Comparative Study Of Probing Done with and without Endoscopic Assistance

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1 Comparative Study Of Probing Done with and without Endoscopic Assistance Ishan Acharya 1, Jitendra Jethani 2, Monika Jethani 3 Department of Ophthalmic Plastic Surgery, Orbit, Ocular Oncology and Ocular Prosthesis Dr. T. V. Patel Eye Institute, Baroda 1 Department of Paediatric Ophthalmology and Squint Surgery, Dr. T. V. Patel Eye Institute, Baroda 2 Eye Q Hospital, Vadodara 3 Abstract Aims: The aims of our study were (1) to compare success of probing done blindly and probing done under endoscopic assistance (2) to correlate the findings of blind probing with endoscopic examination findings. Materials and Methods: Retrospective comparative interventional case study. Total 98 eyes of 84 children were included in the study. The probing was performed under brief inhalational anaesthesia with a laryngeal mask. All probings, secondary and in children older than 24 months, were performed under endoscopic assistance only. Results: Total 111 probings were done out of which, ninety-eight (88.29%) were primary and 13 (11.71%) secondary. Seventy-six (68.4%) probings were done without and thirty-five(31.53%) probings were done with nasal endoscopic assistance. Out of 35, 22 (19.81%) probings were primary and 13 (11.71%) secondary. The mean age for probing was / months.thirty eight (45.23%) were females and 46 (54.77%) were males. Out of 76 primary probings, 13 (17.10%) probings failed. The mean age of failed primary probing was /- 6.7 months. All 22 primary probings done under endoscopic guidance had successful outcome. Out of the total 111 probings, 2 (1.80%) probings failed who underwent endonasal dacryocystorhinostomy in the same sitting. Conclusion: Use of simultaneous nasal endoscopy during probing increases the success rate, minimizes secondary procedures and isof prognostic value for children with Congenital nasolacrimal duct obstruction (CNLDO). Keywords: congenital nasolacrimal duct obstruction, probing, endonasal endoscope Congenital nasaolacrimal duct obstruction (CNLDO) is a common problem in the first year of life, affecting 6% to 20% of infants. 1 It is usually due to a membranous obstruction at the distal nasolacrimal duct. 2,3 In 88% to 96% of these infants, the problem resolves spontaneously before the age of 1 year. 1,4 Hydrostatic massage may increase the frequency of resolution. 5 Probing of the lacrimal system is the standard treatment for those children who remain symptomatic of epiphora. The optimal age for probing is controversial; some advocate an office probing within the first few months of life, 6 while others suggest that there is a significant rate of spontaneous resolution up to age 18 months and older. 7 The success rate for nasolacrimal duct probing is 90% to 97% when performed within the first 13 months of life, decreasing with age. 8 In recent years, the study of congenital nasolacrimal duct obstruction has been a dynamic area, with the number of new surgical treatments and options for patient care growing rapidly. In children, when one probing is not effective, repeat probing 8 or silastic intubation of the nasolacrimal system Quick Response Code Access this article online Website DOI is common practice. 9 The development of the rigid nasal endoscope has allowed a better understanding of rhinologic diseases. 10 In recent years, nasal endoscopy has been used in the diagnosis and treatment of pediatric nasolacrimal system diseases. 11,12 It has also been used in association with intubation of the nasolacrimal system with silicone tubes 13,14 and endoscopic dacryocystorhinostomy. 15 This study was therefore carried out to compare the success of probing done blindly to that performed under endoscopic assistance and to correlate the findings of blind probing with endoscopic examination findings.to the best of our knowledge, no study has been published in the literature comparing blind probing versus endoscopically assisted probing. Materials and Methods The records of paediatric patients who had undergone probing between Jan 2006 to Jan 2010 as a primary or secondary procedure were reviewed, including detailed preoperative and postoperative evaluations, surgical reports, medical management and follow-up visits. Total 98 eyes of 84 children (38 females and 46 males) were included in the study. Patients with bipunctal agenesis and canalicular obstruction were excluded from the study. A total of 111 probings were done. Seventy six probings were done without and 35 probings were done with endonasal endoscopic assistance. The diagnosis of CNLDO was clinical, as evidenced by epiphora, matted lashes, increased tear meniscus height, recurrent mucopurulent discharge and reflux of the contents of the lacrimal sac on pressure. The fluorescein dye disappearance test (FDDT) 20

2 E-ISSN Original Article was used to confirm the diagnosis, if the clinical signs did not corroborate with the history. 8 Indications for probing included failure of conservative treatment (no improvement after conservative treatment for at least 3 months), age more than 10 months on presentation, or recurrent dacryocystitis. All probings were performed by the same ophthalmic plastic surgeon (Dr I.A.) and/or an otolaryngologist (Dr. M.N.). All probings, secondary and in children older than 24 months, were performed under endoscopic (E-class Hopkins II, 300, Karl Storz) guidance only. The probing was performed under brief inhalational anaesthesia with a laryngeal mask. The technique followed was as described by Honavar et al. 16 After dilatation of upper punctum, the initial probing was done with size 00 Bowman probe. Once the nasolacrimal duct was entered, the probe was gently advanced until resistance was encountered. Then firm pressure was applied to the probe, attempting to advance it beyond the obstruction. The type of obstruction was noted when the probe was passed. The obstruction was considered membranous when the obstruction gave way without much resistance and firm when the obstruction produced a gritty or bony sensation. In firm obstruction, probing was repeated with sequentially finer-sized probes until the obstruction could be successfully manoeuvred. Probing was then repeated with sequentially larger sized probes until resistance was encountered again. Probing was considered as a failure if even the finest probe could not be passed. The patency of nasolacrimal system was evaluated by irrigation of fluorescein stained saline through upper punctum. Flow of the saline into the nose was confirmed by a paediatricsize suction catheter when endonasal endoscope was not available. For probing done under endoscopic guidance, a nasal pack soaked in adrenaline (1:100,000) was put in the inferior meatus to shrink the turbinate. Endoscope was introduced in the nose after removing the pack and the inferior turbinate was either elevated or infractured ( in cases of impacted inferior turbinate 17 decided by not being able to view the meatus-apex clearly with the endoscope), with Freer s periosteal elevator depending on the view and space available for manipulation in the inferior meatus. Inferior meatus was examined for a membrane. (Figure 1) All the above mentioned steps were repeated for probing. (Figure 2) If the opening was not sufficient with probe, membranectomy was done with sickle knife. Free passage of fluorescein stained fluid was then observed under direct visualization with endoscope. The probe was relocated in case there was a false passage. Postoperatively, each patient was given antibiotic-steroid eye drops four times a day for 2 weeks after probing. Follow up was done at 1 week, 1 month, 3 months and 6 months after probing. Success of probing was defined by complete remission of symptoms and signs within 3 weeks of the procedure and continued remission at 6 months. Repeat probing was done after 6 weeks and was always under endoscopic guidance. Results The study group comprised of 84 children who underwent nasolacrimal duct probing. The mean age for Figure 1: Membrane bulging with pus seen after elevation of inferior turbinate Figure 2: Probe seen through the membrane probing was / months (8 to 60 months). Fourteen (16.66%) children had bilateral congenital nasolacrimal obstruction. Out of the total 84 children, 38 (45.23%) were females and 46 (54.77%) were males. Presenting age for females was 44.4+/-21.6 months and for males was / months. A total of 111 probings were done. Seventy six (68.47%) probings were done without endonasal endoscope-assistance. Thirty five (31.53%) probings were done with endonasal endoscopic assistance. Out of the total 111 probings, 98 (88.29%) probings were primary and 13 (11.71%) secondary.out of 35 endoscopic assisted probings, 22 (n=111, 19.81%) probings were primary, 13 (n=111, 11.71%) secondary and 12 (n=111, 10.81%) probings were done in children over 24 months of age. (Table 1) Out of 76 primary probings done without endoscopic assistance, 13 (17.10%) probings failed. The mean age of failed primary probing was /- 6.7 months. All 22 primary probings done under endoscopic guidance had successful outcome. 21

3 Out of 13 secondary probings done under endoscopic guidance, 2 (0.26%) probings failed. Finally, out of 111, 2 (1.80%) probings failed. (Table 2) Out of 13 (n=111, 11.71%) failed primary probings without endoscopic assistance, firm obstruction was felt at the distal end of the nasolacrimal duct in 12 (n=76, 15.70%) where even No probe could not be passed. (n=76, 1.31%) lacrimal system(ls) had membranous obstruction which was broken with No. 000 probe and had partially patent LS on table. (Table 3) Table 1: Total probings done (n=111) Probing Primary Secondary Total Blind 76 (68.40%) - 76 (68.40%) Endoscopic 22 (19.81%) 13 (11.71%) 35 (31.55%) Total 98 (88.29%) 13 (11.71%) 111 Table 2: Failed Probings Failed Primary Blind Probings 13 (17.10%) (n=76) Failed Primary Endoscopic Probings 0 Failed Secondary Endoscopic Probings 02 (5.71%) (n=35) Figure 3: False passage around the operculum of middle turbinate Table 3: Findings in blind probings. (n=76) Firm Obstruction at the distal NLD 12 (15.79%) Partially Patent 01 (1.31%) All these LS underwent secondary probing under endonasal endoscopic assistance. Nine LS had impacted inferior nasal turbinate on endonasal examination, two had complete nasolacrimal duct obstruction where no probe could be seen in the inferior meatus even after infracture and two had stenosis of the opening which was corrected by infracturing the inferior turbinate under direct endoscopic observation and enlarging the mucosal opening with sickle knife. Out of 13 secondary probings, 11 (84.61%) lacrimal systems had successful secondary outcome. The remaining two LS with complete nasolacrimal duct obstruction underwent endonasal endoscopic dacryocystorhinostomy in the same sitting. Out of 22 primary endoscopic guided probings, 16 LS had membranous obstruction, 5 LS had firm obstruction, and 1 LS had stenotic opening. Out of 5 firm obstructions, 3 had impacted inferior turbinate, 1 had false passage (Figure 3) and 1 had passage submucosally (Figure 4) beyond the normal site. (Table 4) In the patient having passage of probe submucosally the probe was brought out by cutting the mucosa over the probe. All 22 LS had successful primary probing. Total 12 (12 out of 35, 34.28%) LS had impacted inferior turbinate which underwent infracture of the turbinate with successful outcome. All in all, only 2 (1.8%) LS had failed probing. Figure 4: Passage of probe submucosally Discussion Probing of the nasolacrimal system is a standard therapeutic procedure in the management of congenital nasolacrimal duct obstruction. However, there is no clear consensus as regarding the timing of probing and its outcome in older children. 16 The commonest cause of congenital nasolacrimal duct obstruction at birth is a membranous obstruction at the distal end of nasolacrimal duct. 2,3 It varies between thick membranous obstructions to thin obstruction or just relative Table 4: Findings in Endoscopic Assisted Probings. (n=35) Findings Membranous Firm Impacted Inferior Turbinate Stenosis False Passage Complete Obstruction Primary 16 (45.71%0 5 (14.28%) 3 (8.57%) 1 (2.86%) 2 (5.71%) - Secondary (25.71%) 2 (5.71%) - 2 (5.71%) 22

4 E-ISSN Original Article stenosis of the lower end of the nasolacrimal duct. Conventional probing is a blind procedure with variable success rate. For cases that do not resolve by 1 year of age probing is effective in approximately 90%, with additional 6% cure rate after second probing. 18 Failure of probing can result from several factors, including increasing age (36 months), 16 false passage of the probe, recurrence of obstruction if the opening at the valve of Hasner membrane is too small 19 and tight inferior turbinate. 17 Kushner, 20 Honavar et al, 16 and Kashkouli et al 21 showed that congenital nasolacrimal duct obstruction can be either membranous or complex (firm, nonmembranous or complex). Honavar et al, 16 concluded that the success of probing declines with increasing age; age older than 36 months is a predictor of poorer outcome because firm obstructions were more common in older children. But none of these previous reports were able to clarify the reason for the firm obstruction. The reported success rates of probing are variable and are often presented as a function of the age of the child at probing, with an inverse relationship between age and success of probing being found. 22 However, as the natural history of spontaneous resolution is well recognized, 2,4 it has been suggested that the decreasing success rate with increasing age is actually due to the process of natural selection, with cases of simple membranous obstruction at the distal NLD resolving, while more complex obstructions persist and accumulate in number. 23 There have been a few studies recently on the role of nasal endoscopy in congenital nasolacrimal duct obstruction None of them have compared the conventional probing with the endoscopic assisted probing. We found a cure rate of 82.9% in primary probing without endoscopic guidance, 100% in primary probing with endoscopic guidance and 85.71% in secondary probing with endoscopic guidance. Combined (primary and secondary) final success rate was 98.19%. We attribute this higher success rate to simultaneous nasal endoscopy which allowed accurate guidance of the probe under direct visualization in most cases and therefore a reduction in the number of false passages. It also provided a more accurate diagnosis regarding the level and degree of outflow obstruction. Previous studies have been unable to comment on the site of obstruction, having conducted blind probings. This may explain why the success rates have been so variable between studies. The lower mean age (15.2 +/- 6.7 months) of failed probing is explained by the fact that the all children older than 24 months underwent endoscopic assisted probing only. This again confirms that the success rate of blind probing does tend to reduce with increasing age, and it is the site and not the age which is predictive of probing failure. Firm obstruction felt in blind probing may be because of impacted inferior turbinate or false passage in which probe reaches nasal floor submucosally or also because of complete obstruction of NLD. These can only be confirmed by nasal endoscopy. Gardiner et al 24 compared probing with correction of intranasal abnormalities under direct endoscopic visualization to intubation of the nasolacrimal system in children whose previous nasolacrimal duct probing failed. They were unable to show any benefit of nasal endoscopy over intubation of the nasolacrimal system with silicone tubes in the treatment of failed probing. Endoscopy may have advantages in that it is less invasive, may require less time, and eliminates concerns regarding tube extrusion/ removal. Wallace EJ et al 25 did a prospective interventional study on endoscopic-assisted probing for congenital nasolacrimal duct obstruction. They got an overall cure rate of 89% with the initial attempt at probing and 100% success for atresia and stenosis at lower part of nasolacrimal duct. They attributed higher success rate in comparison to previous studies to the use of nasal endoscopy. MacEwen et al 26 prospectively studied 40 cases in which probing was done under endoscopic assistance. Ten patients had upper upper lacrimal system anomalies and 4 patients had physiological obstruction. Twenty patients had stenosis and 6 patients had atresia of lower NLD. They noted two methods of probe entering the inferior meatus: (1) A false passage was formed with the probe entering the nose at a site which was disparate from the valve of Hasner, (2) the probe was visualised in the submucosal space and continued its passage into the floor of the nose without actually perforating the mucosa and entering the nose. Their overall success rate was 85%, but if we include only cases with lower NLD abnormality, the success rate was 92.30%. They concluded that nasal endoscopy was useful in direct visualization of abnormality of lower NLD and probe location. This minimises the formation of false passages and allows manipulation of probe and inferior turbinate. Sener et al 27 and Kouri et al 28 also concluded that nasal endoscopy is a very useful adjunct to probing in the management of congenital nasolacrimal duct obstruction We have demonstrated that accurate localization of the site of obstruction and intranasal abnormalities could be possible only with the assistance of nasal endoscopy. This has prognostic value for children with CNLDO. Nasal endoscopy can minimize the number of second procedures required by performing definitive surgery at the same time as the probing and by improving the understanding of the reasons for failure and thus preventing replication of a procedure which was doomed to be failure again. Though the incorporation of endoscopy may increase the cost of the procedure, we believe that it is justified because of the improvement in the cure rate and the advantage of providing an overview of NLD opening. The significance of the intranasal abnormalities and their role in causing nasolacrimal symptoms might be better elucidated through a larger study including a group to document endoscopy findings in asymptomatic agematched healthy control subjects. Much larger numbers of patients will be required to decide this and hopefully other surgeons will employ the procedure and report full details of their patients to enable eventual meta-analysis. Presently the use of this procedure has increased our understanding of congenital nasolacrimal duct obstruction and its failures. Therefore use of simultaneous nasal endoscopy during probing increases the success rate, minimizes secondary 23

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