Document Type : Research Paper


1 ORL-H&N Surgery, Basrah Teaching Hospital, Basrah, Iraq

2 Department of Surgery, College of Medicine, University of Basrah, Basrah, IRAQ.


The goals of this study were to evaluate the results of endoscopic endonasal dacryocystorhinostomy (DCR) and to compare the surgical success rates of the different procedures (with or without mucosal flap) in patients with nasolacrimal duct obstruction. This prospective study investigated the results of 39 patients, they were 36 females (92.3%) and 3 males (7.7%). Endoscopic endonasal DCR was performed at the Basrah Teaching Hospital, Department of Otolaryngology in the period between July 2018 to July 2019. The patients were divided into two groups; with or without flap. During surgery, the mucosal flap was preserved in 13 patients (group B) and removed in 26 patients (group A). For all patients, silicone stents were put at the end of surgery. The silicone tube was removed within 6 months after surgery. After six months follow-up, the results were; patent ostium reported in 17 patients (81%) in group A and in 10 patients (90.9%) in group B. There was no statistically significant difference between the groups (P-Value 0.461). The overall incidence of crustation and adhesion is more in group A than in group B but it was also statistically not significant.In conclusion, endoscopic endonasal DCR carries no significant difference of success ratewhether it is with or without mucosal flap.


Introduction cquired nasolacrimal duct obstruction (NLDO) is fairly a common disorder and most authors believe that surgical intervention is the treatment of choice1 . The intranasal approach for endoscopic dacryocystorhinostomy was first described and introduced by Caldwell in 18931 . John West in 1914 modified this technique by creating a bony window within the lacrimal and maxillary bones to clear the area of lacrimal sac and nasolacrimal duct into the middle meatus2,3. Rice first introduced the concept of endoscopic endonasal DCR in cadavers in 1988 and showed its feasibility as a good alternative to an external DCR4 . McDonogh and Meiring in 1989 introduced endoscopic endonasal DCR5 . The basic principle of the surgical treatment is to create a large bypass above the obstruction by connecting the lacrimal sac through a surgically made boney ostium to the nasal cavity has remained the same since it was described over a century ago6,7. Powered and mechanical endoscopic DCR was described by Peter-John Wormald in 20028 . Patients and methods This prospective, comparative study was carried on 39 patients who underwent endoscopic DCR and it was done in the period from July 2018 to July 2019 at Basrah Teaching Hospital in the department of otolaryngology. Patients were randomly divided into two groups: Group A (26 patients); are those in which the mucosal flap was not preserved. AEndoscopic dacryocyctorhinostomy with or without flap Wissam Egab Aziz & Ahmed M Al-Abbasi Bas J Surg,June, 27, 2021 26 Group B (13 patients); the mucosal flap was preserved. All patients were complaining from epiphora due to acquired NLDO for more than one year, they were assessed by the ophthalmologist and after exclusion of the other causes, patients were referred to otolaryngologist who did a thorough history taking and careful rhinological examination by rigid nasoendoscopy. The exclusion criteria were: cases of congenital dacrocystitis, suspected presacal obstruction, coexisting nasal pathologies which could influence the outcome of the surgery, immune compromised patients, and any uncontrolled medical diseases. All patients were informed about the nature of the operation, silicon stent placement and timing of removal which was after six weeks to six months postoperatively. Surgical procedure: All surgeries were done under general anesthesia, in supine position with head elevated 15 degrees and tilted toward the surgeon. Surgery was carried out by using 0 degree endoscope. Lignocaine 2% with adrenaline 1:100000 was injected anterior and above the anterior attachment of middle turbinate. Circular incision was kept anterior to the uncinate process at the anterior maxillary line. The frontonasal process of maxilla, lacrimal crest and lacrimal bone were exposed. The frontonasal process of maxilla was removed by Kerrison punch forceps or drilling to expose the lacrimal sac adequately. The upper and lower punctum of the eye were dilated by Nettleship lacrimal punctum dilator and the Bowman lacrimal probe was passed through the punctum, canaliculi and lacrimal sac. The lacrimal sac then confirmed and its medial wall was incised by sickle knife or blade and partially removed (group A) or marsupialized (group B). In all patients, stenting was done. The follow-up was done at one, three and six months postoperatively. Before the removal of the silicon tube, assessment of lacrimal patency was done by subjective method for improvement of epiphora whether present or absent and objective methods by fluorescein dye disappearance test and by checking of the new ostia in the nose with rigid nasoendoscope. After removal of the silicone stent, syringing of the lacrimal system through the inferior punctum with saline was done to confirm the patency, endoscopically or the patient have taste the salty saline. Statistical package of social sciences version 23 was used to determine the difference between the results of the two groups in one, three and six months postoperatively. A P-value of

1.Woog JJ, Kennedy RH, Custer PL, Kaltreider SA, Meyer DR, Camara JG. Endonasal dacryocystorhinostomy. Ophthalmology. 2001;108(12):2369-77. 2.Watkins LM, Janfaza P, Rubin PA. The evolution of endonasal dacryocystorhinostomy. Survey of ophthalmology. 2003;48(1):73- 84. 3.PA. C. Dacryocystorhinostomy. Trans Am Ophthalmol Soc. 1936;34::240–63. 4.Rice DH. Endoscopic intranasal dacryocystorhinostomy,A cadaver study. American Journal of Rhinology. 1988;2(3):127-8. 5.McDonogh M, Meiring J. Endoscopic transnasal dacryocystorhinostomy. The Journal of Laryngology & Otology. 1989;103(6):585-7. 6.Toti A. Nuovo metado conservatore di radicale delle suppurazioni croniche del sacco lacrimale (dacriocystorhinostomia). Cli Mod Pisa. 1904;10:385-7. 7.Caldwell G. Two new operations for obstruction of the nasal duct, with preservation of the canaliculi. Am J Ophthalmol. 1893;10:189-92. 8.Wormald PJ. Powered endoscopic dacryocystorhinostomy. The Laryngoscope. 2002;112(1):69-72. 9.Leong SC, MacEwen CJ, White PS. A systematic review of outcomes after dacryocystorhinostomy in adults. American journal of rhinology & allergy. 2010;24(1):81-90. 10.Green R, Gohil R, Ross P. Mucosal and lacrimal flaps for endonasal dacryocystorhinostomy: a systematic review. Clinical Otolaryngology. 2017;42(3):514-20. 11.Mann BS, Wormald PJ. Endoscopic assessment of the dacryocystorhinostomy ostium after endoscopic surgery. The Laryngoscope. 2006;116(7):1172-4. 12.Simon GJB, Joseph J, Lee S, Schwarcz RM, McCann JD, Goldberg RA. External versus endoscopic dacryocystorhinostomy for acquired nasolacrimal duct obstruction in a tertiary referral center. Ophthalmology. 2005;112(8):1463-8. 13.Cokkeser Y, Evereklioglu C, Er H. Comparative external versus endoscopic dacryocystorhinostomy: results in 115 patients (130 eyes). Otolaryngology,Head and Neck Surgery. 2000;123(4):488-91. 14.Kennedy DW, Bolger WE, Zinreich SJ. Diseases of the sinuses: diagnosis and management: PMPH-USA; 2001. 15.Yoon SW YY, and Lee SH. . Clinical results of endoscopic DCR using a microdebrider. Korean J Ophthalmol. 2006;20:1-6. 16.Saurabh Kamal MJA, and Akshay Gopinathan Nair. Outcomes of endoscopic dacryocystorhinostomy: Experience of a fellowship trainee at a tertiary care center. Indian J Ophthalmol. 2016 64(9): 648–53. 17.Linberg JV MCS. Primary acquired nasolacrimal duct obstruction. A clinic pathological reports and biopsy technique. Opthalmo. Aug.1986; (8):1055-63. 18.Aniruddha Majumder MS, Chiranjib Das, Saumik Das, and Tapan kanti Hazra. Endonasal Dacryocystorhinostomy with Mucosal Flaps: Our Experience. Indian J Otolaryngol Head Neck Surg. 2013 Aug;65:371–5. 19.Tsirbas A WP. Mechanical endonasal dacryocystorhinostomy with mucosal flaps. Br J Ophthalmol. 2003;87(1):43-7. 20.Navaneethan N. Endoscopic dacryocystorhinostomy without mucosal flap. Bangladesh J Otorhinolaryngol. 2013;19(1): 41-5. 21.Ambani K, Suri N, Parmar H. Study of success rates in endoscopic dacrocystorhinostomy with and without stenting. International Archives of Integrated Medicine. 2015;2(4):52-6. 22.Ji QS ZJ, Tu YH, Wu WC. New mucosal flap modification for endonasal endoscopic dacryocystorhinostomy in Asians. Int J Opthalmol. 2012;5(6):704-7. 23.Grover AK BA. Modern Opthalmology. First Edition ed1994. 24.SW. G. Etiology of dacryocystitis and epiphora. Arch Opthalmol. 1942;27:167–88. 25.Kansu L, Aydin E, Avci S, Kal A, Gedik S. Comparison of surgical outcomes of endonasal dacryocystorhinostomy with or without mucosal flaps. Auris Nasus Larynx. 2009;36(5):555-9. 26.Khalifa MA, Ragab SM, Saafan ME, El-Guindy AS. Endoscopic dacryocystorhinostomy with double posteriorly based nasal and lacrimal flaps: a prospective randomized controlled trial. Otolaryngology--Head and Neck Surgery. 2012;147(4):782-7. 27.Sonu Parmar Bharti Solanki, Ankit Goyal Endonasal dacryocyctorhinostomy. Paripex-Indian Journal Of Research. 2016;5(8):496-8. 28.Evelyn Tai Li Min JMPT, Wan Hazabbah Wan Hitam ,Ramiza Ramza , Baharudin Abdullah , Adil Hussein. Effect of stenting and mucosal flap preservation onoutcome of endoscopic dacryocystorhinostomy. Int Eye Sci. 2014;14:381-5. 29.Telang R, Maheshwary M, Joshi S. A study of endoscopic endonasal dacrocystorhinostomy with mucosal flap technique. J Evid Based Med Healthcare. 2015;2:8050-9. 30.Gurdeep S. Powered endoscopic dacryocystorhinostomy with mucosal flaps without stenting. Med J Malaysia. 2008;63(3):237. 31.Rashmi Goyal SG. Analysis of 104 Cases of Endonasal Dacryocystorhinostomy in a Tertiary Care Hospital: A Prospective Study. Indian J Otolaryngol Head Neck Surg. 2014 66(1):102–5.