|Year : 2019 | Volume
| Issue : 2 | Page : 83-86
Feasibility of endoscopic dacryocystorhinostomy in patients with coexistent atrophic rhinitis and chronic dacryocystitis
Satvinder Singh Bakshi
Department of ENT and Head and Neck Surgery, Mahatma Gandhi Medical College and Research Institute, Puducherry, India
|Date of Web Publication||14-May-2019|
Dr. Satvinder Singh Bakshi
House Number B2, Shree Pushpa Complex, 15th Bharathi Street, Ananda Nagar, Puducherry - 605 009
Source of Support: None, Conflict of Interest: None
AIM: Atrophic rhinitis and chronic dacryocystitis are common in India. Sometimes, both of these conditions coexist. Conventionally, these patients are operated by external approach; however, we endeavor to prove the efficacy of the endoscopic approach in these patients.
MATERIALS AND METHODS: Six patients with atrophic rhinitis and chronic dacryocystitis were seen by the authors over a period of 2 years. They were treated preoperatively for atrophic rhinitis for 6–8 weeks, following which they were operated by endoscopic approach.
RESULTS: A total of ten eyes were operated, two of which required revision surgery, which was also operated by the endoscopic approach. The operative time and blood loss were comparable to those of normal patients; however, there was increased crusting and delayed wound healing, requiring prolonged follow-up.
CONCLUSION: Meticulous preoperative preparation and regular postoperative follow-up help improve the results of endoscopic dacryocystorhinostomy in patients with atrophic rhinitis.
Keywords: Atrophic rhinitis, chronic dacryocystitis, endoscopic dacryocystorhinostomy
|How to cite this article:|
Bakshi SS. Feasibility of endoscopic dacryocystorhinostomy in patients with coexistent atrophic rhinitis and chronic dacryocystitis. Int J Health Allied Sci 2019;8:83-6
|How to cite this URL:|
Bakshi SS. Feasibility of endoscopic dacryocystorhinostomy in patients with coexistent atrophic rhinitis and chronic dacryocystitis. Int J Health Allied Sci [serial online] 2019 [cited 2019 Sep 21];8:83-6. Available from: http://www.ijhas.in/text.asp?2019/8/2/83/258177
| Introduction|| |
Nasolacrimal duct obstruction is caused by a variety of acquired and congenital etiologies. The standard treatment is dacryocystorhinostomy (DCR), with the gold standard being the external DCR. However, transnasal endoscopic DCR has gained popularity in recent years, which is primarily due to avoidance of a cutaneous scar, direct access to the rhinostomy site, and the ability to inspect other associated intranasal anatomy at the time of surgery. Other potential advantages are shorter operative time and shorter postoperative recovery. Atrophic rhinitis is characterized by atrophy of the nasal mucosa along with thick nasal crusts. People with chronic dacryocystitis with coexistent atrophic rhinitis have traditionally been operated by external DCR. We came across six patients of chronic dacryocystitis with atrophic rhinitis, who were operated by endoscopic approach in our institute. We endeavor to prove that endoscopic DCR is effective in treating patients with chronic dacryocystitis and atrophic rhinitis.
| Materials and Methods|| |
A retrospective review of charts of a total of six patients with atrophic rhinitis and chronic dacryocystitis with epiphora, seen in our institute from April 2014 to December 2016, was done. Four patients had bilateral disease and therefore, a total of ten endoscopic DCRs were performed.
The diagnosis of atrophic rhinitis was based on history and clinical and nasal endoscopic examination of thick nasal crusts, roomy nasal cavity, and atrophy of the turbinates. Tests for ruling out tuberculosis, leprosy, syphilis, and other secondary causes for atrophic rhinitis were carried out. None of the patients had a history of trauma, nasal surgery, or irradiation to the nose. Tests to rule out syphilis, tuberculosis, rhinoscleroma, and leprosy were negative. X-ray of the paranasal sinuses was done to rule out concomitant sinusitis. The biopsy from the nasal mucosa was confirmatory of atrophic rhinitis [Figure 1]. Nasolacrimal duct obstruction was confirmed by regurgitation test, lacrimal syringing, and probing.
|Figure 1: Histopathology of the nose showing squamous metaplasia with atrophy of the goblet cells and lamina propria containing dense inflammatory infiltrate (H and E, ×100)|
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The patients were treated with alkaline nasal douching, saline nasal drops, and 25% glucose glycerin drops for 6–10 weeks. Only when the mucosa looked healthy and no crusts were seen on endoscopic examination, did the patients undergo the surgical procedure.
All the patients were operated under general anesthesia. All the surgeries were performed by the same surgeon using the 0° endoscope. The nose was prepared using cotton strips soaked in 4% lignocaine and adrenalin (1:10,000) in a ratio of 4:1, 10–15 min prior to surgery. Two percent lignocaine with 1:100,000 adrenalin was submucosally injected into the lateral nasal wall, superior and anterior to the attachment of the middle turbinate, and then along the maxillary line.
A posterior-based mucoperiosteal flap was elevated on the lateral wall of the nose by making three incisions with the help of a scalpel, first starting 8 mm above the axilla of the middle turbinate and extending it in forward direction for 0.5–0.7 cm and then vertically downward for 1.25 cm and thereafter, it proceeded posteriorly. The flap was elevated with an Freer elevator and then reposited on the middle turbinate. This flap helps prevent damage to the middle turbinate. Next, the osteotomy was performed with straight, 2-mm Kerrison punch forceps. The lacrimal bone and some portions of the frontal process of maxilla were removed. The complete medial wall of the lacrimal sac was exposed, with the size of the osteotomy measuring approximately 20 mm × 15 mm.
The medial wall of the sac was infiltrated with a small amount of 2% lignocaine with adrenalin (1:100,000), in order to obtain local anesthesia of the sac wall and to improve hemostasis. The incision on the lacrimal sac was made vertically at the middle and extended horizontally at the superior and inferior margins, thus creating anterior- and posterior-based flaps.
The sac was visualized with a 30° endoscope, and the stomal patency was checked by syringing with saline solution. The lacrimal flaps were used to cover the newly created stoma; the nasal flap was trimmed and also reposited on the posterior end of the ostia. The surgical site was packed with a dressing to ensure hemostasis, which was removed by the 1st postoperative day. The postoperative biopsy was confirmatory [Figure 2].
|Figure 2: Histopathology of the lacrimal sac showing chronic inflammatory cell infiltration in the stroma (H and E, ×400)|
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Postoperative care and follow-up
The dressing was removed after 24 h, and the patients were discharged on oral antibiotics for 3 days and saline nasal drops, which were to be instilled ten to twelve times a day in the nose to prevent crust formation. Patients were followed up weekly for a month. Nasal endoscopy was performed in order to remove the crust and granulation. The patency of the rhinostomy was also checked using lacrimal irrigation at each visit. The surgery was deemed successful if the patients had no epiphora, and the patency of the lacrimal drainage system was confirmed by nasal irrigation. The follow-up ranged from 3 to 9 months.
| Results|| |
Six patients underwent a total of ten endoscopic DCRS. The age ranged from 28 to 45 years, and most of them were females. The patient characteristics are summarized in [Table 1].
|Table 1: Patient characteristics and results of endoscopic dacryocystorhinostomy|
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The operative time ranged from 45 to 90 min, and the healing time ranged from 9 to 12 weeks. The patients also required multiple follow-up visits (an average of four visits a month). The surgery was successful, and there was complete resolution of the epiphora in eight eyes at 3-month follow-up; however, two patients developed failure with recurrence of symptoms. The recurrence was seen in one patient with unilateral disease at 6 weeks and the other one on the left side with bilateral disease at 8 weeks. On endoscopic examination, there was stenosis of the rhinostomy site; the patients were re-operated using endoscopic approach and were asymptomatic at 6 months of follow-up.
| Discussion|| |
The incidence of primary atrophic rhinitis or ozena has decreased markedly over the past years; this is likely to be due to increased antibiotic use in patients with chronic nasal discharge and obstruction. However, it can still be found in developing countries such as India, Turkey, China, and Egypt. Secondary atrophic rhinitis, however, is more common and is caused due to prior trauma or iatrogenically from extensive reductive sinonasal surgery, nutritional deficiencies, Hereditary conditions, autoimmune diseases, and chronic granulomatous diseases.
Dacryocystitis is a chronic inflammation of the lacrimal sac and is derived from the Greek words dákryon (tear), cysta (sac), and itis (inflammation). Conventionally, chronic dacryocystitis has been treated surgically by the external approach. Caldwell reported the first intranasal approach at the start of the last century, and McDonough and Meiring described the first endoscopic endonasal DCR in 1989. Although problems such as false localization of the lacrimal sac, inadequate removal of the medial wall of the sac, and synechae between the lateral wall and the middle turbinate exist in the endoscopic approach, the avoidance of facial scar, shorter hospital stay, reduced morbidity, and reduced intraoperative blood loss make it an attractive and preferred approach for chronic dacryocystitis.
There are various possible mechanisms by which atrophic rhinitis may lead to chronic dacryocystitis. The nasolacrimal duct opening may be blocked by thick nasal crusts, there may be osteitis of the maxillary bone due to atrophic rhinitis leading to narrowing of the bony canal of the nasolacrimal duct, or there may be squamous metaplasia as seen in atrophic rhinitis of the ciliated epithelium of the nasolacrimal duct. This leads to stasis of secretions in the nasolacrimal duct and the lacrimal sac, which may promote chronic infection, leading to inflammation and fibrosis of the lacrimal sac and chronic dacryocystitis.
Due to the decreased healing ability of the nasal mucosa and chronic persistent disease with thick nasal crusting, atrophic rhinitis has traditionally been a relative contraindication for endoscopic DCR. The operative time in our study was as similar to our other cases of endoscopic DCR, and no major difference in the technique was required. The only difference was that the healing time was prolonged in most of the patients ranging from 9 to 12 weeks and the patients required more follow-up visits (an average of four visits a month) and endoscopic clearance than our normal cases (an average of two visits a month). The increase in the number of follow-up visits was due to crusting. At each follow-up, alkaline nasal douching, nasal endoscopy and removal of crusts, and nasolacrimal sac irrigations were performed.
We have shown that, with meticulous preoperative management leading to reduced crusting and inflammation, the success rate of endoscopic DCR in atrophic rhinitis is good and the procedure can be recommended in these patients.
| Conclusion|| |
Endoscopic DCR can be successfully carried out in patients with atrophic rhinitis. The success depends on preoperative reduction of the nasal crusts, meticulous operative technique involving complete sac exposure, adequate bone removal to create a wide osteotomy, and postoperative regular follow-up to remove crusts and synechae.
Informed consent was obtained from all individual participants included in the study.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for 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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[Figure 1], [Figure 2]