DOI No.: 10.21176/ ojolhns.0974-5262.2016.10.

A COMPARATIVE STUDY OF ENDOSCOPIC

DACRYOCYSTORHINOSTOMY WITH AND WITHOUT THE
ADJUVANT MITOMYCIN C.
Prakash N.S MS*, Srijoy Gupta MBBS**
Date of receipt of article- 04-04-2016
Date of acceptance -2-5-2016
DOI-10.21176/ojolhns.2016.10.1.3
ABSTRACT
Objective: The aim of this study is to evaluate and compare the changes in Quality of Life (QoL ) before and
after Endoscopic Dacryocystorhinostomy with & without Mitomycin C.
Introduction: With the advent of Endoscopic Dacryocystorhinostomy over the last few decades there arises
need for reducing failure and tackling the complications of this surgery. Studies done still show a better success
rate for External Dacryocystorhinostomy over the endoscopic approach. Mitomycin-C can be used to reduce
fibrous proliferation to maintain patency of stoma and improve the success rate.
Objective and Study Design: A Prospective Randomized study to compare the patency of stoma and relief of
epiphora after Endoscopic Dacryocystorhinostomy with Mitomycin C and without in cases of Chronic
Dacryocystitis.
Materials and Method: 22 patients with Chronic Dacryocystitis were included in the study after considering
inclusion and exclusion criteria. 11 cases underwent Endoscopic Dacryocystorhinostomy with adjuvant application
of Mitomycin-C 0.4mg/ml at the rhinostomy site and 11 without. They were followed up for 2 weeks, 4 weeks
and 6 months after surgery and evaluated both subjectively and objectively
Results: The success rate at 6 months after surgery was found to be 100% for Endoscopic Dacryocystorhinostomy
irrespective of the use of Mitomycin C. Presence of synechae in the post-operative period was found to be less
with the drug but not statistically significant.
Conclusion: Mitomycin C has no significant bearing on the success of Endoscopic Dacryocystorhinostomy. It
does appear to induce a good healing profile in terms of mucosal recovery and wound healing. An atraumatic
and meticulous surgical technique ensures good results irrespective of the adjuvant usage of Mitomycin C .
Key words: Endoscopic Dacryocystorhinostomy, Mitomycin C, Chronic Dacryocystitis.

Vol.-10, Issue-I, Jan-June - 2016

INTRODUCTION
Integrity of the Lacrimal Apparatus in its secretory
function and drainage mechanism is most vital for
normal functioning of the eye. All factors which upset
the drainage mechanism distal to the sac or at
Nasolacrimal duct level can lead to the clinical condition
of Dacryocystitis. The traditional treatment for
Chronic Dacryocystitis has been External
Dacryocystorhinostomy (EXT-DCR) performed by an
ophthalmologist 1. Success rates of 87% to 97% for EXTDCR have been reported 1, 2.
The endonasal approach was introduced in 1893
by Caldwell and was later modified by West and Halle.
18

With the advent of rigid endonasal endoscopes,

otorhinolaryngologists have popularized Endoscopic
Dacryocystorhinostomy (EN-DCR) over the last three
decades. It is now a well established alternative to the
external approach with various studies showing a success
rate of 80 to 95% 3,6. Major advantages of EN-DCR
Affiliations:
*Professor,** Postgraduate
Department of ENT & Head & Neck Surgery,
JJM Medical College, Davangere,
Karnataka, India
Address of Correspondence:
Dr Srijoy Gupta
Room no Pg10, JJMMC Boys Hostel Old Block
JJM Medical College, Davangere, Karnataka, India 577004,
Mob: 9972224871, Email: srijoy666@gmail.com

DOI No.: 10.21176/ ojolhns.0974-5262.2016.10.1

Thus if we can reduce fibrous proliferation at the

osteotomy site and anastomosis of flaps, the success rate
of EN-DCR could improve. Many methods have been
devised to prevent closure of the stoma such as creation
of mucosal flaps, intubation of canaliculi, lacrimal sac
and stoma using silicone tubes and use of alkylating
agent such as Mitomycin C 4.
The aim of EN-DCR is not only to establish a
free passage between lacrimal sac and the nasal cavity,
but also to keep this passage patent. Some studies have
tried application of 0.2 mg/ml or 0.5mg/ml of
Mitomycin-C to the rhinostomy opening for ensuring
a permanent rhinostomy3,4,5,6, and 8. It has been used in
both EN-DCR and EXT-DCR and quite a few studies
have shown good results. 2, 7, 9 Mitomycin-C,an antibiotic
isolated from Streptococcus caespitosus is used as a
chemotherapeutic agent in neoplastic diseases. It acts as
a bifunctional or trifunctional alkylating agent. It
inhibits DNA synthesis and cross links DNA at the
N6 position of adenine and at the O6 and N7 positions
of guanine.
It has been used as an adjunct to surgery to inhibit
wound healing and reduce scarring 10. Its property of
suppressing fibrosis and vascular in growth may help
in maintaining the patency of stoma in EN-DCR and
improve surgical outcome.
THE AIM OF HE STUDY:
The present study is to compare the patency of
stoma and relief of epiphora after EN-DCR surgery
with Mitomycin C and without in cases of Chronic
Dacryocystitis.
MATERIALS AND METHODS:
Ethical clearance was obtained from the
institutional ethics committee, JJM Medical College,

Davangere. A single blind randomized clinical trial was

conducted on 22 patients (11 cases with Mitomycin C
and 11 cases without) who were diagnosed to have
chronic dacryocystitis between November 2013 and
March 2015 in Bapuji Hospital attached to JJM Medical
College, Davangere. The 22 cases were randomized for
either EN-DCR with Mitomycin C or without.
Patients referred to our Otorhinolaryngology
Out-patient department for nasolacrimal obstruction
were investigated using lacrimal irrigation and probing
of the canaliculi with a blunt tipped Bowmans probe.
The lids were inspected, focussing on the positions of
the lacrimal puncta and the function of the orbicularis
muscle. Anterior rhinoscopy was done for every
patient. The cases with presaccal block, suspicion of
malignancy, pregnant or lactating women and age less
than 12 years were excluded from the study. Patients
who required other nasal procedures like septoplasty,
release of adhesions, and clearance of agar nasi or
functional endoscopic sinus surgery were included in
the study.
The diagnosis was made by patients history of
recurrent infections of the lacrimal sac and intermittent
or permanent epiphora were the most frequent
symptoms. Diagnostic procedures included irrigation
of the lacrimal duct.
All the cases were operated under General
Anaesthesia. A topical decongestant was applied to the
nasal cavity and the mucosa of the lateral nasal wall was
infiltrated with 2% lignocaine with adrenaline (1:
200,000). Under Rigid 4-mm 0 degree endoscopic
guidance, a scalpel is used to cut a mucosal flap starting
approximately 1cm above the insertion of the middle
turbinate on the lateral nasal wall (axilla of the middle
turbinate). This incision is brought anterior to the axilla
for approximately 1cm.
A vertical incision is then made to the midpoint
of the middle turbinate with a sickle knife. The incision
is extended posteriorly to the insertion of the uncinate
process. Mucosa was lifted up using a Freers elevator
keeping the dissection under the mucoperiosteum
(Figure 1). The mucosal flap is tucked around the
anterior end of the middle turbinate. The junction of
the lacrimal sac and nasolacrimal duct was visualized.
A knife and suction elevator are used to elevate the
thin lacrimal bone off the posterior half of the lower
19

Vol.-10, Issue-I, Jan-June - 2016

include the avoidance of a cutaneous wound and the

limitations of tissue injury to the discrete fistula site
without disruption of the medial canthal anatomy and
function.Failures encountered in EN-DCR is due to
closure of the stoma created in the lateral nasal wall
due to scar formation during the healing process
which will decrease or compromise the created
surface area of the osteotomy site. Some of the
common reasons for the surgery to fail are improper
position and size of the ostium, common canalicular
obstructions, development of synechae and lacrimal
fossa pathology 3, 7.

Vol.-10, Issue-I, Jan-June - 2016

DOI No.: 10.21176/ ojolhns.0974-5262.2016.10.1

lacrimal sac. The hard bone of the frontal process of

the maxilla is removed with a Kerrisons forward biting
punch and the anterior half of the lower third of the
lacrimal sac is uncovered (Figure 2).

of 2 groups and constructing suitable contingency table.

Chi square test was used to compare the other results
in the study.

A coarse diamond burr attached to a microdebrider

is used to remove the thick bone overlying the upper
two thirds of the lacrimal sac (Figure 3). Probing was
done to confirm entry into the sac and tenting of the
medial wall of the sac was done in its posterior aspect
(Figure 4). A sickle knife is used to open the sac (Figure
5) as far posterior as possible thereby creating a large
anterior flap. Superior and inferior releasing cuts are
given with a sickle knife after which releasing cuts are
applied in the posterior flap. A sharp through biting
straight Blakesley forceps is then used to cut the middle
third out of the original mucosal flap. This creates a U
shaped flap that, when replaced, meets the flaps from
the lacrimal sac end to end, thus creating a close
apposition of the edges that should result in primary
intention healing without granulation. Syringing was
done to clear discharge and other debris. After creation
of adequate rhinostomy, using single blinded
randomised trial the rhinostomy site was applied with
Mitomycin C 0.4 mg/ml by means of gelfoam for 5
minutes in half the cases. Following this the nasal cavity
and the stoma site is washed with saline. Nose was packed
with Merocel nasal packs soaked with saline for 24
hours. The average time for surgery was 45 minutes.
In 2 cases which had recurrence after a previously done
external Dacrocystorhinostomy stenting with sillicone
tube was done.

In this study 22 EN-DCR operations were done

under a single blinded clinical trial (11 cases with
Mitomycin C and 11 cases without). The age group
ranged from 13 years to 58 years. The mean age was
34.9 years (range 13 to 55 years) in patients where
Mitomycin-C was used and in the other group of
patients where it was not used the mean age was 41.18
years (range 27 to 58 years). The difference was
statistically insignificant (P-value was 0.4232). The group
where Mitomycin C was used comprised of 6 male
individuals (54.5%) and 5 female individuals (45.5%).
The non Mitomycin C group comprised of 4 male
individuals (36.4%) and 7 female individuals (63.6%).
This difference of gender in the groups was found to
be insignificant. 63.6% cases (14/22) had left sided
disease whereas 36.4% cases had right sided disease. The
coexistent nasal pathologies treated or corrected during
the procedure comprised of 3 cases of deviated nasal
septum, 3 cases of a concha bullosa, 1 case of an enlarged
agar nasi cell and a case of Maxillary sinus polyp on
the contralateral side. Procedures such as septoplasty
were done for 3 patients, one in the Mitomycin C group
and two in the other group. Conchoplasty was done
for 3 cases, two in the mitomycin C group and one in
the other group. One patient in the mitomycin C group
underwent clearance of agar nasi cells. One patient in
the non mitomycin C group underwent endoscopic
sinus surgery on the contralateral side of the pathology
for maxillary polyposis.Three cases out of the 22 were
revision cases having undergone External
Dacrocystorhinostomy prior, 2 in the mitomycin C
group and 1 in the non mitomycin C group.

Nasal douching was performed during the follow

up period along with the application of topical
antibiotic eye drops for 1 week. Short term
complications of the procedure like pain, bleeding and
infection were also evaluated. Endoscopic examination
was done during the follow up period to clear secretions,
crusting, granulation and adhesions. The cases were
followed up at the end of 1 week, 1 month and then at
the end of 6 months.

RESULTS:

The surgical outcome was evaluated both

subjectively and objectively in the follow up period.
Subjective evaluation was based on the relief of
symptoms.
Statistical Analysis: Except the age, other
parameters in the study are of qualitative nature. Hence
students unpaired T test was used to compare the ages
20

Figure 1: Endoscopic Picture showing mucosal flap being lifted over

the ascending process of maxilla.

DOI No.: 10.21176/ ojolhns.0974-5262.2016.10.1

Figure 5: Use of sickle knife to open the sac. LS- Lacrimal sac

Figure 2: Endoscopic picture showing bone removal using bone

punch.

Synechae formation was one of the main

complications seen in the post-operative period between
the lateral nasal wall and anterior end of middle
turbinate or nasal septum. 2 of the 11 cases (18.2%) in
the Mitomycin C group had synechae. 4 out of the 11
cases (36.4%) in the non Mitomycin C group had
synechae.

Figure 6: Rhinostomy seen in a Post-operative case after 6 months

of follow up.

Figure 3: Use of burr to remove bone from the frontal process of

maxilla.

Figure 4: Schematic Diagram to show tenting of Lacimal sac into

the nose. LS- Lacrimal sac, MT- Middle Turbinate, IT- Inferior
Turbinate.

All patients had significant subjective improvement

by the third Post-operative visit with disappearance of
symptoms seen prior to surgery. Rhinostomy was
visible in all the cases in the follow up visits. During
follow-up endoscopy the surgical stoma was seen
(Figure 6) along with the visualisation of tears which
were seen to flow with blinking. The surgical stoma
was found to be patent at the end of 6 months in all 22
cases.
DISCUSSION:
The use of nasal endoscopes has gained significant
popularity over the last few years for all nasal and
paranasal sinus surgeries due to its precise technique
and sophisticated instrumentation. To prevent the
formation of granulation/ fibrous tissue occluding
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Vol.-10, Issue-I, Jan-June - 2016

There was no statistical difference between the two

groups however (p=0.33835 and is not significant at
p<0.05).One patient in the non mitomycin-C group
(9.1%) had granulation tissue formation. Other
complications such as bleeding, infection were not seen
in our patients. Serious complications such as damage
to orbit, orbital contents and damage to anterior cranial
fossa resulting in a CSF leak were not seen in our study.

DOI No.: 10.21176/ ojolhns.0974-5262.2016.10.1

rhinostomy site, Mitomycin C placed at the osteotomy

site has been used in different concentrations for
different durations for example 0.5 mg/ml for 10
minutes 11, 0.5mg/ml for 5 minutes 7, 0.2 mg/ml for 3
minutes 4.
In our study the female to male ratio is 6:5. The
difference of gender in between the 2 groups was
statistically insignificant (p=0.3918). Other studies prior
have also shown a female preponderance in the cases 4, 7,
11
and it has been explained that it is due to long duration
of smoke in the kitchen, dust in external environment
and use of cosmetics such as kajal.4
Our study also showed an increased incidence of
left sided disease (63.6%) when compared to right sided
disease (36.4%) as was seen in other studies 1, 4. According
to Arist 12, the left side was more involved than the right
due to the greater angle formed by the nasolacrimal
duct and lacrimal fossa on the right side. Other
explanation could be more right handed people with
preponderance to use their free left hand to clean the
left eye or mop tears which in turn can increase the
chances of infection. Another possibility could be
congenital, anatomic narrowing of Naso lacrimal duct
on the left side. 4

Vol.-10, Issue-I, Jan-June - 2016

A longer operative time is required for EN-DCR

with mitomycin C due to the application of the agent
for 5 minutes.
Also, in our study, an attempt was made to
expose the lacrimal sac fully after removing the maxillary
bone surrounding it. This was followed by adequate
marsupialisation of the lacrimal sac and covering the
exposed bone with preserved nasal mucosal flaps.
Studies prior have shown that if the entire lacrimal sac
is exposed during an endoscopic procedure the results
can be as good as EXT-DCR 13. A small opening at the
medial wall of the lacrimal sac, the sacrificing of nasal
and lacrimal sac mucosa during the procedure,
inadequate exposure of the lacrimal sac have all been
said to hamper the success of the Endoscopic procedure
13, 14
.
The presence of intranasal abnormalities and its
correction also has a significant effect on the outcome
of the surgery 3,7. In our study 8 cases underwent other
nasal procedures simultaneously with 6 of the
procedures having a direct bearing on the results of the
surgery. According to the present study, the overall
22

success rate for endonasal endoscopic DCR was 100%

with or without the adjuvant usage of the anti fibrotic
agent mitomycin C.
The reported success rates for EN DCR ranges
between 80-95% 3-6, 15. While there are some studies
which have said that intraoperative mitomycin C does
not alter the long term outcome8,16, there are others
which recommend its use in preventing nasal adhesion
7
, prevention of shrinkage of osteotomy site 4,5, better
healing profile and less need for debridement 3. Studies
have shown various success rates of EN DCR with
mitomycin C ranging from 84-97% 3-5, 17, 7.
The importance of post-operative care for a period
of at least 6 months cannot be understated and has been
shown to have a significant effect on the results of the
surgery 3, 9.
The incidence of post-operative complications such
as synechae was more when mitomycin C was not used
(36.4%) than when it was used (18.2%), however the
difference in the results were not statistically significant
(p=0.33835). The synechae were released under local
anaesthesia with endoscopic guidance. The number of
debridement sessions following the surgery during the
postoperative period also appeared to be less in that
group of patients where mitomycin C was used. One
patient in the non mitomycin C group developed
granulation tissue around the stoma site which was
removed by endoscopic visualization.
Three cases (two in the mitomycin C group and
one in the other group) had undergone EXT-DCR and
were revision cases. Two of which (one in each group)
underwent silicone tube stenting after the procedure.
The stents were removed after 6 weeks. The case where
mitomycin C was not applied developed synechae
which was treated in the follow up period. Follow up
of all three cases for six months showed good results
with resolution of symptoms and visualization of patent
stoma. While some studies insist on stenting in every
case of EN-DCR 11, 18 others indicate a more selective
use such as in revision cases 8, 9. However one must be
aware that sometimes silicone tubing itself may cause
tissue granulation, predisposing the site to postoperative infection and adhesions along with canalicular
lacerations resulting in surgical failure 7, 9.
For revision DCR, the endoscopic approach with
mitomycin C has been shown to be better than without

the drug 9, 19 but not always 3. Functional and aesthetic

results have been found to be better with EN-DCR
than EXT-DCR in revision cases 9, as it prevents a
second skin incision and also allows one to analyse the
intranasal anatomy at the time of surgery 20.

2.

Mukhtar SA, Jamil AZ, Ali Z. Efficacy of External

Dacryocystorhinostomy (DCR) with and without
Mitomycin-C in Chronic Dacryocystitis. Journal
of the College of Physicians and Surgeons Pakistan
2014; 24(10):732-35

No adverse effects with the use of mitomycin C

was encountered in our study. There have been reports
of complications such as corneal ulcers, corneal
perforations, and scleral calcification in eye surgeries.
However its use has been generally found to be safe in
EN-DCR 3, 6, 9.

3.

Ragab SM, Elsherif HS, Shehata EM, Younes A,

Gamea AM. Mitomycin C-Enhanced Revision
Endoscopic Dacryocystorhinostomy: A
Prospective Randomized Controlled Trial.
Otolaryngology- Head and Neck Surgery 2012;
147(5):937-42

4.

Harugop AS, Rekha BK, Mudhol RS et al. A

randomized placebo controlled trial of MitomycinC in surgical outcome of primary endoscopic
dacryocystorhinostomy. Al Ameen Journal
Medical Sciences 2013; 6(3):231-36

5.

Mudhol RR, Zingade ND, Mudhol RS, Das A.

Endoscopic Ostium Assessment Following
Endonasal Dacryocystorhinostomy with
Mitomycin C Application. Al Ameen Journal
Medical Sciences 2012; 5(3):320-24

6.

Prabhakar SK, Ravishankar C, Satish HS, Reddy

MY, Nithyashree J. A Prospective, Comparative
Study of Outcomes of Primary Endoscopic
Dacryocystorhinostomy
With
and
Withoutmitomycin-C. IOSR Journal of Dental
and Medical Sciences 2015; 14(1)[II]:29-33

7.

Farooq MU, Ansari MA, Khyani IA. Role of

mitomycin C in endoscopic management of
nasolacrimal duct obstruction. Journal of the Dow
University of Health Sciences 2013; 7(2):63-67

8.

Ghosh S, Roychoudhury A, Roychaudhuri BK.

Use of Mitomycin C in ENDO-DCR. Indian
Journal of Otolaryngology and Head and Neck
Surgery 2006; 58(4):368-69

9.

Cheng SM, Feng YF, Xu L, Li Y, Huang J-h

(2013). Efficacy of Mitomycin C in Endoscopic
Dacryocystorhinostomy: A Systematic Review
and Meta-Analysis; PLoS One 8(5):e62737.
Doi:10.1371/journal.pone.0062737

CONCLUSION:
EN-DCR is a safe and effective procedure with
the success rate appearing to be better than or at least
nearly equal to EXT-DCR. An adequate bony window,
marsupialisation of the lacrimal sac along with
preservation of nasal and lacrimal sac mucosa helps in
ensuring a good surgical outcome. Simultaneous
correction of other nasal pathologies such as a concha
bullosa or a deviated nasal septum which may have an
effect on the results of the surgery, reduces the chances
of failure.
Our study shows no improvement in the success
rate of EN-DCR with the application of Mitomycin
C. However Mitomycin C when used shows a
beneficial effect in preventing synechae post operatively,
induces a good healing profile and reduces the number
of debridement sessions.
An atraumatic and meticulous surgical technique
along with a good follow up care post-operatively
establishes EN-DCR as a better alternative to EXTDCR.
DISCLOSURES
(a)
(b)
(c)
(d)

Competing interests/Interests of Conflict- None

Sponsorships - None ,
Funding - None
No financial disclosures

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