Dacryocystitis is the inflammation of the lacrimal sac. It is usually secondary to obstruction of nasolacrimal duct followed by bacterial infection. Dacryocystitis is of two main types acute and chronic. Acute dacryocystitis is a sudden, painful infection of the lacrimal sac characterized by redness, swelling, and tenderness over the medial canthus, often associated with fever and abscess formation. ⁽¹⁾

Chronic dacryocystitis is a long-standing condition presenting with persistent watering of the eye and mucopurulent discharge on pressure over the lacrimal sac, usually without significant pain or acute inflammation. Chronic dacryocystitis is most commonly caused by obstruction of the nasolacrimal duct. ^(1,2)

Dacryocystorhinostomy (DCR) is a commonly performed operation in which a fistulous tract is created between the lacrimal sac and the nasal cavity to alleviate epiphora caused by nasolacrimal duct obstruction. External DCR is done via external incision below the medial canthal tendon by ophthalmologists & endonasal DCR is done by Otorhinolaryngologists through nasal cavity with the help of rigid endoscopes. The endonasal approach offers advantages over external DCR, including absence of a skin scar, preservation of the medial canthal anatomy, and reduced postoperative morbidity. ^(3,4)

Two main techniques are used in endonasal DCR: mucosal flap preservation, where the nasal mucosa around the neo-ostium is retained and flap resection, where the mucosa is removed. Preservation may promote primary healing and prevent granulation formation, but may be technically challenging in narrow nasal cavities. The surgical outcomes of both the methods were comparable. However, in presence of deviated nasal septum or any other anatomical variations due to lack of sufficient space mucosal flap resection method is useful. ^(5,6)

Despite numerous studies, ^(7,8) there remains no clear consensus regarding the superiority of one technique over the other. Some authors report higher anatomical and functional success rates with flap preservation due to better mucosal healing, while others demonstrate comparable outcomes with flap resection, emphasizing surgical simplicity and reproducibility. Additionally, factors such as surgeon experience, size of osteotomy, postoperative care, and patient-related variables may influence surgical success. ^(7,8)

Therefore, the present study aims to compare the outcomes of flap preservation versus flap resection in endonasal DCR.

Objective: To study the surgical outcome of endonasal dacryocystorhinostomy with mucosal flap preservation v/s resection.

MATERIALS AND METHODS:

The present study was conducted to compare surgical outcome of endonasal dacryocystorhinostomy with mucosal flap preservation v/s resection at tertiary care hospital.

Study Design: The present study was a prospective analytical study.

Study Setting: The study was conducted at the Department of Otorhinolaryngology, Pt. J.N.M. Medical College & Dr. B.R.A.M. Hospital, Raipur, from January 2024 to January 2025.

Study Participants: All patients visiting between 10–70-year age group with either unilateral or bilateral with history of chronic epiphora, swelling near medial canthus (chronic dacryocystitis), regurgitation of pus discharge after applying pressure over lacrimal sac region (ROPLAS test +ve) or obstruction of the lacrimal sac or nasolacrimal duct (confirmed by syringing)

Sample Size: Sample size was calculated using G*Power based on a statistical test for two independent proportions. The expected proportion (P1) of surgical success rate in Group A (with preserved mucosal flaps) was taken as 1.00 (100%), while the proportion (P2) in Group B (with resected mucosal flaps) was 0.883 (88.3%). With a level of significance set at 0.05 and a study power of 95%, the calculated sample size was 66 patients, of whom 34 were allocated to Group A and 32 to Group B.

Sampling Method: Consecutive sampling method

Inclusion criteria:

• Age 10–70 years
• Chronic epiphora with or without swelling near medial canthus
• Positive ROPLAS test
• Nasolacrimal duct obstruction confirmed by syringing

Exclusion criteria:

• Acute dacryocystitis
• Previous lacrimal surgery
• Canalicular obstruction
• Acute ocular inflammatory conditions
• Post-traumatic deformity
• Chronic systemic illness or bleeding diathesis

Methodology:

All surgeries were performed using standard endoscopic equipment including 0° and 30° endoscopes, Kerrison bone punch, Blakesley forceps, lacrimal probes, punctum dilator, and suction instruments, following proper aseptic preparation with povidone-iodine and sterile draping. Local infiltration of 2% lidocaine with 1:100,000 epinephrine was administered near the middle turbinate under endoscopic guidance to achieve adequate hemostasis and analgesia.

The procedure was conducted under general anesthesia with emphasis on maintaining optimal surgical field visibility. Patients were positioned in a 10–15° head-up (reverse Trendelenburg) position to reduce venous congestion. Additional measures to control bleeding included nasal decongestion with xylocaine and adrenaline, use of tranexamic acid, and preference for total intravenous anesthesia. Postoperatively, patients were managed with adequate analgesia, with most experiencing minimal discomfort.

Surgical Technique:

All patients underwent endoscopic endonasal DCR under general anesthesia with hypotensive technique and topical nasal decongestion.

Group A: Nasal mucosal flap elevated and preserved; approximated to lacrimal sac flap; gel foam placed to maintain position.

Group B: Nasal mucosal flap resected; lacrimal sac opened and medial wall removed as needed.

Postoperative care included topical antibiotics and steroids, nasal saline irrigation, and avoidance of nose-blowing for one week.

Follow-up and Outcome Measures

Patients were follow-up at 2 weeks, 1 month, and 3 months. Primary outcome includes anatomical patency (syringing and endoscopic evaluation) while secondary outcomes include symptom resolution and postoperative complications (granulations, synechiae, restenosis).

Statistical Analysis:

Data was entered in MS excel and analyzed using suitable statistical software SPSS version 23. Categorical/Descriptive data was presented in numbers and percentage while quantitative data was presented in Mean ± SD or median (IQR). Normality of the data was checked and accordingly chi square test was used to identify the statistically significant; p<0.05 considered statistically significant.

RESULTS:

Table 1. Distribution according to patient’s profile: (n=66)

The table no. 1 shows that mean age was significantly higher in Group A (45.88±16.37 years) vs Group B (37.94±16.18 years; p=0.027). Females predominated in both groups (67.6% vs 78.1%, p=0.339). The maximum incidence of chronic dacryocystitis among group A (flap preservation technique) with duration of complaints ranging from 1-5 years is 18 (52.9%) patients while among group B (flap resection technique) duration of complaints less than 1 year was 12 (37.5%) patients.

Table 2: Distribution of Complaints among the patients (n=66)

The complaints of chronic dacryocystitis among both groups was epiphora in 100% patients, swelling near the medial canthus was reported in 26.5% of patients in the preservation group and 15.6% in the resection group with no statistically significant difference. (p = 0.684).

Regurgitation of pus on applying pressure over the lacrimal sac area was present in 20.6% of patients in the preservation group and 18.7% in the resection group. This difference was also not statistically significant (p = 0.768). (Table 2)

Table 3: Distribution of various tests among the patients (n=66)

ROPLAS test of chronic dacryocystitis was positive in 7 (20.6%) patients among group A (flap preservation technique) and 5 (15.6%) patients among group B (flap resection technique). The maximum patients of chronic dacryocystitis among group A (flap preservation technique) had mixed fluid in 16 (47.1%) patients, while among group B (flap resection technique) was Clear fluid in 17 (53.1%) patients with no statistically significant difference. (Table 3)

Table 4: Distribution of endoscopic findings among the patients (n=66)

The distribution of preoperative endoscopic findings showed significantly higher proportion of patients in the preservation group had a centrally placed nasal septum (64.7%), whereas deviation to the left (43.7%) and right (50.0%) was more common in the resection group (p = 0.0001). Similarly, for the middle turbinate, medialization was more common in the preservation group (76.5%), whereas lateralization was more frequent in the resection group (62.5%), showing a statistically significant difference (p = 0.0013). Overall, these findings indicate that anatomical variations were significantly more prevalent in the resection group. (Table 4)

Table 5: Distribution of outcomes among the patients (n=66)

At 3 months, ostium patency was slightly higher in Group A. Both groups achieved high symptom resolution rates (>90%). Granulation tissue occurred in 1/34 (2.9%) in Group A vs 4/32 (12.5%) in Group B. Synechiae occurred only in Group B (6.25%). No cases of orbital fat prolapse or medial rectus injury were reported. (Table 5)

DISCUSSION:

The present study was an attempt to compare the outcomes of endonasal DCR with mucosal flap preservation and resection techniques.

In the present study on chronic dacryocystitis, the majority of patients were in the 26–35 years age group with a mean age of 42.8 years, which is comparable to findings reported by Kansu et al ⁽⁹⁾ (47 years), Prakash et al ⁽¹⁰⁾ (40.8 years), and Ofira et al ⁽¹¹⁾ (51.1 years).

Females constituted 72.7% of cases with a male:female ratio of 1:2.67, similar to Tsirbas et al ⁽¹²⁾ (1:1.87), Prakash et al ⁽¹⁰⁾ (1:2.5), Parmar et al ⁽¹³⁾ (1:1.9), Chacko et al ⁽¹⁴⁾ (1:2.33), and Hosam et al ⁽¹⁵⁾ (1:2.31), confirming female predominance.

Right-sided involvement was observed in 60.6% of cases compared to 39.4% on the left side, which is in agreement with Prakash et al ⁽¹⁰⁾ (59.5% right-sided) and Parmar et al ⁽¹³⁾ (46% right-sided), demonstrating a similar trend of laterality.

In the study, central septum involvement is predominantly associated with the Preservation group, while left and right septum involvement is more frequently managed with Resection. These findings suggest that the anatomical location of the septum plays a critical role in determining the appropriate surgical approach. Middle turbinate, medialization was more common in the preservation group (76.5%), whereas lateralization was more frequent in the resection group (62.5%), showing a statistically significant difference (p = 0.0013). These findings suggest that the position and condition of the inferior turbinate strongly influence the choice of surgical technique.

The success rate of endonasal DCR in group A (endonasal DCR with mucosal flap preservation) was 97.1% (33/34) as compared to group B (endonasal DCR with mucosal flap resection) 93.8% (30/32) (p-< 0.05). The findings were consistent with the previous study by, Parmar et al ⁽¹³⁾ 2016 with the success rate of endonasal DCR  in group A was 92% as opposed to group B 88%, Ofira et al ⁽¹¹⁾ 2019 with the success rate of endonasal DCR  in group A was 86.8%  as opposed to group B 82.1%, Chacko et al ⁽¹⁴⁾ in which the success rate of endonasal DCR  in group A was 96% as opposed to group B 82%  & Hosam et al ⁽¹⁵⁾ with the success rate of endonasal DCR  in group A was 92.9% as opposed to group B 84%.

Nasal endoscopy of surgical failure showed restenosis by formation of granulation tissue around neo-ostium in group A and synechiae in 1 patient each from both the groups.  The surgical outcomes of both the methods were comparable but preservation of nasal mucosal flap can be used to cover the bared bone with avoidance of granulation tissue formation reducing the risk of closure of ostium and improve success of endoscopic endonasal DCR and also, Mucosal flap preservation maintains the normal anatomy and physiology hence it is better.

Although differences did not reach statistical significance—likely due to the modest sample size—the practical benefit of flap preservation lies in better mucosal healing and reduced need for revision surgery. Flap resection may still be preferred in anatomically narrow nasal cavities or in the presence of septal deviations where space is limited.

The study was limited by a short follow-up period, single-center design, and non-randomized allocation; however, it was strengthened by its prospective design and the use of standardized surgical and postoperative protocols.

CONCLUSION:

Endonasal DCR with either flap preservation or flap resection yields high anatomical and functional success rates. Mucosal flap preservation may offer advantages in reducing granulation tissue and preserving ostium patency, but surgeon preference and anatomical considerations should guide technique selection.

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