197, 1997 Quickert MH, Dryden RM: Probes for intubation in lacrimal drainage. Trans Am Acad Ophthalmol Otolaryngol 74: 431–433, 1970 Shannon GM, Hamdi TN: Repair of injuries of the lacrimal canaliculus. Am J Ophthalmol 62: 974, 1966 Zapala J, Bartkowski AM, Bartkowski SB: Lacrimal drainage system obstruction: management and results obtained in 70 patients. J Cranio-Maxillofac Surg 20: 178–183, 1992 Dr. Punita Kumari Sodhi, MS, DNB, C-7/164, Safdarjung Development Area P.O. Hauz Khas New Delhi-110016

References

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Beigi B, O’Keefe M: Results of Crawford tube intubation in children. Acta Ophthalmol 71: 405–407, 1993

Paper received 7 March 2002 Accepted 5 February 2003