Dr. Umadevi, Dr. Bipasha Mukherjee, Dr. M Shahid Alam
Purpose
To evaluate the surgical outcomes ofdacryocystorhinostomy (DCR) in the pediatric age group
Materials & Methods
This is a retrospective analysis of all DCRs (age ≤ 16 years) between 2000 to 2015. Anatomical success was defined by patent syringing while absence of watering characterized physiological success.
Result
140 eyes of 128 patients were included. 93 were males and 35 were females. 116[91%] cases had unilateral involvement. Mean age was 8 years [Median -7 years]. NLDO was congenital in 91 [65%], primary in 21[15%], and secondary in 28 [20%] eyes. External DCR was done in 109 [78%] and endoscopic DCR in 31[22%] eyes. Mean follow up period was 17 months. Anatomical success rates of Eexternal and Eendonasal DCRs were 95% and 90% respectively while functional success was 78% and 77%.
Conclusion
external and endonasal DCR are effective procedures with high and comparable success rates for NLDO in children
Introduction
Dacrocystorhinostomy (DCR) in paediatric population is a challenging entity because of minimally developed bony structures, paranasal sinuses and anatomical variations as well as related anaesthetic complications.Till date there are very few studies available in the literature on success rates of DCR in paediatric population, and studies comparing external and endonasal in such population is even lesser. The reported success rates of both procedures range from 63% to 97%.1-3The wide range in success is likely due to surgical variability, patient demographics, and lack of standardized outcome measures. The purpose of the current study was to evaluate the indications and management outcomes of external and endonasal dacryocystorhinostomy in paediatric age group.
Materials and Methods
A retrospectives study of paediatric patients who underwent endoscopic or external DCR between January 2000 to January 2015 was done at Sankara Nethralaya, Chennai, Tamil Nadu. The study included 128 paediatric patients, who had 140 DCRs. All cases diagnosed with NLDO with age equal to or less than 16 were included in the study. Demographics, cause of NLDO, type of surgery performed and surgical complications were analysed. Physiological success was defined as absence or mild persistence of watering whereas anatomical success was defined as patent syringing wherever possible with negative ROPLAS (Regurgitation on Pressure over Lacrimal Sac). Success and failure rates of both external and endonasal DCR were compared. Patients were followed up on 1st postop day, 1STst week, 3 months, 6 months and 1 year. All intubation stents were removed after a minimum duration of 3 months.
Results
140 eyes of 128 paediatric patients were included in the study.140 DCRs were enrolled in this study of which 31 eyes underwent endoscopic DCR and 109 eyes underwent external DCRs. There were 93 males (73 %) and 35 females (27 %) and age ranged from 1–16 years with a mean age of 8 years (standard deviation – 4.13years).Right eye was involved in 72 (51%) cases and left eye in 68 (49%) cases. 116 (91%) cases had unilateral involvement whereas only 12 (9%) cases had bilateral involvement. One hundred and twenty seven (91%) eyes underwent primary DCR, whereas 13 (9%) eyes underwent revision DCR. Mean follow up period was 16.6 months. (6-36 months). Ninety one (65%) eyes had Congenital Nasolacrimal Duct Obstruction (CNLDO), 28 (20%) eyes had Secondary Nasolacrimal Duct Obstruction (SANDO), while 21 (14%) eyes had Primary Acquired Nasolacrimal Duct Obstruction (PANDO). Causes of SANDO included trauma (25, 89.2%), Rhinosporidiosis(2) and Tuberculosis(1). Ten eyes had associated congenital anomalies. Sixty three eyes (51.6%) underwent probing prior to DCR, out of which 48 eyes underwent single probing and 15 eyes underwent multiple probing. A total of 70 (50%) eyes underwent intubation (62 external DCR, and 8 endonasal DCR). Patency or anatomical success was achieved in 28 (90.2%) of 31 eyes in the endonasal DCR group, and 103 (94.32%) of 109 eyes in the external DCR group. Anatomical patency and symptom relief (functional success) was achieved in 24 (77%) cases in the endonasal group and in 85 (78%) cases in the external group.
Analysing the results based upon aetiology showed anatomical success rate of 97%, 100%, and 78% for CNLDO, PANDO and SANDO respectively. Functional success rates for the same were 80%, 86% and 64% respectively. Tube removal was done 2-4 months from the date of surgery [Mean duration – 3 months].No major complications were noted in the study, Minor complications included wound gape (3) and suture abscess (5). Stent related complications were noted in 5 cases of which 4 had stent extrusion and 1 had granuloma.
Discussion
Incomplete canalization distally at the valve of Hasner is the most common site of obstruction in infants.4 CNLDO will resolve by the age of 6 to 12 months spontaneously or by Crigglers massaging, so probing delayed until the end of the first year of life. Probing of the lacrimal system is most often curative at this age.5 The optimal timing for probing remains controversial. However, no evidence indicates that early probing has a higher resolution rate than spontaneous resolution.6,7 A large prospective study showed good success rates of probing till 3 years of age.8,9Studies done by Schellini et al10 stated that probing is a good option for children between 2 and 3 years of age who presented with primary CNLDO without any predictive factors of a poor prognosis.11,12,13 DCR could be the option in the management of CNLDO in whom massaging and repetitive probing were failed.14
The ideal age to perform a DCR is also controversial. Some suggest that DCR should be performed after the child reaches 5 years of age, so that the bone formation is complete. Early intervention is required if there is a risk of acute dacryocystitis.13The success rates of external DCR in children are similar to those of adults.14Successful DCR requires a functional upper outflow system. Treatment of upper system (punctum, canaliculus, and common canaliculus) obstruction should be considered separately. Important factors for achieving success in children are wide bone removal to expose the entire lacrimal sac, and anastomosing the lacrimal sac mucosa and nasal mucosa. The success rate of endoscopic DCR is good in paediatric age group.15-17 Endoscopic transnasal DCR has significant advantages of less scarring, minimal postoperative hematoma, shorter postoperative recovery, preservation of the pumping action of the orbicularis oculi muscle and concurrent correction of intranasal abnormalities, which can cause failure from synechiae formation between the ostium and the septum or the middle turbinate..18,21Disadvantages of endonasal DCR are the cost of expensive equipment and instrumentation and a relatively steep learning curve. Despite advantages, endonasal DCR has a number of factors that can lead to failure. Anatomical variation of nasal cavity in children can cause difficulties in surgery. Insufficient size of the osteotomy22, cicatricial ostium closure23,24, and adhesions in the ostium24, synechiae between the ostium and the nasal septum21, and granuloma formation21 can cause postoperative failure. Thus, overcoming anatomical variations and factors causing post-operative failure will improve the success rate of DCR in the paediatric population. Our study included both objective patency results and subjective symptomatic improvement results as an evidence of succes for pediatric endoscopic DCR. It appears to be comparable to the “gold standard” external approach, with success rates ranging from 74% to 92%. Our findings showed a high success rate for both endoscopic and external approach, with 93% of patients showing patency to irrigation and 84% showing improvement or resolution of symptoms. There was no statistically significant difference between the two surgical approaches. Success rates mainly depend on complete pre-operative evaluation to know the anatomy and cause of NLDO and meticulous surgical procedure particularly in children. Tsirbas and Wormald et al25-27 reported high long-term success rates of 89% in endoscopic DCR by fully exposing the lacrimal sac and marsupializing it into the lateral nasal wall with the nasal and lacrimal mucosa in apposition. Seideret al28 reported that early DCR surgery does not have a significant advantage over late surgery in terms of success rates. We had similar results in our study.We haven’t routinely intubated the lacrimal drainage system in all children. Studies29 reported silicone intubation as a measure to keep the canalicular system patent thereby preventing late failure due to scarring. Javed Ali et al30reported the causes of tear drainage failure to be cicatricial ostium closure, scarred common canaliculus, obstructed distal canaliculi, organizing granulomas, and bone neogenesis. Serious complications including orbital and subcutaneous emphysema, retrobulbar hemorrhage, medial rectus paresis, lamina papyracea damage and orbital fat herniation 31are rare in the medical literature for both forms of DCR surgery. Our study correlates well with these studies and we haven’t encountered major complications.
Conclusion
Both the “gold standard” external approach and endonasal DCR proved to be safe and effective surgical procedures. Excellent outcomes were noted in children with nasolacrimal duct obstruction resistant to probing, irrigation and intubation. The endonasal technique is more direct, but demands a more complete understanding of nasal anatomy. Knowledge of anatomical variations, meticulous pre-operative evaluation, gentle handling of tissues to avoid injury will yield impressive results in pediatric DCR.
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