Volume 02 Issue 07-2022
21
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(ISSN
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2771-2265)
VOLUME
02
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07
Pages:
21-27
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5.
694
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(2022:
5.
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ABSTRACT
Purpose of the study
. Modification of the technique of the combined operation of endonasal endoscopic
dacryocystorhinostomy (EEDCR) with simultaneous correction of intranasal structures..
Material and methods
. 13 patients (18 eyes) with chronic dacryocystitis in combination with various pathologies of the
nasal cavity and paranasal sinuses were examined. The age of patients ranged from 31 to 65 years, mean age 48±2.5.
Concomitant pathology of the nasal cavity and paranasal sinuses: deviated septum - 4, hypertrophy of the middle
turbinates - 4, combination of deviated septum with hypertrophy of the middle turbinate - 5.
Results
. All patients with deformity of the nasal septum and hypertrophy of the turbinates were started with their
elimination in the form of septoplasty, conchotomy, or lateroposition of the middle turbinates. Intervention on the
lacrimal ducts was started after preliminary anemization with 0.1% adrenaline under the control of a KarlStors 0 and
30° endoscope. The operation was performed according to the methodology proposed by the authors of the study.
In order to prevent the development of synechia of the nasal septum from the lateral wall on both sides, silicone
splints were introduced into the nasal cavity and fixed with through sutures on the septum for up to 10 days. In the
area of the formed dacryocystorhinostomy, in combination with tubular plasty, a silicone tube was brought into the
nasal cavity, into which loose ointment swabs were additionally inserted for 1-2 days.
Research Article
CLINICAL
RESULTS
OF
ENDOSCOPIC
ENDONASAL
DACRYOCYSTORHINOSTOMY WITH CO-PATHOSIS OF THE NOSE CAVITY
Submission Date:
July 15, 2022,
Accepted Date:
July 25, 2022,
Published Date:
July 30, 2022
Crossref doi:
https://doi.org/10.37547/ijmscr/Volume02Issue07-04
Ulugbek Saidakramovich Khasanov
Tashkent Medical Academy, Uzbekistan
Jakhongir Rakhimov
Tashkent Medical Academy, Uzbekistan
Jamolbek Abdukakharovich Djuraev
Tashkent Medical Academy, Uzbekistan
Journal
Website:
https://theusajournals.
com/index.php/ijmscr
Copyright:
Original
content from this work
may be used under the
terms of the creative
commons
attributes
4.0 licence.
Volume 02 Issue 07-2022
22
International Journal of Medical Sciences And Clinical Research
(ISSN
–
2771-2265)
VOLUME
02
I
SSUE
07
Pages:
21-27
SJIF
I
MPACT
FACTOR
(2021:
5.
694
)
(2022:
5.
893
)
OCLC
–
1121105677
METADATA
IF
–
5.654
Publisher:
Oscar Publishing Services
Servi
In the postoperative period, systemic antibiotic therapy was prescribed for 5-7 days and corticosteroids with daily
toilet of the nasal cavity for 7-10 days. Splints were removed after 10 days, silicone tubes after 3-6 months. In 2 patients,
a granuloma was noted, which caused episodic epiphora.
Conclusion
. Careful preoperative preparation, combined operations that prevent the development of synechia using
modern technologies, and good postoperative care are the main factors in the effectiveness of the treatment of this
pathology.
KEYWORDS
Chronic dacryocystitis, dacryocystorhinotomy, combined operations, synechiae, intranasal structures
INTRODUCTION
The problem of chronic dacryocystitis seems to be
relevant to the present time, which is due to a
significant number of such patients and accounts for
more than 7% of all eye pathology. The most constant
symptom in this disease is persistent lacrimation, less
often - purulent discharge. Excess tears and
lacrimation worsen vision, often reduce working
capacity, limit the choice of profession, which
determines not only the medical, but also the social
significance of dacryocystitis. Lacrimal duct diseases
(SDS) are a polyetiological pathology, where diseases
of the nose and paranasal sinuses, adverse
environmental factors (professional and climatic), the
consequences of infectious diseases, injuries, and
congenital malformations are important [4, 7, 9, 10].
The close relationship between the lacrimal apparatus
of the eye and the ENT organs expands the range of
possible triggers for this pathology. An exceptionally
high incidence of rhinological pathology in patients
with dacryocystitis is known, the rates of which reach,
according to different authors, 80–97% [3].
Moreover, some authors believe that, from an
anatomical point of view, SOS can be considered an
integral part of the nasal cavity and paranasal sinuses
[6]
Until the last decade, the scope of the most frequently
performed corrective operations in the nasal cavity in
the treatment of recurrent dacryocystitis was limited
to submucosal resection of the nasal septum, partial or
complete
conchotomy,
partial
or
complete
ethmoidotomy [1, 7, 9]. The previously used technique
of surgical interventions did not take into account
many aspects of functional rhinosurgery, which was
one of the reasons for the recurrence of dacryocystitis
[1-7, 10-12]. The advent of nasal endoscopes has made
endonasal approaches more accessible. Several
options
for
endonasal
endoscopic
dacryocystorhinostomy (EEDCR) using mucosal flaps,
monotubular or bitubular tubes and the use of
conservative therapy have been described. It is
imperative to find a simple and effective combined
surgery for the treatment of the comorbid disorder.
Volume 02 Issue 07-2022
23
International Journal of Medical Sciences And Clinical Research
(ISSN
–
2771-2265)
VOLUME
02
I
SSUE
07
Pages:
21-27
SJIF
I
MPACT
FACTOR
(2021:
5.
694
)
(2022:
5.
893
)
OCLC
–
1121105677
METADATA
IF
–
5.654
Publisher:
Oscar Publishing Services
Servi
The aim
of this study was to modify the technique of
the combined operation of endonasal endoscopic
dacryocystorhinostomy (EEDCR) with simultaneous
correction of intranasal structures..
MATERIAL AND METHODS
The study was conducted from 20 to 20 in the ENT clinic
of the Research Institute.
The study included 13 patients (18 eyes) with
dacryocystitis and obstruction of the lower tubules in
combination with various pathologies of the nasal
cavity. There were 4 men (30.7%), women - 9 (69.3%)
aged from 31 to 65 years, mean age 48±2.5 years.
Epiphora and mucopurulent discharge are their main
complaints with an average duration of 7 years. Among
thirteen patients with dacryocystitis, 5 were bilateral
and the remaining eight were unilateral. Regarding
inferior tubular obstruction, nine had left inferior
tubule obstruction and three had right inferior tubular
obstruction. Of the concomitant pathology of the nasal
cavity, deviated nasal septum was diagnosed in 4
patients, hypertrophy of the middle turbinates - in 4, a
combination of curvature of the nasal septum with
hypertrophy of the middle turbinate - in 5.
General information on 13 patients, as well as the
location of lacrimal duct obstruction in combination
with nasal pathology, are summarized in Table 1.
№
Age
(years)
Gender
Continue
validity
(years)
Dacryocystitis
Nose pathology
Place
Side
Dev. nasal
septum
hypertrop
hy of tur.
nose
Dev. nose
with
hypertroph
y of mid.
tur.nose
1
41
W
4
Unilateral
Left
side
_
+
2
60
W
2
Bilateral
Left
side
-
+
3
54
M
3
Unilateral
Left
side
+
4
65
M
8
bilateral
Left
side
-
+
5
49
W
1
Unilateral
Right
side
+
6
31
M
5
bilateral
Right
side
+
7
52
W
5
Unilateral
Left
side
+
8
59
W
17
Unilateral
Left
side
+
Volume 02 Issue 07-2022
24
International Journal of Medical Sciences And Clinical Research
(ISSN
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2771-2265)
VOLUME
02
I
SSUE
07
Pages:
21-27
SJIF
I
MPACT
FACTOR
(2021:
5.
694
)
(2022:
5.
893
)
OCLC
–
1121105677
METADATA
IF
–
5.654
Publisher:
Oscar Publishing Services
Servi
9
49
W
2
Unilateral
Right
side
-
+
10
53
W
14
bilateral
Left
side
+
11
39
W
10
Unilateral
Left
side
+
12
37
M
5
Unilateral
Left
side
-
+
13
32
W
4
bilateral
Left
side
+
The analysis of complaints included the following:
mucopurulent discharge, which refluxed from the
point of the upper tubules during washing with saline;
the probe could not pass through the lacrimal bone or
touch it when probing the blocked lower tubule;
swelling of the inner corner of the eye with a painful
symptom, aggravated by palpation, difficulty in nasal
breathing
All patients during their stay in the hospital underwent
general
clinical,
otorhinolaryngological,
ophthalmological and radiological methods of
examination. Depending on the presence of
concomitant pathology, both of the div as a whole
and the state of the intranasal structures, a list of
preoperative preparation, tactics for eliminating the
concomitant pathology of the nasal cavity and
paranasal sinuses was determined in order to restore
the patency of the lacrimal ducts as sparingly as
possible.
For diagnostic purposes, the West fluorescein test
(tubular) and active lacrimal-nasal test were used. The
canalicular test was positive in all patients, the lacrimal-
nasal test was negative. A passive tear-nasal test was
also performed. When washing the lacrimal ducts, the
fluid did not pass into the nose of the
patients and flowed out with the contents of the sac
through the free upper lacrimal opening. In addition, all
subjects underwent CT scan, nasal endoscopy, and
imaging.
All surgical interventions were performed under
general endotracheal anesthesia.
RESULTS AND DISCUSSION
All patients with deformity of the nasal septum and
hypertrophy of the turbinates were started with their
elimination in the form of septoplasty, conchotomy, or
lateroposition of the middle turbinates. So, four out of
13 patients with concomitant pathology of the nasal
cavity underwent surgical treatment with septoplasty,
five patients underwent septoplasty with conchotomy
of the middle turbinates, two patients underwent only
conchotomy with lateroposition of the middle
turbinate, one patient underwent conchotomy of the
middle turbinate and radiofrequency ablation of the
inferior turbinate. .
Volume 02 Issue 07-2022
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International Journal of Medical Sciences And Clinical Research
(ISSN
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VOLUME
02
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07
Pages:
21-27
SJIF
I
MPACT
FACTOR
(2021:
5.
694
)
(2022:
5.
893
)
OCLC
–
1121105677
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IF
–
5.654
Publisher:
Oscar Publishing Services
Servi
Elimination of nasal septal deformity was carried out
depending on the type and degree of curvature using
the methods proposed by V.I. Voyachek:
"mobilization", "circular resection", "redressation",
"partial submucosal resection", which allow almost
completely preserving the supporting function of the
nasal septum and the physiological state of the
intranasal structures. Conchotomy or its combination
with lateroposition or the method of radiofrequency
ablation of the middle turbinates was performed with
pronounced hypertrophy of their anterior ends, when
it was in contact with the nasal septum precisely in the
projection of the lacrimal sac. With a slight hypertrophy
of the middle turbinates, either the lateroposition of
the nasal turbinates or a sparing conchotomy were
performed. In all cases, it was taken into account that
in the postoperative period there is no close contact of
the nasal septum with the lateral wall of the nasal
cavity at the location of the lacrimal sac, which is the
main thing for preventing the development of
postoperative synechia.
Intervention on the lacrimal ducts was started after
preliminary anemization with 0.1% adrenaline under the
control of a Karl Stors 0 and 30° endoscope. a square
mucosal flap above 8-10 mm to the gill cover of the
middle turbinate was dissected with a blade. Below,
the maxilla and anterior process of the maxilla were
thinned with a powerful burr and then removed with
Kerrison forceps to expose the entire medial wall of
the lacrimal sac. The introduction of the probe from
the top point into the protrusion of the medial sac
allows the curved scleral knife to completely open the
sac. After checking patency with saline irrigation
through the superior and inferior canalicular points,
the nasal mucosal flap was trimmed and repositioned
to cover the open maxilla. Then, the tubular
obstruction was repaired as follows: the site of the
tubular obstruction was found with a probe under a
microscope, and a vertical incision of about 5 mm was
made in accordance with the site of the blockage. The
scar tissue over the canalicular duct was carefully
removed with scissors until the probe could slide freely
into the newly opened distal canalicular duct, which
was identified along a vertical line to the probe
inserted from the superior point. The silicone tube was
inserted from the upper and lower points through the
newly opened tubule into the nasal cavity and the knot
was left free in the nasal cavity [8, 9]. 2-3 pairs of 8-0
absorbable sutures were placed proximal to distal
around the tubule lumen and tied together. In order to
prevent the development of synechia of the nasal
septum, silicone splints were introduced from the
lateral wall on both sides of the nasal cavity and fixed
with through sutures on the nasal septum for up to 1-2
months.
In
the
area
of
the
formed
dacryocystorhinostomy, loose ointment swabs were
inserted into the nasal cavity, which were removed
after 1-2 days.
All 13 patients underwent successful surgery in
approximately 2 hours of surgical time. Complications
associated with EE-DCR and tubular plasty included a
small granuloma around the nasal mouth in 2 cases, but
these complications did not lead to lacrimal drainage
system re-obstruction. After more than 6 months of
postoperative follow-up, the mucopurulent discharge
completely disappeared in all patients, and all had a
normal fluorescein dye disappearance test and an
open intranasal orifice. The symptom of epiphora
completely disappeared in 11 patients, and in the
remaining two patients, epiphora was episodic or
intermittent. Based on the results above, there was an
83% (11 out of 13) functional success rate for combined
surgery.
Volume 02 Issue 07-2022
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VOLUME
02
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Pages:
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In the postoperative period, during the first 3
postoperative days, tears were douched with
dexamethasone and tobramycin once a day. The skin
sutures were removed 7 days after the operation. Clots
and crusts in the nasal cavity were cleaned under a
nasal endoscope 2 weeks after surgery. The follow-up
period was set at 10-14 days, 1, 3 and 6 months after the
operation, and then once a year. Splints were removed
after 10 days. The silicone tube was removed
approximately 3–6 months after surgery. Slit lamp,
fluorescent dye disappearance test, lacrimal douching,
lacrimal endoscopy, and nasal endoscopy are the main
observations for each of the follow-up periods.
Success rates were calculated according to the results
of EEDRT and tubular plasty at the end of the follow-up
period.
judeniya. The functional success of the combined
operation was mainly determined by the absence of
epiphora and mucopurulent discharge and a normal
test for the disappearance of the fluorescein dye.
Anatomical success was mainly defined as open
irrigation or probing.
Based on the foregoing, we can conclude that the
issues of complex treatment (combined operations
and conservative therapy) of this pathology are
currently assessed as more effective, but for further
improvement they require close cooperation between
otorhinolaryngologists and ophthalmologists..
CONCLUSION
A
modified
version
of
endoscopic
dacryocystorhinostomy improves the functional
results of surgical treatment.
A comprehensive examination of patients with
dacryocystitis by an ophthalmologist and an ENT
doctor makes it possible to minimize the likelihood of
an error in making a diagnosis and reduce
complications during surgery and in the postoperative
period. Combined operation technique - correction of
intranasal structures and dacryocystorhinostomy -
improves visualization of the surgical field and reduces
the risk of recurrence, reduces the anesthetic burden
on the patient, and minimizes the stress factor for the
patient.
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International Journal of Medical Sciences And Clinical Research
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VOLUME
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Pages:
21-27
SJIF
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OCLC
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Oscar Publishing Services
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