Introduction
Endoscopic dacryocystorhinostomy (EDCR) is a minimally invasive surgery used in the treatment of nasolacrimal duct obstruction and chronic dacryocystitis. In addition to being minimally invasive, it has advantages such that its short operation duration, little bleeding, not leaving an external scar, not causing injury of medial chantal anatomy or lacrimal sac pump dysfunction (1,2).
After the bone window has been opened and the medial wall of the nasolacrimal sac has been incised in the EDCR operation, various stents (Ss) or intubation tubes can be used in order to prevent closing of the rhinostomy formed (3,4). There are studies demonstrating that the rhinostomy formed in the EDCR operation works successfully also when S is not placed (5). The purpose of this study is to investigate the effect of the use of silicone S in EDCR operation on the surgical success and to compare the results of the patients who had silicone Ss placed or not.
Materials and Methods
The files of 38 patients (46 eyes) who admitted to otorhinolaryngology clinic of Aydın Adnan Menderes University with epiphora between May 2013 and January 2015, diagnosed with chronic dacryocystitis and nasolacrimal duct obstruction and undergone EDCR operation were reviewed retrospectively. All of the cases had non inflamed lacrimal sac obstruction. Prior to surgery, all patients were performed lacrimal system lavage by an ophthalmologist and the diagnosis was confirmed by dacryocystography.
All patients were operated with general anesthesia. The stages of the surgery include decongestion of the nasal cavity (with 1/100000 lidocaine with adrenaline soaked swabs), injection of 1/100000 lidocaine with adrenaline into the lateral nasal wall, localization of the sac, mucosal incision, flap elevation, removal of bone window with chisel/hammer or drill, dilatation of punctum and bowman cannulation, incision of the sac and excision of the medial wall of the sac. After this stage of the operation, some of the patients were inserted silicone S whereas some of them could not be inserted. In the group which has not been inserted silicone S, after excision of the medial wall of the sac, a small piece of spongostan was placed between the sac and the nasal passage and spongostan pack was placed into the nasal cavities of all patients at the end of the procedure.
In the postoperative period, 1 week of peroral systemic antibiotic, nasal irrigation with ringer lactate, two weeks of eye drops with antibiotic and steroid were applied. In the postoperative first week, lacrimal lavage was performed to clean up the debris and post-surgery 1st week, 1st, 2nd and 6th month follow-ups were carried out regularly. The follow-up period was between 9-30 months. The mean S removal time was 2.5±1.0 months.
The patients for whom post-surgery silicone S was used comprised the group with S and the rest comprised the group without stent (WS). The operation was considered successful if complete remission of the symptoms was achieved in the post-operative period, the patency was shown by lacrimal lavage and lacrimal drainage from rhinostomy was observed in the endoscopic examination. The operation was considered unsuccessful if partial but not complete remission of the complaints was achieved and the patency could not be shown by lacrimal lavage or lacrimal drainage from rhinostomy was not observed in the endoscopic examination. S and WS groups were compared with respect to the surgical outcomes. The data were analyzed by Fisher’s exact test and t-test. P<0.05 was considered statistically significant. This study was conducted in accordance with the principles of Helsinki Declaration 2013. The study were approved by the Adnan Menderes University of Local Ethics Committee (protocol number: 13.2.2015, 2015/538).
Results
Fifteen of the cases were male and 23 were female. 46 eyes of 38 cases were involved in the study. The mean age was 61.3±15.1 in the S group and 56±18.7 in the WS group (between 13-83 years old.). There was no statistically significant difference between the groups in terms of age or gender (p=0.346, p=0.507). 30 of the cases were operated unilaterally and 8 were operated bilaterally. The obstruction was 60.9% in the left eye (n=28) and 39.1% in the right eye (n=18). Six of the patients were revision cases who had previously undergone EDCR operation.
All cases in the WS group were operated using drill. 4 of the cases in the S group were operated using drill and 15 of them using chisel/hammer. 58.7% of all operations were performed with drill and 41.3% with chisel/hammer. Twenty-four eyes of 19 patients in the S group (n=24) were operated with S and 22 eyes of 19 patients in the WS group (n=22) were operated WS. Epiphora was evaluated with complete remission of symptoms, lacrimal lavage and endoscopic examination of rhinostomy. Epiphora was corrected 91.7% in the S group (n=22) and 86.4% in the WS group (n=19). The intergroup difference in terms of the correction of epiphora was not found statistically significant (p=0.659). Results and some features of groups are shown in Table 1.
Discussion
There are a large number of studies in the literature about EDCR operation. The effect of the use of silicone S on biofilm formation, microbial growth, flora changes and surgical success are among the research subjects (6-9). In this study we aimed to examine the effect of silicone intubation on the surgical success within our patient group.
There are some disadvantages of the use of silicone S. There are studies reporting Pseudomanas aeruginosa colonization on the silicone Ss and the formation of biofilm layer on the S even if the S culture is negative (8,10). In addition to this microbiological change of Ss, it is known that resistant microorganisms colonize in the nasal flora after EDCR operations in which silicone S was used (9). Granulation tissue formation around silicone Ss has been reported as a factor leading to unsuccess (11). The use of silicone S is likely to increase the operational cost. In EDCR, there may be difficulties associated with the use of silicone tube (12). Therefore, especially at the beginning of the surgery experience, cooperation with an ophtalmologist for the placement of the S may be necessary. These may be regarded as some disadvantageous aspects of silicone S.
During surgery, drill, chisel/hammer, rounger, forceps, curette or laser can be used to open the bone window (13,14). In this study, the bone window was opened by drill in all cases of the WS group and chisel/hammer was used in most of the cases of the S group. We think that the use of drill is easier than the use of chisel/hammer and the bone window can be widened as much as needed by using drill. The only disadvantage of using drill is the need for cold water irrigation in order to prevent thermal damage to the bone tissue from heat. We haven’t encountered any literature knowledge about the effect of drill related thermal damage to EDCR. Yet we do not think it has any negative effect as a clinical observation.
The factors affecting the success of EDRC operation are the correct localization of the sac, opening the rinostomy at the correct place, forming a wide bone window and sufficient excision of the medial wall of the sac (15). Silicone S is used to maintain new rhinostomy opening formed by EDCR operation (9). There are studies where mitomycin C is used to prevent closure of the rhinostomy opening (16). On the contrary, some authors argue that silicone S is not required for surgical success. Pittore et al. (17) have reported their success rate of endoscopic DCR operations they have performed without using silicone S as 90%. Yeon and Shim (18), in their study comparing the EDCR operations performed with or without silicone S, have reported that there was no statistically significant difference between the two groups. There are authors reporting higher success rates in non-stented EDCR operations than the stented ones (19). In our study too, no statistically significant intergroup difference was found with respect to the correction of epiphora. Our success rates are 91.7% in the S group and 86.4% in the WS group. Therefore, we suggest that the use of silicone S in the EDCR operations does not affect success.
As a result, EDCR operation with or WS placement is successful and efficient. The success rates are similar in the EDCR operations performed with or WS placement. The use of silicone S in the EDCR operations does not affect success. In addition to the fact that the use of silicone S does not affect success, considering the granulation tissue formation around it, that it increases cost, the biofilm layer formation and the change of flora it causes, we recommend not to use S in EDCR operations.
Acknowledgements
We thank İmran Kurt MD. for expert help with data analysis.
Ethics
Ethics Committee Approval: The study were approved by the Aydın Adnan Menderes University of Local Ethics Committee (protocol number: 13.2.2015, 2015/538)
Informed Consent: Consent form was filled out by all participants.
Peer-review: Externally peer-reviewed.
Authorship Contributions
Surgical and Medical Practices: Y.B., A.İ.A.Ü., C.G., Concept: Y.B., A.İ.A.Ü., S.B., C.G., A.E., Design: Y.B., A.İ.A.Ü., S.B., C.G., A.E., Data Collection or Processing: Y.B., A.İ.A.Ü., C.G., A.E., Analysis or Interpretation: Y.B., A.İ.A.Ü., S.B., C.G., Literature Search: Y.B., A.İ.A.Ü., C.G., A.E., Writing: Y.B., A.İ.A.Ü., S.B., C.G., A.E.
Conflict of interest statement: The authors have declared that no conflict of interest exists.
Financial Disclosure: The authors declared that this study received no financial support.