Postoperative care after endoscopic sinus surgery

Surgiflo® hemostatic matrix versus NasoPore® nasal packing following postassium titanyl phosphate laser surgery for hereditary hemorrhagic telangiectasia: A randomized controlled trial

Background

To help ensure adequate hemostasis immediately following potassium titanyl phosphate (KTP) laser treatment, many centres treating hereditary hemorrhagic telangiectasia (HHT) routinely use nasal packing post-operatively. The purpose of this study was to compare hemostatic thrombin matrix with standard packing for postoperative bleeding, patient pain, and comfort.

Methods

A prospective, randomized, double-blinded, non-inferiority study was conducted with participants at an HHT centre of excellence (COE) and randomized to the treatment group with reconstituted thrombin gelatin matrix (Surgiflo®) or control group with a biodegradable synthetic polyurethane foam (NasoPore®). Adult subjects with confirmed HHT and moderate to severe epistaxis (a minimum calculated epistaxis severity score [ESS] of 4.0) warranting KTP laser treatment were recruited. Data was collected 2 weeks post operatively by a blinded reviewer completing a visual outcomes evaluation and each patient completing a subjective symptoms questionnaire. Non-parametric statistical analysis was employed.

Results

Twenty-eight adult patients were randomized to the treatment and control arms with comparable preoperative epistaxis severity scores. Postoperative nasal bleeding was equivalent. Significantly less pain was found in the treatment arm (p = .005). While there were trends towards less obstruction and increased satisfaction in the treatment group as well as less crusting in the control group, these findings were not statistically significant. Allocation to the treatment group was associated with an approximately $75 higher cost.

Conclusions

When compared to NasoPore® for hemostasis, Surgiflo® hemostatic matrix performed equivalently while causing less discomfort in HHT patients following nasal KTP treatment.

Level of evidence

1b.

Efficacy of Rhino-Protect ointment after endoscopic sinus surgery: a prospective, randomized, multicenter study

OBJECTIVE

Blocking airflow into the sinonasal cavity after surgery may help to keep the cavity moist and thus decrease postoperative crusting. Here we investigated the efficacy of Rhino-Protect ointment following endoscopic sinus surgery (ESS).

SUBJECTS AND METHODS

A total of 93 patients with chronic rhinosinusitis who underwent identical ESS were enrolled. After surgery, all patients were instructed to perform nasal saline irrigation and deliver a nasal spray to each nostril, then to apply Rhino-Protect ointment to one nostril only; the other nostril served as a control. Subjective symptoms, postoperative Lund-Kennedy (LK) endoscopic scores, and adverse reactions 14 and 28 days after treatment were evaluated.

RESULTS

The Rhino-Protect ointment significantly reduced pain (p = 0.015 at 28 days), dryness (p = 0.009 at 14 days and p = 0.045 at 28 days), and crusting (p = 0.047 at 14 days), and was associated with significantly lower LK scores 14 and 28 days after treatment (p = 0.037 and p = 0.007, respectively). Statistically significant differences were noted in the LK edema subscore at 14 days (p = 0.043) and in LK crusting subscores at 14 and 28 days (p = 0.005 and p = 0.006, respectively). No patient reported any serious adverse event associated with Rhino-Protect use.

CONCLUSION

Applying Rhino-Protect after ESS significantly reduced the formation of edema and crusts, leading to improving the patients' discomfort for pain, dryness, and crust.

Utility of Second-Look Endoscopy with Debridement After Pediatric Functional Endoscopic Sinus Surgery in Patients with Cystic Fibrosis

OBJECTIVES

To determine the utility of Second-look endoscopy with debridement (SLED) after functional endoscopic sinus surgery (ESS) in pediatric cystic fibrosis (CF) patients. To compare outcomes in pediatric CF patients undergoing sinus surgery for chronic sinusitis with or without SLED. To describe findings present at the time of SLED.

METHODS

Retrospective chart review of 61 ESS procedures performed at a tertiary care pediatric center from 2013 to 2016. Data collected included demographics, SLED findings, and 6-month pre-/postoperative disease specific outcomes including incidence of sinonasal and pulmonary exacerbations and revisions.

RESULTS

Sixty-one cases were reviewed. SLED was performed in 38 cases on average 22.4 days postoperatively. Average preoperative Lund-Mackay score was 14.9 and 14.8 among patients undergoing ESS with and without SLED, respectively. Pre-/postoperative intranasal steroid use and extent of surgery performed was similar among all patients. At the time of SLED, rates of synechiae, polyps and maxillary antrostomy obstruction were 26.3%, 23.7%, and 7.9%, respectively. The incidence and number of days to onset of postoperative sinonasal exacerbations requiring antibiotic therapy within 6 months of ESS were 1.0 (SD 1.0) and 85 days (SD 45.7); and 1.3 (SD 1.0) and 80.4 days (SD 40.5) for patients undergoing ESS with and without SLED, respectively (P value .33). The number of days to first pulmonary exacerbation was 113.9 (SD 45.5) and 47.4 (SD 34.1) among SLED and non-SLED patients, respectively (P value .01). No significant difference was observed in revision rates and time to revision ESS (30% and overall average 1.4 years, respectively).

CONCLUSION

The utility of SLED among pediatric CF patients remains unclear. While debridement did not have a significant impact on sinonasal exacerbations or revision rates, pulmonary exacerbations for patients undergoing SLED were delayed. Further studies are needed to clarify the impact of SLED.

The effects of erythromycin towards the treatment of persistent rhinosinusitis after functional endoscopic sinus surgery: A randomized, active comparator-controlled study

BACKGROUND

Long-term, low-dose macrolide treatment has been in recent use to treat chronic rhinosinusitis. In this study, we investigated the effect of long-term, low-dose erythromycin on patients who had persistent rhinosinusitis after functional endoscopic sinus surgery (FESS).

METHODS

Patients with persistent rhinosinusitis for 3 months after FESS were recruited and randomly assigned to two groups. Patients in the erythromycin group took erythromycin (250 mg twice a day) for 12 weeks, while those in the intranasal steroid group were administered with mometasone furoate nasal spray for 12 weeks. Both before and after treatment, sino-nasal symptoms were assessed via questionnaires. Patients also received an endoscopic examination, acoustic rhinometry, smell test, and saccharine transit test. A bacterial culture was obtained from the middle meatus.

RESULTS

Seventy-two patients completed the study, with 35 in the erythromycin group and 37 in the intranasal steroid group. Endoscopic scores decreased significantly after treatment in both groups. Erythromycin improved the smell threshold and saccharine transit time better than the intranasal steroid. In contrast, the intranasal steroid increased the second minimal cross-sectional area of the nasal cavity at a level greater than erythromycin had.

CONCLUSION

Our study showed that long-term, low-dose erythromycin treatment improved the endoscopic score, smell threshold, and saccharine transit time in patients with persistent rhinosinusitis after FESS.

The efficacy of cotton ball packing after endoscopic sinus surgery: A prospective, randomized, controlled trial

OBJECTIVE

The blocking of airflow into sinonasal cavity may decrease postoperative crusting and the development of adhesions. The purpose of this study was to investigate the efficacy of cotton ball packing in patients following endoscopic sinus surgery (ESS).

METHODS

Thirty nine patients with chronic rhinosinusitis requiring the same extent of ESS were included. As a part of postoperative care, the patients were instructed to perform a nasal saline irrigation and apply a nasal spray in each nostril, and then informed to put a cotton ball in a one side of nostril, and the other side was kept to be empty as a control. Patients' subjective symptoms, patients' pain while receiving sinonasal cavity debridement, time required to perform debridement, and postoperative wound healing were evaluated.

RESULTS

Although cotton ball packing resulted in less discomfort for postnasal drip, rhinorrhea, headache, and facial pain than no packing, there were no statistically significant differences between the groups. The cotton ball packing was associated with significantly less pain on while performing postoperative debridement, therefore less time was needed to perform debridement. The cotton ball packing appears to improve wound healing within the sinus cavities up to 1 month postoperatively.

CONCLUSION

The use of the cotton ball packing after ESS results in significantly less formation of crusts and adhesions, leading to decreasing pain and time during postoperative debridement and promoting faster wound healing.

Antiadhesive Effect of the Mixed Solution of Sodium Hyaluronate and Sodium Carboxymethylcellulose after Endoscopic Sinus Surgery

Background

We evaluated the clinical efficacy and safety of the mixed solution of sodium hyaluronate and sodium carboxymethylcellulose (HA-CMC) for prevention of adhesion after endoscopic sinus surgery.

Methods

Preoperative computed tomography (CT) scans were graded. At the completion of surgery, HA-CMC was applied to Merocel and repeatedly applied after the removal of Merocel. As a control, normal saline was applied. Endoscopic examination was performed postoperatively and grading was done.

Results

The rate of adhesion was the highest at 2 weeks postoperatively and was significantly lower in the HA-CMC–treated group than the control on all postoperative days. The grouping of cases by CT scores at 2 weeks postoperatively showed lower adhesion formation with the HA-CMC treatment than the control. The safety profile of the patients was normal at 4 weeks postoperatively.

Conclusion

HA-CMC is an efficacious and safe material in decreasing the incidence of adhesion after endoscopic sinus surgery.

The in vitro mucolytic effect of xylitol and dornase alfa on chronic rhinosinusitis mucus

BACKGROUND

The overproduction and stagnation of purulent mucus impair mucociliary clearance and exacerbate the symptoms of chronic rhinosinusitis (CRS). There is a clinical need for effective topical mucolytic agents to facilitate removal of mucus and improve postoperative outcomes.

METHODS

The effects of xylitol (5%) and dornase alfa (1 mg/mL) on mucus and mucus crusts were investigated. Viscoelasticity and viscosity of wet mucus derived from 30 CRS patients was measured with a plate rheometer. Postoperative dried mucus crust dissolution was measured by examining peripheral transparency, central transparency, and border definition of treated crust samples from 17 CRS patients.

RESULTS

Xylitol and dornase alfa reduced wet mucus viscoelasticity at a frequency of 0.1 Hz significantly more than the saline control. Treatments also produced significantly lower viscosities than saline at a shear rate of 10 and 100 seconds^-1 . Xylitol and dornase alfa significantly decreased mucus crust border definition relative to saline.

CONCLUSION

Xylitol and dornase alfa may be efficacious mucolytics, encouraging the breakdown of postoperative mucus crusts and the reduction of viscoelasticity and viscosity of wet mucus. In vivo study is required to evaluate the potential of these agents in treating recalcitrant CRS.

Comparison of three different polyvinyl alcohol packs following functional endoscopic Nasal surgery

OBJECTIVES/HYPOTHESIS

To compare the extent of bleeding and patient discomfort during packing removal of three different polyvinyl alcohol (PVA) packs: 1) a standard PVA sponge (s-PVA) (Mondocel Standard 10 cm; Mondomed NV, Hamont-Achel, Belgium); 2) a PVA sponge with oxidized cellulose (oc-PVA) (Merocel Hemox 10 cm; Medtronic Xomed Surgical Products, Jacksonville, FL); and 3) a PVA sponge with polyethylene film (pf-PVA) (Merocel 2000 8 cm; Medtronic Xomed Surgical Products, Jacksonville, FL), after functional endoscopic sinus surgery and inferior turbinoplasty.

STUDY DESIGN

A prospective, randomized, blinded, controlled trial.

METHODS

Ninety consecutive patients were enrolled and randomized to receive in each side one pack in the middle meatus and another pack of the same material in the nasal fossa. The patients were equally divided in three groups of 30 patients each. Group A received the pf-PVA; group B received oc-PVA; and group C received s-PVA. Postoperatively, bleeding after removal of the entire nasal packing was evaluated by an observer, whereas the severity of pain was rated by patients with visual analog scales.

RESULTS

Our study evaluated three nasal packing materials, demonstrating that the pf-PVA is less painful than the others but with intermediate bleeding ratio. However, the oc-PVA has an intermediate pain score but minimum bleeding. The s-PVA showed the worst pain and bleeding results.

CONCLUSIONS

Considering that removal of the second pack (middle meatus) is more painful than the first (nasal fossa), our results suggest that a pf-PVA can be placed in the middle meatus and a oc-PVA in the nasal fossa in order to reduce patient's discomfort in terms of pain and bleeding.

LEVEL OF EVIDENCE

1b.

Postoperative Care with Chinese Herbal Medicine or Amoxicillin after Functional Endoscopic Sinus Surgery: A Randomized, Double-blind, Placebo-controlled Study

Background

A number of herbal preparations have been reported being used as adjunctive treatment of patients with chronic rhinosinusitis (CRS) after functional endoscopic sinus surgery (FESS). This study was designed to examine the efficacy of Chinese herbal medicine (CHM) in the postoperative care of post-FESS patients.

Methods

Patients with CRS who underwent FESS were prospectively enrolled in the study. Before surgery, they were evaluated by various methods, including the Chinese version of the Rhinosinusitis Outcome Measure (CRSOM-31), nasal endoscopy, acoustic rhinometry, and computed tomography (CT). After surgery, they were randomized to take CHM (Tsang-Erh-San extract granules and Houttuynia extract powder) for 8 weeks, amoxicillin for 4 weeks, or placebo. They were revaluated by CRSOM-31, nasal endoscopy, and acoustic rhinometry at 8 weeks and by CT at 12 weeks after surgery.

Results

Ninety-seven patients (33 in the CHM group, 34 in the amoxicillin group, and 30 in the placebo group) completed the study. In the CHM group, CRSOM-31 and endoscopic scores significantly decreased, and the second minimal cross-sectional area of the nasal cavity measured by acoustic rhinometry significantly increased after treatment. In the amoxicillin and placebo groups, CRSOM-31, endoscopic, and CT scores significantly decreased after treatment. However, there were no significant differences in subjective and objective treatment outcomes among three groups of patients.

Conclusion

Our results showed there was no significant benefit of using CHMs (Tsang-Erh-San extract granules and Houttuynia extract powder) or oral amoxicillin in post-FESS care of CRS patients. Additional investigation is necessary for post-FESS care.

Prophylactic antibiotics in endoscopic sinus surgery: a short follow-up study

BACKGROUND

The study was designed to assess the usefulness of postoperative antibiotics in patients undergoing endoscopic sinus surgery (ESS).

METHODS

The effects of antibiotics in the postoperative period of ESS patients were evaluated in a prospective, randomized, double-blind, placebo-controlled study. Fifty patients were treated with amoxicillin/clavulanate for 2 weeks after ESS, while the other half received placebo. Preoperatively, the symptom, endoscopic, and CT scores were recorded. In the postoperative period, symptom and endoscopic scores were recorded on the 5th, 12th, 21st, and 30th days. In estimating the length of the blood crust formation episode, a Kaplan-Meier plot was used.

RESULTS

Seventy-five patients completed the study: forty in the antibiotic-treated group and thirty-five in the placebo group. On the 5th day, nasal obstruction and drainage were significantly better in the antibiotic-treated group. In addition, a statistically significant difference in the endoscopic scores was noted between the treatment and placebo groups on days 5 and 12.

CONCLUSION

The use of an antibiotic (amoxicillin/clavulanate) in the postoperative period is able to improve the outcome in the early blood crust healing phase: nasal obstruction and drainage are reduced and the endoscopic score objectively showed a faster recovery.

[Complications of endoscopic sinus surgery in a residency training program]

INTRODUCTION

Endoscopic sinus surgery presents a series of complications that can vary depending on the technique used and the surgeon's experience. This technique needs a learning curve, which must be developed during the residence training program.

METHODS

Descriptive and retrospective study, reviewing the medical records of endoscopic sinus surgery for nasal polyps of 192 patients who had undergone operations performed by residents at our department between January 2002 and January 2008. Patient sex, age, affectation scale and minor and major complications were described. All these procedures were performed by 3rd or 4th-year residents under the supervision of a faculty member.

RESULTS

Of the 192 patients, 127 (66.14%) were male and 65 (33.85%) female, aged between 24 and 78 years old, with a mean age of 49 years old. Nasal endoscopy revealed polyposis of grade i, 19 (9.8%) cases; grade ii, 55 (28.6%); and grade iii, 118 (61.45%). There were 44 (22.9%) total complications, 40 (20.8%) minor and 4 (2.08%) major complications. The most common minor complication was synechia formation in 21(10.93%) cases, followed by bleeding without need for transfusion in 12 (6.25%). The major complication was a breach of the lamina papyracea in 4 patients (2.08%). There were no cases of blindness, cerebrospinal fluid rhinorrhea, or death.

CONCLUSIONS

Endoscopic sinus surgery in an otolaryngology residency training program is a relatively safe procedure, especially when performed under faculty supervision.

Postoperative antibiotic care after functional endoscopic sinus surgery

BACKGROUND

Antibiotics are used routinely in the postoperative care of functional endoscopic sinus surgery (FESS), but their efficacy has not been well evaluated.

METHODS

Patients with chronic rhinosinusitis who underwent FESS were enrolled in this study. They were randomly divided into two groups: a study group and a control group. In the study group, patients took amoxicillin/clavulante for 3 weeks after FESS. In the control group, no antibiotic was given after FESS. Before FESS, all patients filled out a symptom questionnaire and received nasal endoscopy. Swab specimens were taken from the middle meati for bacterial cultures. These procedures were done again 3 weeks after FESS.

RESULTS

Seventy-one patients completed the study. Thirty-one patients were in the study group, and 40 patients were in the control group. The symptom scores significantly decreased after surgery in both groups, but bacteria identified before and after FESS were statistically different in both groups. There were no differences in the symptom and endoscopic scores, rates of bacterial culture, and drug sensitivity to amoxicillin/clavulante between the two groups after FESS.

CONCLUSION

This study showed that postoperative care with amoxicillin/clavulante did not improve the short-term outcome of FESS on chronic rhinosinusitis or decrease bacterial growth 3weeks after FESS, although the long-term influence was not evaluated in this study.

A prospective controlled trial of pulsed nasal nebulizer in maximally dissected cadavers

BACKGROUND

Nasal douching is common practice in treatment of chronic sinusitis and after endoscopic sinus surgery. Current nasal delivery techniques show inconsistent sinus penetration. The aim of this study was to compare sinonasal penetration of nasal douching to an optimized nasal nebulizer in an operated cadaver model.

METHODS

Fourteen preserved cadavers were used receiving complete sphenoethmoidectomies with a Draf III, wide maxillary antrostomy, or medial maxillectomy. Seven control cadavers received nasal douching with one standardized squeeze bilaterally of a 200-mL nasal irrigation bottle and seven intervention cadavers were nebulized with 3 minutes of the PARI sinus device bilaterally. Douching solutions were stained with methylene blue. Independent observers documented sinonasal anatomy, staining intensity, and percentage area covered by dye using standardized grading protocols.

RESULTS

Combined data showed a significant increase in intensity of stain (2.06 versus 0.26, p < 0.001), percentage of stain (49.96% versus 4.19%, p < 0.001), and circumference stained (76.59% versus 12.7%, p < 0.001) with the plastic nasal irrigation squeeze bottle versus PARI device. Analysis of individual sinuses consistently showed significant increases in indices of nasal douching relative to nebulization. The PARI sinus nebulizer was noted to reach the ethmoids regularly (92% incidence), whereas the other sinuses were not reached as regularly with incidences noted at frontal (43%), maxillary (46%), and sphenoid (54%). This compares to 96% of all sinuses being stained by the squeeze bottle.

CONCLUSION

In all measured indices, the nasal douching method with the squeeze bottle was superior to the PARI sinus nebulizer in highly dissected sinonasal cadaver models.

Relationship between the frequency of postoperative debridement and patient discomfort, healing period, surgical outcomes, and compliance after endoscopic sinus surgery

OBJECTIVES/HYPOTHESIS

To determine the optimal frequency of postoperative care after endoscopic sinus surgery, we evaluated the relationship between the frequency of postoperative debridement and patient discomfort, healing period, surgical outcomes, and compliance.

STUDY DESIGN

A prospective randomized study.

METHODS

Patients diagnosed with chronic rhinosinusitis with or without nasal polyposis were randomly allocated to three groups (N = 10 each group), according to the frequency of office visits for postoperative debridement during a 4-week postoperative period. Group 1 underwent debridement twice a week, group 2 once a week, and group 3 once every 2 weeks. Four weeks after the procedure, the patients in each group were asked about discomfort between visits for postoperative debridement, including nasal obstruction, nasal discharge, foul odor, postnasal drip, and headache. Responses were scored using the visual analogue scale (VAS). Six months after surgery, the healing period was evaluated and both subjective and objective surgical outcomes were assessed using the Sinonasal Outcome test 20 and endoscopic findings. Patient compliance to postoperative debridement was also evaluated using the VAS. We compared the statistical significance of these parameters among the three groups.

RESULTS

In groups 1, 2, and 3, nasal polyposis was present in eight, eight, and six patients, respectively, and five, one, and four patients had unilateral sinusitis. The VAS scores for four of the five main symptoms regarding patient discomfort differed significantly among the groups; group 3 reported the worst scores. However, healing periods, Sinonasal Outcome test-20 scores, and objective endoscopic findings did not show statistical differences among the groups. Patient compliance to the frequency of postoperative debridement differed significantly among the groups. Patients in group 1 reported the greatest disturbance in academic and socioeconomic activities, whereas the patients in groups 2 and 3 demonstrated similar scores.

CONCLUSIONS

One-week intervals seem to be the optimal frequency for postoperative debridement during the healing period after endoscopic sinus surgery. However, patient individualization should be taken into account depending on the extent of surgery and healing progress.

Balloon catheter sinusotomy: one-year follow-up--outcomes and role in functional endoscopic sinus surgery

OBJECTIVE

The primary objective was to assess the long-term effectiveness of balloon catheter sinusotomy.

METHODS

Patients who had sinus ostia dilated with balloon catheters were prospectively evaluated 1 year after surgery with nasal endoscopy, a CT scan, and the Sino-Nasal Outcome Test (SNOT-20).

RESULTS

Sixty-six patients (202 sinuses) were examined. One hundred seventy-two of 202 sinus ostia (85%) were endoscopically patent, 1 percent (2/202) were nonpatent, and ostial patency could not be determined by endoscopy in 28 of 202 (14%). In these "indeterminate" sinuses, the CT scans were normal in 13, implying functional patency in 91.6 percent of sinuses (185/202). Sinus CT scan scores were 1.95 at 1 year versus 8.89 at baseline (P < 0.001), and 1-year SNOT-20 scores (0.91) were significantly improved from baseline (2.14, P < 0.0001).

CONCLUSION

Balloon catheter sinusotomy results were durable over the study period, showing long-term effectiveness.

Multicenter Registry of Balloon Catheter Sinusotomy Outcomes for 1,036 Patients

Objectives:

This study assesses the safety and effectiveness of balloon catheters used as instruments in sinus surgery in a “real-world” multicenter registry of 1,036 patients across 27 US otolaryngology practices.

Methods:

Data were collected by standardized chart review with centralized database administration for all consecutive functional endoscopic sinus surgeries that included the use of balloon catheters across the 18-month time period from December 2005 to May 2007.

Results:

Balloon catheters were used in 3,276 peripheral (maxillary, frontal, and sphenoid) sinuses, for an average of 3.2 sinuses per patient. There were no major adverse events related to the use of balloon catheter instruments. The revision rate was 1.3% of sinuses treated with a balloon catheter after an average follow-up of 40.2 weeks. Sinus symptoms were improved in 95.2%, unchanged in 3.8%, and worse in 1.0% of patients. Postoperative sinus infections were significantly less frequent and less severe compared to infections before surgery. The results were consistent across all patient categories, including balloon-only patients and revision patients.

Conclusions:

Use of balloon catheters as instruments in sinus surgery appears to be relatively safe and effective and to improve the patient's quality of life. The results are consistent and generalizable across a wide range of sinusitis patients and physician practices. The complication rates, revision rates, and patient symptom improvement rates all compare favorably with previously reported results of functional endoscopic sinus surgery.

The effects of debridement after endoscopic sinus surgery

OBJECTIVES/HYPOTHESIS

The aim of this randomized, partly blinded, controlled clinical trial was to evaluate the effects of debridement 6 and 12 days after endoscopic sinus surgery.

METHODS

Sixty patients (male/female = 26/34; mean age, 43.5 years; age range, 23-73 years) with chronic or acute recurrent rhinosinusitis were included. The patients were randomized to postoperative debridement or not. Primary outcome variables were adhesions between the middle turbinate and the lateral nasal wall 10 to 14 weeks after surgery judged by blinded evaluation of endoscopic video recordings. Secondary outcome variables were crusts in the nasal cavity 12 days after surgery and pain caused by debridement.

RESULTS

We found a significant reduction in adhesions in the group that underwent debridement (P < .001). At 12 weeks, bilateral adhesions were observed in nine control patients but in only one debridement patient. Unilateral adhesions were found in 11 control patients and in nine debridement patients. Twelve days after surgery, we found significantly less severe crusts in the debridement group (P < .01). Patients with severe crusts in the middle meatus 12 days after surgery had more adhesions 12 weeks postoperatively. The debridement group used more analgesics the days after the first debridement (3.7 days [standard deviation 2.3] vs. 2.3 days [standard deviation 2.6] in the control group, P < .041).

CONCLUSIONS

Crusts in the middle meatus after sinus surgery is associated with postoperative adhesions. Debridement of the nasal cavity reduces crusts and postoperative adhesions significantly compared with saline irrigation only. However, the procedure induces more postoperative nasal pain.

Office-based procedures in rhinosinusitis

The availability of nasal endoscopes enables the rhinologist to visualize pathology in the posterior nasal cavity and middle meatus. With limited surgical equipment, the surgeon skilled in local anesthesia can perform biopsies, debridements, polypectomies, and turbinate reductions successfully in the office. With more specialized equipment and powered instrumentation,endoscopic maxillary antrostomies and other limited sinus surgeries become possible. On occasion, the surgeon might perform a limited ethmoidectomy,revise a sphenoidotomy, or remove polyps from within the maxillary sinus. For the properly selected patient, office surgery provides convenience and cost savings by eliminating hospital fees, anesthesia charges and preanesthesia testing. For the busy surgeon, office surgery allows improved efficiency by eliminating travel and anesthesia time.

Revision endoscopic frontal sinus surgery

PURPOSE OF REVIEW

Recurrent or persistent frontal sinus disease after endoscopic sinus surgery poses formidable challenges owing to the frontal sinus outflow tract's complex variable anatomy, close proximity to vital structures, and predilection for scarring and stenosis. Frontal sinus obliteration used to be the preferred technique of most sinus surgeons for addressing difficult frontal sinus disease; however, several effective endoscopic techniques exist as excellent alternative procedures for addressing this difficult clinical problem.

RECENT FINDINGS

Several endoscopic techniques have been described for addressing these problems including endoscopic frontal sinusotomy, the frontal sinus rescue procedure, endoscopic transseptal frontal sinusotomy, and the modified Lothrop procedure. Advances in treating recurrent frontal sinus disease have included recent articles reviewing the long-term outcomes of some of these techniques, the prevalence of frontal sinus cells, the optimization of medical management, and the spectrum of postoperative debridement regimens.

SUMMARY

When used in the appropriate setting, these less invasive revision endoscopic techniques provide excellent results with low morbidity and several advantages. This article reviews recent developments in the treatment of recurrent or persistent frontal sinus disease including incorporation of these techniques.

Advantages and disadvantages of topical packing in endoscopic sinus surgery

PURPOSE OF REVIEW

Practices regarding the use of nasal packing after endoscopic sinus surgery vary widely among surgeons. Recent trends have included the use of various topical, absorbable agents. The purpose of this review is to clarify the rationale for the selection of these products.

RECENT FINDINGS

Although many of these materials have proven to be effective as hemostats, data are conflicting regarding their effect on mucosal healing. Studies in both humans and animals have raised the concern that these agents may be associated with increased scar tissue formation.

SUMMARY

The exact roles for the various available materials are yet to be established. The primary advantage is that they do not require removal, which may improve patient comfort. Currently, however, it does not appear that the use of topical absorbable packing is a substitute for routine postoperative debridement.