Randomized, Controlled, Study of Absorbable Nasal Packing on Outcomes of Surgical Treatment of Rhinosinusitis with Polyposis

Effect of carboxymethylcellulose nasal packing on wound healing after functional endoscopic sinus surgery

BACKGROUND

Functional endoscopic sinus surgery (FESS) has become the treatment of choice for patients with medically resistant chronic rhinosinusitis. Nasal packing is usually placed after the surgery to support wound healing and prevent adhesions. The purpose of this study was to investigate the effect of carboxy-methylated cellulose (CMC) nasal packing on wound healing after FESS compared with no nasal packing.

METHODS

Twenty-six patients underwent bilateral FESS. The patients were randomized to receive CMC mesh or gel packing on one side and no packing on the opposite side. The patients were followed at 2, 4, and 12 weeks after surgery. Endoscopically visible CMC, crusting, mucosal integrity, synechia formation, granulation tissue formation, and adverse side effects were assessed and documented.

RESULTS

No adverse side effects were observed. No significant differences were found between the CMC-packed side and the unpacked side with respect to the outcome measure of wound healing. No difference was found between two different forms of CMC in terms of wound healing. Two weeks after surgery, endoscopically visible CMC was detected in four patients of the CMC mesh group, whereas none of the patients in the CMC gel group had endoscopically visible CMC (p = 0.040).

CONCLUSION

As we were unable to establish an effect, we must question the efficacy of this packing material and the necessity of its use after FESS based on the technique of the Graz University Medical School. The mesh form of CMC could be potentially useful as a vehicle for extended drug delivery owing to its longer retention time in the nose.

Endoscopic outcomes of resorbable nasal packing after functional endoscopic sinus surgery: a multicenter prospective randomized controlled study

Nasal packings can aid in control of postoperative bleeding and healing following functional endoscopic sinus surgery (FESS), but traditional non-resorbable stents have several inherent drawbacks. We performed a randomized, controlled, multicenter clinical trial to assess efficacy of resorbable nasal packing in patients undergoing FESS for chronic rhinosinusitis. A total of 66 patients for 88 nasal cavities were randomized to receive either hyaluronan resorbable packing (MeroGel) or standard non-resorbable nasal dressing after FESS. All underwent preoperative rhinoscopy, CT of sinuses, and, after surgery, were reassessed by rhinoscopy at 2, 4, and 12 weeks in blinded fashion. A total of 44 nasal cavities (MeroGel-group) received resorbable packing, whereas the remaining 44 were packed with non-resorbable nasal dressing. At follow-up endoscopic visit, the presence of nasal synechia was evaluated as primary outcome. Moreover, the tolerability and surgical handling properties of MeroGel and its comfort were assessed by surgeons and patients. Preoperative severity of rhinosinusitis was similar in both groups. No significant adverse events were observed in all patients. Follow-up endoscopy showed a lower proportion of nasal adhesions in MeroGel-group at both 4 (P = 0.041) and 12 weeks (P < 0.001). Moreover, an improvement of other endoscopic nasal findings such as re-epithelialization, presence of granulation tissue, and appearance of nasal mucosa of nasal cavities after FESS was observed in the MeroGel-group. Tolerability and surgical handling properties of MeroGel were positively rated by clinicians and the overall patient judged comfort of MeroGel was favorable. In conclusion, MeroGel can be considered a valid alternative to standard non-resorbable nasal dressings. It is safe, well-accepted, well-tolerated, and has significant advantage of being resorbable. Moreover, it may favor improved healing in patients undergoing FESS and reduce formation of adhesions.

No Packing versus Packing after Endoscopic Sinus Surgery: Pursuit of Patients’ Comfort after Surgery

Background

This study was designed to evaluate the necessity of postoperative nasal packing and to find factors relevant in determining if nasal packing was required after endoscopic sinus surgery (ESS).

Methods

From January 2007 through June 2007, 64 consecutive patients who underwent ESS were evaluated. The decision whether or not to perform nasal packing depended on the surgeon's judgment of the bleeding after surgery. Demographic characteristics, medical history, disease extent, surgical procedures, and subjective and objective amount of intraoperative bleeding were analyzed. Postoperative symptoms and endoscopic findings were evaluated also.

Results

Forty-eight (75%) of the 64 patients included in this study did not have nasal packing after ESS. One patient from the no-packing group needed nasal packing postoperatively because of persistent nasal bleeding. Symptom scores of nasal obstruction and postnasal drip on the 1st postoperative day were lower in the no-packing group. In unilateral ESS cases, subjectively estimated blood loss and mucosal inflammation scores were lower in the no-packing group. It was observed that preoperative steroid use was more frequent in the packing group. All other parameters did not show significant differences between the two groups.

Conclusion

Nasal packing can be safely used less frequently to help the patients experience less discomfort after ESS. The need for nasal packing after ESS can be decided by judicious estimation of bleeding during and after the surgery.

A Scientific Review of Middle Meatal Packing/stents

Background

Nasal packing usually is placed after endoscopic sinus surgery (ESS) to control hemorrhage, but also may be used to prevent adhesions from forming and promote faster healing of damaged mucosa.

Methods

A literature review was performed to identify all forms of scientifically evaluated absorbable packing for ESS. Only English studies identifiable within the PubMed database were included. Studies were categorized by level of evidence and evaluated for methodological errors.

Results

Thirty-eight studies met the inclusion criteria. There was a diverse range of article evidence and quality.

Conclusion

The most effective hemostatic agent currently available is FloSeal; however, this product causes an increase in adhesion formation. For the purpose of preventing adhesions, resorbable packs appear to have no benefit over either nonresorbables or no packing. If the middle turbinate is unstable at the conclusion of surgery, suturing it to the septum may reduce adhesions. Although mitomycin C, hyaluronic acid, and retinoic acid all have shown potential in these roles, to date, none have shown to be useful in the post-ESS chronic sinusitis human patient.