Middle meatal spacers for the prevention of synechiae following endoscopic sinus surgery: a systematic review and meta-analysis of randomized controlled trials

[Fundamentals and practice of the application of nasal packing in sinonasal surgery]

BACKGROUND AND OBJECTIVES

This paper presents an overview on nasal packing materials which are available in Germany. The current literature is analyzed whether there are robust criteria regarding use nasal packing after sinonasal surgery, whether there are fundamental and proven advantages or disadvantages of products, and what this means in clinical practice.

MATERIALS AND METHODS

Selective literature analysis using the PubMed database (key words "nasal packing", "nasal tamponade", "nasal surgery", "sinonasal surgery", or "sinus surgery"), corresponding text books and resulting secondary literature.

RESULTS AND CONCLUSIONS

Because of systematic methodological shortcomings, the literature does not help in the decision-making about which nasal packing should be used after which kind of sinonasal surgery. In fact, individual approaches for the many different clinical scenarios are recommended. In principle, nasal packing aims in hemostasis, should promote wound healing, and should not result in secondary morbidity. Nasal packing materials should be smooth (non-absorbable materials), inert (absorbable materials), and should not exert excessive pressure. Using non-absorbable packing entails the risk of potentially lethal aspiration and ingestion. For safety reasons inpatient control is recommended as long as this packing is in situ. With other, uncritical packing materials and in patients with special conditions, outpatient control could be justified.

Otolaryngology Considerations of Pituitary Surgery: What an Endocrinologist Should Know

Endoscopic endonasal skull base surgery is the preferred surgical approach for the management of pituitary adenomas. Perioperative management of pituitary lesions requires multidisciplinary care and typically includes a dual surgeon team consisting of a neurosurgeon and an otolaryngologist. The involvement of the otolaryngologist allows for a safe surgical approach with excellent intraoperative visualization of the tumor to enable an effective resection of the tumor by the neurosurgeon. Detection and treatment of sinonasal pathology is essential prior to surgery. Patients may experience sinonasal complaints following endoscopic transsphenoidal surgery, although this is typically temporary. Sinonasal care in the postoperative period can expedite recovery to baseline. Here we discuss the perioperative factors of endoscopic pituitary surgery that endocrinologists should be aware of, ranging from preoperative patient selection and optimization to postoperative care, with a particular emphasis on anatomic and surgical factors.

Use of intraoperative frontal sinus mometasone-eluting stents decreased interleukin 5 and interleukin 13 in patients with chronic rhinosinusitis with nasal polyps

BACKGROUND

Mometasone-eluting stents (MES) have demonstrated improvement in short-term endoscopic outcomes and reduce short- to medium-term rescue interventions. Their effect on the local inflammatory environment, longer-term patient-reported outcomes, and radiographic severity have not been studied.

METHODS

Middle meatal mucus and validated measures of disease severity were collected before and 6 to 12 months after endoscopic surgery in 52 patients with chronic rhinosinusitis with nasal polyps (CRSwNPs). Operative findings, type 2 mediator concentrations, intraoperative variables, and disease severity measures were compared between those who did and those who did not receive intraoperative frontal MES.

RESULTS

A total of 52 patients with CRSwNPs were studied; 33 received frontal MES and were compared with 19 who did not. Pre-endoscopic sinus surgery (ESS) middle meatus (MM) interleukin (IL) 13 and eosinophil cationic protein (ECP) were higher in the stented group (p < 0.05), but pre-ESS clinical measures of disease severity were similar as were surgical extent and post-ESS medical management. Intraoperative eosinophilic mucin was more frequent in the stented group (58% vs 11%, p = 0.001). IL-5 (p < 0.05) and IL-13 (p < 0.001) decreased post-ESS in the stented group, but this was not observed in the nonstented group. Post-ESS IL-4 and IL-13 were higher in the nonstented vs stented group (p < 0.05 for both).

CONCLUSION

Although patients who received intraoperative frontal MES had significantly higher pre-ESS MM IL-13 and ECP, patients who received frontal MES had lower concentrations of IL-4 and IL-13 than those who did not at a median of 8 months post-ESS. However, these changes did not correspond to significantly different measures of symptomatic or radiographic disease severity.

Wedge-shape Merocel Pack After Functional Endoscopic Sinus Surgery: Our Experience With 697 Patients

Background:

Chronic rhinosinusitis (CRS) is a disease characterized by inflammation of the paranasal sinus mucosa for a duration of more than 12 weeks. It is one of the most frequently diagnosed chronic diseases that is encountered in everyday practice with an overall prevalence ranges from 7% to 27%

Objective:

To evaluate our long-term experience using wedge-shape middle meatal Merocel packing after functional endoscopic sinus surgery (FESS) for chronic rhinosinusitis (CRS).

Methods:

charts and electronic records of consecutive adult CRS patients who failed to respond to medical treatment and underwent endoscopic sinus surgery using wedge-shaped middle meatal Merocele packing were retrospectively reviewed. Demographic data, presence and absence of nasal polyps and/or asthma, postoperative bleeding, middle meatal adhesions and/or lateralization, and requirement of adhesiolysis were reviewed.

Results:

697 patients (1394 nasal sides) were included. The mean age was 34 years. CRS with nasal polyps was observed in 224 patients (32%) and 185 (27%) had associated asthma. Postoperative pain and discomfort while the pack in place were tolerable and no patient required pre-scheduled pack removal. All packs were removed in the clinic with tolerable discomfort. No major bleeding that required re-packing was seen, but mild oozing or minor bleeding was encountered in some cases which was controlled by small cotton packs soaked with diluted adrenaline. Thirty-four patients (4.9%) had middle meatal adhesions. Right side adhesions were seen in 13 patients (38.2%), left side adhesions in 12 patients (35.3%), and bilateral in 9 patients (26.4%). Significant severe lateralized middle turbinate was observed in 2 cases. No infectious complications related to the pack have happened.

Conclusion:

Wedge-shaped Merocel pack is an effective middle meatal pack after FESS. It is easy to shape, widely available, and economical. It can decrease early postoperative bleeding and also it provides support to the middle turbinate preventing lateralization and adhesions.

Comparison of Absorbable Packing versus No Packing in Wound Healing after Endoscopic Sinus Surgery: A Systematic Review and Pooled Analysis

INTRODUCTION

Nasal packing after endoscopic sinus surgery (ESS) is controversial. The aim of this systematic review was to compare absorbable packing versus no packing in wound healing after ESS for the treatment of chronic rhinosinusitis.

DATA SOURCE

English electronic databases, including Cochrane Library, EMBASE, MEDLINE, and PubMed, were searched, and only randomized controlled trials were included.

METHODS

The outcome measures were the presence of synechiae/adhesion formation, mucosal edema, crusting, granulation formation, and infection. The McNemar's test was used for pooled analysis.

RESULTS

Four studies with 148 participants were included. The pooled analysis showed that absorbable packing may offer benefit in reducing adhesion at 6-8 weeks (odds ratio [OR]: 0.3864; 95% confidence interval [CI]: 0.2136-0.7235) and 12 weeks (OR: 0.2396, 95% CI: 0.08267-0.7709) postoperatively compared with no packing. There was no significant difference between the packed and the unpacked side at 2, 6-8, and 12 weeks after ESS in terms of presence of crusting, edema, and granulation formation.

CONCLUSION

There is insufficient evidence to suggest that absorbable packing after ESS does not increase mucosal edema, granulation formation, and infection. However, the absorbable packing may be more effective than no packing for the prevention of mucosal adhesion after ESS. The use of absorbable nasal packing after ESS is recommended when used to reduce postoperative mucosal adhesion. More research in this area is clearly needed.

[Postoperative treatment following paranasal sinus surgery]

Postoperative care is a crucial aspect for the success of paranasal sinus interventions. Basic procedures include saline nasal wash, which should be started on the first postoperative day, topical steroids, and antibiotics in cases of infection. Medical treatment involves aspiration of secretion in the inferior meatus during the first week. Removal of scabs in the surgical field should be carried out under endoscopic control beginning at the second week. Intervals are scheduled individually. Occlusion of the nose for the time of epithelium regeneration provides a moist space in the ethmoid, which improves wound healing.

International consensus statement on allergy and rhinology: rhinosinusitis 2021

I.

EXECUTIVE SUMMARY

BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document.

METHODS

ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary.

RESULTS

ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided.

CONCLUSION

This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.

High Variability of Postsurgical Anatomy Supports the Need for Individualized Drug-Eluting Implants to Treat Chronic Rhinosinusitis

Chronic rhinosinusitis (CRS) is a common disease in the general population that is increasing in incidence and prevalence, severely affecting patients’ quality of life. Medical treatment for CRS includes self-management techniques, topical and oral medical treatments, and functional endoscopic sinus surgery (FESS). FESS is a standard procedure to restore sinus ventilation and drainage by physically enlarging the inflamed sinus passageways. Nasal drug-releasing stents are implanted to keep the surgically expanded aperture to the sinus frontalis open. The outcome of such an intervention is highly variable. We defined the anatomical structures which should be removed, along with ‘no-go areas’ which need to be preserved during FESS. Based on these definitions, we used cone beam computed tomography (CBCT) images to measure the dimensions of the frontal neo-ostium in 22 patients. We demonstrate anatomical variability in the volume and diameter of the frontal sinus recess after surgery. This variability could be the cause of therapy failure of drug-eluting implants after FESS in some patients. Implants individually made to fit a given patient’s postsurgical anatomy may improve the therapeutic outcome.

Comparison of effects of baby shampoo vs. saline irrigation on endoscopic sinus surgery outcomes and quality of life

OBJECTIVE

Nasal irrigation is an important step of functional endoscopic sinus surgery (FESS) postoperative care. This study was performed to compare the effects of diluted baby shampoo (BS) and normal saline solution (NSS) irrigation on patients' quality of life (QoL) and surgical outcomes after FESS.

METHODS

This study included 77 patients who underwent FESS to treat chronic rhinosinusitis with nasal polyps. Lund-Mackay score, Lund-Kennedy endoscopic score (LKES), synechia score and QoL (using the Sinonasal Outcome Test (SNOT-22)) were evaluated.

RESULTS

LKES was significantly better in the BS group (p=0.001), especially in terms of nasal discharge and crust formation (p=0.024 and p=0.030, respectively) at 1 month postoperatively. However, no significant difference was found at 3, 6 or 12 months postoperatively (p=0.833, p=0.263, and p=0.346, respectively). The reduction of SNOT-22 score (between preoperative assessment and 1 month postoperatively) was significantly better in the BS than in the NSS group (p=0.025). However, no statistically significant differences were found between groups at 3, 6, or 12 months postoperatively (p=0.312, p=0.280, and p=0.285, respectively). In the evaluation of SNOT-22 subdomains, changes in psychological, rhinological and extranasal rhinological subdomains were significantly better in the BS group at 1 month postoperatively (p=0.019, p=0.010 and p=0.002, respectively).

CONCLUSION

Compared to irrigation with NSS, BS usage following FESS led to reductions of crusting, nasal discharge and synechia formation; moreover, it was associated with improved SNOT-22 scores, especially in psychological, rhinological and extranasal rhinological subdomains.

Complications Are Rare From Middle Turbinate Resection: A Prospective Case Series

Background

When chronic rhinosinusitis with nasal polyps (CRSwNP) fails to respond to medical therapy, endoscopic sinus surgery (ESS) plays an integral role in management. Some studies have shown that middle turbinate resection (MTR) during ESS leads to decreased polyp recurrence and revision ESS rates. Other studies suggest MTR can lead to complications.

Objective

The purpose of this study was to assess the safety of MTR during ESS for CRSwNP by determining the incidences of intraoperative cerebrospinal fluid (CSF) leak, postoperative epistaxis requiring operative intervention, and postoperative complete frontal stenosis.

Methods

A multiinstitutional, prospective case series of 91 adult CRSwNP patients was conducted. Patients with medically refractory CRSwNP underwent primary or revision ESS plus MTR by 3 surgeons. Two of the surgeons performed partial MTRs, and one of the surgeons performed complete MTRs. Patients were evaluated for the following complications: intraoperative CSF leak during MTR, postoperative epistaxis requiring operative intervention, and postoperative complete frontal ostial stenosis. Secondary outcomes included changes from preoperative to postoperative 22-item Sinonasal Outcome Test (SNOT-22) scores and revision ESS rates.

Results

Unilateral or bilateral complete ESSs with MTRs were performed on 91 CRSwNP patients. In total, 173 MTRs were performed. Two surgeons performed 97 partial MTRs on 49 patients, and the third surgeon performed 76 complete MTRs on 42 patients. One CSF leak occurred during partial MTR (1/173, 0.57%). No patients suffered postoperative epistaxis requiring operative intervention, and no patients developed complete frontal stenosis. From preoperatively to postoperatively, mean SNOT-22 scores decreased from 53.7 to 13.1 ( P = .001). No revision ESS was needed during the follow-up period. Mean follow-up time was 7.5 ± 5.4 months.

Conclusions

Partial and complete MTR during ESS for CRSwNP in this cohort resulted in very low, acceptable intraoperative and short-term postoperative complication rates and no detriment to SNOT-22 scores.

Analysis of Absorbable Hemostatic Packing Compared to Physiologic Hemostasis in Functional Endoscopic Sinus Surgery With or Without Septoplasty

Background

There currently are no randomized studies examining if absorbable hemostatic packing (AHP) results in better objective and subjective outcomes than physiologic healing in sinus surgery with or without septoplasty.

Objective

The objective of this study is to examine outcomes after functional endoscopic sinus surgery (FESS) with or without septoplasty with the use of AHP versus physiologic hemostasis and healing.

Methods

A prospective randomized control trial was performed at 2 tertiary academic institutions. Fifty-nine patients undergoing bilateral FESS with or without septoplasty were enrolled and randomized to receive AHP in 1 middle meatus and no packing contralaterally. Subjective outcomes (pain, bleeding, obstruction, discharge) on self-reported visual analog scale questionnaires were tabulated on postoperative days 0, 1, 7, and 14 by the patient. Endoscopic outcomes (synechiae formation, edema, infection, granulation, debridement, crusting) were measured at 1 week, 2 weeks, and 6 weeks postoperatively by their surgeon.

Results

No significant differences were identified in subjective or endoscopic outcomes with AHP use. Concurrent septoplasty patients with AHP experienced no sustainable difference in subjective or endoscopic outcomes compared to septoplasty control. No sustainable differences were found among the types of AHP or the 2 surgeons.

Conclusion

This first reported prospective randomized study of patients with nonstrict selection criteria found AHP made no significant difference on subjective and objective postoperative outcomes as compared to physiologic hemostasis. Previous AHP-specific studies have shown differences in carefully selected patient groups. Generalizing study-proved benefits of specific AHP to all AHP is shown to be not appropriate.

Partial resection of the middle turbinate during endoscopic sinus surgery for chronic rhinosinusitis does not lead to an increased risk of empty nose syndrome: a cohort study of a tertiary practice

BACKGROUND

The treatment of the middle turbinate (MT) during endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) remains a contentious issue with arguments both for and against its resection. The purpose of this study was to examine the clinical impact of partial MT resection (PMTR) during ESS, paying particular attention to the risk of developing empty nose syndrome (ENS) and alteration to olfaction.

METHODS

This cohort study was performed on prospectively collected data. A total of 177 patients underwent ESS for CRS; 93 had PMTR and 84 MT preservation (MTP). Preoperative data collection included subjective symptom scores as per the Adelaide Disease Severity Score (ADSS), Lund-Mackay scores, and nasal polyp status. The Empty Nose Syndrome 6-Item Questionnaire (ENS6Q) was administered by telephone consultation and analyzed alongside postoperative symptom scores.

RESULTS

There was no difference in ENS6Q scores in patients who underwent PMTR vs those who had MTP. Patients who underwent PMTR had a higher baseline disease on Lund-Mackay scoring, and were more likely to be nasal polyp patients and be undergoing revision surgery. ADSS scores demonstrated significant improvements in all rhinologic symptoms, with no difference between the cohorts.

CONCLUSION

PMTR is an adjunctive procedure to ESS. This study has established that PMTR as performed by the senior author carries no additional risk of developing ENS symptoms as defined by the ENS6Q, and that it carries no additional risk to olfaction or other rhinologic symptoms. PMTR can be safely considered at time of ESS, especially in patients at risk of lateralization of the MT.

Comparing the efficacy of Silastic and gloved-Merocel middle meatal spacers for functional endoscopic sinus surgery: a randomized controlled trial

BACKGROUND

Spacers are inserted into the middle meatal space (MMS) following functional endoscopic sinus surgery (FESS) to prevent lateralization of the middle turbinate, scarring, and synechiae. Our objective was to determine if the incidence of postoperative synechiae, facial pain/discomfort, pain during spacer removal, scarring, and discharge differed between nasal cavities receiving Silastic or gloved-Merocel (GM) spacers following FESS.

METHODS

A double-blind, randomized controlled trial (RCT) was conducted in adults requiring bilateral FESS for chronic rhinosinusitis (CRS) ± nasal polyposis. Participants served as their own controls, with each subject receiving both a Silastic and GM spacer. Spacers were inserted into the MMS during FESS and left in situ for 6 days. Participants were reviewed at 6 days, 5 weeks, and 12 weeks postoperatively. The presence of synechiae and scarring were evaluated endoscopically. Inflammation, discharge, and pain during spacer removal were assessed using a visual analogue scale (VAS).

RESULTS

Forty-eight participants (96 nasal cavities) were recruited. Preoperatively, Lund-Mackay computed tomography (CT) scores were similar between Silastic-treated and GM-treated cavities (6.38 ± 2.35 vs 6.18 ± 2.17). The incidence of synechiae and scarring did not differ significantly between spacers up to 12 weeks postoperatively. Pain during spacer removal was significantly greater for Silastic than GM spacers (2.13 ± 1.34 vs 1.51 ± 1.23, p = 0.020). Facial pain prior to removal and extent of discharge did not differ significantly between spacers.

CONCLUSION

Following FESS, patients report less pain during removal of GM than Silastic spacers. However, the likelihood of synechiae and scarring did not differ between either of the spacers.

Potential risk factors associated with the development of synechiae following functional endoscopic sinus surgery

PURPOSE

Synechiae formation in the middle meatus is the most common complication of functional endoscopic sinus surgery (FESS). Our objectives were to determine the incidence of synechiae occurring in a cohort of patients that have undergone FESS and identify characteristics associated with the development of synechiae postoperatively.

METHODS

A retrospective chart review was conducted of CRS patients, with or without nasal polyposis, that had undergone bilateral FESS in the past. All patients had received non-absorbable spacers intraoperatively that were left in situ for 6 days. Demographic and preoperative variables were analyzed to identify synechiae risk factors. A multivariable logistic regression model was constructed to estimate the probability of developing synechiae, given demographic and preoperative variables.

RESULTS

Two hundred cases of bilateral FESS were retrospectively reviewed. Thirty-eight (19.0%, 95% CI 13.6-24.4%) patients developed synechiae. Individuals receiving primary FESS and nasal septal reconstruction (NSR) were strongly associated with the development of synechiae (OR 3.5, 95% CI 1.5-8.5; OR 3.0, 95% CI 1.3-6.9). A multivariable logistic regression model adjusting for NSR, recurrent FESS, concha bullosa, requirement of anterior and posterior ethmoidectomy, Lund-Mackay CT score and gender, identified the likelihood of developing synechiae with a sensitivity of 68%, specificity of 73%, positive predictive value of 38% and likelihood ratio of 2.5.

CONCLUSION

Patients undergoing primary FESS and NSR are at greatest odds of developing postoperative synechiae. Methods of assessing risk factors and preventing synechiae formation in this population should be evaluated in future prospective investigations.

Comprehensive review on endonasal endoscopic sinus surgery

Endonasal endoscopic sinus surgery is the standard procedure for surgery of most paranasal sinus diseases. Appropriate frame conditions provided, the respective procedures are safe and successful. These prerequisites encompass appropriate technical equipment, anatomical oriented surgical technique, proper patient selection, and individually adapted extent of surgery. The range of endonasal sinus operations has dramatically increased during the last 20 years and reaches from partial uncinectomy to pansinus surgery with extended surgery of the frontal (Draf type III), maxillary (grade 3-4, medial maxillectomy, prelacrimal approach) and sphenoid sinus. In addition there are operations outside and beyond the paranasal sinuses. The development of surgical technique is still constantly evolving. This article gives a comprehensive review on the most recent state of the art in endoscopic sinus surgery according to the literature with the following aspects: principles and fundamentals, surgical techniques, indications, outcome, postoperative care, nasal packing and stents, technical equipment.

State of the art: a systematic review of the surgical management of aspirin exacerbated respiratory disease

BACKGROUND

Endoscopic sinus surgery is an important modality to the armamentarium of the otolaryngologist managing chronic rhinosinusitis (CRS). Within the spectrum of CRS, there exists a subset of patients who are recalcitrant to conventional treatment strategies, including those with aspirin-exacerbated respiratory disease (AERD). Although surgery is frequently undertaken in this group, there has been no general consensus on the efficacy or optimal extent of surgery.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic review of published studies was conducted. Inclusion criteria included original publications of adult patients with AERD undergoing surgery, cohorts of greater than five subjects, a minimum follow-up of 3 months, and measurable clinical outcomes. An electronic search was performed using OVID MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Web of Science.

RESULTS

Sixteen studies met the criteria for analysis. For our primary objective, sinus surgery appeared to improve patient-reported quality of life (QoL) and symptom profile in AERD. Overall, most studies reported a decrease in radiographic grading, endoscopy scores, and asthma severity. Compared with aspirin-tolerant asthmatic patients, AERD patients may have worse objective measures of disease severity both pre- and postoperatively; however, patient-reported QoL and symptom improvement may be similar after sinus surgery. Finally, this review showed that patients with AERD required revision surgeries sooner and more frequently compared with other subtypes of CRS. We also discussed the role of maximal surgical techniques and additional benefit of postoperative adjunctive therapies in the management of this disease entity.

CONCLUSION

The state of the art in the management of AERD patients suggests that surgery does play an important role in helping establish symptomatic control. In the future, more rigorous studies evaluating the comprehensiveness of surgery and postoperative adjuncts are required to understand their impact on long-term patient outcomes.

The role of antibiotics in endoscopic sinus surgery

PURPOSE OF REVIEW

To review and discuss recent literature regarding the use of antibiotics in relation to endoscopic sinus surgery (ESS), including perioperative antibiotics, postoperative antibiotics, and antibiotic usage in the setting of postoperative packing.

RECENT FINDINGS

Perioperative antibiotics are not recommended by the American Society of Health-System Pharmacists. The necessity of antibiotics following ESS is a heavily debated topic. Most studies show little to no improvement in outcomes. Significant improvement in quality-of-life outcomes and endoscopic scoring appears limited to the early postoperative period using conventional postoperative antibiotics. Prolonged macrolide therapy may improve long-term outcomes. There is no convincing evidence to show the need for antibiotics in the setting of postoperative packing.

SUMMARY

The available evidence regarding antibiotic use in relation to ESS overall fails to demonstrate routine benefit; however, the studies have various limitations. Overall, future, well designed, large-scale prospective studies would be beneficial to direct appropriate antibiotic use, whether systemic or topical, in relation to ESS.

Absorbable Steroid-Impregnated Spacer After Endoscopic Sinus Surgery to Reduce Synechiae Formation

OBJECTIVE

Middle meatal synechiae formation after endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) leads to higher rates of revision surgery. We aimed to determine if there are different rates of postoperative synechiae following ESS for CRS between patients who received a nonabsorbable spacer (NAS) placed in the ethmoid cavity versus patients who had a steroid-impregnated absorbable spacer (AS) placed at the middle meatal entry.

METHODS

We conducted a retrospective cohort study of patients who underwent ESS for CRS at a single tertiary referral center from October 2009 to October 2013. We collected data on synechiae formation between the middle turbinate and lateral nasal wall within 1 month of surgery and postoperative epistaxis.

RESULTS

One hundred forty-six patients with 252 nasal cavities (52.0%) received steroid-impregnated AS, and 128 patients with 233 nasal cavities (48.0%) received NAS. Synechiae formation occurred in 2.0% of cavities with AS and 5.6% of cavities with NAS, but this difference was not statistically significant (OR = 0.34, P = .052). One patient in each cohort had significant postoperative epistaxis requiring additional nasal packing (P > .99).

CONCLUSION

Steroid-impregnated absorbable spacers had statistically insignificant reduction in postoperative synechiae formation when compared to nonabsorbable spacers. Low rates of postoperative epistaxis were observed regardless of the type of spacer used.

Self-cross-linked hyaluronic acid hydrogel in ethmoidectomy: a randomized, controlled trial

BACKGROUND

This study was designed to evaluate the safety and efficacy of a novel, self-cross-linked hyaluronic acid (HA) hydrogel compared with carboxymethylcellulose (CMC) viscous foam in promoting healing when applied after ethmoidectomy. A prospective, randomized, controlled, blinded clinical trial was performed. The study was performed by four surgeons operating in two community hospitals.

METHODS

Thirty patients with bilateral chronic rhinosinusitis underwent bilateral total ethmoidectomy. Intraoperatively, each patient received 5 mL of HA hydrogel in one ethmoid cavity and 5 mL of CMC contralaterally. The material applied within each ethmoid cavity was randomly assigned before surgery. An independent surgeon, blinded to the material used to treat each ethmoid cavity, evaluated postoperative endoscopic video at 1 and 2 weeks for edema, crusting, and mucopurulence and at 6 and 12 weeks for remucosalization and scarring/synechiae. Twenty-item Sino-Nasal Outcome Test SNOT-20 data were collected at each visit. A small sample underwent endoscopic mucosal biopsy.

RESULTS

Twenty-nine of 30 patients completed the protocol. The difference in edema, crusting, and mucopurulence at 1 and 2 weeks was not statistically significant; however, at 6 and 12 weeks, the HA hydrogel showed statistically significant reduction in both overall endoscopic grade (p < 0.05), as well as synechiae formation (p < 0.05), with a trend toward superiority in remucosalization (p = 0.08). Histological analysis of six subjects at 12 weeks showed a nonsignificant trend toward a greater amount of regenerated cilia present with the HA hydrogel (p = 0.23). SNOT-20 scores declined 78.8% from preoperative scores.

CONCLUSION

Self-cross-linked HA hydrogel provides superior wound healing to CMC after ethmoidectomy.

A systematic review of nonabsorbable, absorbable, and steroid-impregnated spacers following endoscopic sinus surgery

BACKGROUND

Middle meatal (MM) spacers may reduce adhesions following endoscopic sinus surgery (ESS). However, there is no consensus as to which materials and adjuncts are the most effective for this purpose. The primary objective of this study was to examine the effectiveness of absorbable spacers (AS) vs nonabsorbable spacers (NAS) in reducing adhesions following ESS for chronic sinusitis. Secondarily, we assessed steroidal vs nonsteroidal MM spacers in reducing adhesions.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic review of randomized controlled trials (RCTs) was conducted and a meta-analysis on relevant outcome data was performed. Electronic search was done using OVID MEDLINE, EMBASE, Cochrane Central register of Controlled Trials, and Web of Science. Independent data extraction and evaluation was conducted.

RESULTS

For our primary objective, 6 RCTs were included in the systematic review. A pooled estimate of relevant trials revealed a nonsignificant trend favoring AS in reducing adhesion formation compared to NAS (Relative Risk (RR), 0.40; 95% confidence interval [CI], 0.15-1.03). This trend was not apparent if NAS are left for greater than 48 hours after ESS. For our secondary objective, we identified 5 RCTs that compared steroidal vs nonsteroidal spacers. Although a pooled analysis could not be achieved due to inconsistent reporting of MM adhesions, 2 studies demonstrated significantly less adhesions in the steroidal spacer group.

CONCLUSION

Comparison between NAS and AS showed that there was no significant difference in adhesion rates if NAS are used for at least 48 hours after surgery. Steroidal spacers may reduce adhesions, but more consistent data reporting is required for meta-analysis.