While the availability of nasal endoscopy is essential in pediatric lacrimal surgery the question remains: is it necessary for all pediatric lacrimal procedures? Certainly, in cases of a suspected intranasal cyst in a newborn with a dacryocystocele or in an endonasal dacryocystorhinostomy the nasal endoscope is indispensable. When a lacrimal surgeon approaches the treatment for an uncomplicated congenital nasolacrimal duct obstruction (CNLDO), however, the nasal endoscope may be more of a bystander than a diagnostic tool. In other words, it provides no additional clinical information. Furthermore, it is an instrument with which a benefit may not outweigh the cost or risk to the patient.
With the vast armamentarium of treatments for CNLDO from probing alone to stenting or balloon catheterization many previous authors have reported a success rate close to or around 90%.Citation1,Citation2 This means 9 out of 10 patients do not need an endonasal endoscopic exam for diagnosis or treatment as it won’t improve the outcome. Thus, the concept of exposing most lacrimal patients with CNLDO to an otherwise unnecessary procedure presents an ethical dilemma for the lacrimal surgeon.
The choice of using an endoscope during surgery has a financial, technical and peri-operative impact on a patient. The cost of endonasal equipment including scopes, cameras, monitors and sterilization is not to be minimalized. In addition, there is a steep learning curve as an endonasal surgeon requiring specialized training that most ophthalmologists and oculoplastic surgeons have not been exposed to. This is coupled with the fact that pediatric patients have a smaller anatomy raises the concerns for iatrogenic injury. As a lacrimal surgeon that has had to once manage my own induced cerebral spinal fluid leak on a patient from a microfracture to the skull base I cannot minimize the fact that the endoscope needs to be used with care. As does the use of any nasal speculums, which too can induce a CSF leak.Citation3 In addition, the need to pack the nose for hemostasis, the increase in surgical time for set up and for surgery and the increase in cost to the patient should be recognized. A probing and irrigation with stent usually can be performed in under 10 minutes for a bilateral case, and often can successfully be accomplished with a laryngeal mask airway by the anesthesiologist. With the new pushed stents available some authors even use a mask airway alone without intravenous access or an artificial airway.Citation4 Any procedure using an endoscope will prolong surgical time with equipment set up, nasal packing with the proper delay for adequate nasal hemostasis and require a more complex anesthetic airway for the endoscopy procedure. With all of these factors the surgeon must ask, do the risks and benefits for nasal endoscopy outweigh these added costs, surgical risks and increase in surgical time? In addition, when one considers the surgery performed with fast turnovers in a surgical center, is the use of an endoscope on every lacrimal patient practical?
Rather than approach all pediatric lacrimal obstructions as the same, it may be better to consider the need for an endoscope on a case-by-case basis. An endonasal exam is critical for any complex NLDO. This would include previously failed cases, trauma, craniofacial deformities and tumors. My surgical approach is to start every case with a probing and irrigation under anesthesia to confirm system patency and locate any obstruction and possibly the mechanism of obstruction. If probing alone raises a concern for the nasal anatomy a surgeon may want to open an endoscope set (scope and camera) to diagnose the mechanism of a distal obstruction. The simple act of metal-to-metal contact if performed with gentle care and not force is a key maneuver to confirm duct patency. The clinical importance of this maneuver has been stressed by many surgeons and is helpful to diagnose duct patency.Citation5,Citation6 It will not, however, discover the creation of a false passage or distally malformed duct, and thus reveals the limit of tear duct surgery without an endoscope. Regardless, nasal endoscopy is not necessary for a majority of simple procedures in the treatment of CNLDO, but is essential for more complex cases.
Disclosure statement
The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.
References
- Engel JM, Hichie-Schmidt C, Khammar A, Ostfeld BM, Vyas A, Ticho BH. Monocanalicular silastic intubation for the initial cor- rection of congenital nasolacrimal duct obstruction. J AAPOS. 2007;11:183–186. doi:10.1016/j.jaapos.2006.09.009.
- Bernard JA, Fayet B, Pouliquen Y. New models of the punctum plug and inserter. Bull Soc Ophtalmol Fr. 1989;89:1131–1132.
- Fayet B, Racy E, Assouline M. Cerebrospinal fluid leakage after endonasal dacryocystorhinostomy. J Fr Ophtalmol. 2007 Feb;30(2):129–134. doi:10.1016/S0181-5512(07)89561-1.
- Fayet B, Racy E, Katowitz J, Katowitz W, Ruban JM, Brémond-Gignac D. Insertion of a preloaded Monoka™ stent for congenital nasolacrimal obstruction: intraoperative observations. A preliminary study. J Fr Ophtalmol. 2019 Mar;42(3):248–254. doi:10.1016/j.jfo.2018.12.004.
- Wobig J. Astra Symposium. Colorado: Springs; November 1981.
- Katowitz WR, Nazemzadeh M, Katowitz JA. Initial management of pediatric lower system problems: probing, stents and balloons. In: Katowitz JA, Katowitz WR, eds. Pediatric Oculoplastic Surgery. Springer-Verlag; 2017 June. pp. 479–500.