Intraoperative lacrimal intubation to prevent epiphora

1. 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.

2. 1. 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
Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan
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 Fukuura,
Kanazawa-ku, Yokohama 236-0004, Japan
7. Ryo Fujimakia- Department of Oral and Maxillofacial Surgery, Yokohama City University Hospital, 3-9 Fukuura,
Kanazawa-ku, Yokohama 236-0004, Japan
8. Makiko Okuboa- Department of Oral and Maxillofacial Surgery, Yokohama City University Hospital, 3-9 Fukuura,
Kanazawa-ku, Yokohama 236-0004, Japan
9. Iwai Tohnaia- Department of Oral and Maxillofacial Surgery, Yokohama City University Hospital, 3-9 Fukuura,
Kanazawa-ku, Yokohama 236-0004, Japan
10. Jiro Maegawab- Department of Plastic and Reconstructive Surgey, Kanagawa Children’s Medcial Centre, 2-138-4 Mutsukawa, Minami-ku, Yokohama
232-8555, Japan

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

4. • 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.

5. • To assess the effectiveness of intra-operative lacrimal
intubation to prevent epiphora as a result of injury to the
nasolacrimal system.

6. • 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

7. 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

9. • 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.

10. • 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)

12. • 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)

13. • 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.

14. • 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.

15. • 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.

16. 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