內視鏡淚囊鼻腔造瘻術治療淚溢症

Transnasal Endoscopic Dacryocystorhinostomy for Epiphora

劉博仁(Po-Jen Liu)

《中華民國耳鼻喉科醫學雜誌》 37卷5期 (2002/08) Pp. 336-341

https://doi.org/10.6286/2002.37.5.336

摘要

背景：淚溢症是一惱人的疾病，經常發生於慢性淚囊炎或鼻淚管阻塞的患者，眼科醫師會依照發生原因及部位來做保守治療，若治療無效則可考慮手術。目前眼科醫師幾乎是以外側淚囊鼻腔造廔術來處理。隨著內視鏡手術的進步與應用廣泛，國外許多耳鼻喉科醫師以內視鏡經鼻腔淚囊鼻腔造廔術（transnasal endoscopic dacryocystorhinostomy, TEDCR）為這類患者提供更進一步顏面無傷口的術式。本研究目的則是因國內這類患者仍是以眼科醫師操作外側淚囊鼻腔造廔術為主，故探討耳鼻喉科醫師以TEDCR來治療這類患者的可行性及成功率。
方法：自2000年11月至2001年12月間，收集因慢性淚囊炎或鼻淚管阻塞造成之淚溢症患者，經眼科醫師診斷並保守治療無效，因而轉介至本科實施TEDCR。手術是在全身麻醉下，以內視鏡監視，使用鼻內骨鑽磨開淚骨及部分上頜骨額突，最後將淚囊打開，再從上及下淚小管置放一矽質小管並打結於鼻腔內，隔天出院。
結果：所有接受TEDCR的15名患者中，男性5名，女性10名，男女比為1：2，年齡自30至70歲，平均58歲。以患側來分，11名是雙眼，4名是單眼，其中　3名左眼，1名右眼，共26眼。在施行26次TEDCR中有5名病患合併作鼻中隔矯正手術。19次（73.1%）在劃開淚囊後有膿液或黏液流出，並無淚囊結石發現。有一例（3.8%）在術後當天發生輕微鼻出血。有11隻眼（42.3%）術後有眼內眥瘀青，不過皆在1週左右消失。一眼手術時間自10分至45分鐘不等，平均約23分鐘。術後追蹤6個月至1年1個月不等，平均9個月。滿意度評估以非常好、好、不變、更差來作主觀問卷調查，以術後六個月作為收集療程滿意度問卷調查的時間點，結果表示非常好有20側（76.9%），好有4側（15.4%），不變有2側（7.7%），更差0側。成功率為92.3%（非常好 + 好）。失敗2側。術後鼻腔內視鏡檢查發現此2例皆有肉芽組織形成，形成造口狹窄。其它成功患者24側也有6側（25%）有不同程度肉芽組織出現，但不影響造口之通暢。
結論：以TEDCR來治療因慢性淚囊炎或鼻淚管阻塞造成之淚溢症具備顏面美觀的保持、高成功率、低術中及術後併發症、手術時間短以及眼輪匝肌和內眥肌腱的幫浦功能得以保存等優點，並且對於鼻內其他疾病可一併處理，實可做為國內耳鼻喉科醫師的常規手術項目。

關鍵字

內視鏡 ； 淚囊鼻腔造廔術 ； 淚溢症

並列摘要

BACKGROUND: Epiphora is a very annoying symptom which make patients feel emba-rrassed both functionally and socially. The main reason of epiphora is obstruction of the lacrimal pathways, either congenital or acquired. Dacryocystorhinostomy (DCR) is the treatment of choice for epiphora in cases of obstruction distal to the common canaliculus. External DCR (Toti’s operation) is the most established referenced treatment modality for epiphora by ophthalmologist. With the development of minimally invasive endo-scopic surgery, the transnasal endoscopic DCR (TEDCR) has been introduced over the past a decade. The study was conducted to discuss and analyze our success rates and complications of TEDCR.
METHODS: From November 2000 to December 2001, 15 patients with epiphora were referred from ophthalmologist due to failure of conservative treatment. Under general anesthesia, all the cases underwent TEDCR with silicone tube intubation.
RESULTS: Of the 15 patients, 26 eyes (11 bilateral + 4 unilateral) underwent primary TEDCR. There were 10 women and 5 men (♀ : ♂= 2 : 1) from 30 to 70 years of age (mean58 years). The average operative time was 23 minutes. The follow-up ranged from 6 months to 13 months with a mean of 9 months. Submucosal resection of nasal septum was performed in 5 of 15 patients. In 19 TEDCRs (73.1%), mucous or pus were observed after lacrimal sac incision. There were no intraoperative complications. In the immediate postoperative period, minor epistaxis occurred in 1 side (3.8%) and medial canthus ecchy-mosis occurred in 11 eyes (42.3%). Patients completed a Patient Satisfaction Survey at 6 months after surgery. The results of TEDCR were reported as ‘very good’by 20 sides (76.9%), as ‘good’ by 4 sides (15.4%), as ‘no change’by 2 sides (7.7%), and as ‘bad’zero. The overall success rate was 92.3%. Postoperative endoscopic evaluation found scar-ring and granulations of rhinostoma were the causes of surgical failure. Granulation tissues were also found in 6 sides (25%), but did not influence the patency of stoma.
CONCLUSIONS: TEDCR has the advantages of better cosmesis, high success rate, mini-mal intra and postoperative complications, less time-consuming, and preservation of pump function of the orbicularis oculi muscle and medial canthal tendon. It allows some of intranasal pathology (e.g. nasal septal deviation) treatment at the same time and can be a regular surgical option for ENT surgeons.

並列關鍵字

endoscopic ； dacryocystorhinostomy ； epiphora