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   Table of Contents      
COMMENTARY
Year : 2017  |  Volume : 65  |  Issue : 10  |  Page : 1008-1009

Pediatric dacryocystorhinostomy


Govindram Seksaria Institute of Dacryology, L. V. Prasad Eye Institute, Hyderabad, Telangana, India

Date of Web Publication17-Oct-2017

Correspondence Address:
Mohammad Javed Ali
Govindram Seksaria Institute of Dacryology, L. V. Prasad Eye Institute, Hyderabad - 500 034, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_696_17

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How to cite this article:
Ali MJ. Pediatric dacryocystorhinostomy. Indian J Ophthalmol 2017;65:1008-9

How to cite this URL:
Ali MJ. Pediatric dacryocystorhinostomy. Indian J Ophthalmol [serial online] 2017 [cited 2020 Jul 7];65:1008-9. Available from: http://www.ijo.in/text.asp?2017/65/10/1008/216765

Pediatric dacryocystorhinostomy (DCR) by any route poses unique set of challenges owing to the anatomical factors and healing-related issues.[1],[2],[3],[4] Narrower nasal cavities warrants the use of pediatric instruments, and the presence of a lower skull base and the desired boundaries of a bony osteotomy justifies extra care during surgery. Deviated nasal septum in pediatric patients usually does not pose a major challenge in endonasal DCRs, and septoplasty is preferably avoided to prevent disturbances to growing zones. However, there are exceptional situations such as posttrauma or certain syndromic congenital nasolacrimal duct obstructions (CNLDOs), where a limited septoplasty may be needed, and this entails strict following of certain guidelines by the surgeons.[5],[6] Achieving a good hemostasis in narrower nasal cavities has a bearing on intraoperative comfort and uneventful surgery; however, judicious use of decongestants in consultation with the anesthetist is needed. In addition, an option of a total intravenous anesthesia may be explored as used in adult DCRs and pediatric sinus surgeries.[7],[8] The success rates of pediatric external DCR range from 89% to 97.5%, while that of pediatric endoscopic DCR ranges from 58% to 100%.[1],[2],[3],[4],[5]

Although pediatric DCRs for acquired nasolacrimal duct obstructions are reported to have similar outcomes as compared to patients with persistent CNLDO, this may not be entirely true for syndromic CNLDO.[4],[5],[9] Similarly, although some studies have reported no difference in the outcomes of external DCR between adults and pediatric ages this may not be entirely reflective of the pediatric populations as a whole.[3] However, different pediatric age groups do not appear to be a major prognostic factor for the outcomes as demonstrated in the current study as well as others.

The use of adjunctive measures such as mitomycin C (MMC) and intubation is controversial with strong arguments on both sides of the divide. However, recent meta-analysis and systematic reviews have shown beneficial effects of MMC on ostium patency and outcomes in both primary and revision DCRs, and there is no reason to believe why this cannot be extrapolated to pediatric populations.[10],[11] The intubation dilemma is also unresolved, but recent meta-analysis did not demonstrate an additional advantage with silicone intubation.[12],[13] However, if used, there is mounting evidence to suggest that the duration of 4 weeks should be adequate.[14],[15] There are also no guidelines for an acceptable follow-up in DCR, but the overall literature seems to suggest it at 6 months following surgery.

The role of postoperative systemic antibiotics is also a matter of debate. The current study used it only in cases of acute dacryocystitis, and this may be justified in view of recent evidence from general surgery, intraoperative bacteremia during DCR, and global issue of antibiotic resistance.[16],[17] However, this call should be best left to the surgeon's discretion.

Complications of endoscopic DCR have been reported in up to 8.6% of the patients and include hemorrhage, granulomas, emphysema, sinusitis, and rare complications such as orbital intracranial traumas.[1],[2],[3],[4],[5] Causes of failures are mostly related to aggressive healing responses resulting in cicatricial closures of ostia and granuloma formation.[1],[2],[3],[4],[5] The measures to be taken to achieve successful outcomes in pediatric DCRs include adequately sized and positioned osteotomy, full-length sac marsupialization, and a 360° mucosa to mucosa approximation to facilitate healing by primary intention.[7] Primary intention healing would itself ensure minimal postoperative occurrences of ostial granulomas. Good postoperative endoscopy would help in identifying, classifying, and managing them according to published protocols.[18]

The author would advise the readers to embark on to pediatric DCR under expert guidance, once they have gained confidence and reasonable experience in adult surgeries. The outcomes of pediatric DCR by external or endoscopic approaches are excellent and that of nonendoscopic endonasal approach is encouraging. However, comparison of approaches in pediatric DCRs in light of the current literature would not be very fruitful in view of limited case series with low sample sizes and numerous confounding factors that may influence the outcomes.

Financial support and sponsorship

Dr. Ali receives royalties from Springer for the textbook “Principles and Practice of Lacrimal Surgery” and for the treatise “ Atlas More Details of Lacrimal Drainage Disorders.” Dr. Ali's research is funded by the Alexander Von Humboldt Foundation of the Federal Republic of Germany.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Komínek P, Cervenka S, Matousek P, Pniak T, Zeleník K. Primary pediatric endonasal dacryocystorhinostomy – A review of 58 procedures. Int J Pediatr Otorhinolaryngol 2010;74:661-4.  Back to cited text no. 1
    
2.
Leibovitch I, Selva D, Tsirbas A, Greenrod E, Pater J, Wormald PJ. Paediatric endoscopic endonasal dacryocystorhinostomy in congenital nasolacrimal duct obstruction. Graefes Arch Clin Exp Ophthalmol 2006;244:1250-4.  Back to cited text no. 2
    
3.
Limbu B, Katwal S, Lim NS, Faierman ML, Gushchin AG, Saiju R. Comparing outcomes of pediatric and adult external dacryocystorhinostomy in Nepal: Is age a prognostic factor? Orbit 2017;36:237-242.  Back to cited text no. 3
    
4.
Chan W, Wilcsek G, Ghabrial R, Goldberg RA, Dolman P, Selva D, et al. Pediatric endonasal dacryocystorhinostomy: A multicenter series of 116 cases. Orbit 2017:1-6. [Epub ahead of print].  Back to cited text no. 4
    
5.
Ali MJ, Paulsen F. Syndromic and nonsyndromic systemic associations of congenital lacrimal drainage anomalies: A major review. Ophthal Plast Reconstr Surg 2017; [Epub ahead of print].  Back to cited text no. 5
    
6.
Cingi C, Muluk NB, Ulusoy S, Lopatin A, Sahin E, Passali D, et al. Septoplasty in children. Am J Rhinol Allergy 2016;30:e42-7.  Back to cited text no. 6
    
7.
Ali MJ, Psaltis AJ, Bassiouni A, Wormald PJ. Long-term outcomes in primary powered endoscopic dacryocystorhinostomy. Br J Ophthalmol 2014;98:1678-80.  Back to cited text no. 7
    
8.
Ragab SM, Hassanin MZ. Optimizing the surgical field in pediatric functional endoscopic sinus surgery: A new evidence-based approach. Otolaryngol Head Neck Surg 2010;142:48-54.  Back to cited text no. 8
    
9.
Jones DT, Fajardo NF, Petersen RA, VanderVeen DK. Pediatric endoscopic dacryocystorhinostomy failures: Who and why? Laryngoscope 2007;117:323-7.  Back to cited text no. 9
    
10.
Qian Z, Zhang Y, Fan X. Clinical outcomes of dacryocystorhinostomy with or without intraoperative use of mitomycin C: A systematic review and meta-analysis. J Ocul Pharmacol Ther 2014;30:615-24.  Back to cited text no. 10
    
11.
Cheng SM, Feng YF, Xu L, Li Y, Huang JH. Efficacy of mitomycin C in endoscopic dacryocystorhinostomy: A systematic review and meta-analysis. PLoS One 2013;8:e62737.  Back to cited text no. 11
    
12.
Sarode D, Bari DA, Cain AC. The benefit of silicone stents in primary endoscopic dacryocystorhinostomy: A systematic review and meta-analysis. Clin Otolaryngol 2007;42:307-14.  Back to cited text no. 12
    
13.
Feng YF, Cai JQ, Zhang JY, Han XH. A meta-analysis of primary dacryocystorhinostomy with and without silicone intubation. Can J Ophthalmol 2011;46:521-7.  Back to cited text no. 13
    
14.
Murphy J, Ali MJ, Psaltis AJ. Biofilm quantification on nasolacrimal silastic stents after dacryocystorhinostomy. Ophthal Plast Reconstr Surg 2015;31:396-400.  Back to cited text no. 14
    
15.
Ali MJ, Psaltis AJ, Ali MH, Wormald PJ. Endoscopic assessment of the dacryocystorhinostomy ostium after powered endoscopic surgery: Behaviour beyond 4 weeks. Clin Exp Ophthalmol 2015;43:152-5.  Back to cited text no. 15
    
16.
Pinar-Sueiro S, Fernández-Hermida RV, Gibelalde A, Martínez-Indart L. Study on the effectiveness of antibiotic prophylaxis in external dacryocystorhinostomy: A review of 697 cases. Ophthal Plast Reconstr Surg 2010;26:467-72.  Back to cited text no. 16
    
17.
Ali MJ, Ayyar A, Motukupally SR, Sharma S, Naik MN. Bacteremia during dacryocystorhinostomy: Results of intra-operative blood cultures. J Ophthalmic Inflamm Infect 2014;4:27.  Back to cited text no. 17
    
18.
Ali MJ, Wormald PJ, Psaltis AJ. The dacryocystorhinostomy ostium granulomas: Classification, indications for treatment, management modalities and outcomes. Orbit 2015;34:146-51.  Back to cited text no. 18
    




 

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