Incidence of Symptomatic Lacrimal System Obstruction Following Maxillectomy

Poster Title: Incidence of Symptomatic Lacrimal System Obstruction Following Maxillectomy

Student: Glen McKinney, Class of 2024

Faculty Mentor and Department: J. Dale Browne, Otolaryngology – Head and Neck Surgery

Funding Source: Department of Biomedical Engineering, Wake Forest School of Medicine

ABSTRACT

Background: The most common head and neck malignancy is Squamous Cell Carcinoma (SSC); many such tumors arise within or invade the maxilla and commonly involve pre/post-operative radiation therapy in addition to a maxillectomy to achieve complete tumor removal and clear margins. Many maxillectomy surgeries, given the maxilla’s proximity to the lateral nasal wall and nasolacrimal duct, have the potential to damage the nasolacrimal drainage system during surgical resection. The resultant changes often manifest as lacrimal obstruction which typically presents as epiphora or lacrimal infection; it can also result in myriad ophthalmological complications for the patient including vision change, periorbital edema, ptosis, and diplopia. Intraoperatively, surgeons can attempt to prevent lacrimal obstruction by placing lacrimal stents during the maxillectomy to preserve the drainage pathway and/or can surgically repair an obstructed lacrimal duct through a dacryocystorhinostomy (DCR) procedure. The aim of this study was to examine the incidence of lacrimal system obstruction following maxillectomy surgeries. Additionally, we sought to explore the effectiveness of intraoperative lacrimal stents, whether preoperative or postoperative radiation has effects on lacrimal obstruction, and the effectiveness of DCR surgery on relieving lacrimal system obstruction.

Hypothesis: We hypothesized that the incidence of lacrimal system obstruction would be between 1.9% and 29%, in line with what previous research suggests. Additionally, it was hypothesized that lacrimal stent placement decreases the incidence of lacrimal obstruction, that DCR is an effective means of lacrimal repair, and that post-op radiation would result in less lacrimal obstruction than pre-op radiation.

Methods: An IRB approved retrospective study was performed containing 128 study patients who underwent maxillectomy surgery involving the lacrimal duct between the years of 2012 and 2021. We examined the patients’ electronic medical records to obtain information regarding the management of their cancer. We gathered information from the preoperative consultation notes, surgical notes, hospital stay notes, and postoperative follow-up notes to gather the data pertinent to our study. The data collected included information on their cancer pathology, specific surgery, intraoperative stent placement, radiation treatment plan, post-op lacrimal obstruction and ophthalmological symptoms, and how the symptoms were resolved.

Results: Analysis of the data revealed that out of 128 study patients, 17.18% experienced symptoms of lacrimal obstruction and 32.81% of patients experienced ophthalmological complications. Among the patients who received an intraoperative stent (n=10), 60% experienced zero lacrimal obstruction symptoms following surgery whereas 85% percent of patients who did not receive a stent (n=118) experienced zero lacrimal obstruction symptoms (p=0.0179). Among the patients who required corrective DCR surgery, 100% experienced relief of symptoms. Lastly, 55.55% of patients who received pre-operative radiation therapy experienced lacrimal obstruction symptoms while only 27.77% of patients who received post-operative radiation therapy experienced lacrimal obstruction symptoms (p=0.0019).

Conclusions: The data confirmed our hypothesis regarding the incidence of lacrimal obstruction symptoms as 17.18% is roughly in line with numbers reported in previous studies. Additionally, our study surprisingly revealed that intraoperative stent placement resulted in a higher incidence of lacrimal obstruction than not placing a stent, suggesting stent placement is an ineffective measure at preventing lacrimal obstruction. This conclusion however is limited by the small sample size of stented patients (n=10). The study also suggests that patients who received pre-op radiation were more likely to experience lacrimal obstruction symptoms following surgery. The data also reinforces the effectiveness of DCR as a mean of lacrimal system repair although this conclusion is also limited by a small sample of DCR patients (n=3).