The authors have no funding, financial relationships, or conflicts of interest to disclose.
Triological Society Best Practice
Is postoperative stenting necessary in endoscopic dacryocystorhinostomy?
Version of Record online: 25 APR 2013
Copyright © 2013 The American Laryngological, Rhinological and Otological Society, Inc.
Volume 123, Issue 11, pages 2589–2590, November 2013
How to Cite
Liang, J. and Lane, A. (2013), Is postoperative stenting necessary in endoscopic dacryocystorhinostomy?. The Laryngoscope, 123: 2589–2590. doi: 10.1002/lary.24111
- Issue online: 28 OCT 2013
- Version of Record online: 25 APR 2013
- Manuscript Accepted: 25 FEB 2013
Dacryocystorhinotomy (DCR) is a common procedure used to treat nasolacrimal duct obstruction. The modern external DCR, in which the lacrimal sac is opened directly into the nasal cavity, was first described in 1904 by Toti. Since that time, DCR techniques have evolved, including a transnasal endoscopic approach that has gained popularity in parallel with the growth of endoscopic sinus surgery. Endoscopic DCR has challenged the external approach as the gold standard for addressing mechanical nasolacrimal duct obstruction. With either method, a transcanalicular stent is typically placed at the time of surgery to maintain patency of the DCR ostium. The importance of postoperative stenting is an ongoing topic of controversy among both otolaryngologists and ophthalmologists. This article reviews the evidence regarding the impact of stenting on endoscopic DCR outcomes.
Transcanalicular stenting was first described in the 1950s for external DCR and in the 1960s for endoscopic DCR. Thereafter, stents rapidly became favored by ophthalmologists. Outcome studies in the 1980s that reported high success rates with external DCR stenting largely account for its routine practice today. Early reports suggested a benefit of stenting primarily in the setting of excessive bleeding, previous DCR failure, or concurrent canalicular disease. Silicone tubing was preferred for its nonantigenic properties and its ease of stenting the common canaliculus and rhinostomy. Early critics, who were in the minority, challenged the routine placement of stents, even suggesting an association with failure. This idea has gained momentum recently, with support from prospective studies and refinements in endoscopic postoperative outcome assessment.
There is strong evidence that both external and endoscopic DCR achieve high success rates of >90%. The advantages to the endoscopic approach are numerous, including better visualization, avoidance of external scars, ability to correct associated nasal pathology, decreased operating time and costs, and preservation of the natural pumping mechanism. Despite the fact that endoscopic DCR allows the rhinostomy to be performed in a controlled and minimally traumatic fashion, bicanalicular intubation remains commonly performed to stent the newly created ostium. Soft silastic tubing (Guibor lacrimal tubing) is looped through the superior and inferior canaliculi and secured intranasally. In the literature, stents have been maintained in the postoperative period from 4 weeks to 6 months in duration. Arguments against the routine use of stents include granulation tissue formation, infection, canalicular injury, dislodgement, and patient discomfort. In addition, stents often entail more involved postoperative care and maintenance. Finally, increased operative time and surgical costs have been cited as additional disadvantages of stenting with endoscopic DCR.
There have been three recent randomized control trial (RCT) studies evaluating outcomes of endoscopic DCR with and without stenting. Outcomes were commonly measured by patient symptoms, dye testing, and DCR ostium patency on endoscopy. The first RCT was performed by Smirnov et al. and included 46 cases (44 patients) followed over a 6-month period and outcomes were evaluated by symptoms and in-office dye testing to assess patency. This was followed by a RCT by Unlu et al., which included 38 cases (38 patients) followed over a 100-month period and evaluated by endoscopy and dye testing. The largest of these RCTs was a recent study by Al-Qahtani that included 173 cases (173 patients) followed over a 12-month period and evaluated by symptoms and endoscopy. All of these RCTs found no significant difference between stented and nonstented patients who underwent endoscopic DCR. Interestingly, Unlu et al. did note an increased incidence of granulation at the rhinostomy site in the intubation group, but this was not statistically significant. Also of note, all of the failures in the Smirnov et al. study were in the stented group. A summary of these RCTs is listed in Table 1.
|Al-Qahtani, 2012||173||Symptoms, endoscopy||12 months||Not specified in study||Stented group 97% success; nonstented group 90% success; no significant difference|
|Unlu et al., 2009||38||Endoscopy, dye test||100 months||8 weeks||Stented group 90% success; nonstented group 95% success; no significant difference|
|Smirnov et al., 2008||46||Symptoms, dye test||6 months||8 weeks||Stented group 78% success; nonstented group 100% success; No significant difference|
The lack of a clear benefit provided by stenting is further suggested by two recent meta-analyses. Feng et al. analyzed five RCTs and four cohort studies and demonstrated no advantage to the use of silicone stents in primary DCR (either external or endonasal). Gu and Cao analyzed two RCTs and concluded that there was no difference in the success rates in endoscopic DCR, with a relative risk of 0.85 and a 95% confidence interval of 0.71 to 1.02.
A related unresolved issue is the duration of stent placement, which is highly variable among surgeons. There have been no investigations comparing DCR outcomes as a function of the length of time stents remain in place after endoscopic DCR. Furthermore, the placement of stents in specific clinical settings is not well established. Early reports suggested a benefit of stents in cases of revision surgery and concurrent canalicular disease, but this has not been revisited in recent literature. There have been no published analyses of the role of stents in endoscopic DCR in patients with concurrent rhinosinusitis. The technique of endoscopic DCR and postoperative management in specific clinical scenarios will continue to evolve, and strong level 1 evidence studies will help illustrate optimal treatment strategies.
Endoscopic dacryocystorhinostomy is a safe and effective surgery for treatment of epiphora due to nasolacrimal duct obstruction. Based on the external DCR literature and the established practice of ophthalmologic surgeons, silicone stents have been favored with endoscopic DCR and remain widely utilized today. However, review of the current literature demonstrates comparable outcomes in endoscopic DCR whether stents are used or not. Endoscopic DCR without stenting reduces the intensity of postoperative management and avoids the potential for stent-related complications.
LEVEL OF EVIDENCE
The level of evidence for review in the endoscopic dacryocystorhinostomy literature is strong, with multiple level 1 evidence studies (RCTs).
- 1Nuovo metodo conservatore di cura radicale delle suporazioni croniche del sacco lacrimale (dacriocistorinostomia). Clin Mod Firenze 1904;10:385–389..
- 6Silicone intubation and endoscopic dacryocystorhinostomy: a meta-analysis. J Otolaryngol Head Neck Surg 2010;39:710–713., .