Eur Arch Otorhinolaryngol (2011) 268:1283–1288 DOI 10.1007/s00405-011-1585-z
RHINOLOGY
Pediatric endocanalicular diode laser dacryocystorhinostomy: results of a minimally invasive surgical technique ¨ nder Uysal • Muammer O ¨ zc¸imen I˙smail O Halil I˙brahim Yener • Ali Kal
•
Received: 1 January 2011 / Accepted: 15 March 2011 / Published online: 27 March 2011 Ó Springer-Verlag 2011
Abstract The purpose of this study was to evaluate the effectiveness of endocanalicular diode laser dacryocystorhinostomy (DCR), which is a minimally invasive surgical technique, in pediatric patients with congenital nasolacrimal duct obstruction (NLDO). A retrospective study was carried out on patients treated between October 2008 and August 2009 for nasolacrimal duct obstruction with an endocanalicular diode laser procedure. Patients diagnosed as having nasolacrimal duct obstruction were included in this study and an endocanalicular diode laser procedure was performed. The main outcome measures were patients’ previous treatments, clinical presentation, operative and postoperative complications, postoperative follow-up and resolution of epiphora. Eighteen children (10 girls, 8 boys) with a mean age of 6.11 ± 2.08 years (range, 4–10) underwent 20 endocanalicular laser DCR operations for congenital NLDO. In all eyes (100%), there was a history of epiphora and chronic dacryocystitis; two (10%) presented with acute dacryocystitis. Previous procedures included probing and irrigation of all eyes (100%) and silicone tube intubation in nine eyes (45%). None of the patients underwent any previous DCR operations. During a mean postoperative follow-up period of 20.50 ±
¨ . Uysal (&) ˙I. O Department of Otolaryngology, Cumhuriyet University School ¨ niversitesi Tıp Faku¨ltesi, of Medicine, Cumhuriyet U 58140 Sivas, Turkey e-mail:
[email protected] ¨ zc¸imen H. ˙I. Yener M. O Aknet Eye Hospital, Konya, Turkey A. Kal Department of Ophthalmology, Baskent University Hospital, Konya, Turkey
3.24 months (range, 14–24 months), the anatomical success rate (patency of ostium on nasal endoscopy) was 100%, and the clinical success rate (resolution of epiphora) was 85%. Endocanalicular diode laser DCR is an effective treatment modality for pediatric patients with congenital NLDO that compares favorably with the reported success rates of external and endoscopic endonasal DCR. Moreover, it has an added advantage of shorter operative time, less morbidity and avoidance of overnight admission. Keywords Dacryocystorhinostomy Pediatric Nasolacrimal duct obstruction Diode laser Endocanalicular
Introduction Epiphora in children is a common condition during the first year of life, affecting up to 20% of all babies [1–4]. This usually results from a failure of canalization of the distal end of the nasolacrimal duct with persistence of a membranous web at the level of the Hassner valve. This is currently called congenital nasolacrimal duct obstruction (NLDO). Fortunately, over 90% of these obstructions resolve spontaneously with little or no treatment during the first year of life [1, 2]. When spontaneous resolution does not occur, nasolacrimal probing and dilatation or nasolacrimal intubation is generally a curative procedure in most cases. When epiphora persists despite probing or intubation, surgical intervention with a dacryocystorhinostomy (DCR) is usually the next preferred treatment modality [1]. External DCR is a commonly used treatment modality in both adults and children. In different series, it is reported to have a success rate of 83–96% in treating congenital
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NLDO [1, 5, 6]. Endoscopic endonasal DCR has also gained an important role in the treatment of NLDO in the last few years as a result of the introduction of rigid fiberoptic endoscopes [7, 8]. Technological improvements of the medical laser systems led to the introduction of new techniques in the treatment of NLDO. The aim of this study was to report our experience with a series of pediatric patients who were treated with endocanalicular diode laser DCR. Compact laser emitting diodes of gallium–aluminum–arsenide are now available for incorporation into clinical lasers in ophthalmology. These lasers are cheap, portable and have low running costs. The laser probes are reusable. The system works with standard electric network, so laser tubes are not necessary.
Materials and methods The study group included all children aged 10 years or younger who underwent endocanalicular laser dacryocystorhinostomy for congenital NLDO between October 2008 and August 2009 in one medical center. All children were symptomatic since birth. All children underwent a complete ophthalmic and nasal examination, including assessment for lid and punctal abnormalities. The evaluation was done in an eye clinic by an ophthalmologist and ear, nose and throat (ENT) surgeon. The technique of endocanalicular laser DCR was used in all cases. All surgeries were performed under general anesthesia. Surgical time was approximately 20 min in each case. Nasal decongestion and administration of intranasal anesthesia for vasoconstriction was first performed. The superior and inferior puncta were dilated, and the canaliculi were probed to a hard stop. After removing the probe, an 800-l laser fiber was introduced (Biolase, San Clemente, USA) via the lower canaliculus. The anesthetic packing was removed and a 30° 4-mm rigid nasal endoscope was introduced into the nasal cavity. The aiming beam was identified transmucosally. Under endoscopic guidance, continuous-wave contact laser energy between 6 and 8 W was used. The laser was applied inferior and anterior to the root of the middle turbinate, extending inferiorly and anteriorly to create an ostium of approximately 5 9 8 mm in size (Fig. 1). The probe was also placed in the upper canaliculus to widen the ostium in 13 cases (65%). After removal of the laser fiber, canalicular irrigation was performed with saline. Silicone tube intubation of the ostium was performed (Fig. 2). The tubes were left in place for approximately 4 months. Nasal packing was not necessary in our cases as postoperative bleeding was not a major concern.
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Fig. 1 Perioperative appearance. Enlarged ostium, necrosis and coagulation
Patients were discharged on the day of surgery. The postoperative regimen included antibiotic and steroid eye drops for 14 days. Mometasone furoate nasal spray and nasal saline were also used twice a day for 1 month. Postoperative evaluation was performed with routine follow-up at 1-week, 1-month, and 3-month postoperative intervals. Surgical success was defined as complete resolution of preoperative symptoms (based on clinical findings, parental observation and slit-lamp examination) and the presence of patent DCR ostium with free drainage of saline. At the follow-up visits, objective confirmation of free drainage of fluorescein sodium (1%) from conjunctiva to the nose and endoscopic osteotomy patency was performed in all cases.
Results The study group included 18 patients (10 girls, 8 boys) with a mean age of 6.11 ± 2.08 years (range 4–10 years) who underwent endocanalicular diode laser DCR operations for congenital NLDO. In 16 patients, it was a unilateral operation (8 patients right side, 8 patients left side), and in 2 patients a bilateral operation was performed (Table 1). In all eyes (100%), there was a history of epiphora and chronic dacryocystitis, and two (10%) presented with acute dacryocystitis. Previous procedures included probing and irrigation of all eyes and silicone tube intubation in nine eyes (45%). None of the patients underwent any previous DCR operations. There was no major complication. Bicanalicular silicone tubes were placed in all eyes and were later removed after an average of 4 months (range, 3–5 months). The mean followup period was 20.50 ± 3.24 months (range, 14–24 months). In all eyes, there was free flow of saline, and the ostium was patent on nasal endoscopy at the follow-up visits (Fig. 3). In
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inferior canalicular stenosis was observed. Dilatation of the inferior canaliculus by diode laser was performed and reintubated with silicone tube. This eye was also followed by observation only as the symptoms were acceptable. Premature prolapse of the tube was seen in two eyes. In one of the eye, the tube was reintubated and knotted intranasally and in the second it was removed. They did not have epiphora or discharge. Two eyes had stent retraction and punctal deformation. They had early stent extubation and experienced only mild epiphora. As the symptoms were acceptable and the cause for epiphora was only the punctal deformation, they were followed by observation. At the last office visit, there was complete resolution of epiphora and the fluorescein dye disappearance test was positive.
Fig. 2 Silicone tube intubation
17 eyes (85%), there was complete resolution of epiphora, whereas in the other 3 (15%) there were residual epiphora, one of which was symptomatic with exposure to wind. The patient was followed by observation only. The other eye was always symptomatic and underwent a revision surgery. On endoscopic examination, the ostium was seen to be patent, but there was crusting and granulation tissue occluding the passage. The crust was removed and nasal steroid and saline spray treatment was given to this patient. In the other eye in which we dilated the inferior canaliculus perioperatively,
Discussion When epiphora persists despite probing or intubation, surgical intervention with either external or endoscopic endonasal DCR is usually the next preferred treatment modality. Endocanalicular laser DCR represents one of many recent attempts to improve lacrimal surgery [9]. Our study included children with congenital NLDO who were not treated previously with DCR and who had no
Table 1 Patients undergoing transcanalicular multidiode laser-assisted dacryocystorhinostomy No
Age (years)
Gender
Laterality
Preoperative procedures
Follow-up (months)
Comments
1
4
M
Right and Left
P ? STI
19
S
2
10
F
Right
P ? STI
24
S
3
9
F
Right
P
16
F/observation only (symptomatic in wind)
4
7
F
Left
P ? STI
24
S
5
5
M
Right
P
23
S
6
4
F
Left
P ? STI
23
S
7 8
4 6
M M
Left Right
P ? STI P ? STI
21 24
S S
9
5
M
Left
P
23
S
10
6
M
Right
P
16
S
11
6
F
Left
P
18
F/revision(crust removal and nasal steroid therapy)
12
6
F
Left
P
22
S
13
10
F
Left
P
22
S
14
5
F
Right
P
18
S
15
4
M
Right and Left
P
17
Right: S Left: F/revision (ECL-DCR) (symptoms acceptable)
16
6
F
Left
P
14
S
17
9
F
Right
P ? STI
22
S
18
4
M
Right
P ? STI
23
S
M male, F female, P probing, STI = silicone tube intubation, S success, F failed, ECL-DCR endocanalicular laser dacryocystorhinostomy
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Fig. 3 Patient ostium seen at 16th month follow-up
associated lacrimal pathologies. The anatomical success rate (based on a patent ostium) was 100%, and the clinical success rate (based on resolution of epiphora) was 85%. VanderVeen et al. [10] reported a series of 17 children (22 operations) with congenital NLDO who underwent endoscopic DCR, with a success rate of 88%. Cunningham and Woog [11] reported four successful cases of endoscopic DCR in children aged 10 months to 6 years. Leibovitch et al. [12] reported 92.3% cure rate in children who underwent endoscopic endonasal DCR. Other studies have shown a success rate ranging from 82 to 88% for endoscopic DCR in children [10, 11, 13–15]. In our series, we observed complete resolution of the ocular symptoms in 17 out of 20 procedures. One had epiphora when exposed to the wind. The other who had stenosis of the inferior canaliculus preoperatively was symptomatic all the time. The third one was always symptomatic and underwent a revision surgery. Our findings are comparable to the high success rates reported in these series. External DCR is well accepted as an excellent treatment for pediatric NLDO, with success rates ranging from 88 to 96% in most series [16–18]. Complications related with external DCR in children are uncommon. Welham and Hughes [19] reported postoperative bleeding requiring transfusion in 1.25% of cases. In the other large series, there were no cases of significant bleeding reported. The rate of postoperative wound infection ranges from 4.5 to 8% [11, 14, 16]. A potential disadvantage is the cutaneous incision and scar, which may be significant in children. The technique also involves disruption of the medial canthal anatomy and orbicularis oculi muscle, and may influence the lacrimal pump function [8]. Endonasal DCR, though technically difficult in small children, offers a number of advantages over the external approach. It avoids skin incision and consequent scarring. It enables accurate creation of a drainage ostium, and it is accompanied by much more limited perioperative bleeding.
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Comparing endocanalicular diode laser DCR with endonasal DCR is more challenging, as reported success rates with the endonasal technique vary significantly [20, 21]. With the endocanalicular technique, we obtained complete hemostasis and, certainly, hemorrhage was not sufficient to compromise endonasal viewing or to interrupt surgery. The endocanalicular technique has a shorter operation time. Like all surgery, it demonstrates a learning curve, but once familiar, it is quick and simple to perform. It obviates the need to perform more complex surgical maneuvers in the narrow nose of a child. A decade ago Choudary et al. [22], Doyle et al. [23] and Nemet et al. [24] argued that the laser devices could be used in DCR operation and added that their cost were very high and it did not appear to improve results. Hong et al. [9] described the outcomes of endocanalicular laser dacryocystorhinostomy for 118 adult patients with nasolacrimal duct obstruction. They concluded that endocanalicular laser DCR offered a minimally invasive alternative procedure for the treatment of NLDO. We decided to create a drainage ostium with diode laser in children, which had some advantages over the conventional techniques. Laser was applied inferior and anterior to the root of the middle turbinate, extending inferiorly and anteriorly to create an ostium. This was achieved by introducing the laser probe obliquely. This helps us to create an ostium at the very inferior portion of the lacrimal sac, so preventing any stasis. The manipulation and visualization is better and damage to the nasal tissues is much less in this area. We believe that manipulation and visualization will not be sufficient and stasis may be seen at the inferior part, if the laser is applied horizontally. Postoperative cares, consisting in the removal of fibrin, crusts and granulations under endoscopic guidance, are very difficult in very young patients [12, 13, 22, 25, 26] and so not done on a routine basis in this series of patients. At the follow-up visits, on endoscopic examination the ostium was seen to be patent in all cases. In case of crusting and granulation tissue occluding the passage, the crust was removed under endoscopic guidance in older children, and nasal steroid and saline spray treatment was given to these patients. In very young patients, the mother was instructed to irrigate the child’s nose with a physiologic solution, to put a nasal spray and eyedrops with antibiotic and steroids four times a day. Nasolacrimal intubation is quick and relatively complication free. The correct tensioning of the tubes is necessary to avoid cheesewiring through the puncta (when the tubes are too tight) or tube prolapse from the puncta (when the tubes are too loose). It requires experience, but when cheesewiring occurred, the cure rate was not affected. Tube prolapse was distressing for the family, but did not cause the child any great discomfort and did not cause any corneal epithelial damage [27].
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Silicone tubing is a controversial issue in literature. Some authors placed it in all their cases, while others used it only in situations in which canalicular stenosis was suspected or in case of revision surgery [10–14, 25, 26, 28]. The advantage of stenting is that it secures the patency of newly created pathway. The disadvantage is the potential for canalicular trauma and subsequent stenosis [29], which is rare, and the need to perform an additional procedure for the removal of the silicone stent, usually requiring general anesthesia. The question of the optimum duration for the tubes remaining in situ needs an answer. Aggarwal et al. [30] recommended that the tubes remain in place for 6 months. However, Marr et al. [27] have suggested that this was unnecessarily long and their practice was to remove the tubes after 6 weeks. Onerci [26] did not recommend leaving it in place for longer than 3 months to avoid any complications. In our series, all cases had bicanalicular silicone stent intubation and remained in place for approximately 4 months except for three cases, because, as mentioned above, intubation is quick and relatively complication free. Tube removal procedure under general anesthesia was very beneficial, as it gave us the chance to examine the drainage ostium endoscopically and perform lacrimal irrigation. Endoscopic osteotomy patency at the last visit of each patient was thought to be related to regular follow-ups and relevant intervention in case of necessity.
Conclusion Endocanalicular diode laser DCR is an effective procedure for treating primary congenital NLDO in children and compares favorably with success rates of external and endoscopic endonasal DCR. With increasing awareness of parents and older children to facial cosmesis, this procedure may provide a significant alternative to transcutaneous approach. A teamwork with an oculoplastic surgeon, a pediatric ophthalmologist and an ENT surgeon is expected to provide the optimal preoperative evaluation, surgical treatment and postoperative care. We need larger series and longer follow-up periods for better understanding of the endocanalicular diode laser DCR technique and its results for treating primary congenital NLDO in children. Conflict of interest disclose.
We have no conflict of interest that we should
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