Intraoperative lacrimal intubation to prevent epiphora as a

Toshinori Iwai, Kazunori Yasumura, Yuichiro Yabuki, et al Intraoperative lacrimal intubation to prevent epiphora as aresult of injury to the nasolacrimal system after fracture of the naso-orbitoethmoid complex. British Journal of Oral and Maxillofacial Surgery 51 (2013) e165–e168

PRESENTED BY – DR. SHEETAL KAPSE

GUIDED BY – DR. RAJASEKHAR G.

AUTHOR1. Toshinori Iwaia - Department of Oral and Maxillofacial Surgery, Yokohama City University Hospital, 3-9

Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan

2. Kazunori Yasumurab- Department of Plastic and Reconstructive Surgery, Yokohama City University

Hospital, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan

3. Yuichiro Yabukib-Department of Plastic and Reconstructive Surgery, Yokohama City University Hospital, 3-9


4. Susumu Omurac-Department of Oral and Maxillofacial Surgery, Yokohama City University Medical Centre, 4-57

Urafunecho, Minami-ku, Yokohama 232-0024, Japan

5. Yoshiro Matsuid- Department of Oral and Maxillofacial Surgery, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe,

Kagawa 761-0793, Japan

6. Shinji Kobayashie- Department of Oral and Maxillofacial Surgery, Yokohama City University Hospital, 3-9


7. Ryo Fujimakia- Department of Oral and Maxillofacial Surgery, Yokohama City University Hospital, 3-9


8. Makiko Okuboa- Department of Oral and Maxillofacial Surgery, Yokohama City University Hospital, 3-9


9. Iwai Tohnaia- Department of Oral and Maxillofacial Surgery, Yokohama City University Hospital, 3-9


10. Jiro Maegawab- Department of Plastic and Reconstructive Surgey, Kanagawa Children’s Medcial Centre, 2-138-4 Mutsukawa, Minami-ku,

Yokohama 232-8555, Japan

CONTENTS

• Introduction• Aim of the study• Patients and methods• Surgical technique• Results • Discussion• Cross references• Conclusion• References

INTRODUCTION

• Symptomatic lacrimal obstruction develops after 0.2% of nasal fractures

and 3% of maxillary fractures (Le Fort II or III fracture),1but the incidence

is considerably higher with fractures of the NOE complex, at 12–29.3%

• Delayed approach to surgical treatment of post-traumatic lacrimal

obstruction is usual.

• The incidence of permanent post-traumatic epiphora is high and additional

invasive treatment with dacryocystorhinostomy (DCR) is required.

Aim of the study

• To assess the effectiveness of intra-operative lacrimal

intubation to prevent epiphora as a result of injury to the

nasolacrimal system.

PATIENTS AND METHODS• Patients with NOE fractures between June 2005 and April 2011 were included in

the study.

• ORIF was done for all along with lacrimal tube intubation(intra-operative) by plastic surgeon.

• Lacrimal Tube -N-S tube; KANEKA MEDIX (Osaka, Japan)

Male Female Unilateral Bilateral

11 2 10 3

LACRIMAL TUBE

The material consists of two malleable, stainless steel probes (55 mm long and 0.45 mm in diameter) connected by 105 mm of silicone tube (inner iameter 0.5 mm, outer diameter 1 mm).

No need to fix the tube, and removal is easy.

The tube has different coloured tips (blue and clear), which are useful for endoscopic examination in the nasal cavity because the different colours are used to indicate the superior and inferior lacrimal canaliculus

Results

Discussion

• Glatt’s evaluated lacrimal duct obstruction secondary to facial fracture using

CT or CT-dacryocystography, Epiphora - Caused by the plates or wires, or

both, that are used for internal fixation. Permanent epiphora results from

direct injury such as laceration or interruption of the nasolacrimal duct.

• Becelli et al retrospectively analyzed 58 NOE complex fractures. Incidence

of post-traumatic postoperative epiphora was 47% (27/58patients). Of their

58 patients, 10 (17%) with temporary epiphora and 17 (29%) with permanent

epiphora had DCR.

Discussion

• Early treatment is ORIF, and surgical treatment (DCR) of post-traumatic

lacrimal obstructions is commonly delayed, because intubation of lacrimal

pathways during the primary operation on facial fractures may injure an

intact lacrimal system.

• Incidence of epiphora after such fractures is high, as mentioned earlier,

hence prophylactic lacrimal intubation has been suggested for its

prevention (Although still controversial)

Cross references

• Becelli et al retrospectively analyzed 58 NOE complex fractures. Incidence of post-traumatic postoperative epiphora was 47% (27/58patients).

• Of their 58 patients, 10 (17%) with temporary epiphora and 17 (29%) with permanent epiphora had DCR.

• Early treatment is ORIF, and surgical treatment (DCR) of post-traumatic lacrimal obstructions is commonly delayed, because intubation of lacrimal pathways during the primary operation on facial fractures may injure an intact lacrimal system.

• Incidence of epiphora after such fractures is high, as mentioned earlier, hence prophylactic lacrimal intubation has been suggested for its prevention (Although still controversial)

• Used prophylactic lacrimal intubation with silicone tubes for 19 patients with midfacial fractures involvingt he NOE complex, and removed the tubes 4 (2–11) months postoperatively.

• Although 3 of the 19 patients had postopera-tive epiphora, these resolved spontaneously within 6 weeks.

• Harris and Fuerste recommended that lacrimal stents shouldbe maintained for 4–6 months; however, our results suggestthat post-traumatic epiphora can be prevented by lacrimalintubation for at least 2 months.

Conclusion

• These results confirm that intra operative lacrimal intubation

is useful to prevent permanent epiphora and offers greater

benefits than omitting it.

• The authors therefore recommend intra operative lacrimal

intubation to avoid DCR.

References

1. Becelli R, Renzi G, Mannino G, Cerulli G, Ianetti G. Posttrau-matic obstruction of lacrimal pathways: a retrospective analysis of 58consecutive naso-orbitoethmoid fractures. J Craniofac Surg 2004;15:29–33.

2. Spinelli HM, Shapiro MD, Wei LL, Elahi E, Hirmand H. The roleof lacrimal intubation in the management of facial trauma and tumorresection. Plast Reconstr Surg 2005;115:1871–6.

3. Harris GJ, Fuerste FH. Lacrimal intubation in the primary repair ofmidfacial fractures. Ophthalmology 1987;94:242–7

Health & Medicine

Intraoperative lacrimal intubation to prevent epiphora as a