Comments on “Nasolacrimal Duct Management During Endoscopic Sinus and Skull Base Surgery”

Abstract

To the Editor: We read with interest the article by Rotsides et al entitled “Nasolacrimal Duct Management During Endoscopic Sinus and Skull Base Surgery” highlighting the functional outcome after nasolacrimal duct (NLD) transection performed during sinus and skull base surgery where a multi-institutional series of 29 patients was analyzed. The authors compared two groups of patients undergoing endoscopic medial maxillectomy and NLD simple transection or NLD marsupialization, respectively. Only 1 patient submitted to simple NLD transection and postoperative radiotherapy due to malignant sinonasal squamous cell carcinoma developed postoperative epiphora. The failure rate calculated in the simple NLD transection subgroup was 7.7%. Although no patients in the marsupialization group suffered from postoperative epiphora, the data were insufficient to statistically determine the better efficacy of one surgical technique over the other. The authors concluded that endoscopic NLD simple transection or with flap marsupialization during endoscopic sinus and skull base surgery carries a low risk of postoperative epiphora. We would praise the authors for having proposed marsupialization of the transected NLD for the management of the lacrimal pathway during medial maxillectomy as a valid alternative for the surgeons in addition to concurrent dacryocystorhinostomy (DCR) or lacrimal preserving approaches to the maxillary sinus. However, we would highlight that more than one variable could have biased the results, starting from the inclusion criteria of the study. Patients treated for sinonasal diseases of different histopathological nature (inflammatory or neoplastic) were analyzed together, as well as patients who received postoperative radiotherapy. Acute on chronic inflammation, chronic sinusitis and epithelial cysts represent different entities requiring functional endoscopic sinus surgery, where the NLD is preferably preserved. Probably, radiation therapy of the midface determines an increased risk of epiphora due to lacrimal canaliculi and nasal mucosal scarring, which increases when it follows maxillectomy for sinonasal cancers, with recently reported rates of 29%. Not least, it is our feeling that the rate of NLD stenosis in the postoperative period might have been underestimated, given the short follow-up time between NLD transection and the last clinical examination reported in the paper (mean 10.5 months, range 1-33 months). In this context, we would like to share our experience reporting on the rate of epiphora after NLD simple transection in a homogenous and continuous cohort of patients endoscopically treated for sinonasal inverted papilloma by the same senior surgeon between 2002 and 2017 (see Table 1). Over a series of 116 patients, 30 (25.8%) were submitted to transnasal endoscopic partial maxillectomy type 3A and 3B (TurriZanoni, Battaglia and Karligkiotis, 2017) with NLD simple transection to obtain adequate surgical control within the maxillary sinus. No lacrimal stent was placed. After a median 64 months follow-up time (IQR 37-91), 3 patients (10%) developed postoperative epiphora after 3, 32 and 84 months since surgery, respectively. They were thus operated on endoscopic DCR with complete resolution of symptoms documented at mean 48 months follow-up. These data might find a rationale in the overall small number of the case series that undoubtedly increases the risk of different results. Rotsides et al presented a brief literature review on the management of NLD during endoscopic procedures. When analyzing only papers reporting patients treated with endoscopic medial maxillectomy with NLD transection for IP removal, the overall rate of epiphora ranges between 0% to 12% with a mean follow-up of 47 months. 873353 AORXXX10.1177/0003489419873353Annals of Otology, Rhinology & LaryngologyCazzador et al letter2019