Assessment of Long-Term Outcomes Associated With a Lobulated Pedicled Nasal Mucosa Flap Technique for Endoscopic Dacryocystorhinostomy Without Stenting.

OBJECTIVE: This study describes a surgical approach wherein a lobulated pedicled nasal mucosa flap technique was employed for endoscopic dacryocystorhinostomy (EDCR) as a means of treating nasolacrimal duct obstructions. This study also assessed the long-term outcomes of this EDCR approach when implemented without stenting. METHODS: This was a retrospective study of a total of 63 patients (67 eyes) treated for nasolacrimal duct obstructions between January 2011 and November 2016. All patients had undergone ophthalmic diagnosis followed by EDCR treatment using a lobulated pedicled nasal mucosa flap without stenting. Patients were then monitored for both anatomical patency and sustained symptom relief during the follow-up period in order to assess objective and subjective study outcomes. RESULTS: Patients were followed for a mean of 25.3 ± 1.2 months (range: 24-28 months), with a 100% anatomical patency success rate (67/67) and a 94.03% symptomatic cure rate (63/67). There were no instances of complications. CONCLUSIONS: The use of a lobulated pedicled nasal mucosa flap technique for EDCR without stenting is a straightforward, effective, and safe approach that keeps bone exposure to a minimum while offering a high rate of satisfactory outcomes, making it a procedure worthy of consideration as a means of treating patients suffering from nasolacrimal duct obstructions.

Comparison of Piezosurgery and Hammer-Chisel in Endoscopic Dacryocystorhinostomy.

BACKGROUND: In this study, we compared the advantages and disadvantages of piezosurgery and hammer-chisel used in endoscopic dacryocystorhinostomy (EDCR). MATERIAL AND METHODS: Between January 2012 and January 2016, 10 women and 8 men in whom piezosurgery was used (group 1) and 11 women and 7 men in whom hammer-chisel was used (group 2) during EDCR operations were compared retrospectively. Recurrence, operation time, postoperative bleeding, and operative cost were evaluated in patients who were followed for an average of 11.8 months. In addition, visual analogue scale (VAS) was used to assess pain at 6 hours postoperatively. RESULTS: No recurrence was observed in group 1, but recurrence was observed in 2 patients in group 2 (P = 0.685). There was no postoperative bleeding in both groups. The mean duration of operation was 30.6 ±â€Š8.2 minutes in group 1 and 46.8 ±â€Š9.5 minutes in group 2 (P = 0.038). The VAS score in group 1 was 2.7 ±â€Š1.4 and the VAS score in group 2 was 5.8 ±â€Š2.2 (P = 0.01). Piezosurgery costs an additional $325 for each patient while the use of the hammer-chisel does not incur additional costs. CONCLUSION: Piezosurgery causes shorter operation time, less recurrence, and less pain when compared with hammer-chisel.

Endoscopically assisted Crawford tube placement results in shorter general anesthesia times in pediatric patients.

BACKGROUND: Crawford tube placement is commonly used to achieve patency of nasolacrimal ducts for epiphora secondary to nasolacrimal duct obstruction. The nasal passages of pediatric patients are narrower than adults, and the result is a relatively higher risk of intranasal complications (e.g., synechiae, bleeding) with Crawford tube placement. There is evidence that general anesthesia may negatively affect the neurocognitive function and behavioral development of children, which prompts efforts to decrease operation times for potential health benefits and also potentially to reduce health care costs. Analysis of research reports supports the use of nasal endoscopy to reduce intranasal complications with Crawford tube placement; however, no publications currently address the effect of nasal endoscopy concurrent with Crawford tube placement on operative times on pediatric patients or the resulting effects on health care costs. OBJECTIVE: To determine the difference in procedure time and cost between Crawford tubes placed traditionally and those placed with endoscopic assistance in pediatric patients. METHODS: A chart review was performed from January 1, 2011 to December 31, 2016 for cases using CPT codes 68815 or 31231. Within this group of patients, the patient in whom nasal endoscopy was performed were placed in the "endoscopic" group and the patients without endoscopy were placed in the "traditional" group. Procedure times were noted, and the t-test was performed to examine for any statistically significant difference in operative times. Estimates of anesthesia cost savings were made. We identified 24 patients in the traditional group and 7 patients in the endoscopic group. RESULTS: The average operative time for the traditional group was 27.3 minutes compared with 14.0 minutes for the endoscopic group (p = 0.02). The cost comparison data revealed no significant difference with the traditional group averaging $9369 per procedure and the endoscopic group averaging $8891 (p = 0.51). CONCLUSION: An endoscopically assisted Crawford tube placement resulted in patients who had less time under general anesthesia compared with the traditional technique at no difference in cost.

Probing for congenital nasolacrimal duct obstruction.

BACKGROUND: Congenital nasolacrimal duct obstruction (NLDO) is a common condition causing excessive tearing in the first year of life. Infants present with excessive tearing or mucoid discharge from the eyes due to blockage of the nasolacrimal duct system, which can result in maceration of the skin of the eyelids and local infections, such as conjunctivitis, that may require antibiotics. The incidence of nasolacrimal duct obstruction in early childhood ranges from 5% to 20% and often resolves without surgery. Treatment options for this condition are either conservative therapy, including observation (or deferred probing), massage of the lacrimal sac and antibiotics, or probing the nasolacrimal duct to open the membranous obstruction at the distal nasolacrimal duct. Probing may be performed without anesthesia in the office setting or under general anesthesia in the operating room. Probing may serve to resolve the symptoms by opening the membranous obstruction; however, it may not be successful if the obstruction is due to a bony protrusion of the inferior turbinate into the nasolacrimal duct or when the duct is edematous (swollen) due to infection such as dacryocystitis. Additionally, potential complications with probing include creation of a false passage and injury to the nasolacrimal duct, canaliculi and puncta, bleeding, laryngospasm, or aspiration. OBJECTIVES: To assess the effects of probing for congenital nasolacrimal duct obstruction. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), which contains the Cochrane Eyes and Vision Trials Register (2016, Issue 8); MEDLINE Ovid (1946 to 30 August 2016); Embase.com (1947 to 30 August 2016); PubMed (1948 to 30 August 2016); LILACS (Latin American and Caribbean Health Sciences Literature Database; 1982 to 30 August 2016), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), last searched 14 August 2014; ClinicalTrials.gov (www.clinicaltrials.gov), searched 30 August 2016; and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en), searched 30 August 2016. We did not use any date or language restrictions in the electronic searches for trials. SELECTION CRITERIA: We included randomized controlled trials (RCTs) that compared probing (office-based or hospital-based under general anesthesia) versus no (or deferred) probing or other interventions (observation alone, antibiotic drops only, or antibiotic drops plus massage of the nasolacrimal duct). We did not include studies that compared different probing techniques or probing compared with other surgical procedures. We included studies in children aged three weeks to four years who may have presented with tearing and conjunctivitis. DATA COLLECTION AND ANALYSIS: Two review authors independently screened studies for inclusion and independently extracted data and assessed risk of bias for the included studies. We analyzed data using Review Manager software and evaluated the certainty of the evidence using GRADE. MAIN RESULTS: We identified two RCTs and no ongoing studies; one of the included RCTs was registered. The studies reported on 303 eyes of 242 participants who had unilateral or bilateral congenital nasolacrimal duct obstruction. For both included studies, the interventions compared were immediate office-based probing to remove the duct obstruction versus deferred probing, if needed, after 6 months of observation or once the child reached a certain age.The primary outcome of the review, treatment success at 6 months, was reported partially in one study. Treatment success was not reported at this time point for all children in the immediate probing group; however, 77 of 117 (66%) eyes randomized to deferred probing had resolved without surgery 6 months after randomization and 40 (34%) eyes did not resolve without probing. For children who had unilateral NLDO, those randomized to immediate probing had treatment success more often than those who were randomized to deferred probing (RR 1.41, 95% CI 1.12 to 1.78; 163 children; moderate-certainty evidence). Treatment success for all children was assessed in the study at age 18 months; as an ad hoc analysis in the included study, results were presented separately for children with unilateral and bilateral NLDO (RR 1.13, 95% CI 0.99 to 1.28 and RR 0.86, 95% CI 0.70 to 1.06, respectively; very low-certainty evidence).In the other small study (26 eyes of 22 children), more eyes that received immediate probing were cured within one month after surgery compared with eyes that were randomized to deferred probing and analyzed at age 15 months (RR 2.56, 95% CI 1.16 to 5.64). We considered the evidence to be low-certainty due to imprecision from the small study size and risk of bias concerns due to attrition bias.One study reported on the number of children that required reoperation; however, these data were reported only for immediate probing group. Nine percent of children with unilateral NLDO and 13% with bilateral NLDO required secondary procedures.One study reported cost-effectiveness of immediate probing versus deferred probing. The mean cost of treatment for immediate probing was less than for deferred probing; however, there is uncertainty as to whether there is a true cost difference (mean difference USD -139, 95% CI USD -377 to 94; moderate-certainty evidence).Reported complications of the treatment were not serious. One study reported that there were no complications for any surgery and no serious adverse events, while the other study reported that bleeding from the punctum occurred in 20% of all probings. AUTHORS' CONCLUSIONS: The effects and costs of immediate versus deferred probing for NLDO are uncertain. Children who have unilateral NLDO may have better success from immediate office probing, though few children have participated in these trials, and investigators examined outcomes at disparate time points. Determining whether to perform the procedure and its optimal timing will require additional studies with greater power and larger, well-run clinical trials to help our understanding of the comparison.

Early loss of monocanalicular silicone tubes in congenital nasolacrimal duct obstruction: incidence, predictors, and effect on outcome.

PURPOSE: To study predictors and implications on outcome of premature silicone tube-loss, a post-operative complication of monocanalicular intubation (MCI) performed for treatment of congenital nasolacrimal duct obstruction (CNLDO). METHODS: We conducted a retrospective analysis of cases of post-operative loss of monocanalicular silicone tubes occurring at one medical center from January 2007 to December 2013. RESULTS: During the study period monocanclicular silicone tubes were lost in 24/54 eyes (44%) of 19/46 children. Multivariate regression analysis identified bilateral intubation as an important predictor of early tube-loss (r=0.54, P=0.006). Seven of eight (88%) children who had both eyes intubated prematurely lost their tubes compared to 12/38 (32%) children who had unilateral intubation (P=0.005). Treatment success was lower in eyes with early tube-loss (17/24 eyes, 71%) compared to eyes with full tube retention (25/30 eyes, 83%), however this difference was not statistically significant (P=0.333). In our study, treatment outcome correlated with duration of intubation (r=0.51, P=0.002). Surgical success was achieved in 33/39 eyes (85%) in which the tubes were retained at least 2 months compared to 7/15 eyes (47%) with shorter period of intubation (P=0.012). CONCLUSIONS: Spontaneous tube-loss is a post-operative complication of monocanalicular silicone intubation that can occur more frequently than previously reported in certain populations. Tube-loss occurring soon after surgery is often associated with persistent symptoms and increased need of reoperation.

Cannula dacryocystorhinostomy: a simple, innovative and cost-effective method of lacrimal surgery.

To compare our innovative, cost-effective method of lacrimal surgery with other methods. A prospective cohort study. The study included 80 eyes of 80 consecutive patients who presented to our clinic between January 2009 and December 2011. The patients underwent surgery using a new technique with a specially designed cannula and were followed according to our protocol. Patency on irrigation. Of the 80 cases enrolled, the procedure was successful in 52.5 % with a mean follow-up of 247.2 days. The success rate was significantly affected by the preoperative conditions (p = 0.001) and follow-up duration (p = 0.006). This simple innovative technique was cost-effective and the results were comparable with those of other techniques.

Efficacy of endonasal dacryocystorhinostomy, using 'cold steel' instruments without stenting, in treatment of distal nasolacrimal duct obstruction.

OBJECTIVE: To assess the efficacy of an endonasal dacryocystorhinostomy technique using conventional instruments, without the use of any adjunctive techniques. STUDY DESIGN: Prospective, non-randomised, cohort study. METHODS: Patients diagnosed with nasolacrimal duct obstruction between January 2006 and December 2008 were included in the study. Seventy-eight endonasal dacryocystorhinostomies (primary or revision) were performed with conventional 'cold steel' instruments. The technique involved complete exposure and marsupialisation of the lacrimal sac. No adjunctive procedures were used. Success was defined as complete resolution of epiphora and a patent lacrimal system, evaluated by lacrimal irrigation and endoscopy, one year post-operatively. RESULTS: Seventy-four of the 78 cases were symptom-free after a minimum follow up of 12 months, giving an overall success rate of 94.9 per cent. The success rates for primary and revision cases were 95.5 and 90.9 per cent, respectively. CONCLUSION: Meticulous surgical technique can ensure high success rates with the use of conventional cold steel instruments, without the use of adjunctive procedures, making endonasal dacryocystorhinostomy a cost-effective, reliable procedure.

The otologic T-tube: a cost effective dacryocystorhinostomy stent.

Endoscopic endonasal dacryocystorhinostomy (EDCR) has established itself as a popular means of relieving post-saccal obstruction of the naso-lacrimal ducts. Soft tissue stenosis of the rhinostomy is a significant cause of long-term failure. We describe the technique of using a standard otological T-tube as a cheap and easy self-retaining stent to ensure a patent rhinostomy following EDCR.