| Abstract|| |
Background: Dacryocystorhinostomy (DCR) refers to the surgical procedure that is used to relieve the chronic obstruction of the nasolacrimal duct obstruction (NLDO). In a maxillofacial setting, NLDO may arise subsequent to a facial trauma or orthognathic surgery. There is a dearth of literature from this part of the world. This article intends to provide a single maxillofacial center experience in DCR. Materials and Methods: This is a retrospective, noncomparative, noninterventional, record audit type of study of all consecutive patients fulfilling inclusion and exclusion criteria. All patients with epiphora and diagnosed with lacrimal apparatus damage between 1 January 2008 and 31 December 2017 requiring DCR were considered for the study. Details of demographics, phase of treatment (primary/retreatment), types of bones involved, age, complications, period suffering from epiphora, and follow-up were obtained. All data were entered and analyzed using the Statistical Package for the Social Service (version 16; IBM). Descriptive statistics of the frequency and mean ± standard deviation (SD) as appropriate were presented. Chi-square test and one-way analysis of variance were used appropriately. P ≤ 0.05 was taken to be statistically significant. Results: In all, 83 patients fulfilled the inclusion and exclusion criteria. It is more common in males (n = 56, 67.47%) with a mean ± SD of 32.24 ± 10.80 (18–59 years) with 27 (32.53%) of them presenting primarily after fractures. Fracture was the most common pathology seen in 81.93% (n = 68) of cases, while the rest were as a result of orthognathic cases. Le Fort II and III set of bones contributed to 59% of cases, while the orbitonasal complex contributed to only three cases. NLD obstruction was seen in 68 (81.9%) of cases. On an average, the patients suffered for 9.3 ± 6.74 months (range 0.5–22 months) before seeking treatment and the average follow-up was 31.07 ± 11.69 months (range 15–54 months). Discussion and Conclusion: Fractures and surgeries involving nasal bones carry an innate risk of damaging the NLD system. The pattern of need for DCR and occurrence of NLDO in this part of the world have been described. The extent of the anatomical variations and need for proper surgical planning are highlighted.
Keywords: Dacryocystorhinostomy, epiphora, nasal trauma, nasolacrimal duct obstruction, tearing of the eyes
|How to cite this article:|
Balaji S M, Balaji P. Epiphora drainage by DCR – Long-term results. Indian J Dent Res 2019;30:337-41
| Background|| |
Congenital and acquired lacrimal drainage disorders cause excessive, unprovoked watering of the eye, referred as epiphora. Dacryocystorhinostomy (DCR) is a type of mid-facial surgical procedure that is used to recreate and establish a gravity-dependent, low-resistance drainage pathway between the lacrimal sac and the nasal cavity. This is achieved by creating a patency between lacrimal sac and the lateral nasal wall mucosa. The earliest successful procedure was reported by Dupuy-Dutemps and Bourguet in 1921 with a success rate of 94.8% in more than 1000 consecutive cases of lacrimal gland pathology, often causing serious epiphora. The procedure advocated was later modified by Gibbs in later half of 1960s to involve silicone tubes pushed through an external incision, bony window causing anastomosis. Later, the newly created path was epithelialized and tubes were removed. The use of such tube has been demonstrated to be nonirritating, extremely flexible, and with favorable results.,,,
The silicone tube intubation is generally performed with a Guibor or Crawford bicanalicular tube or Nunchaku-style silicone tube or O'Donohue silicone tubes [Figure 1]., Also, the procedure has been performed with or without endoscopes., There are several reports describing the outcomes of performance of these types of DCRs. However, there are very few research on DCR in maxillofacial setting from this part of the world and that compares between primary DCR and revision DCR. Hence, this work was carried to address these lacunae.
|Figure 1: Skin incision placed, lacrimal sac exposed, and osteotomy of nasal bone done. Silicone tube placed through the lacrimal sac and new ostium|
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| Materials and Methods|| |
This was a retrospective, noncomparative, noninterventional, record audit type of study of all consecutive patients fulfilling inclusion and exclusion criteria. As this is a retrospective audit study from clinical records of patients, it was exempted from further ethical review. All patients with epiphora and diagnosed with lacrimal apparatus damage between 1 January 2008 and 31 December 2017 requiring DCR were considered for the study. All data were retrieved from records anonymously. Patients complaining of epiphora after a trauma or surgery were investigated for the cause. A failed DCR, chronic dacryocystitis (acquired nasolacrimal duct stenosis leading to outflow obstruction and subsequent infection and inflammation of retained stagnant contents within the lacrimal sac), fistula formation, and nasolacrimal duct (NLD) obstruction were diagnosed by regurgitation of mucopurulent material on pressure over the lacrimal sac., Prior to surgery, conventional history of nasal blockage, type of trauma (road traffic accidents, fall, interpersonal violence), or orthognathic surgery records were pursued [Table 1]. A basic nasal examination was done to rule out gross pathology involving the nasal and lacrimal apparatus. All surgeries were performed by the authors with due training in the technique.
|Table 1: Demographic parameters of the study group (n=83) who underwent DCR|
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Inclusion criteria included any case of epiphora or that requiring DCR, above the age of 18 years, of either gender, providing consent for the treatment, and not suffering from any systemic condition that could influence lacrimal apparatus patency and function, with adequate follow-up and all relevant case records. Those patients without sufficient follow-up of at least 12 months or incomplete records were excluded. Also, cases that had dacryocystitis (acute or chronic) were excluded from the study.
From the case records, age, gender, phase (primary DCR or retreatment DCR), primary pathology or cause of epiphora (fracture/orthognathic), bones involved (Le Fort I/II/III/zygomatic complex/naso-oribtal ethmoid complex/orbitonasal), cause as either chronic dacryocystitis or a failed DCR, or a long-standing fistula or NLD obstruction were obtained. Also, the duration of time suffering from epiphora was noted down. The complications, if any, were noted down.
Under general anesthesia, standard surgical preparations were carried out. Lignocaine 2% with adrenaline was infiltrated as required along the incision for the purpose of hemostasis as and when required. Initial punctal dilation was carried out using a Nettleship dilator. A O'Donohue type of bicanalicular stent, about 40 cm in length, made up of biological grade silicone with stainless steel probes at both the ends was used. An end of the stent was passed through the superior dilated punctum under direct vision. It was then slowly passed through the avulsed end of the NLD and further into the canal, until a hard stop was felt. If no stoppage was observed, the stent was pushed through the inferior meatus, and then visualized and grasped. The other end of the stent was similarly passed through the inferior punctum to pass through the nasolacrimal canal to reach the inferior meatus [Figure 2]a and [Figure 2]b.
|Figure 2: (a) Lacrimal probe inserted through the lacrimal canaliculus parallel to the medial canthal tendon. (b) Lacrimal intubation set with silicone tube|
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If a hard stop was felt, the incision for the nasal-mucosal flap was done at about 8 mm above the middle turbinate, extending vertically or in a curvilinear fashion down to the bone, as anatomy indicates. A periosteal elevator (Freer) was used to elevate the nasal mucosa, exposing the frontal process of the maxilla. If required, the flap was excised with a forceps (Weil-Blakesley). If required, Rongeurs were used to trim the exposed maxillary frontal process. Osteotomy was gradually enlarged till the end of the stent was visualized. If there was a fistula, pathological canalization along the path of least resistance has to be removed [Figure 3]a.
|Figure 3: (a) Skin incision placed, lacrimal sac exposed, and osteotomy of nasal bone done. Formation of anterior and posterior flaps between the lacrimal sac and nasal mucosa followed by lacrimal silicone tube insertion. (b) Naso-ethmoid complex fracture fixed using y plate. Silicone tube inserted into the ostium to facilitate the drainage of lacrimal secretions into the nose|
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The length of the bicanalicular stent was then adjusted between the superior and inferior punctum to prevent tension before tying the two ends securely [Figure 3]b. This bicanalicular silicone stent acts as a temporary surgical stent during the healing process of the damaged NLD. Intraoperatively, irrigation through the lower canaliculus would confirm the patency of the lacrimal drainage system. The patient was managed with corticosteroid and antibiotic eye drops for a week following surgery to prevent ocular infection.,
All data were entered and analyzed using the Statistical Package for the Social Service (version 16; IBM, Chicago, IL, USA). Descriptive statistics of the frequency and mean ± standard deviation (SD) as appropriate were presented. Gender, type of pathology, bones involved, cause, age, period suffering with epiphora, and follow up formed the predictors, while the primary and retreatment formed the outcome variable. Pearson's Chi-square test was used to identify the association of predictors with the primary or retreatment groups. Similarly, one-way analysis of variance (ANOVA) was used to identify the difference between the primary and retreatment procedures. Similarly, the period of epiphora and age were compared for the type of bones involved using one-way ANOVA. P ≤ 0.05 was taken to be statistically significant.
| Results|| |
During the study period, 83 patients fulfilled the inclusion and exclusion criteria. It is more common in males (n = 56, 67.47%) with a mean ± SD of 32.24 ± 10.80 (18–59 years), with 27 (32.53%) of them presenting primarily after fractures. Fractures was the most common pathology seen in 81.93% (n = 68) of cases, while the rest were as a result of orthognathic cases. Le Fort II and III set of bones contributed to 59% of cases, while the orbitonasal complex contributed to only three cases. NLD obstruction was seen in 68 (81.9%) of cases. On an average, the patients suffered for 9.3 ± 6.74 months (range 0.5–22 months) before seeking treatment and the average follow-up was 31.07 ± 11.69 months (range 15–54 months). Postoperatively, the mild epiphora was observed in the two fistula cases that healed by 3 weeks time frame; slight bleeding was observed in four cases and minor ocular infection in two cases. All such complications were managed effectively.
[Table 2] shows the comparison of demographic predictor variables with the phase of treatment using Pearson's Chi-square test. Gender (P = 0.263) was not significant, while basic pathology (P = 0.001), bones involved (P = 0.001), and cause (P = 0.012) were statistically significant. Time period with complaint (in months) was statistically significant between primary and retreatment. There were no differences in age or follow-up [Table 3]. [Table 4] shows the difference in age and time period with complaint and follow-up compared by various set of bones involved with statistical significance of P = 0.005 with the former and P = 0.001 for the latter.
|Table 2: Comparison of demographic predictor variables with the phase of treatment|
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|Table 3: Difference in Age, Time period with Complaint and follow up compared by primary and re-treatment cases|
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|Table 4: Difference in Age and Time period with Complaint and follow up compared by various set of bones involved|
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| Discussion|| |
There are few studies on the incidence of lacrimal system damage due to maxillofacial trauma. Such studies report of the involvement of NLD system in 7%–15% of all instances of trauma. There are reports that the incidence of nasolacrimal duct obstruction (NLDO) following a nasoorbitoethmoidal (NOE) fracture ranges between 29% and 68%. With the surgical correction, most of the damages, notably of the NLDO, are corrected and symptomatic epiphora rarely persists beyond 4–6 weeks with appropriate management. In a small subset of population, the damages still persists. Based on the level of trauma and bony displacement as well as the type of surgical intervention, there could be an NLDO or fistula formed. Irrespective of the same, there would be an epiphora associated. When the accumulated tears get stagnated, infection may follow leading to acute or chronic dacryocystitis, leading to more radical surgery involving lacrimal sac. The clinical features of NLDO and subsequent infections in different types of facial trauma are routinely described in standard textbooks.
The involvement of the NLDO in the maxillary orthognathic surgeries of any Le Fort type is a possibility. The surgery involves extensive manipulation of the complex nasomaxillary osseous apparatus. In case of the anatomical deviation or poor surgical planning or control of fracture lines, the NOE may be damaged or broken segments of bone could impinge the NLD causing NLDO. The mechanism of such a damage in Le Fort I has been extensively reviewed. The chance of the NLDO in Le Fort II and III types of orthognathic surgeries has been primarily due to abnormal anatomy or poor surgical planning., Literature is sparse on the incidence of NLDO post orthognathic surgeries.,
In the present research work, there were minor complications that were medically managed. Proper preoperative follow-up is needed to avoid future issues and persistence or failure of the DCR. Similar successful reports were also reported earlier., Persistent infection, possibly as chronic dacryocystitis in the lacrimal apparatus, could also lead to the formation of a fistula. Management of such fistula is complex and would need elimination of the new path of drainage, the epithelization.
The intent of this article is to compare the characteristics between the primary repair and retreatment of DCR in a maxillofacial clinical setting. DCR is often required for a case of NLDO, after a trauma (spontaneously or after fracture reduction) or in orthognathic cases. In either scenario, abnormal anatomy and improper studying of the radiographs, especially of the NOE region, could be one of the major causes of NLDO and subsequent epiphora. NLDO due to swelling, inflammation, or major infection often recedes with proper medical attention. However, bony impingements or improper alignment of the bones causing obstruction (full/partial) on the NLD system could lead to epiphora. The study used retrospective analysis from a single center, operated by the primary author with adequate experience and training in surgical procedure. Hospital admission bias is a possibility and results thus need to be carefully considered. The high number of retreatment cases, often referred from external centers (n = 56), is the reason for the same. Of the 68 cases that had maxillofacial trauma, only 27 (39.7%) sought primary treatment with epiphora, while the rest 41 (60.3%) were retreatment cases. In orthognathic cases, all (n = 15) cases were retreatment cases. The difference was statistically significant (P = 0.002).
The fractures of bones involving the nasal apparatus required DCR. The highest risk was the Le Fort II pattern followed by Le Fort III type of fractures. NOE alone was less when compared with Le Fort. The least was Le Fort I mostly due to orthognathic surgeries. Anatomical abnormalities have been suggested as the cause., Patients suffering from epiphora owing to primary cause reported a mean period of 1.03 months, while the retreatment sought was for a mean of 13.34 months. The difference was statistically significant (P = 0.000). The set of bones have a different time frame of seeking treatment. Those who had only orbitonasal bone fractures sought treatment earlier at 1.08 months, while those with Le Fort I type of fractures/orthognathic surgeries waited for 14.8 months before seeking treatment. The difference was statistically significant (P = 0.005). This has clinical significance. Depending the types or sets of bones involved, the clinical severity of the epiphora may vary, necessitating the patients to seek immediate relief. Those with the orbitonasal fractures sought treatment earlier, while those with Le Fort I pattern of bone involvement sought treatment later. This could be a reflection of the severity of the compliant. Future studies would need to consider the severity of epiphora and/or identify a grading system for the same. There are no previous studies in the direction of comparing clinical features between primary and retreatment of DCR. Hence, the results of the studies cannot be discussed in light of existing literature.
Anatomical complexities of the NOE region and deviation from normal are often noted. The operating surgeon while planning for fracture reduction or orthognathic surgeries has to carefully consider the locoregional radiological anatomy., In nearly 10% of all trauma cases involving NOE region, there would be radiological evidence suggestive of NLDO, resulting in epiphora. If it persists beyond 4 to 6 or not amenable to medical management, DCR should be considered.
| Conclusion|| |
The difference in clinical characteristics of features between primary and retreatment DCR is presented. The study also underlines the need for proper radiological and clinical examination to detect anatomical deviation and the need for proper surgical planning while operating in the mid-facial region.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Dr. S M Balaji
Balaji Dental and Craniofacial Hospital, 30, KB Dasan Road, Teynampet, Chennai, Tamil Nadu - 600 018
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4]