The effects of debridement after endoscopic sinus surgery

Assessing the effect of absorbable steroid sinus implant: a state-of-the-art systematic review

OBJECTIVES

Endoscopic sinus surgery is not a definitive treatment for chronic rhinosinusitis (CRS). The use of sinus stents after surgery to maintain sinus patency and deliver local steroids has gained popularity. The first steroid-eluting bioabsorbable implant (SEBI) approved for this indication, later Propel, was developed in 2011. This state-of-the-art review aims to summarize the available evidence, as well as to point out potential pitfalls and lack of specific analyses to guide future research on this new therapeutic option.

DATA SOURCES

Pubmed (Medline), the Cochrane Library, EMBASE, SciELO.

REVIEW METHODS

Nine research questions were defined: Are steroid-eluting Sinus implants useful for the control of CRS symptoms after surgery? Do they improve surgical field healing after CRS surgery? Do they decrease polyp regrowth after ESS? Do they decrease the need for ESS? Are they useful in symptom control as in-office procedure? Are they better than other steroid-impregnated resorbable materials? Do they have a positive impact on olfaction? Are they safe? Are they cost-effective? Retrieved articles were reviewed by two authors.

RESULTS

Twenty nine studies were included: 3 metanalysis, 1 systematic review, 10 randomized clinical trials, 4 quasi-experimental studies, 1 retrospective cohort study, 4 cost studies, 3 case series and 2 expert consensus. The review encompassed a population of 3,012 patients treated with SEBI and 2826 controls.

CONCLUSIONS

This is the first state-of-the-art review assessing steroid eluting bioabsorbable stent evidence. Despite the effort in recent years, still several questions remain unanswered. This review will hopefully guide future research efforts to better define the role of SEBI in the otolaryngology practice.

The efficacy of steroid-eluting stents on the local inflammation of chronic rhinosinusitis with nasal polyposis after endoscopic sinus surgery: a multicenter prospective longitudinal study

PURPOSE

Attenuating local inflammation of chronic rhinosinusitis with nasal polyps (CRSwNP) after endoscopic sinus surgery (ESS) was crucial. Corticosteroids were generally exploited to ameliorate the postoperative state of CRSwNP. This study aims to verify the efficacy of steroid-eluting stents on the local inflammation of CRSwNP following ESS.

METHODS

57 CRSwNP were enrolled from September 2021 to April 2022. 30 were with stents, and 27 were without stents after ESS. Eosinophilic cationic protein (ECP), myeloperoxidase (MPO), eosinophil, and neutrophil levels in nasal secretions, as well as visual analog scale (VAS) and modified perioperative sinus endoscopy (POSE) scores, were assessed preoperatively and after 2, 4, 8, and 12 weeks.

RESULTS

All subjects of CRSwNP exhibited reduced results of eosinophil levels, neutrophil levels, nasal obstruction, nasal discharge, loss of smell, and total VAS scores after 12 weeks compared to the preoperative ones (p < 0.05). Compared with control subjects, CRSwNP with stents acquired lower levels of ECP, MPO, loss of smell, total VAS, and POSE scores at four follow-up visits, as well as reduced eosinophil and neutrophil levels in nasal secretions after 12 weeks (p < 0.05). Correlation analysis revealed that postoperative ECP and MPO levels of CRSwNP in nasal secretions correlated strongly with eosinophil and neutrophil levels, respectively, as well as POSE scores (r > 0.6).

CONCLUSION

These findings indicated that steroid-eluting stents might be an acclaimed option for CRSwNP in alleviating local inflammation to acquire a superior state after ESS.

Nasal Crust-Related Morbidity and Debridement After Endoscopic Skull Base Surgery

Introduction:  Nasal crust after endoscopic skull base surgery can cause nasal congestion, obstruction, and pain, which can affect quality of life. The use of debridement aims to provide symptomatic relief and improve quality of life. Generally, most adult patients tolerate office-based debridement, except in a few select patients that require further sedation in the operating room for a debridement. The study sought to determine the rate of symptomatic crust-related morbidity and the rate of debridement in both the office and the operating room. Methods:  Premorbid, operative, and postoperative data of adult patients who had endoscopic skull base surgery in our institution from 2014 to 2018 were reviewed retrospectively. The characteristics of nasal symptoms in the postoperative period were determined and the number of debridements in the office and the operating room were analyzed. Results:  Two hundred and thirty-four (234) patients with 244 surgeries were included in the study. The majority, 68.9%, had a sellar lesion and a free mucosa graft (FMG) was the most common skull base reconstruction at 53.5%. One hundred and twenty (49.0%) had crust-related symptoms during the postoperative period and 11 patients (4.5%) required the operating room for debridement. The use of a pedicled flap, anxiety, and preoperative radiotherapy were significantly associated with intolerance to in-office debridement ( p -value=0.05). Conclusions:  The use of a pedicled flap or anxiety may predispose patients to require an OR debridement. Previous radiotherapy also influenced the tolerance to the in-office debridement.

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.

The Factors Related to the Time for Sinus Debridement after Functional Endoscopic Sinus Surgery - A Retrospective Study

Introduction

Post-operative care after functional endoscopic sinus surgery (FESS) is essential for managing the long-term success of chronic rhinosinusitis. Post-operative sinus debridement promotes proper wound healing, but the procedure can be accompanied by discomfort and pain. Hence, we analysed the clinical factors related to sinus debridement time after FESS.

Materials and Methods

We evaluated retrospectively the clinical factors affecting the time taken for post-operative sinus debridement on the first visit after the discharge. We reviewed 101 patients who underwent FESS at our hospital by the same surgeon and extracted patient information. The time for post-operative sinus debridement at the first outpatient clinic was measured.

Results

The days of putting the cotton ball in the operated nostril were negatively associated with sinus debridement time (coefficient - -16.4 ± 5.7 seconds/day, P = 0.005). In contrast, current or history of asthma, amount of bleeding during the surgery, number of opened sinuses by the operation or the number of eosinophils in resected tissues under a microscope at ×400 was not associated.

Discussion

We recommend the use of a cotton ball in the nostril after FESS because it shortens the sinus debridement time. Placing cotton balls in the nostril helps to maintain a humid wound environment and reduce crusting, leading to easier sinus debridement and better wound healing.

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.

General health, vitality, and social function after sinus surgery in chronic rhinosinusitis

Objectives

Chronic rhinosinusitis (CRS) has an impact on health-related quality of life (HRQOL). The objective of this study was to examine generic and disease-specific HRQOL and symptoms in CRS patients with (CRSwNP) and without (CRSsNP) nasal polyps before and 6 months after sinus surgery, and to identify preoperative patient factors associated with HRQOL outcome in the two groups separately.

Methods

This prospective, observational study consisted of 220 CRSwNP and 196 CRSsNP patients. Generic and disease-specific HRQOL were measured using the Short-Form-Health-Survey (SF-36) and Sino-Nasal-Outcome-Test (SNOT-20). Symptoms were assessed on a visual analog scale.

Results

Preoperatively, CRSwNP patients reported worse score in general health (SF-36), rhinologic subset (SNOT-20): nasal obstruction, nasal discharge, and altered sense of smell compared to CRSsNP patients, who reported worse score in physical role, bodily pain, ear/face subset, and facial pain. After surgery, generic and disease-specific HRQOL and symptoms improved in both groups. CRSwNP patients had greater improvement in general health, vitality and social function, nasal obstruction, and altered sense of smell, compared to CRSsNP-patients. In both groups, higher age, daily smoking, and having had sinus surgery previously were associated with less generic HRQOL improvement, in addition to female sex and allergy in CRSsNP patients.

Conclusion

The greater improvement in general health, vitality, and social function after surgery may indicate a greater potential for generic HRQOL improvement in CRSwNP patients compared to CRSsNP patients. Female sex and allergy was associated with less improvement of generic HRQOL in the CRSsNP group, but not in the CRSwNP group.

Level of evidence

2c outcome research.

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.

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.

Outcomes of Endoscopic Dacryocystorhinostomy in Secondary Acquired Nasolacrimal Duct Obstruction: A Case-Control Study

INTRODUCTION

Secondary acquired nasolacrimal duct obstruction (SANDO), where the obstruction is caused by a known process, is becoming more commonly treated by endoscopic dacryocystorhinostomy (endoDCR). This study evaluates outcomes of endoDCR for cases of SANDO in comparison to endoDCR outcomes treating primary acquired nasolacrimal duct obstruction (PANDO).

METHODS

All patients undergoing endoDCR from 2006 to 2015 at a tertiary referral center were reviewed for etiology of nasolacrimal duct obstruction (NLDO) and success of procedure. Inclusion criteria were preoperative determination of NLDO via probing and irrigation, greater than 60-day follow up with assessment of duct patency via probing and irrigation after silicone tube removal, and postoperative survey for recurrent epiphora. Exclusion criteria were cases treating partial NLDO, patients undergoing concurrent conjunctivodacryocystorhinostomy, and patients lost to follow up or with incomplete records. Preanalysis stratification was performed for the following preexisting conditions: PANDO, granulomatosis with polyangiitis, sarcoidosis, midfacial radiotherapy, radioactive iodine therapy, severe prolonged sinusitis, prior failed DCR, and midface trauma. The primary outcome was postoperative anatomical patency of the nasolacrimal system with resolution of epiphora. Fisher-Freeman-Halton exact tests were performed comparing each SANDO group to the PANDO group with statistical significance set at p < 0.05.

RESULTS

Fifty-nine cases of NLDO underwent endoDCR in this series, 21 of which had a diagnosis consistent with SANDO. All patients treated with the aggressive perioperative management protocol the authors describe achieved anatomical patency. Patients with history of radioactive iodine therapy and radiotherapy had statistically worse outcomes compared with patients with PANDO, p = 0.011, p = 0.045, respectively. Stratified groups with increased intranasal sinus inflammation trended toward worse outcomes, but were not statistically different.

CONCLUSIONS

EndoDCR is a viable approach for the treatment of SANDO. In patients with history of radiotherapy or radioactive iodine therapy, however, endoDCR demonstrated decreased success rates as compared with patients with PANDO. Modifications of operative and postoperative management based on underlying etiology of NLDO may improve outcomes of endoDCR in SANDO cases. The authors describe an aggressive protocol for perioperative management of patients with pathologic nasal inflammation undergoing endoDCR.

Comprehensive Postoperative Management After Endoscopic Skull Base Surgery

To maximize outcomes from endoscopic skull base surgery, careful early postoperative management is critically important. Standardized postoperative regimens are lacking. The type of reconstruction and presence and type of cerebrospinal fluid leak dictate management. If a leak is encountered intraoperatively, patients should avoid maneuvers that increase intracranial pressures for at least 1 month. Early postoperative care focuses on minimizing and managing nasal crusting. This article reviews the evidence in the literature on postoperative management, complications, and quality of life after surgery, and outlines our experience in the management of patients after endoscopic skull base surgery.

Review article: outcomes in endoscopic sinus surgery

Chronic rhinosinusitis has a significant impact on health-related and generic quality-of-life, has a high cost burden to both society and patients, and may be associated with absenteeism, loss of productivity and poor respiratory function. Though there is a paucity of level 1 evidence, endoscopic sinus surgery may be considered in medically refractory patients and a variety of objective and subjective outcome measures exist to assess the effectiveness of intervention. We outline the outcome measurements available and review in-depth the published outcomes to date. Furthermore we discuss the literature that indicates that endoscopic sinus surgery can have a positive effect on respiratory function in asthma. How patient selection, timing and extent of surgery, and post-operative care interventions may optimise surgical outcomes is explored.

Practice patterns in endoscopic dacryocystorhinostomy: survey of the American Rhinologic Society

BACKGROUND

The introduction of advanced endoscopic techniques has facilitated significant growth in endoscopic dacryocystorhinostomy (EnDCR). The purpose of this study is to evaluate clinical practice patterns of otolaryngologists performing EnDCR.

METHODS

A 25-item survey was electronically disseminated to the American Rhinologic Society (ARS) membership from November 17, 2014 to December 14, 2014. The target group encompassed 1157 ARS members.

RESULTS

A total of 85 (7.3%) physicians completed the survey. EnDCR was performed by 87% of respondents. The annual average number of EnDCR cases ranged from 1 to 10 in 65% of respondents, 11 to 25 in 15%, 26 to 50 in 6%, and >50 in 1%. A total of 48% of respondents had some to a lot of DCR exposure during training, and 60% had completed a rhinology fellowship. Respondents frequently perform preoperative nasal endoscopy and computed tomography (CT) imaging, but very infrequently perform ophthalmologic workup. Lacrimal stents were used often or always in 80%, with 38% keeping stents in place for 6 to 8 weeks. The mucosal flap preservation technique was used often or always in 40%. Topical antimetabolites were used often or always in only 1%. Ophthalmology was present in most cases to perform lacrimal intubation. Postoperative antibiotics, topical ophthalmic steroids, and oral steroids were prescribed often or always in 62%, 47%, and 23%, respectively. Postoperative endoscopic debridement was performed often or always in 69%. A total of 81% of respondents followed DCR patients for >2 months, with 17% following these patients for >1 year.

CONCLUSION

There is widespread integration of EnDCR procedures into rhinologic clinical practice among respondents. EnDCR practice patterns demonstrate moderate variation. In conjunction with evidence-based medicine, these trends can highlight areas of controversy and help advance patient care.

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.

Postoperative nasal debridement following functional endoscopic sinus surgery, a systematic review of the literature

BACKGROUND

Chronic rhinosinusitis is a significant health problem, and the optimal postoperative treatment regime for patients post functional endoscopic sinus surgery has been a topic debated for years.

OBJECTIVE OF REVIEW

To systematically review and critically evaluate the evidence relating to postoperative debridement of the nasal cavity following functional endoscopic sinus surgery to guide best practice.

SEARCH STRATEGY

A search of the following databases was performed: Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effectiveness, and Cochrane Central Register of Control Trials. Ovid Medline, EMBASE, Pubmed. The following key words were used: Postoperative, functional endoscopic sinus surgery, sinus surgery, debridement, follow-up, from 1970 to 2013.

EVALUATION METHOD

Two independent reviewers assessed the relevant articles using the consort guidance on systematic reviews Moher et al. BMJ 2010; 340: c869.

RESULTS

The best evidence available was 1B, with six Randomsied control trial (RCTs) identified. Four studies compared debridement against no debridement, and two looked at the frequency of the debridement. Cumulatively, results for 337 patients were included. Visual analogue scores were used in all studies. None of the results at the long-term follow-up showed any difference in sino-nasal outcome test scores or objective endoscopic scores. Four of the six studies demonstrated some benefit in symptom scores but only one in the long term. Two papers demonstrated the debridement group suffered more pain in the postoperative period.

CONCLUSIONS

Currently, there is no clear evidence for frequent postoperative debridement. Further well-designed RCTs are required to establish clear benefit, optimal frequency, extent and timing of debridement.

Clinical consensus statement: pediatric chronic rhinosinusitis

OBJECTIVE

To develop a clinical consensus statement on the optimal diagnosis and management of pediatric chronic rhinosinusitis (PCRS).

METHODS

A representative 9-member panel of otolaryngologists with no relevant conflicts of interest was assembled to consider opportunities to optimize the diagnosis and management of PCRS. A working definition of PCRS and the scope of pertinent otolaryngologic practice were first established. Patients of ages 6 months to 18 years without craniofacial syndromes or immunodeficiency were defined as the targeted population of interest. A modified Delphi method was then used to distill expert opinion into clinical statements that met a standardized definition of consensus.

RESULTS

After 2 iterative Delphi method surveys, 22 statements met the standardized definition of consensus while 12 statements did not. Four statements were omitted due to redundancy. The clinical statements were grouped into 4 categories for presentation and discussion: (1) definition and diagnosis of PCRS, (2) medical treatment of PCRS, (3) adenoiditis/adenoidectomy, and (4) endoscopic sinus surgery (ESS)/turbinoplasty.

CONCLUSION

Expert panel consensus may provide helpful information for the otolaryngologist in the diagnosis and management of PCRS in uncomplicated pediatric patients.

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.

The influence of spray cryotherapy on wound healing following endoscopic sinus surgery in chronic rhinosinusitis

OBJECTIVES/HYPOTHESIS

The aim of this study was to assess the influence of spray cryotherapy on wound healing following endoscopic sinus surgery (ESS).

STUDY DESIGN

A prospective, randomized, double-blinded, controlled trial.

METHODS

The study included 22 consecutive adult patients with chronic rhinosinusitis with and without polyps scheduled for bilateral ESS. At the end of the surgical procedure, patients were randomized to the distribution of spray cryotherapy in one middle meatus and saline contralaterally. Outcomes were only measured for endoscopy scores. Thus, postoperative healing and the amount of edema, crusting, secretions, and scarring were assessed using the validated Lund-Kennedy and Perioperative Sinus Endoscopy (POSE) scores.

RESULTS

There were no baseline differences concerning POSE and Lund-Kennedy scores between the two groups. Nevertheless, a significant difference was recorded at one, 2, 4, 8, and 12 weeks in both POSE (P = .001, P = .012, P = .02, P = .006, P = .001) and Lund-Kennedy (P = .002, P = .005, P = .02, P = .02, P = .03) scores.

CONCLUSIONS

These preliminary results reveal an improvement in postoperative scores, demonstrating enhanced healing following spray cryotherapy. However, without patient subjective outcomes, the study is limited. Additional studies with longer follow-up and larger samples are needed to describe the effects of cryotherapy on wound healing.

Bacterial sinusitis can be a focus for initial lung colonisation and chronic lung infection in patients with cystic fibrosis

A major purpose of treating patients with cystic fibrosis (CF) is to prevent or delay chronic lung infections with CF-pathogenic Gram-negative bacteria. In the intermittent stage, bacteria can usually be eradicated from the lungs with antibiotics, but following eradication, the next lung colonisations often occur with bacteria of identical genotype. This may be due to re-colonisation from the patient's paranasal sinuses. In our study, we found that approximately two-thirds of CF patients having sinus surgery (FESS) had growth of CF-lung-pathogenic Gram-negative bacteria in their sinuses (Pseudomonas aeruginosa, Achromobacter xylosoxidans, Burkholderia cepacia complex). The environment in the sinuses is in many ways similar to that of the lower respiratory tract, e.g. low oxygen concentration in secretions. Sinus bacteria are more difficult to eradicate than in the lungs, thus, having good conditions for adapting to the environment in the lungs. In the presence of bacteria, the environment of the sinuses differs from that of the lower respiratory tract by having a higher immunoglobulin A (IgA): IgG ratio, and reduced inflammation. We found a significant correlation between the concentration of IgA against P. aeruginosa (standard antigen and alginate) in nasal secretions and saliva and CF patients' infection status (not lung colonised, intermittently colonised or chronically lung-infected with P. aeruginosa). This supports the hypothesis that infections often originate in the sinuses and can be a focus for initial lung colonisation or for maintaining lung infections in CF patients. We are confident that anti-P. aeruginosa IgA can be used as an early supplementary tool to diagnose P. aeruginosa colonisation; P. aeruginosa being the microorganism causing most morbidity and mortality in CF patients. This is important since urgent treatment reduces morbidity when CF patients are early colonised with P. aeruginosa, however, there is a lack of diagnostic tools for detecting the early colonisation in the lungs and in the sinuses. We initiated a treatment strategy for CF patients to prevent sino-nasal bacteria being seeded into the lower airways: we recommended extensive functional endoscopic FESS with creation of sufficient drainage from all involved sinuses with subsequent i.v. antibiotics and at least 6 months of twice daily nasal irrigation with saline and antibiotics. By this strategy, sinus bacteria could be eradicated in a large proportion of patients. Essentially, growth of CF-pathogenic bacteria from the lower respiratory tract was decreased following the treatment. Furthermore, a number of patients have been free from CF-pathogenic bacteria for more than one year after FESS, and thus re-classified as "not lung colonised". We also corroborated that CF patients obtain an improved quality of life and reduction in their symptoms of chronic rhinosinusitis after FESS. It is primarily intermittently lung colonised CF patients with CF-pathogenic bacteria in their sinuses that seem to benefit from the treatment strategy. This is in accordance with the fact that we did not see a significant increase in lung function and only a small decrease in specific antibodies after FESS; a high systemic immune and inflammatory response and a decreasing lung function is generally not present in patients who primarily have sinus CF-pathogenic bacteria. It is important that guidelines are created for how CF patients with CF-pathogenic bacteria in the sinuses are to be treated, including criteria for who may likely benefit from FESS, and who may be treated exclusively with conservative therapy, e.g. saline and antibiotic irrigations.

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.

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.

A blinded randomized controlled trial evaluating the efficacy of chitosan gel on ostial stenosis following endoscopic sinus surgery

BACKGROUND

Stenosis of sinus ostia following endoscopic sinus surgery (ESS) is the most common reason for revision surgery. Chitosan-dextran (CD) gel has been shown to be an effective hemostatic agent; however, its effects on ostial stenosis are unknown. This study aims to quantify the effect of CD gel on circumferential scarring following ESS.

METHODS

A prospective, blinded, randomized, controlled trial was conducted in 26 patients undergoing ESS. Measurements of neo-ostia were taken using a standard-sized measuring probe. CD gel was applied unilaterally, while contralateral sides received no gel. Ostial diameters were measured by a blinded observer at 2, 8, and 12 weeks postoperation. Sinus ostial areas calculated as a proportion of the original were compared for each ostium at each time point.

RESULTS

Intraoperative ostial areas were comparable for CD gel and control sides (38 mm(2) vs 39 mm(2) , 131 mm(2) vs 120 mm(2) , and 203 mm(2) vs 193 mm(2) , in frontal, sphenoid, and maxillary ostia, respectively; p > 0.05). CD gel significantly improved sinus ostial patency. The largest difference was seen when ostial areas at 12 weeks were compared with their corresponding baseline areas (66% vs 31% frontal, p < 0.001; 85% vs 47% sphenoid, p < 0.001; and 74% vs 54% maxillary ostia, p = 0.002). The difference between raw ostial areas reached statistical significance in sphenoid (p < 0.001) and maxillary (p = 0.01), but not in frontal ostia (p > 0.05) at 12 weeks.

CONCLUSION

CD gel produced significantly less stenosis of all neo-ostia following ESS and may reduce the necessity for revision surgery in patients with chronic rhinosinusitis.

Mometasone implant for chronic rhinosinusitis

The Propel mometasone-eluting stent (Intersect ENT, Palo Alto, CA) is the first Food and Drug Administration-approved device for delivering steroid medication into the ethmoid cavity following surgery. The implant is composed of a biodegradable polymer in a lattice pattern that expands in a spring-like fashion to conform to the walls of a dissected ethmoid cavity and contains a total of 370 μg of mometasone furoate designed for gradual release over 30 days. The purpose of this article is to review the mode of action and the evidence supporting the efficacy of this novel technology. Three recently published clinical trials have demonstrated that the mometasone-eluting stent produced statistically significant reductions in inflammation, polyp formation, and postoperative adhesions. In addition, the implant has been found to significantly reduce the need for postoperative administration of oral steroids and to decrease the frequency of postoperative lysis of adhesions. Minimal adverse effects were reported in these trials and included infection, crusting, and granulation tissue formation. Although the placement of steroid-impregnated packing, stents, sponges, and gels has previously been used in the postoperative sinus cavities, the Propel mometasone-eluting stent introduces a new mechanism for localized and controlled delivery of topical therapy directly to the nasal mucosa for chronic rhinosinusitis.

Advance II

Objective. Endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) may be compromised by postoperative inflammation, polyposis, and adhesions, often requiring subsequent intervention. To address this issue, the authors investigated the safety and effectiveness of controlled delivery of mometasone furoate to the sinus mucosa via bioabsorbable implants deployed at the time of ESS.

Study Design. Prospective, multicenter, randomized, controlled, double-blind trial using an intrapatient control design.

Setting. Otolaryngology–head and neck surgery centers; both academic and private practices.

Subjects and Methods. The study enrolled 105 patients with CRS undergoing bilateral ethmoidectomy to compare the effect of drug-releasing to non-drug-releasing implants using an intrapatient control design. Postoperative interventions, polyposis, and adhesions were assessed postoperatively. Efficacy was determined through independent analysis of randomized video-endoscopies by 3 blinded sinus surgeons. Safety assessments included ocular examinations.

Results. Implants were successfully deployed in all 210 ethmoid sinuses. Compared with control sinuses with non-drug-releasing implants, the drug-releasing implant provided a 29.0% relative reduction in postoperative interventions ( P = .028) and a 52% ( P = .005) decrease in lysis of adhesions. The relative reduction in frank polyposis was 44.9% ( P = .002). Similar reductions were observed in real-time grading performed by the clinical investigators. No clinically significant changes from baseline in intraocular pressure or cataracts were observed.

Conclusion. This study provides a high level of evidence that use of steroid-releasing implants that apply a sustained release of corticosteroid improves surgical outcomes by reducing synechiae formation, polyposis, and the need for postoperative interventions, with no observable ocular safety risk.

Early postoperative care following endoscopic sinus surgery: an evidence-based review with recommendations

BACKGROUND

Early postoperative care following endoscopic sinus surgery (ESS) has been suggested to minimize avoidable complications and optimize long-term outcomes. Several postoperative care strategies have been proposed but a formal comprehensive evaluation of the evidence has never been performed. The purpose of this article is to provide an evidence-based approach to early postoperative care following ESS.

METHODS

A systematic review of the literature was performed and the Clinical Practice Guideline Manual, Conference on Guideline Standardization (COGS), and the Appraisal of Guidelines and Research Evaluation (AGREE) instrument recommendations were followed. Study inclusion criteria were: adult population >18 years old; chronic rhinosinusitis (CRS) based on published diagnostic criteria; ESS following failed medical therapy; primary study objective was to evaluate an ESS early postoperative care strategy; and clearly defined primary clinical end-point.

RESULTS

This review identified and evaluated the literature on 7 early postoperative care strategies following ESS: saline irrigations, sinus cavity debridements, systemic steroids, topical steroids, oral antibiotics, topical decongestants, and drug-eluting spacers/stents.

CONCLUSION

Based on the available evidence, use of nasal saline irrigation, sinus cavity debridement, and standard topical nasal steroid spray are recommended early postoperative care interventions. Postoperative antibiotic, systemic steroid, nonstandard topical nasal steroid solution, and/or drug-eluting spacers/stents are options in postoperative management. These evidence-based recommendations should not necessarily be applied to all postoperative patients and clinical judgment, in addition to evidence, is critical to determining the most appropriate care.

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

Objective:

There is currently no standardised management protocol following functional endoscopic sinus surgery. This study assessed frequent endoscopic cleaning versus minimal intervention in the early post-operative period following such surgery.

Study design:

Prospective, randomised controlled, single-blinded, within-subject trial involving 24 patients with bilateral chronic rhinosinusitis undergoing bilateral functional endoscopic sinus surgery.

Main outcome measure:

The primary outcome measure was ethmoid cavity healing, based on endoscopic appearance, graded using a modified Lund–MacKay endoscopic score.

Secondary outcome measure:

Lund–MacKay symptom score before and after surgery.

Results:

There was no overall statistically significant difference between the two groups (p = 0.37). Subgroup analysis revealed a significant effect of regular suction clearance on adhesions at three months (p = 0.048), but not on oedema, polyps, granulation, discharge or crusting.

Conclusion:

There is no evidence from this study to support frequent endoscopic cleaning in the early post-operative period after functional endoscopic sinus surgery. Less intensive post-operative management is recommended, resulting in decreased patient morbidity and fewer post-operative follow-up appointments.

[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.

The Efficacy of a Novel Chitosan Gel on Hemostasis after Endoscopic Sinus Surgery in a Sheep Model of Chronic Rhinosinusitis

Background

Postoperative bleeding remains a major problem after endoscopic sinus surgery (ESS). Patients who continue to bleed after ESS are at risk of airway compromise from inhalation of blood clots or from aspiration of blood-stained vomitus. The aim of this study was to determine the in vivo efficacy of a novel gel on hemostasis after ESS in a sheep model of chronic rhinosinusitis.

Methods

Twenty-one sheep infested with Oestrus ovus underwent ESS with standardized mucosal injuries created at the anterior ethmoid region using a microdebrider. Immediately after injury a baseline bleeding time was taken using the Boezaart Surgical Field Grading Scale. Computer randomization was performed to either receive chitosan/dextran (CD) gel or no treatment (control). Boezaart bleeding scores were calculated for each side every 2 minutes. Each postoperative day videoendoscopy was performed to document crusting/CD gel dissolution.

Results

The CD gel side was significantly more hemostatic at 2, 4, and 6 minutes after injury. Average time to hemostasis was significantly better for the intervention side versus control side, 4.09 (±1.61) versus 6.57 (±2.20), respectively (p = 0.049). Complete hemostasis occurred by 6 minutes for all CD gel sides; however, control side bleeding was noted on three sides at 8 minutes and on one side at 10 minutes. There was no significant difference in crusts scores at days 1, 3, 7, and 14.

Conclusion

In the sheep model of ESS, CD gel significantly improved hemostasis compared with the control at 2, 4, and 6 minutes after mucosal injury.

Isolated sphenoid sinusitis or mucocele: a potential complication of endonasal transsphenoidal surgery

Rhinosinusitis/mucocele are rare complications of transsphenoidal surgery. We present a retrospective analysis of 323 patients who received transsphenoidal surgery for pituitary adenoma. Twenty of the 323 patients (6.2%) developed rhinosinusitis/mucocele after transsphenoidal surgery as shown by MRI. All 20 patients with rhinosinusitis/mucocele occurred in the group who received the small sphenoidotomy approach and simple postoperative nasal care. Medical management was successful in 13 of 20 cases (65%). The remaining seven patients received endoscopic sphenoidotomy. On re-operation, purulent pus was discovered in two, a necrotic fat graft in one, mucocele in one, a dropped tumor in two, and a bone chip in one. Sphenoid sinusitis resolved in all seven cases. The formation of sphenoid sinusitis/mucocele is related to the size of the sphenoidotomy, frequency of postoperative nasal care, and foreign body accumulation. Early surgical drainage is necessary in patients with rhinosinusitis/mucocele refractory to medical management to prevent ascending meningitis.

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.