Dacryocystorhinostomy ostium: parameters to evaluate and DCR ostium scoring

Mohammad Javed Ali, Alkis James Psaltis, Peter John Wormald, Mohammad Javed Ali, Alkis James Psaltis, Peter John Wormald

Abstract

Aim: This study aims to provide a systematic protocol for the evaluation of a dacryocystorhinostomy (DCR) ostium and to propose a scoring system to standardize the assessment.

Methods: Retrospective evaluation of 125 consecutive lacrimal ostia post-DCR was performed. Medical records were screened, and photographs and videos were assessed to note the details of various ostial parameters. The major time points in evaluation were 4 weeks, 6 weeks, 3 months, and 6 months post-DCR. The ostia were defined and parameters like shape, size, location, and evolution of ostium were noted. Evaluation parameters were defined for internal common opening (ICO), ostium stents, and ostium granulomas. Ostium cicatrix and synechiae were graded based on their significance. Surgical success rates were computed and ostium characteristics in failed cases were studied.

Results: A total of 125 ostia were evaluated on the aforementioned ostium parameters. Because five ostia showed a complete cicatricial closure with no recognizable features, the remaining 120 ostia were studied. The ostium location was anterior to the axilla of middle turbinate in 85.8% (103/120) of the cases. Moreover, 76.6% (92/120) of the ostia were circular to oval in shape, with a shallow base. The ostium size was >8×5 mm in 78.3% (94/120) of the cases. The ICO was found to be located in the central or paracentral basal area in 75.8% (91/120). The anatomical and functional success rates achieved were 96% and 93.6%, respectively. All the five cases with anatomical failures showed a complete cicatrization and the ICO movements were poor in all the three cases of functional failure.

Conclusion: The article attempts to standardize the postoperative evaluation of a DCR ostium and provides a systematic protocol and scoring system for possible use by surgeons and researchers alike.

Keywords: DCR; lacrimal; nasal endoscopy; ostium; score.

Figures

Figure 1
Figure 1
Endoscopic view of an ostium. Notes: Ostium view showing different parts that define it. (A-anterior edge, B-base, I-inferior edge, P-posterior edge, S-superior edge) (A). High magnification showing a closer view of the base and the two edges (B). An ostium behind the axilla of the MT. A small inferior-edge granuloma can also be appreciated (C). A circular ostium with a deep base (D). Abbreviation: MT, middle turbinate.
Figure 2
Figure 2
Evaluation of an DCR ostium. Notes: Endoscopic view of a large ostium with a shallow base (A). A crescentric ostium (B). Measuring an ostium with a scale (C). A small ostium (D). Evolution of an ostium at 1 week (E) and at 4 weeks postoperatively (F).
Figure 3
Figure 3
Evaluating the ostium cicatrization and synechiae. Notes: Endoscopic view of the pseudocicatrix with a dehiscence (A). View of a large ostium with positive FEDT from the edge of the pseudocicatrix (B). Incomplete and irregular cicatrization (C). Complete cicatricial closure of ostium (D). Noninterfering ostioseptal synechiae (E). Interfering ostioseptal synechiae (F). Abbreviation: FEDT, functional endoscopic dye test.
Figure 4
Figure 4
Evaluation of the DCR ostium and its pathologies. Notes: Endoscopic view of the ICO (arrow) situated at the base of the ostium (A). Posterior-edge ICO with a small mucus plug anterior to it (B). ICO covered by overhanging anterosuperior edge. Note the clue provided by the dye (C). ICO with a thin membrane in front of it being elevated by a probe (D). A granuloma threatening the ICO (E). A granuloma abutting the ICO and entrapping the silicone stent (F). Soft tissue infection of the ostial and periostial tissues (G). Diffuse edema of an ostium (H). Gross discharge originating near the ostium (I). Opened-up ethmoids near the ostium (J). Abbreviation: ICO, internal common opening.

References

    1. Tarbet KJ, Custer PL. External dacryocystorhinostomy. Surgical success, patient satisfaction and economic costs. Ophthalmology. 1995;102:1065–1070.
    1. Türkcü FM, Oner V, Taş M, Alakuş F, Işcan Y. Anastomosis of both posterior and anterior flaps or only anterior flaps in external dacryocystorhinostomy. Orbit. 2012;31:383–385.
    1. Cokkeser Y, Evereklioglu C, Er H. Comparative external versus endonasal dacryocystorhinostomy: results in 115 patients. Otolaryngol Head Neck Surg. 2000;123:488–491.
    1. Dolman PJ. Comparison of external dacryocystorhinostomy with non-laser endonasal dacryocystorhinostomy. Ophthalmology. 2003;110:78–84.
    1. Hartikainen J, Grenman R, Puukka P, Seppa H. Prospective randomized comparison of external dacryocystorhinostomy and endonasal laser dacryocystorhinostomy. Ophthalmology. 1998;105:1106–1113.
    1. Tsirbas A, Wormald PJ. Endonasal dacryocystorhinostomy with mucosal flaps. Am J Ophthalmol. 2003;135:76–83.
    1. Davies MJ, Lee S, Lemke S, Ghabrial R. Predictors of anatomical patency following primary endonasal dacryocystorhinostomy: a pilot study. Orbit. 2011;30:49–53.
    1. Codere F, Denton P, Corona J. Endonasal dacryocystorhinostomy: a modified technique with preservation of the nasal and lacrimal mucosa. Ophthal Plast Reconstr Surg. 2010;26:161–164.
    1. Walland MJ, Rose GE. The effect of silicone intubation on failure and infection rates after dacryocystorhinostomy. Ophthalmic Surg. 1994;25:597–600.
    1. McLachlan DL, Shannon GM, Flanagan JC. Results of dacryocystorhinostomy: analysis of the re-operation. Ophthalmic Surg. 1980;11:427–430.
    1. Allen KM, Berlin AJ, Levine HL. Intranasal endoscopic analysis of dacryocystorhinostomy failure. Ophthal Plast Reconstr Surg. 1988;4:143–145.
    1. Welham RA, Wulc AE. Management of unsuccessful lacrimal surgery. Br J Ophthalmol. 1987;71:152–157.
    1. Konuk O, Kurtulmusoglu M, Knatova Z, Unal M. Unsuccessful lacrimal surgery: causative factors and results of surgical management in a tertiary referral center. Ophthalmologica. 2010;224:361–366.
    1. Linberg JV, Anderson RL, Bumsted RM, Barreras R. Study of intranasal ostium at external dacryocystorhinostomy. Arch Ophthalmol. 1982;100:1758–1762.
    1. Ezra EJ, Restori M, Mannor GE, Rose GE. Ultrasonic assessment of rhinostomy size following external dacryocystorhinostomy. Br J Ophthalmol. 1998;82:786–789.
    1. Ben Simon GJ, Brown C, McNab AA. Larger osteotomies results in larger ostia in external dacryocystorhinostomy. Arch Facial Plast Surg. 2012;14:127–131.
    1. Argin A, Görür K, Ozcan C, Arslan E, Ozmen C, Vayisoglu Y. The role of larger osteotomy in long term success in external dacryocystorhinostomy. J Plast Reconstr Aesthet Surg. 2008;61:615–619.
    1. Baldeschi L, Nolst Trenité GJ, Hintschich C, Koornneef L. The intranasal ostium after external dacryocystorhinostomy and the internal opening of lacrimal canaliculi. Orbit. 2000;19:81–86.
    1. Mann BS, Wormald PJ. Endoscopic assessment of the DCR ostium after endoscopic surgery. Laryngoscope. 2006;116:1172–1174.
    1. Chan W, Selva D. Ostium shrinkage after endoscopic dacryocystorhinostomy. Ophthalmology. 2013;120:1693–1696.
    1. Rootman D, DeAngelis D, Tucker N, Wu A, Hurwitz J. Cadaveric anatomical comparison of the lateral nasal wall after external and endonasal DCR. Ophthal Plast Reconstr Surg. 2012;28:149–153.
    1. Yazici B, Yacizi Z. Final nasolacrimal ostium after external dacryocystorhinostomy. Arch Ophthalmol. 2003;121:76–80.
    1. Wormald PJ, Kew J, Van Hasselt CA. The intranasal anatomy of the nasolacrimal sac in endoscopic dacryocystorhinostomy. Otolaryngol Head Neck Surg. 2000;123:307–310.
    1. Rebeiz E, Shapshay S, Bowlds J, Pankratov MM. Anatomical guidelines for dacryocystorhinostomy. Laryngoscope. 1992;102(10):1181–1184.
    1. Kamal S, Ali MJ, Naik MN. Circumostial injection of MMC (COS MMC) in external and endoscopic dacryocystorhinostomy: efficacy, safety profiles and outcomes. Ophthal Plast Reconstr Surg. 2014;30:187–190.
    1. Lee A, Ali MJ, Li EY, Wong AC, Yuen HK. Balloon dacryoplasty in internal ostium stenosis following endoscopic dacryocystorhinostomy. Ophthal Plast Reconstr Surg. 2014;30:7–10.
    1. Ali MJ, Joshi DS, Naik MN, Honavar SG. Clinical profile and management outcomes of acute dacryocystitis: two decades of experience in a tertiary eye care center. Semin Ophthalmol. 2013 2013 Oct 30; Epub.
    1. Tsirbas A, Wormald PJ. Agger nasi cell mucosal autograft for lacrimal sac reconstruction during endonasal dacryocystorhinostomy. Orbit. 2004;23:105–110.
    1. Roithmann R, Burman T, Wormald PJ. Endoscopic dacryocystorhinostomy. Braz J Otorhinolaryngol. 2012;78:113–121.
    1. Tsirbas A, Davis G, Wormald PJ. Mechanical endonasal dacryocystorhinostomy versus external dacryocystorhinostomy. Ophthal Plast Reconstr Surg. 2004;20:5–56.
    1. Tsirbas A, Wormald PJ. Mechanical endonasal dacryocystorhinostomy with flaps. Br J Ophthalmol. 2003;87:43–47.

Source: PubMed

Sponsorer och medarbetare

Medicinska tillstånd

Läkemedelsinterventioner

3
Prenumerera