Diagnostic Algorithm for Proper Selection of Patients Undergoing Endoscopic Dacryocysto rhino stomy


The Departments of Otorhinolaryngology, Hearing & Speech Institute* and Ophthalmology, 6th October University Hospital**


Abstract Background: Increased lacrimation or tearing is considered a symptom of a large number of pathologies and differential diagnoses. It may be due to increased lacrimal outflow as a result of infection, allergy, and trauma, or may be due to defective drainage function of the lacrimal system resulting in epiphora (1). Defective drainage function may be due to obstruction or stenosis at any level of the drainage system, or may be due to week apposition of the lacrimal puncti on the eye globe like patients with ectropion due to scarring or muscle weakness in which the lid gets outwards eversion, a condition that is called ectropion. This condition can be caused by various etiologies, the most important of which are tractional by scarring or paretic by facial paralysis or senile atrophy (2). So proper identification of the nature of tearing (lacrimation or epiphora) and the level of obstructed drainage is of para-mount importance to target our management or surgical approach and to obtain higher success rates, less failures and minimal recurrences (3). Depending upon the level of the obstruction, specific surgical procedures were used. These may include any of the following procedures, punctual dila-tation, punctoplasty, Canalicular reconstruction, Canaliculo-dacryocystorhinostomy, Close dacryointubation, dacryo-cystorhinostomy (External and Endoscopic), Conjunctivo dacryocystorhinostomy and Dacryocystectomy etc (4). Endo-scopic dacryocystorhinostomy is considered an effective and safe approach addressing obstructive etiology of epiphora other than punctual pathologies (5). So proper preoperative diagnostic work at various levels (history, examination and investigations) is essential for successful management. Aim of Study: 1- The first aim of our study is to construct a diagnostic algorithm and management plan for patients with obstructive lacrimal pathology and epiphora. 2- To evaluate this Algorithm as regards the surgical outcome of endoscopic dacryocystorhinostomy. Patients and Methods: A prospective, study conducted from September 2015 to December 2020 on 20 patients suffering increased lacrimation. Patients have been subjected to special stepwise diagnostic algorithm and classified into three main groups A, B and C according to the pathology and treatment plan. Group A of 11 patients suffering retro-punctual obstruction managed by endoscopic dacryocystorhinostomy while 5 patients in group B suffering punctual etiology (ob-struction and diversion or malposition) and 4 patients in group C suffering increased lacrimation rather than obstruction have been fulfilled the exclusion criteria and referred for proper ophthalmological management. Results: In group A, 11 patients undergone the diagnostic algorithm and fulfilled the inclusion criteria of retro-punctual obstruction of the lacrimal drainage system. Patients in group A have been managed by endoscopic dacryocystorhinostomy except one infant patient. They were doing well throughout the follow up period (4-6 months). In the 10 operated patients and before silicon tube removal, 7 patients reported complete improvement of epiphora, 2 patients reported decreased epiphora and 1 patient has no change of epiphora. After stent removal all operated patients of group A (10) reported complete improvement of epiphora with no recurrence after 6 months. 5 Patients in group B suffering punctual etiology (obstruction and diversion) and 4 patients suffering increased lacrimation rather than obstruction have been referred for ophthalmologist and managed accordingly. They were doing well except two patients in group B suffering punctual stenosis and obstruction who needed repeated dilatations and one patient reported to be indicated for punctoplasty. Conclusion: Application and following the diagnostic Algorithm steps and adhering to it have markedly improved patient selection and the final outcome of endoscopic dacry-ocystorhinostomy and effectively referred non obstructive or punctual patients for proper ophthalmologic management to avoid non indicated endoscopic dacryocystorhinostomy and treatment failure.