Endoscopic endonasal laser versus endonasal surgical dacryocystorhinostomy for epiphora due to nasolacrimal duct obstruction: prospective, randomised, controlled trial

Background: Rhinostomy patency is a problem in all forms of dacryocystorhinostomy. Laser-assisted procedures are potentially fast and result in excellent haemostasis. However, they may induce more fibroblastic activity, resulting in excessive scarring and stenosis of the rhinostomy, compared with non-laser dissection. Objectives: The objective of this study was to compare subjective outcomes following dacryocystorhinostomy conducted with endoscopic endonasal laser and with endonasal surgical techniques. Study design: Prospective, randomised, controlled trial comparing potassium titanyl phosphate endonasal laser dissection with endonasal surgical techniques, for dacryocystorhinostomy to treat epiphora due to primary, acquired nasolacrimal duct obstruction. Participants: One hundred and twenty-six adult patients with chronic epiphora due to primary, acquired nasolacrimal sac or duct obstruction. Interventions: Interventions comprised endonasal dacryocystorhinostomy, performed using potassium titanyl phosphate laser or surgical dissection, in order to open the lacrimal sac into the nasal cavity. Outcome measures: These were: symptom score and symptom relief of epiphora (at three and 12 months post-procedure); duration and ease of procedure; and duration of hospital stay. Results: Sixty patients underwent endonasal laser dacryocystorhinostomy and 66 underwent endonasal surgical dacryocystorhinostomy. Symptomatic success was 82 per cent at three months and 68 per cent at 12 months in the laser group, and 76 per cent at three months and 74 per cent at 12 months in the surgical group. A two-point reduction in the symptom score was associated with symptomatic success at three and 12 months. Eight patients randomised to the laser group required additional instrumentation in order to remove thick bone over the lacrimal sac. Conclusions: At three months, endonasal laser dacryocystorhinostomy had better results than endonasal surgical dacryocystorhinostomy. However, at 12 months, the surgical procedure had better results than the laser procedure. There was no statistically significant difference between the two groups at three or 12 months with regard to symptomatic outcome. The ease of procedure (on a scale of zero to 10) was 4.5 for the laser procedure and 4.1 for the surgical procedure. The average times for the procedures were 25 minutes in the laser group and 20 minutes in the surgical group. No statistical difference was found when comparing: symptom score improvement for local anaesthetic vs general anaesthetic; ages over and under 70 years; laterality; or operating surgeon. Change in the symptom score was a useful indicator of symptomatic success.