Transnasal endoscopic dacryocystorhinostomy for the treatment of lacrimal pathway stenoses in pediatric patients

doi:10.1016/S0165-5876(03)00188-5

International Journal of Pediatric Otorhinolaryngology

Volume 67, Issue 10, October 2003, Pages 1069-1074

https://doi.org/10.1016/S0165-5876(03)00188-5 Get rights and content

Abstract

Lacrimal pathway stenoses in pediatric patients are uncommon after the age of 1 year. Various conservative treatments (massages, hot compresses, topical antibiotics, probing and intubation of the lacrimal pathways) are generally used to resolve these disorders. When non-invasive procedures fail, dacryocystorhinostomy (DCR) is indicated. While this surgical procedure has traditionally been performed by an external approach, a less-invasive endonasal technique has recently been advocated. We herein review a series of six children affected by lacrimal pathway stenosis who were treated at the Department of Pediatric Otorhinolaryngology, Spedali Civili, Brescia (Italy) between November 2000 and January 2002. All patients underwent successful transnasal endoscopic DCR and, to date, no re-stenoses have occurred. A review of the literature focusing on diagnostic work-up and different therapeutic options is also presented.

Introduction

Epiphora and recurrent dacryocystitis are the characteristic symptoms of lacrimal outflow impairment. At birth, an extremely variable prevalence of this disorder has been reported, ranging from 6 to 84%. However, only 2–4% of lacrimal obstructions are symptomatic [1], [2], [3], [4]. Several treatments have been advocated for the resolution of lacrimal pathway stenoses, ranging from topical antibiotic therapy to dacryocystorhinostomy (DCR) [5], [6], [7], [8], [9], [10], [11], [12]. This surgical procedure is usually performed through an external incision at the level of the medial canthus, although in recent years more conservative approaches using transnasal endoscopic or microscopic techniques have been described [13], [14], [15], [16], [17], [18]. Herein, we report our experience on six children with lacrimal obstruction and evaluate the diagnostic procedures and different therapeutic options for treatment of this disorder.

Section snippets

Patients and methods

Between November 2000 and January 2002, six children affected by congenital lacrimal pathway stenosis were admitted to the Department of Pediatric Otorhinolaryngology, Spedali Civili, Brescia (Italy). The patient cohort consisted of three males and three females, with a mean age of 6 years (range: 2–14 yr). Lacrimal obstruction was unilateral in five children and bilateral in the remaining patient. Since birth, all subjects suffered from recurrent dacryocystitis and epiphora, which in three

Results

Neither anatomic sinonasal abnormalities nor inflammatory changes of nasal mucosa were found by nasal endoscopy. The Jones I and II tests showed the presence of an anatomic stenosis in all children.

Dacryocystography (Fig. 1) revealed an obstruction of the lacrimal sac and of the upper third of the nasolacrimal duct in two and four children, respectively. Dilatation of the proximal lacrimal system was evident in three cases. No anatomic abnormalities or sinonasal alterations were found by CT

Discussion

Embryologically, the lacrimal system originates from an epithelial column, which starts to canalize at the 12th week of gestation beginning at the most superior end and proceeds then inferiorly. This process results in a tubular system that is closed at the distal end by a thin plica called HV [19].

Once produced by the lacrimal gland proper, the accessory glands of Krause and Wolfring, and the Zeis and Meibomian glands, tears flow down medially and penetrate the lacrimal pathway through the

Conclusions

Congenital lacrimal pathway stenoses are a frequent disorder in children. The pathology usually resolves spontaneously and surgical treatment is rarely required. When necessary however, TEDCR can be considered a safe and successful treatment for saccular and post-saccular stenoses in pediatric patients.

The creation of a DCR under direct view, the absence of facial scars, short hospitalization times, a low incidence of complications, the preservation of the pump mechanism of tearing, and

Acknowledgements

The paper has been presented as a poster at the 8th International Congress of Pediatric Otorhinolaryngology, Oxford, UK, September 11–14, 2002.

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Endonasal dacryocystorhinostomy in children: Our experience
2017, International Journal of Surgery
Citation Excerpt :
Silicon tubing is a controversial issue in the literature. Some preferred to use it in all their cases whereas others used it only in situations where a canalicular stenosis was suspected or in revision cases [3,8,17,22–24]. We used lacrimal stenting only in 13 cases which presented to us with chronic symptoms or a formed lacrimal fistula.
Epiphora affects approximately 20% neonates, but most resolve spontaneously. Dacryocystorhinostomy (DCR) is indicated only when conservative management fails.
To observe clinical presentation, treatment modalities and effectiveness of endoscopic DCR in paediatric population.
It is a prospective study of 21 children done at our tertiary care hospital from 2011 to 2016. All were initially subjected to a trial of conservative management. Those that responded and didn't require surgery were excluded.
The age group ranged from 40 days to 11.5 years. 19 underwent unilateral & 2 underwent bilateral endoscopic DCR. After a 6 month follow-up, 20 children were benefitted by surgery, 2 had an incomplete resolution and 1 required revision surgery. The overall success rate was 95.23% and failed cases were mainly due to post-traumatic distortion of the anatomy. No major complications were noted.
Endoscopic DCR is safe and effective in children presenting with persistent epiphora.
The outcomes of endoscopic dacryocystorhinostomy in children: A systematic review
2015, International Journal of Pediatric Otorhinolaryngology
Citation Excerpt :
Silicone tubing is a controversial issue in the literature and appears common both for external and endoscopic DCR. Some authors place it in all their cases when others use it only in situations in which canalicular stenosis is suspected or in case of revision surgery [13–15,43,44]. The purpose of nasolacrimal stanting is to maintain DCR ostium patency but there is evidence that it may rather increase the changes of failure by inciting granulomatous inflammation at nasolacrimal fistula site [45].
To systematically review and discuss the published results about the application of endoscopic dacryocystorhinostomy in treating children with nasolacrimal duct obstruction.
In October 2014 an appropriate string was run on PubMed to retrieve all relevant articles. A cross-check was performed by two of the authors on abstracts and full-text articles found using the selected inclusion and exclusion criteria. A non-comparative meta-analysis concerning the procedures’ rate of success and failure was performed.
Fourteen studies were identified comprising a total of 346 subjects affected by nasolacrimal duct obstruction (unilateral or bilateral). Overall there were 393 surgical procedures, all performed with an exclusive endoscopic approach. The average length of follow-up was reported in twelve studies resulting 15.2 months and ranging from 3 to 27.1 months. On the basis of our statistical analysis the mean (95% CI) rate of failure was 0.14 (0.09–0.21). The mean (95% CI) rate of success resulted 0.87 (0.80–0.91).
Although in young patients the nasal anatomy is more complex and narrow than in adults our review showed as the endoscopic dacryocystorhinostomy allows similar results in terms of success compared to the external approach.
Pediatric endonasal endoscopic dacryocystorhinostomy
2013, International Journal of Pediatric Otorhinolaryngology
Nasolacrimal duct obstruction is a relatively common problem among children. Although spontaneous resolution is possible and various conservative treatment options are available, dacryocystorhinostomy is recommended for persistent epiphora. The aim of this study was to report our experience of performing 83 procedures of pediatric endoscopic dacryocystorhinostomy.
This retrospective study included 71 children who underwent endonasal endoscopic dacryocystorhinostomy between 2000 and 2011. Thirteen of these children had bilateral procedures. The diagnosis of nasolacrimal duct obstruction was based on the presence of eye discharge, the patient's history obtained from his or her parents and the results of testing the patency of the nasolacrimal canal by irrigating the lacrimal sac. The procedure was considered to be successful if the patient's eye discharge was completely resolved and the dacryocystorhinostomy ostium was patent at end of the postoperative first year.
Eighty-three dacrycystorhinostomy procedures were performed in 71 children. There were 35 (49.3%) male and 36 (50.7%) female patients. The age of the patients ranged between 11 months and 14 years, with a mean of 8.9 years. The mean follow-up period was 27.1 months (range of 14–84 months). The overall success rate for primary endoscopic dacryocystorhinostomy was 92.7%. No major complications were encountered in any of the surgical procedures.
Pediatric endonasal endoscopic dacryocystorhinostomy is a safe and effective procedure to correct nasolacrimal system obstruction in cases that are unresponsive to conservative treatments. It has a high success rate and a low incidence of complications.
Primary pediatric endonasal dacryocystorhinostomy-A review of 58 procedures
2010, International Journal of Pediatric Otorhinolaryngology
Citation Excerpt :
A debate continues on the proper timing and procedures for treatment of CNDLO. The DCR is seldom needed in recalcitrant cases of a CNDLO resistant to massages, irrigation, imposibility to probe the nasolacrimalt duct and/or in some traumatic injuries of the lacrimal system and history of relapsing dacryocystitis in children under 1 year of age [1,3–11]. Refractory cases have been historically managed by external dacryocystorhinostomy (EXT-DCR).
The objectives of this study are to report the outcomes of pediatric patients with lacrimal system obstruction who underwent primary endoscopic dacryocystorhinostomy (EDCR).
The authors conducted a retrospective noncomparative case series.
The operative and postoperative data have been collected in 58 children aged between 3 months and 13 years (mean 4.1 years). The total of 58 primary EDCRs has been performed by two surgeons using a standardized surgical technique. The EDCRs were performed 52 times on one eye, 6 times on both eyes (3 times simultaneously, 3 times at the separate sitting with an interval of 4–6 months). The follow-up evaluations include taking history, clinical examinations including a fluorescein disappearance test.
The follow-up interval ranged from 12 to 36 months (mean 17 months, median 15 months). The success rate was 51/58 (87.9%) in all 58 EDCRs. The success rate was 47/51 (92.2%) in the group of postsaccal obstructions, 3/5 (60.0%) in the group of postsaccal and suprasaccal obstrutions and 1/2 (50.0%) in presaccal obstructions. The procedures were successful in all eight children aged under 1 year old (100%) and in 14 of 15 children between 1 and 2 years old (93.3%). The silicone intubation was used in 54 EDCRs.
The endoscopic DCR is a safe and effective procedure for most children with the success rate comparable to that achieved in the external DCR and in adults. The success rate of the postsaccal obstructions is significantly higher than in presaccal or combined pre- and postsaccal obstructions.
Pediatric endonasal endoscopic dacryocystorhinostomy
2009, International Journal of Pediatric Otorhinolaryngology
Dacryocystorhinostomy (DCR) in children is indicated in cases of common congenital nasolacrimal duct obstruction (CNLDO) unresponsive to medical therapy, probing or intubation.
The purpose of this manuscript is to evaluate the effectiveness of endonasal endoscopic pediatric DCR.
The authors present a series of eight children (seven boys and one girl) who underwent a pediatric endonasal DCR between September 2007 and December 2008. The mean age was: 4.3 years (range: 8 months to 9 years old). Three children had a craniofacial abnormality. There were ten primary DCRs and one revision DCR. In nine cases, the indication was a pure primary low mechanical obstruction persistent after one or more probings. In the 10th case there was also a stenosis of the inferior canaliculus diagnosed during the DCR. The revision DCR was indicated because of the closure of the stoma created 3 years ago. A silicone intubation was put in place only in two cases: in case of a stenosis of the inferior canaliculus (3 months) and the other in case of revision DCR (1 month). The follow-up for primary DCRs was 10.5 months (range: 6–15) and for revision surgery 6 months (after the retrieve of the stent).
In primary DCRs, there was a complete resolution of symptoms in nine out of 10 cases. The 10th case experienced a transient slight epiphora during a viral rhinitis. In case of revision DCR, the child was free of symptoms.
In conclusion pediatric DCR is a very effective and safe procedure for the treatment of a low mechanical obstruction of the lacrimal pathway in children unresponsive to previous probings. Stenosis of the inferior canaliculus can give some slight intermittent epiphora despite a wide and patent stoma. Moreover craniofacial abnormalities are more common in children than in adults undergoing a DCR.
Endoscopic management of pediatric nasolacrimal anomalies
2008, Operative Techniques in Otolaryngology - Head and Neck Surgery
Developmental anomalies of the nasolacrimal drainage system typically manifest early in childhood. Although the majority of cases of congenital nasolacrimal obstruction resolve spontaneously with conservative management, certain anomalies like dacryocystoceles require operative intervention. In children with persistent nasolacrimal obstruction, endoscopic dacryocystorhinostomy (DCR) provides an equally efficacious alternative to external DCR that concurrently allows for the potential correction of any predisposing intranasal pathology. Endoscopic DCR is best performed as a joint otolaryngologic–ophthalmologic procedure.

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View full text

Transnasal endoscopic dacryocystorhinostomy for the treatment of lacrimal pathway stenoses in pediatric patients

Abstract

Introduction

Section snippets

Patients and methods

Results

Discussion

Conclusions

Acknowledgements

Ophthalmology

J. AAPOS

Am. J. Ophthalmol.

Auris Nasus Larynx

Dacryocystitis in infancy

Am. J. Opthalmol.

Congenital impatency of the nasolacrimal duct

Arch. Ophthalmol.

Bilateral congenital lacrimal sac mucoceles with nasal extension and drainage

Arch. Ophthalmol.

Congenital nasolacrimal duct mucocele

Orbit

Paediatric dacryocystorhinostomy

Aust. NZ J. Ophthalmol.

Intubation of the lacrimal pathways under endoscopic control

Ophthalmologica

The technique of endoscopy in the evaluation of nasolacrimal duct obstruction in children

Rhinology

Dacryostenosis in newborns: probing, or syringing, or both?

Eur. J. Ophthalmol.

Probing and bicanalicular silicone tube intubation under nasal endoscopy in congenital nasolacrimal duct obstruction

Ophthal. Plast. Reconstr. Surg.

Reappraisal of probing of the congenital obstruction of the nasolacrimal system: is nasal endoscopy essential?

Int. J. Pediatr. Otorhinolaryngol.

Dacryocystorhinostomy. Diagnosis and treatment of nasolacrimal canal obstructions

Rhinology

Die endonasale mikrochirurgische Behandlung von Tränenwegsstenosen. Indikation, Technik und Ergebnisse

HNO

Endoscopic dacryocystorhinostomy: indications, technique and results

Rhinology

Endonasal endoscopic dacryocystorhinostomy in children

Arch. Otolaryngol. Head Neck Surg.

A multidisciplinary approach to atypical lacrimal obstruction in childhood

Ophthal. Plast. Reconstr. Surg.

Endonasal endoscopic dacryocystorhinostomy for dacryocystocoele in a 4 month old infant

Br. J. Ophthalmol.

Diseases of the lacrimal drainage apparatus