Mounting insights on its optimal pediatric use
By Brandon Hopkins, MD, and Prashant Malhotra, MD
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Epiphora, or watering of the eyes, is a very common pediatric condition, affecting 6 to 20 percent of newborn infants. While up to 96 percent of cases resolve with conservative measures (such as antibiotics and massage) within the first year of life, persistent nasolacrimal duct obstruction or recurrent dacryocystitis (inflammation of the lacrimal sac) may require further treatment. This may include probing, irrigation, balloon dacryoplasty, and stenting of the nasolacrimal duct system. When epiphora does not resolve despite these measures, surgical intervention with dacryocystorhinostomy (DCR) may be indicated.
DCR is a surgical procedure that involves removing a portion of the lacrimal bone and sac to create a connection from the proximal nasolacrimal duct system into the nasal cavity. Traditional DCR, which employs an external approach involving an incision in the skin, achieves successful outcomes in 85 to 95 percent of patients.
In recent years, DCR in adults has evolved to take advantage of an endonasal approach using endoscopic sinus surgical techniques. This approach does not require an external incision and avoids medial canthal dissection, preserving the pump function of the orbicularis oculi. A recent meta-analysis found results for endoscopic DCR in adults to be comparable to those with open techniques while avoiding the risk of facial scarring.
This success with endoscopic DCR in adults has carried over to the pediatric population, as demonstrated in several case series with success rates of over 92 percent. The Pediatric Otolaryngology Section in Cleveland Clinic’s Head & Neck Institute is currently exploring and advancing this technique in children in collaboration with our ophthalmologic/oculoplastic surgery colleagues to provide optimal multidisciplinary care to the youngest patients with persistent epiphora.
Indications in children are evolving. Endoscopic DCR is reserved for failure of more conservative strategies, and we make our decision in conjunction with our oculoplastic surgery colleagues. It is essential to rule out dacryocystocele, very proximal lacrimal system obstruction or other pathologies that may require a different surgical procedure.
Endoscopic DCR has reportedly been successful in children as young as 3 months. A history of prior canaliculitis may raise the risk of an unfavorable outcome. Our experience so far suggests that children with Down syndrome, other genetic syndromes or craniofacial abnormalities may be more prone to revision or failure. This is consistent with the published literature.
Surgery is usually performed on an outpatient basis with general anesthesia. We use a standard endoscopic DCR technique with an endonasal approach using 2.7- or 4-mm rigid telescopes (0 and 30 degrees) and video display. In young children, smaller spaces and relatively larger inferior turbinates may limit the size of the telescope and other instruments, which can result in a more technically challenging procedure.
An incision is made in the lateral nasal wall mucosa, anterior to the insertion of the middle turbinate. The mucosa is elevated, and part of the frontal process of the maxilla and lacrimal bone is removed with endoscopic drills and instruments to allow visualization of the sac. The sac is incised and subsequent intubation of the nasolacrimal system is performed (Figure).
Figure. Endoscopic view (via 4-mm rigid endoscope) after osteotomy and lacrimal sac incision (right) in a 22-month-old patient undergoing endoscopic DCR. The middle turbinate is on the right.
Variations in technique as described in the literature include the use of lasers, a light wand and adjunctive mitomycin C. Adjunctive procedures such as septoplasty or procedures on the middle turbinate may be performed, but they are commonly avoided in the pediatric population. Use of stents and the duration of stenting are also variable.
Although complications associated with DCR in children are uncommon, they may include intra- and postoperative bleeding, punctual erosions from tubes (silicone), orbital fat exposure or orbital injury, conjunctival fistula formation, and intranasal adhesions.
Failure of endoscopic DCR can be attributed to various factors, many of which involve abnormalities in the sinonasal anatomy. These include a small, crowded nasal cavity; septal deviation; middle turbinate disease; and inadequate size or location of osteotomy.
Endoscopic DCR in children is an evolving technique, but a growing body of literature suggests promising outcomes in the treatment of nasolacrimal duct obstruction. Its potential advantages include the following:
While use of endoscopic DCR in the pediatric population is currently limited, it is a viable option in selected patients when conservative measures have failed and when a joint ophthalmologic and otolaryngologic approach can be taken. We look forward to expanding this technique in our practice and to helping to shape our collective understanding of its optimal role.
Dr. Hopkins is a pediatric otolaryngologist in the Section of Pediatric Otolaryngology.
Dr. Malhotra is a pediatric otolaryngologist who was on the staff of Cleveland Clinic Children’s when this article was written.
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