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Journal Français d'Ophtalmologie
Volume 39, n° 8
pages 687-690 (octobre 2016)
Doi : 10.1016/j.jfo.2016.03.009
Received : 3 February 2016 ;  accepted : 18 Mars 2016
Acquired fistula of the lacrimal sac and laisser-faire approach. Description of the natural history of acquired fistulas between the lacrimal sac and the skin occurring before planned endonasal dacryocystorhinostomy (DCR) and without any treatment of the fistula
Fistule acquise du sac lacrymal et laisser-faire. Description de l’évolution spontanée des fistules sacculo-cutanées acquises apparues avant dacryocystorhinostomie (DCR) programmée et sans geste spécifique sur la fistule
 

A. Pison a, b, , J.-L. Fau c, E. Racy d, B. Fayet a
a Hôpital Hôtel-Dieu, 1, parvis Notre-Dame – place Jean-Paul-II, 75004 Paris, France 
b Université Paris Descartes, 12, rue de l’École-de-Médecine, 75006 Paris, France 
c Cabinet privé, 30, place Carriere, 54000 Nancy, France 
d Cabinet privé, 19, rue Oudinot, 75007 Paris, France 

Corresponding author at: Hôpital Hôtel-Dieu, Université Paris Descartes, 75004 Paris, France.
Summary
Introduction

The formation of a fistula between the lacrimal sac and the skin is a classic outcome of resistant lacrimal sac abscesses. There is currently no consensus about treatment in such cases. The goal of this study was to describe the natural history of acquired fistulas between the lacrimal sac and the skin, occurring before planned endonasal dacryocystorhinostomy (DCR) and without any treatment of the fistula.

Materials and methods

This prospective study was only descriptive and included patients between 1999 and 2012. The patients included were adults with a nasolacrimal duct (NLD) obstruction that was planned to be treated with endonasal DCR. A resistant lacrimal sac abscess appeared a few days before the planned surgery, and fistulized spontaneously despite medical treatment. The surgery was not delayed. The DCR was endoscopic. Nothing was done for the fistula. Its healing was spontaneous. The exclusion criteria were the following: congenital fistulas, post-traumatic and/or iatrogenic fistulas, fistulas which had regressed by the day of the surgery, postoperative follow-up less than 5 months, post-traumatic and/or iatrogenic fistulas, any history of previous DCR or any other lacrimal surgery, children.

Results

Twenty adults (25 cases) were included in the analysis. Mean age was 79 years old (from 41 to 90). The mean follow-up was 41 months (from 5 to 108 months). The fistula spontaneously disappeared in all cases, less than one month after it had appeared and in a permanent fashion. No unsightly scar developed.

Discussion

Spontaneously acquired fistulas between the lacrimal sac and the skin may occur in the natural course of abscessed acute dacryocystitis. Our study showed spontaneous healing of the fistula post-endoscopic DCR.

Conclusion

Fistula excision in fistulous acute dacryocystitis does not seem essential to its healing. The laisser-faire approach appears adequate for aesthetic outcomes as well as for functional outcomes of DCR.

The full text of this article is available in PDF format.
Résumé
Introduction

La fistulisation sacculo-cutanée est une évolution classique des abcès du sac lacrymal rebelles. Sa prise en charge ne fait pas l’objet d’un consensus actuellement. Le but de cette étude était de décrire l’évolution spontanée des fistules sacculo-cutanées acquises après dacryocystite aiguë dans les suites de dacryocystorhinostomie (DCR) et sans association à un geste spécifique sur la fistule.

Matériel et méthodes

Il s’agissait d’une étude prospective non comparative entre 1999 et 2012. Elle portait sur des patients adultes présentant une sténose lacrymonasale qui devait être traitée par DCR endonasale. Dans les jours qui ont précédé l’intervention s’est produit un abcès du sac lacrymal rebelle qui s’est fistulisé spontanément malgré le traitement médical. La programmation de l’intervention n’a pas été différée. La DCR a été réalisée par voie endonasale. Aucun geste complémentaire n’a été réalisé sur le trajet fistuleux. Sa cicatrisation a été livrée à elle-même. Ont été exclus : les fistules congénitales, les fistules taries au moment de la DCR, les suivis postopératoires inférieurs à 5 mois, les fistules post-traumatiques et/ou iatrogènes, antécédent de DCR ou toute autre chirurgie lacrymale, enfants.

Résultats

Vingt adultes (25 cas) ont été inclus dans l’analyse. L’âge moyen était de 79ans (de 41 à 90ans). Le recul moyen était de 41 mois (extrêmes de 5 à 108 mois). Dans tous ces cas, la fistule s’est tarie spontanément, en moins d’un mois et de façon pérenne. Aucune cicatrice inesthétique n’a été déplorée.

Discussion

Les fistules sacculo-cutanées acquises spontanées peuvent se produire au cours l’évolution naturelle des dacryocystites aiguës abcédées. Notre étude retrouve une cicatrisation spontanée de la fistule après DCR par voie endonasale.

Conclusion

La résection des trajets fistuleux compliquant les dacryocystites aiguës ne semble pas indispensable à la cicatrisation. Ce laisser-faire semble neutre autant pour le résultat esthétique et que pour le résultat fonctionnel de la DCR.

The full text of this article is available in PDF format.

Keywords : Dacryocystitis, Lacrimal sac abscess, Acquired fistula, Endonasal dacryocystorhinostomy, Scar

Mots clés : Dacryocystite, Sac lacrymal, Fistule acquise, Dacryocystorhinostomie, Cicatrice


Introduction

Spontaneous acquired fistula between the lacrimal sac and the skin is one of the natural possible evolutions of resistant lacrimal sac abscesses [1, 2]. Many different treatments have been described but no consensus has been reached yet.

Some contraindicate dacryocystorhinostomy (DCR) until complete healing of the cutaneous inflammation, and others do not.

The most frequently recommended treatment on the fistula is excision with suture of the edges. This is not always easy to realize with necrotic tissues and does not help the aesthetic outcome that can be deceiving [3, 4, 5, 6].

When external DCR is chosen, some suggest to extend the canthal incision to the fistula. Others prefer not to change their incision and to excise the fistula with another incision [7].

Clinical experience shows that spontaneously fistulised lacrimal abscesses almost always finally heal alone with an excellent aesthetic outcome. This calls into question the need to excise acquired fistulas, and encourages to focus the treatment on the nasolacrimal duct (NLD) obstruction, neglecting the fistula [1, 8, 9].

We report our experience with acquired fistulas between the lacrimal sac and the skin left on their own, during endoscopic DCR.

Materiel and methods

The aim of this study was to describe the evolution of post-lacrimal sac abscess fistulas left on their own. Inclusion criteria were: all cases of spontaneous and active fistula in adults. The lacrimal sac abscess had appeared a few days before surgery. Exclusion criteria were: congenital fistulas, iatrogenic fistulas, history of fistula healed at the moment of the surgery, previous history of DCR or any other lacrimal surgery, follow-up less than 5 months, children.

All the patients received the same treatment.

The endoscopic DCR (BF&ER) included the creation of a mucoperiosteal flap, an osteotomy with rongeurs, and an excision of the medial wall of the lacrimal sac mucosa. The details of the surgical technique have already been published [10].

In all the cases, the fistula has been neglected. Nothing was done. The healing was left on its own without excision or suture.

The following items have been studied:

becoming of the fistula;
aesthetic outcome of the fistula;
functional outcome of the DCR (considered good when there was a disappearance of the epiphora; a permeable tear duct system with mechanical salted serum test, without any reflux; and no dacryocystitis recurrence).

Results

Over a period of 13 years (1999–2012), 1039 endoscopic DCR have been practiced in one center by the same surgeons (BF&ER). Among those lacrimal mucoceles, 25 acute dacryocystitis (2.4%) (20 adult patients) appeared in the days preceding the planned surgery.

Despite medical treatment (antibiotics), they all spontaneously fistulised (25/1039=2.4%). All the cases were consecutive. Mean age was 79 years old (41–90). The mean postoperative follow-up was 41 months (from 5 to 108 months). The fistula spontaneously healed in 100% of the cases. No scarred epicanthus or stellar scar was described. There was no functional failure.

Discussion

Our study included only 25 cases and is only descriptive. No prospective comparative study was found in the literature on the subject. However, our results seem to be indicative about.

The moment of the intervention

Intuitively, one prefer to wait for the tissues to be less inflammatory before surgery. However, delaying surgery is not always easy on a human level (anticoagulation treatment, child care, stress, old patient…). But, in the context of our study, an endoscopic DCR realized early after fistulisation did not result in a pejorative outcome for the healing of the fistula. This finding is in the line with Ari et al. study [5]. This is why early fistulisation before planned surgeries does not delay our surgeries.

The influence of the fistula on the outcome of the DCR

It is commonly believed that the presence of a fistula between the lacrimal sac and the skin might influence pejoratively the outcomes of a DCR.

The excision and suture of the fistula, allowing to drain the tears directly to the nasal cavity, should improve the outcomes of the surgery. However, Subbaiah's study showed a good efficacy (100%) of endoscopic DCR without any gesture on the fistula that spontaneously healed [1]. Our study showed the same findings, and suggest that neglecting an acquired fistula is neutral on postoperative outcomes.

Laisser-faire approach: quickest and simplest method

On a technical level, the laisser-faire approach for acquired fistula seems to be the quickest and simplest method. This attitude is not applicable to congenital fistulas.

Ari et al. showed in 2013 [5] the results of excision of the fistula and external DCR in the treatment of fistulas between the lacrimal sac and the skin after lacrimal sac abscess. This study had two groups: one group of patients with congenital fistulas, and another with acquired fistulas. In the acquired fistulas group, eight patients had acute dacryocystitis and two patients had recurrent fistulised dacryocystitis; the mean follow-up was 14.3±3.7 months. All the patients had permeable tear ducts at the last follow-up, with a closing of the fistula. However, the presence or absence of an unsightly scar was not described.

Healing of the fistula

In 2003, Subbaiah [1] had retrospectively studied seven patients of which nine cases of post-lacrimal sac abscess fistula. The treatment was an endoscopic DCR without any external surgery. The authors had noted a healing of the fistula with a resolution of the epiphora in 100% of the cases. The aesthetic aspect of the fistula scar was not described. Endoscopic DCR with laisser-faire approach for the fistula showed very good results in our study (100% of success, with spontaneous healing of the fistula without unsightly scar). No recurrence was noted.

Laisser-faire approach very effective

On an aesthetic level, the laisser-faire approach for the fistula seems very effective. This is probably because there is no loss of tissue unlike when an excision is done.

Conclusion

The early onset of a fistula between the lacrimal sac and the skin after lacrimal sac abscess does not change the treatment that was planned to fix the nasolacrimal duct (NLD) obstruction (endoscopic DCR alone with laisser-faire approach for the fistula seems to be an effective treatment). Excision of the fistula in acute dacryocystitis does not seem essential. The laisser-faire approach simplifies the surgery and improves aesthetic outcomes. This attitude could be applicable at any age, but other studies are needed to prove it.

Disclosure of interest

The authors declare that they have no competing interest.

References

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