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

Efficacy of a RADA-16 peptide hydrogel versus chitosan-based polymer in improving patient comfort during postoperative debridement: A randomized controlled trial

BACKGROUND

Bioresorbable nasal packing is associated with a decreased incidence of adhesions and bleeding postoperatively after endoscopic sinus surgery (ESS). However, discomfort during postoperative debridement is still a major area of concern for patients. Our objective was to compare the efficacy of a peptide hydrogel to that of a chitosan-based polymer in reducing pain during debridement after ESS.

METHODS

A prospective, multicenter, randomized, blinded trial was conducted in adults undergoing bilateral total ethmoidectomy for chronic rhinosinusitis. Participants served as their own controls with each subject receiving the hydrogel in a randomized ethmoid cavity and chitosan-based polymer in the contralateral ethmoid cavity. Participants were evaluated at 1, 4, and 12 weeks postoperatively. Pain during debridement as well as endoscopic evaluation of mucosal healing and hemostasis were measured.

RESULTS

Thirty patients who underwent ESS were included in this trial. During the week 1 postoperative debridement, patients reported significantly less pain on the hydrogel-treated side compared to the chitosan-based polymer-treated side. There were no significant differences in bleeding severity, Lund-Kennedy scores, debridement time, or need for further intervention between the two groups.

CONCLUSION

This study demonstrated the efficacy of a peptide hydrogel in minimizing pain during postoperative debridement.

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.

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.

Chronic rhinosinusitis as a risk factor for intracranial and extracranial complications after endoscopic transsphenoidal surgery

PURPOSE

To elucidate whether chronic rhinosinusitis (CRS), usually an inflammatory-mediated rather than infectious process, is a risk factor for extracranial and intracranial complications after elective endoscopic transsphenoidal surgery (ETSS).

MATERIALS AND METHODS

A single-center retrospective cohort study of consecutive patients who underwent ETSS between January 2015 and July 2019 was performed, which included chart review and computed tomography assessment. CRS was defined by symptomatology and concurrent endoscopic or radiographic findings.

RESULTS

Of 292 subjects, 11% (n = 33) met criteria for CRS. Median difference in Lund-Mackay scores between the CRS and non-CRS groups was 3.0 (95% CI 2.0-4.0). Complications included acute rhinosinusitis requiring antibiotics (23%, 68/292), epistaxis (10%, 28/292), meningitis (1%, 3/292), cerebrospinal fluid (CSF) leak (7%, 20/292), revision sinonasal procedures (10%, 28/292), and frequent in-office debridement (13%, 39/292). CRS was strongly associated with postoperative acute rhinosinusitis (aRR 1.85, 95% CI 1.18-2.90) and frequent debridement (aRR 1.96, 95% CI 1.00-3.83). Conversely, CRS was not associated with epistaxis (aRR 1.52, 95% CI 0.62-3.72), postoperative CSF leak (aRR 0.91, 95% CI 0.24-3.44), or additional sinonasal procedures (aRR 0.70, 95% CI 0.21-2.29). The rate of meningitis was not significantly higher in the CRS cohort (difference 2.2%, 95% CI -1.0% to 14.5%).

CONCLUSIONS

CRS was a strong risk factor for acute rhinosinusitis and need for frequent in-office debridement after ETSS. It was not associated with other postoperative complications including epistaxis, CSF leak, or revision sinonasal procedures. CRS patients had a slightly higher rate of meningitis, which is likely not clinically meaningful.

Older Age Is Associated With Better Compliance With Follow-up in Taiwan After Functional Endoscopic Sinus Surgery

BACKGROUND/AIM

Functional endoscopic sinus surgery (FESS) is frequently conducted for restoring sinus ventilation and function. Postoperative care is critical for success. However, loss to follow-up is disturbing. The specific aim of this study was to identify critical factors contributing to loss of patients to follow-up and how to improve it.

PATIENTS AND METHODS

A total of 221 patients with chronic rhinosinusitis undergoing FESS were enrolled. Patients were divided into three groups according to their follow-up after surgery: Less than 1 month (short-term), 1-3 months (medium-term) and more than 3 months (long-term). The gender, age, smoking status, comorbidities, laterality, Lund-Mackay score, 22-question Sinonasal Outcome Test, nasal obstruction Visual Analogue Scale and mucociliary clearance were evaluated for their contribution to better compliance in follow-up.

RESULTS

The results revealed that older patients had better compliance in follow-up compared with younger ones (p=0.0093). Other factors were not contributory (p>0.05).

CONCLUSION

In contrast to the US, older patients in Taiwan have better compliance in postoperative follow-up, while younger ones require more education on the importance of follow-up.

[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.

Simultaneous Resection of Pituitary Macroadenoma and Sphenoid Sinus Inverted Papilloma: The Challenge of Operating Sinonasal and Skull Base Pathologies Through a Single-Stage Endoscopic Endonasal Approach

BACKGROUND

Coexistence of sinonasal and skull base tumors is uncommon but possible, and the endonasal route seems to be the best option to manage both lesions simultaneously. We report the first case in the English literature of concomitant sphenoid sinus inverted papilloma and pituitary macroadenoma treated through an endoscopic endonasal approach.

CASE DESCRIPTION

A 68-year-old man presented with a history of progressive visual loss and nasal obstruction. Clinical examination disclosed bitemporal hemianopsia. Computed tomography scan and magnetic resonance imaging obtained on admission showed a large sellar/suprasellar enhancing lesion with a marked mass effect on the optic chiasm. Imaging also showed a second mass extending from the sphenoid sinus to the left nasal cavity with obstruction of the maxillary sinus ostium and development of maxillary sinus mucocele. Both tumors were entirely resected by an endoscopic endonasal approach. Additionally, middle meatal antrostomy and marsupialization with drainage of the maxillary mucocele was performed. Biopsy confirmed the coexistence of a pituitary macroadenoma and sphenoid sinus inverted papilloma.

CONCLUSIONS

This case and the literature suggest that patients with concomitant nasal and skull base pathologies can be simultaneously managed. The otolaryngologist plays an essential role in removing the sinonasal lesion to ensure a safe surgical corridor before entering the intracranial cavity and for planning for the skull base reconstruction.

Assessment and Treatment of Pain during In-Office Otolaryngology Procedures: A Systematic Review

OBJECTIVE

To qualitatively assess practices of periprocedural pain assessment and control and to evaluate the effectiveness of interventions for pain during in-office procedures reported in the otolaryngology literature through a systematic review.

DATA SOURCES

PubMed, CINAHL, and Web of Science searches from inception to 2018.

REVIEW METHODS

English-language studies reporting qualitative or quantitative data for periprocedural pain assessment in adult patients undergoing in-office otolaryngology procedures were included. Risk of bias was assessed via the Cochrane Risk of Bias or Cochrane Risk of Bias in Non-Randomized Studies of Interventions tools as appropriate. Two reviewers screened all articles. Bias was assessed by 3 reviewers.

RESULTS

Eighty-six studies describing 32 types of procedures met inclusion criteria. Study quality and risk of bias ranged from good to serious but did not affect assessed outcomes. Validated methods of pain assessment were used by only 45% of studies. The most commonly used pain assessment was patient tolerance, or ability to simply complete a procedure. Only 5.8% of studies elicited patients' baseline pain levels prior to procedures, and a qualitative assessment of pain was done in merely 3.5%. Eleven unique pain control regimens were described in the literature, with 8% of studies failing to report method of pain control.

CONCLUSION

Many reports of measures and management of pain for in-office procedures exist but few employ validated measures, few are standardized, and current data do not support any specific pain control measures over others. Significant opportunity remains to investigate methods for improving patient pain and tolerance of in-office procedures.

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.

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.

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.

Comprehensive management of the paranasal sinuses in patients undergoing endoscopic endonasal skull base surgery

OBJECTIVE

The endonasal route often provides the most direct and safe approach to skull base pathology. In this article we review the literature with regard to management of the paranasal sinuses in the setting of skull base surgery.

METHODS

We describe our institutional experience and review the literature of concurrent management of the sinusitis in patients undergoing endoscopic skull base surgery.

RESULTS

Patients should be optimized preoperatively to ensure the endonasal route is a safe corridor to enter the intracranial cavity. Often the paranasal sinuses can be surgically addressed at the same time as endoscopic skull base surgery. We describe the technical details of management of the paranasal sinuses when addressing skull base pathology.

CONCLUSIONS

Careful management of the paranasal sinuses throughout the peri-operative course is paramount to optimizing sinonasal function and safety.

Standalone balloon dilation versus sinus surgery for chronic rhinosinusitis: a prospective, multicenter, randomized, controlled trial

BACKGROUND

A prospective randomized controlled study was conducted on patients with chronic rhinosinusitis (CRS) to test the hypotheses that symptom improvement after balloon dilation was noninferior to functional endoscopic sinus surgery (FESS) and balloon dilation was superior to FESS for postoperative debridements.

METHODS

Adults with uncomplicated CRS of the maxillary sinuses with or without anterior ethmoid disease who met criteria for medically necessary FESS were randomized 1:1 to office balloon dilation or FESS and followed for 6 months. A minimum of 36 patients per arm were required to test the hypotheses with 90% power. Symptom improvement using the validated 20-item Sino-Nasal Outcome Test (SNOT-20) survey, debridements, recovery outcomes, complications, and revision surgeries were compared between groups.

RESULTS

Ninety-two patients (50 balloon dilation; 42 FESS) were treated. Mean SNOT-20 improvement was 1.67 ± 1.10 and 1.60 ± 0.96 in the balloon and FESS arms, respectively. Both groups showed clinically meaningful and statistically significant (p < 0.0001) improvement and the balloon arm was noninferior (p < 0.001) to FESS. The mean number of postprocedure debridements per patient was 0.1 ± 0.6 in the balloon arm versus 1.2 ± 1.0 in the FESS arm, with the balloon group showing superiority (p < 0.0001). Occurrence of postoperative nasal bleeding (p = 0.011), duration of prescription pain medication use (p < 0.001), recovery time (p = 0.002), and short-term symptom improvement (p = 0.014) were all significantly better for balloon dilation versus FESS. No complications occurred in either group and one revision surgery was reported in each arm.

CONCLUSION

Balloon dilation is noninferior to FESS for symptom improvement and superior to FESS for postoperative debridements in patients with maxillary and anterior ethmoid disease. Balloon dilation is an effective treatment in patients with uncomplicated CRS who meet the criteria for medically necessary FESS.

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.

Perioperative care in functional endoscopic sinus surgery: a survey study

BACKGROUND

Functional endoscopic sinus surgery (FESS) is largely viewed as the standard of care in the treatment of chronic rhinosinusitis (CRS) refractory to medical treatment. While there is an understanding regarding the importance of some form of routine postoperative FESS care, no consensus currently exists regarding what the specific management routine should include. The authors of this survey study did not intend to examine the efficacy of such treatment protocols, but rather to determine and report on the current practice patterns of perioperative FESS care among otolaryngologists.

METHODS

This survey study was designed in accordance with and approved by our institutional review board. The online-based survey was designed using the online product SurveyMonkey®. A total of 859 otolaryngologists were identified and email addresses were obtained from the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) website directory. Responses were collected anonymously.

RESULTS

Our survey response rate was 32%. Multiple parameters of the otolaryngologists' perioperative care were collected. Among the data, some consistent patterns emerged: 93.2% of respondents use nasal saline irrigations postoperatively; 86.8% of otolaryngologists surveyed prescribe antibiotics in the immediate postoperative period; and office-based endoscopic sinus debridements are performed by a majority (87.9%) of those surveyed.

CONCLUSION

This survey study demonstrates that current practices in perioperative FESS care can vary widely among otolaryngologists, and are not uniformly based on evidence-based outcomes research. Despite the lack of absolutes regarding the specific perioperative care in FESS, practice patterns emerge from the data regarding typical perioperative management among current otolaryngologists.

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.

Impaired mucosal healing and infection associated with Staphylococcus aureus after endoscopic sinus surgery

BACKGROUND

Differentiating normal nasal discharge and postoperative crust from infection after endoscopic sinus surgery (ESS) can be difficult. We investigated whether bacteria cultured at operation was predictive for postoperative mucosal infection-defined as frank pus, thick mucus, and/or abnormal crusting seen on endoscopic examination associated with positive microbiology.

METHODS

The records of 48 patients with chronic rhinosinusitis (CRS) with infection at the time of ESS were retrospectively reviewed. Results of intraoperative cultures were compared with those taken at the time of postoperative mucosal infection.

RESULTS

Fourteen of 16 patients (87.5%) with intraoperative infection with Staphylococcus aureus progressed to postoperative mucosal infection with S. aureus, whereas patients who cultured "other" bacteria intraoperatively progressed to postoperative mucosal infection in 6/19 cases (31.6%), with S. aureus cultured in only 3/19 cases (15.8%; p=0.0001).

CONCLUSION

S. aureus infection at ESS predicts for abnormal, S. aureus-associated mucosal healing and infection post-ESS. Although a prospective trial is warranted, these findings suggest a future role for aggressive anti-S. aureus therapy peri- and/or postoperatively in patients who culture positive for this organism to improve postsurgical outcomes.

[Wound healing after endoscopic sinus surgery and postoperative management]

Understanding the physiological concepts of wound healing after rhinologic procedures facilitates detection and management of more or less obvious problems of wound healing. In this review, the physiologic processes involved in wound healing are explained, and typical clinical constellations are presented. Based on challenges of anatomy and physiology, recent findings are summarized, and possible conclusions for managing the postoperative mucosa are drawn.