Prospective, randomised controlled trial comparing intense endoscopic cleaning versus minimal intervention in the early post-operative period following functional endoscopic sinus surgery

Impact of Patient Guidance Handouts on Outcomes of FESS

Post-operative care in FESS is an important aspect. Nasal saline irrigation and Nasal steroid spray are highly recommended worldwide in post-operative protocol after endoscopic sinus surgery. Hence patients compliance for both these procedures becomes a deciding factor for outcomes following FESS and there is not much evidence in literature regarding the same. The present study was conducted to evaluate the role of giving patients pictorial handouts regarding nasal saline irrigations and various positions of using nasal steroid spray in improving outcomes of FESS. It was a randomised control study.46post operative patients of FESS were randomised into two groups. Group A patients were verbally explained and practically demonstrated the technique of nasal saline irrigation and nasal steroid spray in the language best understood and by showing them the relevant images. Group B patients were also verbally explained as well as practically demonstrated the above mentioned procedure but were also given pictorial handouts (depicting in detail the positions of nasal saline irrigation and steroid spray} which were explained and handed over to them at the time of discharge. The patients were evaluated a 1st, 2nd 3rd and 4th post-operative week for compliance of both the procedures and its effect on post-operative cavity. In the present study there were 21 females versus 25 males. The average male: female ratio in group A was 1.3 versus 1 in group B. The mean age was 35.5652 ± 4.595 in group B versus 33.1739 ± 4.438 in group A. The average compliance over three weeks was 2.5765 ± 0.207 in Group B as compared to 1.4935 ± 0.27 in Group A. The t score for the difference in compliance between two groups was 15.2691. The two-tailed P value was less than 0.0001. The average Lund and Kennedy endoscopic appearance score for crusting was 1.75 ± 0.532, 1.217 ± 0.6, 0.696 ± 0.703 for Group A in post-operative follow up during week 1, 2 and 3 respectively as compared to 1.45 ± 0.59, 0.304 ± 0.47, 0.826 ± 0.49 for Group B. The P value was < 0.05 for the difference in both groups for all three weeks. The average Lund and Kennedy score for edema and other parameters has been enumerated in Table 1. 11/23 followed correct method for nasal saline irrigation in Group A as compared to 20/23 in Group B. 18/23 used nasal steroidal spray in all positions compared to only 9/23 in Group A. 3/23 in group B had polypoidal mucosa at frontal recess area at 1 month post-operative as compared to 16/23. Overall their was a negative correlation between the compliance of nasal saline irrigation with edema, crusting and discharge. The respective R score was -0.5311, -0.25296 and -0.19889 respectively. The pictorial handouts definitely improved compliance and hence outcomes in our study. We recommend this practice in routine to all our fellow rhinologists.

Sinonasal debridement versus no debridement for the postoperative care of patients undergoing endoscopic sinus surgery

BACKGROUND

Endoscopic sinus surgery (ESS) is often recommended for symptomatic patients with recurrent acute or chronic rhinosinusitis who have failed conservative treatment. Postoperative care has been felt to be critical for both maintaining the surgical patency of the operated sinuses and improving patient symptoms. Debridement of the sinonasal cavities is one such postoperative care measure that has frequently been studied in the literature, often with conflicting conclusions.

OBJECTIVES

To assess the effects of postoperative sinonasal debridement versus no debridement following endoscopic sinus surgery.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the ENT Trials Register; Central Register of Controlled Trials (CENTRAL, via the Cochrane Register of Studies); PubMed; EMBASE; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 21 May 2018.

SELECTION CRITERIA

Randomised controlled trials comparing postoperative nasal debridement versus no debridement in adult patients with recurrent acute or chronic rhinosinusitis undergoing endoscopic sinus surgery. We included studies in which the patients acted as self-controls (i.e. one side of the nose underwent debridement and the other side did not) only for the secondary endoscopy outcomes.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane. Our primary outcome measures were: health-related quality of life, disease severity (patient-reported symptom scores) and significant adverse effects (bleeding requiring intervention, severe pain, iatrogenic injury). Secondary outcomes were: postoperative endoscopic appearance of the sinonasal surgical cavities (endoscopic scores), recorded use of postoperative medical treatment and rate of revision surgery. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics.

MAIN RESULTS

We included four studies (152 participants), with a follow-up duration ranging from three months to 12 months. In two studies patients acted as self-controls, i.e. one side of the nose underwent debridement and the other side did not ('split-nose' studies). The risk of bias in all studies was high, mostly due to the inability to blind the patients to the debridement procedure.Primary outcomesDisease-specific health-related quality of life scoresOnly one study (58 participants) provided data for disease-specific health-related quality of life. At six months follow-up, lower disease-specific health-related quality of life scores, measured using the Sino-Nasal Outcome Test-22 (SNOT-22, range 0 to 110), were noted in the debridement group but the difference was not statistically significant (9.7 in the debridement group versus 10.3 in the control group, P = 0.47) (low-quality evidence).Disease severity (patient-reported symptom score)Only one study (60 participants) provided data for disease severity measured by visual analogue scale (VAS) score. No significant differences in total symptom score were observed between groups postoperatively (low-quality evidence).Significant adverse effectsSignificant adverse effects related to the debridement procedure were not reported in any of the included studies, however it is not clear whether data regarding adverse effects were not collected or if none were indeed observed in any of the included studies.Secondary outcomesAll four studies assessed thepostoperative endoscopic appearance of the sinonasal cavities using the Lund-Kennedy score (range 0 to 10). A pooled analysis of endoscopic scores in the two non 'split-nose' studies revealed better endoscopic scores in the debridement group, however this was not a statistically significant difference (mean difference -0.31, 95% confidence interval (CI) -1.35 to 0.72; I² = 0%; two studies; 118 participants) (low-quality evidence). A sub-analysis of the adhesion formation component of the endoscopic score was available for all four studies and revealed a significantly lower adhesion rate in the debridement group (risk ratio 0.43, 95% CI 0.28 to 0.68; I² = 29%; four studies; 152 participants). Analysis of the number needed to treat to benefit revealed that for every three patients undergoing debridement, the endoscopic score would be decreased by one point in one patient. For every five patients undergoing debridement adhesion formation would be prevented in one patient.Use of postoperative medical treatment was reported in all studies, all of which recommended nasal douching. Steroids (systemic or nasal) were administered in two studies. However, the data were very limited and heterogeneous, therefore we could not analyse the impact of concomitant postoperative medical treatment.The rate of revision surgery was not reported in any of the included studies, however it is not clear whether these data were not recorded or if there were no revision surgeries in any of the included studies.

AUTHORS' CONCLUSIONS

We are uncertain about the effects of postoperative sinonasal debridement due to high risk of bias in the included studies and the low quality of the evidence. Sinonasal debridement may make little or no difference to disease-specific health-related quality of life or disease severity. Low-quality evidence suggests that postoperative debridement is associated with a significantly lower risk of adhesions at three months follow-up. Whether this has any impact on longer-term outcomes is unknown.

Postoperative care in endoscopic sinus surgery: a critical review

PURPOSE OF REVIEW

Chronic rhinosinusitis with and without nasal polyps is a common disease affecting people all over the world. Functional endoscopic sinus surgery (FESS) has become the gold standard treatment for medically refractive disease. Postoperative care is recommended by international leaders as an important part of the patient's management. This article is a critical review and discussion focusing on postoperative care, which is based on expert opinion, clinical studies, randomized controlled trials and meta-analysis studies.

RECENT FINDINGS

Postoperative care including nasal rinsing, topical corticosteroids, antibiotics and avoidance of nasal packing are unanimously considered to be the cornerstone of best practice following FESS. However, the effectiveness of in-office nasal debridement is still under debate.

SUMMARY

There is a lack of consensus regarding the necessity of performing in-office nasal debridement and the majority of clinicians carry out their postoperative care according to experience and their own preference. This is often determined by the extent of surgery performed, the severity of the postoperative inflammation, as well as being dependent on the patient's discomfort, the time constraints associated with postoperative care and the costs associated with additional appointments. Ideally, nasal debridement should be performed by the operating surgeon under endoscopic control both gently and atraumatically.

Effects of triamcinolone-impregnated nasal dressing on subjective and objective outcomes following endoscopic sinus surgery

The aim of this study was to compare the effects of triamcinolone (TA)- and saline-soaked biodegradable nasal dressing on subjective symptoms, wound healing and improvement of olfactory dysfunction in patients with chronic rhinosinusitis with nasal polyposis (CRSwNP) after undergoing endoscopic sinus surgery (ESS). The study was a prospective, randomized, double-blinded, placebo-controlled study. A total of 80 patients undergoing bilateral ESS for CRSwNP were enrolled and randomly assigned to two groups. Nasal dressing was impregnated with normal saline in the control group, while patients received triamcinolone-impregnated dressing in the TA group. Sino-Nasal Outcome Test 20 (SNOT-20) and Korean Version of the Sniffin' Stick (KVSS) II test were used to assess the patients' condition preoperatively and at postoperative 1 and 3 months. Lund-Kennedy (L-K) and perioperative sinus endoscopy (POSE) scores were assessed on postoperative months 1, 2, and 3. There were significant differences between the control group and the TA group in terms of postoperative L-K scores and POSE scores at 1 and 2 months. The postoperative endoscopic scores were significantly decreased in the TA group compared to the control at 1 month. Olfactory functions were significantly improved at postoperative 3 months (p = 0.0099) compared to the preoperative score in the TA group. Significant improvement in the olfactory functions among anosmic and hyposmic patients at postoperative 1 month (p = 0.0475) and 3 months (p = 0.0019) compared to their preoperative olfactory function score was observed only in the TA group. TA-impregnated dressing had a significant advantage over saline-soaked dressing with regard to postoperative wound healing and improvement of olfactory function.

Single seventh day debridement compared to frequent debridement after endoscopic sinus surgery: a randomized controlled trial

The aim of this study was to evaluate the postoperative debridement frequency following endoscopic sinus surgery. Individual randomized controlled trial. Sixty-two adult patients with a diagnosis of chronic rhino sinusitis (CRS) with nasal polyps (NP) and CRS without NP meeting the inclusion criteria were enrolled in this prospective study. The patients were randomized equally to frequent debridement (FD; at postoperative weeks 1, 2 and 4) or to a single debridement (SD; at postoperative week 1) after surgery. The outcomes were assessed with visual analog scale (VAS) for nine main symptoms concerning patient discomfort within the first 4 weeks, with the modified Lund-Kennedy endoscopic score (MLKES) at weeks 4 and 24 and with the sino-nasal outcome test-20 (SNOT-20) at week 24. Thirty-seven of the patients were male, and twenty-five were female. The mean age was 36.1 ± 13.5 in FD group and 39.2 ± 14.7 in SD group. In the SD group, the VAS scores at postoperative week four showed significantly less discomfort at visits (p = 0.004) and less negative effects on their work (p = 0.013). There was no statistically significant difference between the two groups in the week 4 and 24 MLKES and in the week 24 SNOT-20 scores (p > 0.05). The endoscopic findings did not show significant differences between the groups. Our data indicate that FD causes more discomfort at the required visits, more facial pain and more negative effects on patients' work; this method is not superior to postoperative single seventh day debridement in terms of the 24-week quality of life and endoscopic scores.

LEVEL OF EVIDENCE

1b.

Risks and medico-legal aspects of endoscopic sinus surgery: a review

The aim of this study was to perform a systematic literature review of risks and medico-legal aspects of endoscopic sinus surgery. The development of sophisticated technologies and instruments for endoscopic sinus surgery (ESS) has caused a dramatic increase in the number of otolaryngologists performing sinus surgery and the number of cases performed. This expansion was accompanied by an increase in malpractice lawsuits. Over the past 20 years, rhinology claims represented 70 % of the total indemnity compensation for otolaryngology claims and ESS was the surgical procedure most often involved. Only then will a careful analysis and assessment of the possible and potential risk factors of ESS, which may mislead the surgeon, allow a correct clinical risk management, with activities and procedures aimed at reducing the possibility of complications that may expose the physician to a malpractice suit.