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Long-term results of intranasal laser-assisted dacryocystorhinostomy with the use of a surgical microscope
Auris Nasus Larynx 37 (2010) 66–70 www.elsevier.com/locate/anl
Long-term results of intranasal laser-assisted dacryocystorhinostomy with the use of a surgical microscope Emmanuel P. Prokopakis a, Alexios S. Vardouniotis a,*, Alexandros D. Karatzanis a, Stylianos G. Malandrakis a, Charalambos S. Siganos b, George A. Velegrakis a a
Department of Otolaryngology, University of Crete School of Medicine, 71414 Heraklion, Crete, Greece b Department of Ophthalmology, University of Crete School of Medicine, Heraklion, Crete, Greece Received 12 October 2008; accepted 5 April 2009 Available online 2 July 2009
Abstract Objective: To address the long-term results of our method that combines intranasal laser-assisted dacryocystorhinostomy with the use of surgical microscope. Methods: The procedure is a modification of the West method. A retrospective series of the long-term results are presented in 105 patients that underwent 118 DCR procedures, over the past 6 years. Selection criteria were mainly acquired idiopathic nasolacrimal duct obstruction. Results: 113 DCR cases (95,8%) were free of symptoms postoperatively (mean follow-up: 24 months). Conclusion: Our method when compared with traditional methods is correlated with excellent postoperative long-term results. # 2009 Elsevier Ireland Ltd. All rights reserved. Keywords: Dacryocystorhinostomy; Nasolacrimal duct; Laser; Endoscopy; Microscopy
1. Introduction Although the diagnosis of nasolacrimal duct obstruction or stenosis is traditionally made by ophthalmologists, surgical treatment – which requires an excellent knowledge of the anatomy of the nose and sinuses – constitutes today an active field for otorhinolaryngologists as well. The goal of dacryocystorhinostomy (DCR) is to re-establish tear flow from the lacrimal system into the nasal cavity. This can be achieved through a series of surgical techniques including external, intranasal and transnasal–transseptal approaches [1]. An ideal procedure should leave a minimal or no external scar at all. It has to be performed with safety and should lead to results similar or superior to those achieved with conventional techniques [2]. The combination of intranasal endoscopy or microscopy with lasers has been demonstrated to meet these criteria. In this study, we report the long-term
* Corresponding author. E-mail address: [email protected] (A.S. Vardouniotis).
results of intranasal laser-assisted dacryocystorhinostomy with the use of a surgical microscope. 2. Materials and methods In our study, ranged from September, 2001 to April, 2007, 105 patients underwent 118 intranasal laser-assisted DCRs with the use of a surgical microscope. There were 89 women and 16 men and the ages ranged from 14 to 78 years old (mean age 49.8). The surgical technique used was a modification of the West method [3]. The same team of surgeons performed all procedures (Figs. 1 and 2). Eight patients underwent bilateral DCRs, while five patients underwent ipsilateral revision procedures. The main indication for the selection of the candidates for DCR was acquired idiopathic nasolacrimal duct obstruction and recurrence of symptoms (such as epiphora and empyema of the lacrimal sac) from previous operations. Ophthalmologists, in co-operation with the doctors of our department, were responsible for the evaluation and candidate’s selection [4]. Before surgery, all the patients
0385-8146/$ – see front matter # 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.anl.2009.04.011
E.P. Prokopakis et al. / Auris Nasus Larynx 37 (2010) 66–70
67
Fig. 1. (a) Infiltration of a local anesthetic and vasoconstrictive agent in the agger nesi area. (b) Ablation of approximately 1 cm3 of the mucosa overlying the bony ostium is performed with the use of CO2 laser. (c) Multiple back-and-forth cuts are made with a cutting burr until a body ostium of at least 1 cm3 is created. (d) The lacrimal sac is adequately revealed.
underwent nasal endoscopy with the use of a 00, 4 mm rigid endoscope (HOPKINS II, 7230AA, Karl Storz). Pathology such as severe septal deviation that caused obstruction and needed septoplasty as well as nasal polyps, were excluded at the time. Patients that had undergone head and neck radiation therapy, presenting with malignancy or had a history of maxillofacial trauma were also excluded. Postoperative follow-up was done by both our clinics. The follow-up period ranged from 12 to 48 months (mean time 24 months). Postoperative success of the procedure was evaluated by the improvement of tearing and passing of fluid during lacrimal irrigation. Furthermore, fluorescein was placed into the inferior eyelid fomix to evaluate the flow of the stain to the middle nasal meatus. In five patients, intranasal endoscopic evaluation for persistent epiphora and difficult silicone tube removal was required postoperatively. Although in the past all our cases were done under general anesthesia, the vast majority of our recent cases, 92 have been operated under local anesthesia keeping general anesthesia in hand mainly for more demanding revision operations. Initially, a cotton swab sprayed with 0.1% xylomethazoline is placed into the nasal canal approximately 15 min before surgery, while the patient is still in the clinic, in order to initiate vasoconstriction of the nasal mucosa. Afterwards, further intranasal vasoconstriction and
anesthesia is achieved with pledgets soaked in a 10% cocaine solution. Finally, an injection of xylocaine–adrenaline 2% solution is performed at the insertion of the middle turbinate and at the agger nasi area. In order to avoid retinal injury, both eyes are protected with a solid, opaque, lasersafe shield. The CO2 laser is then connected to the surgical microscope (lens diameter of 300 mm) via a micro-slad and the microbeam of the CO2 laser is directed towards the medial wall of the nasal cavity overlying the lacrimal sac, just anterior to the middle meatus. Ablation of approximately 1 cm2 of the mucosa overlying the bony ostium is done, with the CO2 laser adjusted at 16-W continuous mode, while at the same time proper hemostasis is achieved. In all the patients and cases in our study, multiple back-and-forth cuts are made with a cutting burr until a bony ostium of at least 1 cm2 is created- and the lacrimal sac is adequately revealed. Using the same parameter settings of the CO2 laser a wide opening of the sac is created. In 29 individuals it was necessary to infracture the middle turbinate in order to obtain better access to the surgical area. After an adequate opening of the sac is created, a lacrimal intubation probe with an integrated silicone tube (Trichter prosthesis) is passed through the lower lacrimal point, into the newly created ostium. The upper lacrimal puncta is then dilated and intubated with the other end of the lacrimal stent. The two
68
E.P. Prokopakis et al. / Auris Nasus Larynx 37 (2010) 66–70
Fig. 2. (a and b) Lacrimal intubation probes with an integrated silicone tube are passed through the lacrimal puncta, into the newly created ostium. (c and d) The two ends of the silicone tube are tied together in the nasal cavity.
ends of the silicone tube are tied together and removed after a 3–6 months period. Mitomycin solution (0.2 mg/ml) was applied locally with the help of a cotton swab following the opening of the lacrimal sac, in all the cases of our current series. Mitomycin is applied for 2 min, and then rinsed away with normal saline irrigation.
3. Results None of the patients who underwent intranasal laserassisted DCR were lost to follow-up, and no complications arose during or following the operation. Eight out of the 105 patients underwent bilateral procedures. Only 5 cases (in 5 individual patients) failed to show any improvement after the initial DCR. In these patients presented with recurrent obstruction and epiphora a second ipsilateral intranasal laser-assisted DCR was performed. They have been symptom free for a mean period of 18 months (12–24 months). Overall, 113 out of 118 surgical procedures (100 out of 105 patients), were totally successful. Accordingly, the use of intranasal laser-assisted DCR with the surgical microscope yielded a success rate of 95.8% in our series regarding primary surgery and 100% (5 out of 5) regarding revision surgery.
The short recovery period – all patients were dismissed 24 h postoperation – avoidance of general anesthesia – we tend to prefer local anesthesia unless the patient chooses different – minimal complications and excellent cosmetic result have been greatly appreciated by all patients in our series. Nevertheless, in patients with a narrow nasal cavity the intranasal approach may prove quite difficult. Additional problems can be created by an unusually thick bone over the lacrimal sac. Applying repeated 3-s laser pulses, 10–12 W, with a 3 mm-focal diameter has been found to work best. Mitomycin application does not seem to alter our statistical data, compared to the results of our preliminary study regarding symptom free patients postoperatively and therefore the application of mitomycin is no longer included in our department’s strategy. Patients were dismissed 24 h postoperation.
4. Discussion Even though Toti’s modified procedure was the gold standard for surgical management of nasolacrimal duct obstruction for most of the past century, several methods have been described for the management of nasolacrimal duct obstruction [2,5].
E.P. Prokopakis et al. / Auris Nasus Larynx 37 (2010) 66–70
The history of this surgical therapy dates back to 1893 when Caldwell first described intranasal DCR. The following years various external approaches were described and it was not till the appearance of fiberoptic endoscopy that the interest for intranasal techniques was renewed. West was the first to describe a method of intranasal DCR with the use of a microscope in 1914 [3]. Intranasal DCR with the use of laser was pioneered by Massaro et al. [6]. This technique utilizes a 20-gauge fiberoptic light pipe, which is placed through the lacrimal canaliculus into the lacrimal sac and whenever further bone removal is necessary it is accomplished with rongeurs or burrs. In their initial cadaver study, Massaro et al. utilized the argon laser beam [6] and later on changed to the potassium titanyl phosphate KTP:YAG or CO2 laser [7]. The use of holmium:YAG laser was also adopted by Woog et al., in order to obtain better hemostasis and remove bone with the least possible thermal damage of tissues [8]. We have already reported our preliminary experience in performing intranasal laser-assisted dacryocystorhinostomy with the use of a surgical microscope in 53 individuals [9]. It is noticeable, that our long-term results are equally satisfying when compared with our initial data, demonstrating the short time associated with what is called ‘‘a learning curve’’. It is also important that the vast majority (92 cases in 92 patients) of the last 118 cases were done under local anesthesia, which is the preferable type of anesthesia by both surgeon and patient. In order to further reduce the recurrence rate in our series we adopted the local use of mitomycin intraoperatively in all the cases presented in this study. Such a measure was taken in order to theoretically delay the healing process, and accomplish a more permanent fenestration of the sac, thus reducing the number of recurrencies of symptoms. Nevertheless, we have not been able so far to obtain a statistically significant difference in the recurrence rate compared to the results of our previous study after the application or not of mitomycin, leading to the conclusion that such a measure is rather unnecessary and only adds to the cost of the operation. The advantages of microscopic laser-assisted DCR are numerous [8,10–12]. The use of the surgical microscope and the laser does not make the procedure more complicated, since it can be performed by a single surgeon. Furthermore, it offers a clear surgical field compared to endoscopic approaches – the microscope does not require cleaning of the lens during the procedure – three-dimensional view of the
69
Table 1 Success rate of the techniques used for the surgical treatment of nasolacrimal duct obstruction. Method
Success rate
Success rate in revision cases
External DCR Endoscopic DCR without laser Endoscopic laser-assisted DCR
85–99% 70–96% 80%
83–85% 75–83% 90–96%
surgical field and a shorter hospitalization [13,24]. In addition, manipulations with the surgical microscope are not hindered by hemorrhage, allowing the surgeon to work with both his hands free, thus causing limited edema and thermal injury to the surrounding tissues and operation site [6]. With the use of a video camera or an observer tube, it can also provide excellent resident teaching as done in our clinic. Finally, no external incision on the face is necessary, avoiding significant risk for interference with the pump action of the orbicularis muscle on the canaliculi, and allowing a better cosmetic result. The success rate of external DCR in international literature is reported to be 85–99% [15–17], while endoscopic DCR without a laser 70–96% [14,17–19], and endoscopic laser-assisted DCR about 80% [20]. Furthermore, in revision cases, the success rate of external DCR is reported to be 83–85% [21], while endoscopic DCR without a laser 75–83% [13,20], and endoscopic laser-assisted DCR 90–96% (Table 1) [21–23]. Kong et al. reported improvement in 77% of patients after the initial surgery [24] that increased to 96% after revision laser DCR. Boush et al. yielded an initial success in 70% of patients, which reached 80% after revision procedure [21], while Metson et al. reported an 85% patency rate for initial procedures [11]. Woog et al. succeeded in 82% of patients after one procedure only [8] and Pearlman et al. [19] reported 85% improvement after one procedure and an overall success rate of 91% with revision surgery (Table 2). Postoperative rehabilitation was uneventful, and no major complications were noted in our series, besides the 5 cases mentioned above were intranasal endoscopy was necessary to remove a firmly attached silicone tube, an incident that one could only regard as a minor complication. According to other studies, intranasal laser dissection and external DCR approach increased the risk of orbital fat exposure in the nasal cavity in 10% of patients [18,24]. In our series no
Table 2 Success rate of endoscopic laser-assisted DCR and intranasal laser-assisted DCR with the use of a surgical microscope. Authors
Method
Number of patients
Success rate
Kong et al. [24] Boush et al. [21] Metson et al. [11] Woog et al. [8] Pearlman et al. [19] Velegrakis et al. [9]
Endoscopic laser-assisted DCR Endoscopic laser-assisted DCR Endoscopic laser-assisted DCR Endoscopic laser-assisted DCR Endoscopic laser-assisted DCR Intranasal laser-assisted DCR with surg. microscope
131 42 40 40 49 53
77% 70% 85% 82% 85% 96.24%
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E.P. Prokopakis et al. / Auris Nasus Larynx 37 (2010) 66–70
evidence of orbital fat exposure was noticed. Moreover, it was not necessary to remove a part of the middle turbinate in any of our patients. Previous studies have used argon [6], KTP [7], and holmium:YAG lasers [11,22,24] for intranasal DCR. All laser beams were directed towards the lateral nasal wall to create a nasolacrimal fistula [6–8]. The Nd:YAG laser is considered to be the best choice because of its superior ability to cut through bone and provide hemostasis [11]. Metson et al. prefer the holmium:YAG to the no contact Nd:YAG because it has less thermal energy penetration [11].
5. Summary The success rate of translacrimal, transnasal, laserassisted DCR in our series was 95.8% with one procedure, and there was a mean follow-up period of 24 months. This percentage is comparable to that obtained with external DCR (90–99%) according to international literature. Both patients and surgeons favor the use of local anesthesia, lack of an associated facial scar, reduction of surgical morbidity, and more rapid return to daily activities. The long-term results of this study show that CO2 laser in combination with the use of a surgical microscope provide an effective and safe surgical technique, with an uneventful postoperative rehabilitation and excellent prognosis.
Acknowledgment Financially supported in part by Theodore Angelopoulos and Gianna Angelopoulos-Daskalaki.
References [1] Tos M, Balle V, Andersen R. Dacryocystorhinostomy. Ann Otol Rhinol Laryngol 1986;95:352–5. [2] Metson R. The endoscopic approach for revision daciyocystorhinostomy. Laryngoscope 1990;100:1344–7. [3] West GM. A window resection of the nasal duct in cases of stenosis. Trans Am Ophthalmol Soc 1914;12:654–8.
[4] Sekhar GC, Dortzbach RK, Gonnering RS, Lemke BN. Problems associated with conjunctivodacryocystorhinostomy. Am J Opthalmol 1991;112:502–6. [5] Jones LT. The cure of epiphora due to canalicular disorders, trauma and surgical failures on the lacrimal passages. Trans Am Acad Ophthalmol Otolaryngol 1962;66:506–10. [6] Massaro BM, Connering RS, Harris GJ. Endonasal laser dacryocystorhinostomy: a new approach to nasolacrimal duct obstraction. Arch Ophthalmol 1990;108:1172–6. [7] Gonnering RS, Lyon DB, Fisher JC. Endoscopic laser-assisted lacrimal surgery. Am J Ophthalmol 1991;111:152–7. [8] Woog JJ, Metson R, Puliafito CA. Holmium;YAG endonasal laser dacryocystorhinostomy. Am J Ophthalmol 1993;116:1–10. [9] Velegrakis GA, Prokopakis EP, Panayotaki I, Pagalos GA, Siganos CS, Helidonis ES. Intranasal laser-assisted dacryocystorhinostomy with the use of a surgical microscope. Am J Otolaryngol 2002;23:272–6. [10] Michalos P, Pearlman SJ, Avila EN, Newton JC. Hemispherical tip contact Nd:YAG translacrimal-nasal dacryocystorhinostomy. Ocular Surg News 1995;13:40–5. [11] Metson R, Woog JJ, Puliafito CA. Endoscopic laser dacryocystorhinostomy. Laryngoscope 1994;104:269–74. [12] Woo KI, Moon SH, Kim YD. Transcanalicular laser assisted revision of failed dacryocystorhinostomy. Ophthalmic Surg Lasers 1998;29:451–5. [13] Metson R. The endoscopic approach for revision dacryocystorhinostomy. Laryngoscope 1990;100:1344–7. [14] Metson R. Endoscopic surgery for lacrimal obstraction. Otolaryngol Head Neck Surg 1991;104:473–9. [15] McLachlan RA, Shannon GM, Flanagan JC. Results of dacryocystorhinostomy: analysis of reoperations. Ophthalmic Surg 1980;11:427–30. [16] Hartikainen J, Grenman R, Puukka P, Seppa H. Prospective randomized comparison of external dacryocystorhinostomy and endonasal laser dacryocystorhinostomy. Ophthalmology 1998;105:1106–13. [17] Sadiq SA, Ohrlich S, Jones NS, Downes RN. Endonasal laser daciyocystorhinostomy medium term results. Br J Ophthalmol 1997;81:1089– 92. [18] Sprekelsen MB, Barberan MT. Endoscopic dacryocystorhinostomy: surgical technique and results. Laryngoscope 1996;106:187–9. [19] Peariman SJ, Michalos P, Leib ML. Translacrimal transnasal laserassisted dacryocystorhinostomy. Laryngoscope 1997;107:1362–5. [20] Manner GE, Millman AL. The prognostic value of preoperative dacryocystography in endoscopic intranasal dacryocystorhinostomy. Am J Ophthalmol 1992;113:134–7. [21] Boush GA, Lemke BN, Dortzbach RK. Results of endonasal laserassisted dacryocystorhinostomy. Ophthalmology 1994;101:955–9. [22] Hehar SS, Jones NS, Sadiq SA, Downes RN. Endoscopic holmium:YAG laser dacryocystorhinotomy-safe and effective as a day-case procedure. J Laryngol Otol 1997;111:1056–9. [23] Mickelson SA, Kirn DK, Stein IM. Endoscopic laser-assisted dacryocystorhinostomy. Am J Otolaryngol 1997;18:107–11. [24] Kong YT, Kim TI, Kong BW. A report of 131 cases of endoscopic laser lacrimal surgery. Ophthalmology 1994;101:1793–800.
Long-term results of intranasal laser-assisted dacryocystorhinostomy with the use of a surgical microscope Emmanuel P. Prokopakis a, Alexios S. Vardouniotis a,*, Alexandros D. Karatzanis a, Stylianos G. Malandrakis a, Charalambos S. Siganos b, George A. Velegrakis a a
Department of Otolaryngology, University of Crete School of Medicine, 71414 Heraklion, Crete, Greece b Department of Ophthalmology, University of Crete School of Medicine, Heraklion, Crete, Greece Received 12 October 2008; accepted 5 April 2009 Available online 2 July 2009
Abstract Objective: To address the long-term results of our method that combines intranasal laser-assisted dacryocystorhinostomy with the use of surgical microscope. Methods: The procedure is a modification of the West method. A retrospective series of the long-term results are presented in 105 patients that underwent 118 DCR procedures, over the past 6 years. Selection criteria were mainly acquired idiopathic nasolacrimal duct obstruction. Results: 113 DCR cases (95,8%) were free of symptoms postoperatively (mean follow-up: 24 months). Conclusion: Our method when compared with traditional methods is correlated with excellent postoperative long-term results. # 2009 Elsevier Ireland Ltd. All rights reserved. Keywords: Dacryocystorhinostomy; Nasolacrimal duct; Laser; Endoscopy; Microscopy
1. Introduction Although the diagnosis of nasolacrimal duct obstruction or stenosis is traditionally made by ophthalmologists, surgical treatment – which requires an excellent knowledge of the anatomy of the nose and sinuses – constitutes today an active field for otorhinolaryngologists as well. The goal of dacryocystorhinostomy (DCR) is to re-establish tear flow from the lacrimal system into the nasal cavity. This can be achieved through a series of surgical techniques including external, intranasal and transnasal–transseptal approaches [1]. An ideal procedure should leave a minimal or no external scar at all. It has to be performed with safety and should lead to results similar or superior to those achieved with conventional techniques [2]. The combination of intranasal endoscopy or microscopy with lasers has been demonstrated to meet these criteria. In this study, we report the long-term
* Corresponding author. E-mail address: [email protected] (A.S. Vardouniotis).
results of intranasal laser-assisted dacryocystorhinostomy with the use of a surgical microscope. 2. Materials and methods In our study, ranged from September, 2001 to April, 2007, 105 patients underwent 118 intranasal laser-assisted DCRs with the use of a surgical microscope. There were 89 women and 16 men and the ages ranged from 14 to 78 years old (mean age 49.8). The surgical technique used was a modification of the West method [3]. The same team of surgeons performed all procedures (Figs. 1 and 2). Eight patients underwent bilateral DCRs, while five patients underwent ipsilateral revision procedures. The main indication for the selection of the candidates for DCR was acquired idiopathic nasolacrimal duct obstruction and recurrence of symptoms (such as epiphora and empyema of the lacrimal sac) from previous operations. Ophthalmologists, in co-operation with the doctors of our department, were responsible for the evaluation and candidate’s selection [4]. Before surgery, all the patients
0385-8146/$ – see front matter # 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.anl.2009.04.011
E.P. Prokopakis et al. / Auris Nasus Larynx 37 (2010) 66–70
67
Fig. 1. (a) Infiltration of a local anesthetic and vasoconstrictive agent in the agger nesi area. (b) Ablation of approximately 1 cm3 of the mucosa overlying the bony ostium is performed with the use of CO2 laser. (c) Multiple back-and-forth cuts are made with a cutting burr until a body ostium of at least 1 cm3 is created. (d) The lacrimal sac is adequately revealed.
underwent nasal endoscopy with the use of a 00, 4 mm rigid endoscope (HOPKINS II, 7230AA, Karl Storz). Pathology such as severe septal deviation that caused obstruction and needed septoplasty as well as nasal polyps, were excluded at the time. Patients that had undergone head and neck radiation therapy, presenting with malignancy or had a history of maxillofacial trauma were also excluded. Postoperative follow-up was done by both our clinics. The follow-up period ranged from 12 to 48 months (mean time 24 months). Postoperative success of the procedure was evaluated by the improvement of tearing and passing of fluid during lacrimal irrigation. Furthermore, fluorescein was placed into the inferior eyelid fomix to evaluate the flow of the stain to the middle nasal meatus. In five patients, intranasal endoscopic evaluation for persistent epiphora and difficult silicone tube removal was required postoperatively. Although in the past all our cases were done under general anesthesia, the vast majority of our recent cases, 92 have been operated under local anesthesia keeping general anesthesia in hand mainly for more demanding revision operations. Initially, a cotton swab sprayed with 0.1% xylomethazoline is placed into the nasal canal approximately 15 min before surgery, while the patient is still in the clinic, in order to initiate vasoconstriction of the nasal mucosa. Afterwards, further intranasal vasoconstriction and
anesthesia is achieved with pledgets soaked in a 10% cocaine solution. Finally, an injection of xylocaine–adrenaline 2% solution is performed at the insertion of the middle turbinate and at the agger nasi area. In order to avoid retinal injury, both eyes are protected with a solid, opaque, lasersafe shield. The CO2 laser is then connected to the surgical microscope (lens diameter of 300 mm) via a micro-slad and the microbeam of the CO2 laser is directed towards the medial wall of the nasal cavity overlying the lacrimal sac, just anterior to the middle meatus. Ablation of approximately 1 cm2 of the mucosa overlying the bony ostium is done, with the CO2 laser adjusted at 16-W continuous mode, while at the same time proper hemostasis is achieved. In all the patients and cases in our study, multiple back-and-forth cuts are made with a cutting burr until a bony ostium of at least 1 cm2 is created- and the lacrimal sac is adequately revealed. Using the same parameter settings of the CO2 laser a wide opening of the sac is created. In 29 individuals it was necessary to infracture the middle turbinate in order to obtain better access to the surgical area. After an adequate opening of the sac is created, a lacrimal intubation probe with an integrated silicone tube (Trichter prosthesis) is passed through the lower lacrimal point, into the newly created ostium. The upper lacrimal puncta is then dilated and intubated with the other end of the lacrimal stent. The two
68
E.P. Prokopakis et al. / Auris Nasus Larynx 37 (2010) 66–70
Fig. 2. (a and b) Lacrimal intubation probes with an integrated silicone tube are passed through the lacrimal puncta, into the newly created ostium. (c and d) The two ends of the silicone tube are tied together in the nasal cavity.
ends of the silicone tube are tied together and removed after a 3–6 months period. Mitomycin solution (0.2 mg/ml) was applied locally with the help of a cotton swab following the opening of the lacrimal sac, in all the cases of our current series. Mitomycin is applied for 2 min, and then rinsed away with normal saline irrigation.
3. Results None of the patients who underwent intranasal laserassisted DCR were lost to follow-up, and no complications arose during or following the operation. Eight out of the 105 patients underwent bilateral procedures. Only 5 cases (in 5 individual patients) failed to show any improvement after the initial DCR. In these patients presented with recurrent obstruction and epiphora a second ipsilateral intranasal laser-assisted DCR was performed. They have been symptom free for a mean period of 18 months (12–24 months). Overall, 113 out of 118 surgical procedures (100 out of 105 patients), were totally successful. Accordingly, the use of intranasal laser-assisted DCR with the surgical microscope yielded a success rate of 95.8% in our series regarding primary surgery and 100% (5 out of 5) regarding revision surgery.
The short recovery period – all patients were dismissed 24 h postoperation – avoidance of general anesthesia – we tend to prefer local anesthesia unless the patient chooses different – minimal complications and excellent cosmetic result have been greatly appreciated by all patients in our series. Nevertheless, in patients with a narrow nasal cavity the intranasal approach may prove quite difficult. Additional problems can be created by an unusually thick bone over the lacrimal sac. Applying repeated 3-s laser pulses, 10–12 W, with a 3 mm-focal diameter has been found to work best. Mitomycin application does not seem to alter our statistical data, compared to the results of our preliminary study regarding symptom free patients postoperatively and therefore the application of mitomycin is no longer included in our department’s strategy. Patients were dismissed 24 h postoperation.
4. Discussion Even though Toti’s modified procedure was the gold standard for surgical management of nasolacrimal duct obstruction for most of the past century, several methods have been described for the management of nasolacrimal duct obstruction [2,5].
E.P. Prokopakis et al. / Auris Nasus Larynx 37 (2010) 66–70
The history of this surgical therapy dates back to 1893 when Caldwell first described intranasal DCR. The following years various external approaches were described and it was not till the appearance of fiberoptic endoscopy that the interest for intranasal techniques was renewed. West was the first to describe a method of intranasal DCR with the use of a microscope in 1914 [3]. Intranasal DCR with the use of laser was pioneered by Massaro et al. [6]. This technique utilizes a 20-gauge fiberoptic light pipe, which is placed through the lacrimal canaliculus into the lacrimal sac and whenever further bone removal is necessary it is accomplished with rongeurs or burrs. In their initial cadaver study, Massaro et al. utilized the argon laser beam [6] and later on changed to the potassium titanyl phosphate KTP:YAG or CO2 laser [7]. The use of holmium:YAG laser was also adopted by Woog et al., in order to obtain better hemostasis and remove bone with the least possible thermal damage of tissues [8]. We have already reported our preliminary experience in performing intranasal laser-assisted dacryocystorhinostomy with the use of a surgical microscope in 53 individuals [9]. It is noticeable, that our long-term results are equally satisfying when compared with our initial data, demonstrating the short time associated with what is called ‘‘a learning curve’’. It is also important that the vast majority (92 cases in 92 patients) of the last 118 cases were done under local anesthesia, which is the preferable type of anesthesia by both surgeon and patient. In order to further reduce the recurrence rate in our series we adopted the local use of mitomycin intraoperatively in all the cases presented in this study. Such a measure was taken in order to theoretically delay the healing process, and accomplish a more permanent fenestration of the sac, thus reducing the number of recurrencies of symptoms. Nevertheless, we have not been able so far to obtain a statistically significant difference in the recurrence rate compared to the results of our previous study after the application or not of mitomycin, leading to the conclusion that such a measure is rather unnecessary and only adds to the cost of the operation. The advantages of microscopic laser-assisted DCR are numerous [8,10–12]. The use of the surgical microscope and the laser does not make the procedure more complicated, since it can be performed by a single surgeon. Furthermore, it offers a clear surgical field compared to endoscopic approaches – the microscope does not require cleaning of the lens during the procedure – three-dimensional view of the
69
Table 1 Success rate of the techniques used for the surgical treatment of nasolacrimal duct obstruction. Method
Success rate
Success rate in revision cases
External DCR Endoscopic DCR without laser Endoscopic laser-assisted DCR
85–99% 70–96% 80%
83–85% 75–83% 90–96%
surgical field and a shorter hospitalization [13,24]. In addition, manipulations with the surgical microscope are not hindered by hemorrhage, allowing the surgeon to work with both his hands free, thus causing limited edema and thermal injury to the surrounding tissues and operation site [6]. With the use of a video camera or an observer tube, it can also provide excellent resident teaching as done in our clinic. Finally, no external incision on the face is necessary, avoiding significant risk for interference with the pump action of the orbicularis muscle on the canaliculi, and allowing a better cosmetic result. The success rate of external DCR in international literature is reported to be 85–99% [15–17], while endoscopic DCR without a laser 70–96% [14,17–19], and endoscopic laser-assisted DCR about 80% [20]. Furthermore, in revision cases, the success rate of external DCR is reported to be 83–85% [21], while endoscopic DCR without a laser 75–83% [13,20], and endoscopic laser-assisted DCR 90–96% (Table 1) [21–23]. Kong et al. reported improvement in 77% of patients after the initial surgery [24] that increased to 96% after revision laser DCR. Boush et al. yielded an initial success in 70% of patients, which reached 80% after revision procedure [21], while Metson et al. reported an 85% patency rate for initial procedures [11]. Woog et al. succeeded in 82% of patients after one procedure only [8] and Pearlman et al. [19] reported 85% improvement after one procedure and an overall success rate of 91% with revision surgery (Table 2). Postoperative rehabilitation was uneventful, and no major complications were noted in our series, besides the 5 cases mentioned above were intranasal endoscopy was necessary to remove a firmly attached silicone tube, an incident that one could only regard as a minor complication. According to other studies, intranasal laser dissection and external DCR approach increased the risk of orbital fat exposure in the nasal cavity in 10% of patients [18,24]. In our series no
Table 2 Success rate of endoscopic laser-assisted DCR and intranasal laser-assisted DCR with the use of a surgical microscope. Authors
Method
Number of patients
Success rate
Kong et al. [24] Boush et al. [21] Metson et al. [11] Woog et al. [8] Pearlman et al. [19] Velegrakis et al. [9]
Endoscopic laser-assisted DCR Endoscopic laser-assisted DCR Endoscopic laser-assisted DCR Endoscopic laser-assisted DCR Endoscopic laser-assisted DCR Intranasal laser-assisted DCR with surg. microscope
131 42 40 40 49 53
77% 70% 85% 82% 85% 96.24%
70
E.P. Prokopakis et al. / Auris Nasus Larynx 37 (2010) 66–70
evidence of orbital fat exposure was noticed. Moreover, it was not necessary to remove a part of the middle turbinate in any of our patients. Previous studies have used argon [6], KTP [7], and holmium:YAG lasers [11,22,24] for intranasal DCR. All laser beams were directed towards the lateral nasal wall to create a nasolacrimal fistula [6–8]. The Nd:YAG laser is considered to be the best choice because of its superior ability to cut through bone and provide hemostasis [11]. Metson et al. prefer the holmium:YAG to the no contact Nd:YAG because it has less thermal energy penetration [11].
5. Summary The success rate of translacrimal, transnasal, laserassisted DCR in our series was 95.8% with one procedure, and there was a mean follow-up period of 24 months. This percentage is comparable to that obtained with external DCR (90–99%) according to international literature. Both patients and surgeons favor the use of local anesthesia, lack of an associated facial scar, reduction of surgical morbidity, and more rapid return to daily activities. The long-term results of this study show that CO2 laser in combination with the use of a surgical microscope provide an effective and safe surgical technique, with an uneventful postoperative rehabilitation and excellent prognosis.
Acknowledgment Financially supported in part by Theodore Angelopoulos and Gianna Angelopoulos-Daskalaki.
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