Introduction
Chronic dacryocystitis is due to inflammation of lacrimal sac and most common cause is obstruction at the junction of sac and nasolacrimal duct or within bony naso lacrimal duct. Repeated infections, dacryoliths, trauma or neoplasm could be the other reasons. Clinically it presents in chronic catarrhal or suppurative variety. Sometimes it presents with mucocoel or fibrotic sac. So bypassing nasolacrimal duct and restoring communication between lacrimal sac and nasal cavity is achieved either by external DCR or endonasal route.
External dacryocystorhinostomy (DCR), proposed by Ohm and by Dupuy-Dutemps and Bourguet in 19212, 1 is still the most preffered technique though requires skill and difficult to do. Other alternatives are nasolacrimal duct intubation and transcanalicular laser DCR.4, 3 Caldwell first introduced the endonasal approach for lacrimal surgery in 1893 and with advent of endoscopy instruments, comparatively it has become easier and then there is no external scar and neurovascular disruption. Inspite of all these advantages external DCR is still preferred due to higher success rate though there is always apprehension about this surgery because of bleeding, unfamiliarity in structure and difficulty in suturing the flaps. The reported success rates of both procedures range from 63% to 97%.5 Originally suturing of both anterior and posterior flaps was recommonded and many surgeons still prefer double flap suturing though it is difficult due to space constraint and flap size is also smaller. Later on various modifications were made and suturing of anterior flaps was found to be equally effective. It is easier and less time consuming due to bigger flaps. Then to avoid overhanging of flaps sutures are passed through orbicularis so it doesn't fall back.
Materials and Methods
We included 46 cases of chronic dacryocystitis who were undergoing DCR surgery in our institute RKDF Medical College H & RC from August 2018 to March 2019.
We divided them in 2 groups we included patients from 20 to 60 years. Mean age was 53.56 ± 7.19 years. Mean age in group A was 52.39± 8.12 years and in Group B is 54.73 ± 6.07 years.
Group A includes patients with Anterior flap anastamosis
Group B includes cases with double flap anastamosis
Inclusion criteria
Cases of Chronic Dacryocystitis, catarrhal or suppurative infections with epiphora and positive regurgitation and cases of mucocoel.
Exclusion criteria
We excluded patients above 60 years, patients with fibrotic sac, canalicular block & atrophic rhinitis.
Preoperative evaluation
Positive regurgitation test and patients with mucocoel are suitable patients for DCR. We didn’t include patients with canalicular block. Heamatological investigations including blood sugar, bleeding and clotting time, tests to rule out HIV and hepatitis are carried out. ENT check up done to rule out nasal abnormalities. Blood thinners and anticoagulants are with held one day before surgery. Haemostats and decongestant nasal drops are also given prior to surgery. Ethamsylate is a hemostatic drug which promotes platelet adhesion and also inhibits platelet disaggregation. Patient is prepared and kept nil orally so if required weak sedation can be given.
Surgical procedure
Topical 4% lignocaine instilled and nasal packing is done with the help of gauze soaked in 2% lignocaine adrenaline jelly in the ipsilateral nostril. It keeps the mucosa taught and checks the bleeding. Local block with sedation is preferred. Lignocaine 2% with 1:100000 adrenaline is infiltrated at medial palpebral ligament and then injected superiorly and inferiorly. Skin level deep curvilinear incision about 2cm is given 3-4 mm away from medial canthus, 2-3 mm above MPL and extending below. Superficial and deep head of MPL is incised and sac is separated with blunt dissector from lacrimal bone. Lamina Papyracea is a thin bone, it is broken with blunt dissector and with bone punch approximately thumb nail sized osteotomy is made involving lacrimal fossa and lacrimal crest and superomedial wall of naso lacrimal canal. Then nasal mucosa is exposed and with 11 no blade knife flaps are made and similarly flaps are made in medial wall of sac. In Group A, we made large anterior flaps and sutured them with 6-0 vikryl suture and posterior edge was trimmed. In Group B we made anterior and posterior flaps of both nasal mucosa and lacrimal sac making anterior flaps a bit larger and then sutured anterior to anterior flap and posterior to posterior flap and compared the results. Lacrimal probe passed through common canaliculus acts as a guide while suturing. While passing sutures through mucosa threads of gauze should be kept separate. When we make anterior flaps only, flaps are larger and may fall so sutures from anterior flaps are passed through orbicularis so that it is lifted anteriorly and chances of fibrosis are minimised. MPL and orbicularis closure is done and then skin is closed with 5-0 silk suture. Chloremphenicol eye ointment is applied. Small patch is applied and closed. Nasal pack is removed after 24 hours.
Follow up was done on the 7th day, at 21 days, 4th month and 8th month. Syringing was done and repeated syringing or probing was required only in case of blocked syringing usually due to clots. Success rate of procedure was assessed by patent syringing and absence of discharge or epiphora at last follow.
Results
In both the groups steps were similar till separation of sac from lacrimal fossa. Mean age of the patient was 53.56 ± 7.19. Mean age in group A was 52.39 ± 8.12 and mean age in group B was 54. 73 ± 6.07. In Group A we made large anterior flaps and included 23 cases and in Group B we included 23 cases and we did two flaps anastamosis. Total mean surgical time was 55.09 ± 3.96 minutes. In Group A it was 51.43 ± 0.99 minutes and in group B it was 58.74 ± 1.78. In Group A mean surgical time was less in comparison to group B and it was statistically highly significant.(chi sqare value 46, p value < 0.001). Difficulty in suturing was seen in 20 cases in group B while in 3 cases we didn’t find it difficult as there was a large mucocoel. In Group A, out of 23 cases, we find difficulty in suturing in only 2 cases and it was due to thin nasal mucosa. Bleeding while making osteotomy was seen in 4 cases in group A and 5 cases in Group B and has no correlation with making one flap or two flaps. Partial block was seen on doing syringing in 3 cases in Group A and 2 cases in Group B at 1st follow up but improved with repeated syringing. Wound gaping was seen in 2 cases in each group. At 8th month follow up, recurrence was seen in 2 cases in group A and in 1 case in group B. So success rate was 91.30% in group A and 95.65% in group B.
Table 2
Showing comparative analysis of anterior flap anastamosis and two flap suturing
Discussion
Endonasal DCR or laser DCR has been preferred over external DCR due to factors like scarring, greater tissue damage and haemorrhages.7, 6 Scarring can be avoided if incision is given along relaxed skin tension lines.8 Though tissue damage is comparatively less with endonasal approach but sometimes septoplasty9 may be required and risk of bleeding can't be denied absolutely. Risk of bleeding is comparable with laser DCR.11, 10 As per literature success rate for endonasal DCR is reported as 75% while success rate for external DCR varies from 90-100%.12
External DCR is a difficult procedure and mainly it is due to dissection of sac, avoiding bleeders and then making and suturing flaps. It requires time as well as surgical experience and success rate varies as per the experience of surgeon. Best patients for external DCR are thin frail patients with large mucocoel and no nasal abnormality. Various modifications have been proposed so far.18, 17, 16, 15, 14, 13 Making of large anterior flaps, their suturing and elevating the flaps by passing the sutures through orbicularis instead of double flap anastamosis are some of the modifications, which is quite easy in comparison to double flap suturing. Balsechi et.al reported success rate of 100%. 19 So success rate of 90-100% has been reported in different studies with anterior flap anastamosis.22, 21, 20 Time required is also less in single flap suturing. In our study we found success rate 91.30% in Group A and 95.65% in group B. Recurrence was noticed in only 2 cases in group A and 1 case in Group B.
Conclusion
Large anterior flap anastamosis and excising posterior flaps makes external DCR comparatively an easy procedure. It saves time also. No significant difference in terms of recurrence is seen in comparison to two flap anastamosis.
