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Introduction

The tears produced at the level of the lacrimal gland flow from the eyes to the nose through the upper and lower lacrimal points, through the lacrimal canal, through the common canal, and through the lacrimal nasal duct⁽¹⁾. Naturally, the nasal mucosa and the conjunctival mucosa are colonized with bacteria. This causes the lacrimal excretory system to be exposed to infection and inflammation. The functional purpose of the lacrimal excretory system is to drain tears from the eyes into the nasal cavity⁽²⁾. The stagnation of tears in the lacrimal sac under the conditions of a stenotic drainage system leads to the appearance of acute and chronic dacryocystitis⁽³⁾.

Chronic dacryocystitis, with frequent episodes of exacerbation, is extremely torturous for the patient, and, after 1-2 years of evolution, it requires a definitive radical solution (Figure 1). Thus, ophthalmologists and ENT surgeons must find solutions for patients with multiple interventional procedures in the nasolacrimal passages⁽⁴⁾.

The therapeutic principles in nasolacrimal canal (NLC) stenosis are instrumental dilation, NLC stenting, endoscopic dacryocystorhinostomy (DCRS), external DCRS, and dacryocystectomy⁽⁵⁾. The approaches are ophthalmic, ENT, and mixed. Before a therapeutic decision, it is essential to investigate using imaging by contrastography, which can objectify the obstruction of drainage through the nasolacrimal canal and the retention of the contrast substance in the tear sac⁽⁶⁾ (Figure 2). Craniocerebral CT/orbit investigation provides additional data on nasal pathology and can be extremely useful before a radical surgical solution such as dacryocystectomy⁽⁷⁾ (Figure 3).

Materials and method

We conducted a retrospective clinical study on 27 patients (29 eyes) hospitalized in the ENT Department of the Bucharest University Emergency Hospital between 2014 and 2018. The inclusion criteria were: chronic dacryocystitis (DC) with NLC stenosis with at least one failed conservative therapeutic procedure. The exclusion criteria were: presacal stenosis of the tear ducts, patients without conservative therapeutic procedures (stent/endoscopic DCRS). The clinical protocol consisted of ophthalmological examination, ENT examination, contrastography, nasal endoscopy, craniocerebral CT, and surgery in a mixed ophthalmologist-ENT team. The post-therapeutic monitoring was performed at 1, 2 and 6 months.
 

Results

Male patients accounted for 67% (18:9) of cases. Most patients were in the age group 41-60 years old (44%). The clinical picture was represented by epiphora (all 29 eyes) and dacryocystocele (18 eyes). Most patients (21) had more than one episode of acute suppurative DC. All patients had at least one instrumental permeabilization procedure of NLC (Figure 4). Craniocerebral CT abnormalities were present in 93% of cases. Nasal endoscopic abnormalities were present in 85.18% of cases (Figure 5). The therapeutic procedures consisted of stents under nasal endoscopic control in 38% of cases, external DCRS in 21% of cases, and dacryocystectomy in 41% of cases. Post-therapeutic monitoring was performed by ophthalmological consultation, ENT consultation and nasal endoscopy, being represented in Figure 4. In the stented cases (11), there were two failures (which were solved one by DCRS, the other by dacryocystectomy). In the cases where external DCRS was performed (6), we did not have any failure, and in cases where we performed dacryocystectomy there was registered failure in one case, in which two reinterventions were necessary. The factors correlated with therapeutic failure were the number of episodes of suppurative acute DC in the antecedents and the number of previous instrumental maneuvers.

Discussion

DCRS has as indications the sacal and postsacal obstruction of NLC, and endoscopic DCRS is the surgical variant to be chosen as the first intention, being a procedure approached by the ENT surgeon. The principle consists in draining the lacrimal sac directly into the nasal cavity by the endonasal route, the nasolacrimal canal being obstructed. The main disadvantage is the stenosis⁽⁸⁾. External DCRS is an alternative to the endoscopic variant, with advantages and disadvantages⁽⁹⁾. It is a procedure approached by the ophthalmologist surgeon or in the ophthalmologist-ENT team. The principle consists in the external creation of a large lacrimal neostoma with wide osteotomy and directed epithelization by creating flaps from lacrimal sac (LS) and nasal mucoperiosteum sutured at the level of the lacrimal fossa⁽¹⁰⁾. The indication consists in the failure of a conservative procedure with a curative visa of endoscopic DCRS type or stenting of nasolacrimal routes. The justification for the external approach could be to avoid the changes produced by a previous intervention at the level of the mucosa of the nasolacrimal pathways^(11,12).

Dacryocystectomy consists in the complete surgical ablation of the lacrimal sac. It was first described by Woodhouse in 1724 and was the surgical standard before the improvement of DCRS in the management of dacryocystitis and lacrimal fistulas. It is the method of choise when we suspect a sacral tumor or lithiasis of the lacrimal sac, and its indications in cases of dacryocystitis are marked epiphora and very dilated/altered lacrimal sac⁽¹³⁾ (Figure 6). As for disadvantages, dacryocystectomy is laborious; there is a risk of residual tear sac with recurrence of the pathology, risk of damage to the medial cantonal tendon, visible scar, permanent epiphora, and it requires general anesthesia⁽¹⁴⁾. In our experience, the disadvantages are not so marked. With a careful surgical technique, the scar is very discreet, and the epiphora is not so marked, especially in the elderly, probably associated with atrophy of the lacrimal gland (Figure 7). The major advantage is that it is a radical procedure, which completely solves the pathology.
 

Conclusions

External DCRS may be a therapeutic option for patients with sacral and postsacal tear stenosis who have a history of curative procedure. This intervention can be adopted in the extension of ENT surgery and performed in a mixed team, ENT surgeon – ophthalmologist. General anesthesia provides comfort to the patient and the surgeon. Dacryocystectomy is the backup surgery for recurrent chronic dacryocystitis. We consider that this intervention has minor consequences on the patient’s quality of life and should be taken into account when compared to iterative conservative interventions, disappointing for the patient, but also for the surgeon. Undoubtedly, in this chronic pathology of the tear ducts, a mixed team (ENT surgeon, ophthalmologist, and the patient) is required in order to obtain the best therapeutic result.  
 

Conflicts of interests: The authors declare no con­flict of interests.