POLYPROPYLENE STENTING IN REVISION

DACRYOCYSTORHINOSTOMY: A PROSPECTIVE STUDY

*M.S.Vijayashree, MS,**B. Viswanatha, MS, PhD, FACS
ABSTRACT
Objective: This study was done to evaluate the clinical efficacy of polypropylene for stenting in endoscopic
revision dacryocystorhinostomy.
Patients and methods: Revision endoscopic dacryocystorhinostomy operation was performed in 10 patients (4
men and 6 women) between 2009 and 2014.After recreating an aperture in the medial wall of the lacrimal sac, 2/
0 polypropylene suture material was inserted through both upper and lower canaliculi into the sac and both the
ends were knotted in the nasal cavity. The polypropylene was left in the lacrimal sac for 3 months. The patients
were followed up for 6 months. Based on the improvement in the complaint of epiphora, they were grouped as
good improvement, partial improvement and no improvement.
Results: In 8 patients (80%) improvement was good, whereas improvement was partial in 1 patient (10%), and
there was no improvement in 1 patient (10%). Granulation tissue formation around the polypropylene was seen
in one patient.
Conclusion: Polypropylene can be used successfully in endoscopic dacryocystorhinostomy as an alternative to
silicone stent. Polypropylene suture material is cheap, effective, and readily available in all operating theaters.
Keywords: Nasolacrimal duct obstruction, dacryocystorhinostomy, stent, polypropyl.

Vol.-9, Issue-II, July-Dec. - 2015

INTRODUCTION
Dacryocystorhinostomy (DCR) is a surgical
procedure performed for the relief of nasolacrimal duct
obstruction of either anatomical or functional cause1.
The first report of DCR (intranasal approach) was by
Caldwell in 18932.DCR is indicated for saccal and postsaccal stenosis and is traditionally performed externally
by Ophthalmologists3. This procedure is based on the
formation of a surgical fistula on the lateral nasal wall
between the nasal cavity and the lacrimal sac. The
operation can be carried out using either an external or
endonasal surgical approach. The external approach is
the surgery of choice for ophthalmologists4. Since its
first description by McDonough and Meiring,
endoscopic DCR gained popularity5.
Advances in endoscopic equipment have led to a
widespread use of the endoscopic transnasal approach
by Otorhinolaryngologists with results comparable to
the external approach and the potential for less
morbidity3.The advantages of endoscopic DCR with
respect to external DCR include the lack of skin incision,
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short operating time, and lower risk of interfering with

the physiological lacrimal pump mechanism, minimal
blood loss and the possibility to correct associated intra
nasal pathological conditions during the same
procedure3,6.
We describe a technique using a polypropylene
suture material as an alternative to silicone stent in
endoscopic DCR procedures. Polypropylene is
commonly used in all surgical disciplines for suturing
and meshing purposes7,8. It is a cheap material and is
readily available when compared with bicanalicular
silicone tube.
Affiliations:
*,**,
Otorhinolaryngology department,
Bangalore Medical College & Research Institute,
Bangalore, India
Address of Correspondence:
B.Viswanatha, MS, PhD, FACS
Professor of ENT,
Bangalore Medical College & Research Institute
Bangalore, INDIA
Email: drbviswanatha@yahoo.co.in
Mobile no: 919845942832

PATIENTS AND METHODS:

This prospective study was done at the tertiary
care institute between 2009 and 2014.In this study there
were ten patients (6 females and 4 males) who underwent
revision endoscopic DCR operations for complaints
of continuous epiphora and recurrent swelling near the
medial canthus after previous DCR surgery. Patients
ages ranged from 26 to 50 years. Informed consent was
obtained from the patients.All patients underwent
routine preoperative ophthalmologic and
otorhinolaryngological examination, diagnostic nasal
endoscopy and blood investigations. Lacrimal sac or
nasolacrimal duct obstruction was confirmed by the
results of lacrimal irrigation.

Fig. 1: Showing polypropylene passing through both the canaliculi.

SURGICAL TECHNIQUE:
All surgeries were performed under local
anesthesia. The nasal cavity was decongested for 15
minutes using cottonoid pledgets soaked in lidocaine 4
% with adrenaline 1:100 000.Patients were given
premedication. Inside the operating room, cottonoid
pledgets were removed from the nasal cavity. Using
nasal endoscope, 2% lidocaine with adrenaline anesthetic
solution was injected submucosally to the lateral nasal
wall corresponding to the sac location just
anterosuperior to the insertion of the middle turbinate.

Lacrimal punctum was dilated using punctum

dilator. Then 2/0 polypropylene was inserted into the
sac through both the canaliculiFig.1. Both ends of the
polypropylene were then fastened with several knotsFig.2.
Precaution was taken to ensure that the polypropylene
stayed loose in the region of the inner canthus to
prevent canalicular laceration.

Fig. 2: Showing polypropylene with multiple knots in the nasal cavity.

POSTOPERATIVE FOLLOW-UP:
The patients were discharged on the next day of
the procedure after removing the nasal pack, and given
oral antibiotics for 1 week. Nasal irrigation and topical
eye drops were given four times a day for 2 weeks.
Patients were examined endonasally in the
otolaryngology clinic in first, second, and fourth week
in the first month. Nasal endoscopy was done once a
month until the stent removal. The polypropylene stent
was removed at the end of 3 months.
The eyes with no epiphora were accepted as good
improvement. The eyes which experienced epiphora
occasionally were designated partial improvement. The
eyes that still had epiphora were placed in the no
improvement group.
Patency of the lacrimal system was assessed by rigid
nasal endoscopy and irrigation with saline. The
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Vol.-9, Issue-II, July-Dec. - 2015

A curved incision was made at the lateral nasal

wall mucosa including periosteum, just anterior to the
attachment of the middle turbinate. A suction Freers
elevator was used to lift the mucosal flap, keeping the
mucosa between the middle turbinate and the lateral
nasal wall intact. Identification of the sac was aided by
passing a lacrimal probe through the inferior canaliculus
into the sac, or by pressing on the skin inferior and
medial to the medial canthus and observing the
movement of the sac. Vertical incision is made on the
medial wall of the sac and it was widened using cutting
punch forceps. The patency of the lacrimal drainage
system was checked with saline irrigation.

resolution of epiphora with patent ostium during nasal

endoscopy at the end of three months was accepted as
a successful result.
RESULTS:
The age range of our patients was between 26 to
50 years. There were 10 patients who underwent
revision endoscopic DCR procedures. The patients were
followed for a period for 6 months. Success was defined
as anatomical patency with lacrimal syringing and
improvement of the epiphora complaint at the end of
3 months.
Eighty (80%) were in the good improvement
group, One patient had partial improvement and one
patient had no improvement. When the patency of
ostium and resolution of epiphora were taken into
account; the endoscopic revision DCR was successful
in 8 out of the 10 cases (80%).One patient had partial
improvement. The procedure was unsuccessful in one
patient who presented with the complaint of epiphora
and evaluation revealed total closure of rhinostomy
opening after the removal of polypropylene stent.
There were no major surgical complications.
Granulation tissue formation near the polypropylene
suture was observed in two patients.
DISCUSSION:

Vol.-9, Issue-II, July-Dec. - 2015

Endoscopic DCR is proposed to be an alternative

surgery to the external DCR operation in cases of
chronic dacryocystitis. With the introduction of high
resolution endoscopes, endoscopic endonasal DCR has
begun to gain popularity 9. Endoscopic DCR is
becoming popular as a relatively quick and easy surgery
for post-saccal obstruction of the nasolacrimal drainage
system4.
Closure of the rhinostomy opening was
considered a major factor for surgical failure in external
DCR9.Thus, insertion of silicone stents is almost
universally employed to prevent rhinostomy stenosis
and to help to stabilize epithelialization between two
mucosal surfaces having surgical continuity10. Many
surgeons may not prefer the stents if the patient has
not had a previous operation (external DCR) and if
they are available for regular postoperative visits4. Some
studies have shown that silicone stent itself is a reason
of surgical failure due to granulation tissue formation
and complications like punctual erosion and slitting of
canaliculi9.
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The success rate depends on providing a wide

intranasal stoma with removal of adequate bone around
the stomal area, reducing the chances of postoperative
stenosis and adhesions. Inadequate bone removal is the
commonest cause of postoperative stomal stenosis11. A
bicanalicular silicone tube is the stent most often used
in DCR procedures to prevent obliteration of the
rhinostomy opening after DCR4.
In 1967, Gibbs used silicone tubes in DCR for
the first time12. Later, Keith and Quickert and Dryden
added probes to the silicone tubes13,14. Many surgeons
prefer to place bicanalicular silicone tubing to stent the
intranasal ostium, with a high success rates.
In the literature, as an alternative method to
silicone intubation, several other materials have been
used to retain the lacrimal aperture following
endoscopic DCR4.
Tamura et al15 used T-sheet made from a penrose
drain tube in seven patients18.In their study results were
very good in four patients (57%), good in two patients
(29%), and showed no change in one patient (14%).
They detected granulation tissue in two of seven patients
and reported spontaneous tube loss in the early period
in1of 7 patients.
Kishore et al16 used standard otologic T-tubes in
endoscopic DCR. Kishore et a6,19 did not observe any
granulation around the T-tube. Erkan et al 17 used
standard otologic T-tubes in endoscopic DCR. In their
study results were every good in 11 patients (50%), good
in five patients (23%), and showed no change in six
patients (27%).They reported spontaneous tube loss in
the early period in 3 of 22 eyes and they did not observe
any granulation around the T-tube.
According to guideline published by The Royal
College of Ophthalmologists (1999) freedom from
epiphora for 3 months after surgery is the marker of
successful procedure18. All our patients were under
follow-up period of 3 months after the removal of
polypropylene, and hence, our patients were under
followed-up for 6 months. Resolution of epiphora and
patent ostium after evaluation by irrigation were the
signs of successful surgery.
In the present study, polypropylene was used as
stents in endoscopic revision DCR operation in 10 eyes.
Its strength, inertness, retention of strength after
application, minimum tissue reactivity, and resistance

CONCLUSION:
In the present study the success of polypropylene
stenting in endoscopic revision DCR procedures was
80%. This result was similar to that of the success rate
of silicone intubation reported in the literature. When
compared to silicon stents, polypropylene is a cheap
material readily available in almost all operating theaters
and it permits tear flow into the nose following surgery.
It is a good alternative to silicone stents.
DISCLOSURES
(a)

Competing interests/Interests of Conflict- None

(b) Sponsorships - None

(c)

Funding - None

(d) No financial disclosures

REFERENCES:
1.

2.

3.

4.

5.

6.

Ambani K, Suri N, Parmar H. Study of success

rate in endoscopic dacryocystorhinostomy with
and without stenting. International Archives of
Integrated Medicine, Vol. 2, Issue 4, April, 2015.
Caldwell G. W. Two new operations of
obstructions of the nasal duct with preservation
of the canaliculi & an incidental description of a
new lacrimal probe. Am J Opthalmol,93.
Pittore B,Tan N, Salis G, Brennan PA, Puxeddu
R. Endoscopic transnasal dacryocystorhinostomy
without stenting: results in 64 consecutive
procedures. Actaotorhinolaryngologica italica
2010; 30:294-298
Aslan S, Oksuz H, Okuyucu S, Akoglu E, Dagli
S. Prolene: a novel, cheap, and effective material
in dacryocystorhinostomy. Acta OtoLaryngologica, 2009; 129: 755-759
McDonough M, Meiring JH. Endoscopic
transnasal dacryocystorhinostomy. J Laryngol
Otol 1989;/103:/585-587.
Yigit O, Samancioglu M, Taskin U, et al. External

and endoscopic dacryocystorhinostomy in chronic

dacryocystitis: comparison of results. Eur Arch
Otorhinolaryngol 2007;264:879-85.
7.

Willatt DJ, Durham L, Ramadan MF, Bark-Jones

N. A prospective randomized trial of suture
material in aural wound closure. J Laryngol Otol
1988;/102:/788-790.
8. Afonso JS, Martins PA, Girao MJ, Natal Jorge
RM, Ferreira AJ, Mascarenhas T, et al. Mechanical
properties of polypropylene mesh used in pelvic
floor repair. Int Urogynecol J Pelvic Floor
Dysfunct 2008;/19:/375-380.
9. V Kakkar, J Chugh, S Sachdeva, N Sharma,
Ramesh. Endoscopic Dacryocystorhinostomy
With And Without Silicone Stent. A Comparative
Study. The Internet Journal of Otorhinolaryngology. 2008 (9) Number 1.
10. Sadiq SA, Ohrlich S, Jones NS, Downes RN.
Endonasal laser dacryocystorhinostomy-medium
term results. Br J Ophthalmol 1997;/81:/10891092.
11. Welham RA. Management of unsuccessful
lacrimal surgery. Br J Ophthalmol 1987;/71:/152157.
12. Gibbs DC. New probe for the intubation of
lacrimal canaliculi with silicone rubber tubing. Br
J Ophthalmol 1967;51:/198.
13. Keith CG. Intubation of the lacrimal passages. Am
J Ophthalmol 1968;/65:/70-74.
14. Quickert MH, Dryden RM. Probes for
intubation in lacrimal drainage. Trans Am Acad
Ophthalmol Otolaryngol 1970;74:/431-433.
15. Tamura M, Kawasaki Y, Mori K, Noda K, Kubo
T. Endoscopic dacryocystorhinostomy using Tsheet. Laryngoscope 2003;/113:/746-748
16. Kishore A, McGarry GW. The otologic T-tube:
a cost effective dacryocystorhinostomy stent. J
Laryngol Otol 2001;/115:/992-993.
17. Erkan AN, Yilmazer C, Altan-Yaycioglu R.
Otologic T-tube in endonasal dacryocystorhinostomy: a new approach. Acta Otolaryngol
2007; 127:/1316-1320.
18. Royal College of Ophthalmologists. Guideline for
clinical governance in ophthalmology. London:
RCO, April 1999.

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Vol.-9, Issue-II, July-Dec. - 2015

to bacterial contamination are its main advantages7.

Polypropylene should be tied with multiple knots to
prevent its prolapse. Granulation tissue around
polypropylene in the nasal cavity was observed in only
one patient. To the best of our knowledge, the use of
polypropylene for DCR stenting has been reported
only by Aslant et al4. This is the second prospective
case series reported in the literature.