Effect of carboxymethylcellulose nasal packing on wound healing after functional endoscopic sinus surgery

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

BACKGROUND AND OBJECTIVES

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

MATERIALS AND METHODS

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

RESULTS AND CONCLUSIONS

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

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

Background:

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

Objective:

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

Methods:

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

Results:

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

Conclusion:

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

The effect of platelet-rich fibrin (PRF) on wound healing, adhesion, and hemostasis after endoscopic sinus surgery in patients with nasal polyposis

PURPOSE

Chronic rhinosinusitis (CRS) is one of the most common chronic diseases seen worldwide. Endoscopic sinus surgery (ESS) has become a widely accepted procedure for medically refractory chronic rhinosinusitis and nasal polyps. Prevention of revision surgery often depends on good wound healing and less adhesion formation. In recent years, the effects of platelet-rich fibrin (PRF) on tissue healing have been addressed in many surgical branches, especially for dental implant surgery and plastic surgery.

METHODS

This prospective study was conducted with 50 patients who underwent endoscopic sinus surgery for the diagnosis of nasal polyposis. While the middle meatus in one nasal cavity was filled with PRF and supported with Nasopore, only Nasopore was used in the other nasal cavity middle meatus. The patients were followed up clinically at weeks 1, 2, 3, 4, 8, and 12 postoperatively. The assessor determined the presence of adhesion, crusting, bleeding, frontal ostium stenosis, granulation, and infection, and if present, the grades of these complications were scored according to a questionnaire.

RESULTS

In our study, adhesion, infection, bleeding, granulation, and frontal ostium stenosis were less common in the PRF group, and a statistically significant difference was found between the groups.

CONCLUSION

In our study, better results were obtained in terms of adhesion, infection, bleeding, granulation, and frontal ostium stenosis after ESS as a result of the effects of PRF on wound healing. The application of PRF is an inexpensive and easy procedure. PRF can be a good alternative to other types of tampons after ESS.

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

INTRODUCTION

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

DATA SOURCE

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

METHODS

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

RESULTS

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

CONCLUSION

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

International consensus statement on allergy and rhinology: rhinosinusitis 2021

I.

EXECUTIVE SUMMARY

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

METHODS

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

RESULTS

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

CONCLUSION

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

Quest for the Ideal Nasal Pack in Post Operative Cases of Septo-Turbinoplasty: Study in a Tertiary Care Hospital

To compare the efficacies and post operative outcomes of patients with nasal packing with merocel, intranasal splints and merocel along with intra-nasal infant feeding tubes following septo-turbinoplasty, in patients with nasal obstruction secondary to septal deviation and inferior turbinate hypertrophy. A prospective study was done in 60 patients of symptomatic deviated nasal septum with inferior turbinate hypertrophy. Septoturbinoplasty was performed. Patients' nasal cavity was packed for 48 h after being randomly divided into 3 groups: (1) packing using merocel, (2) intra-intra nasal septal silicone splint, (3) packing using truncated merocel along with infant feeding tube. Patients were given a questionnaire 24 h post operatively and their reponse was analysed to compare nasal blockage, epistaxis, epiphora and headache. Pain on pack removal was recorded after 48 h. We found that merocel with infant feeding tube had better tolerance than plain merocel in almost all cases, with symptoms of nasal blockage, epiphora, headache and pain on pack removal being lesser than with plain merocel, and comparable to the results produced by nasal splints. Also the epistaxis control in merocel with infant feeding tube was better than with nasal splints. Truncated merocel with infant feeding tubes provides a suitable and cheap replacement for nasal splints which may not be affordable to a lot of patients, or may not in available in many settings. The results are superior to plain merocel and the control of post operative bleeding is better than with intra nasal splints.

The Effects of Halofuginone on Wound Healing in the Rat Nasal Mucosa

Background

Halofuginone is an alkaloid febrifugine analogue and bioactive molecule that was isolated incidentally from the Dichroa febrifuga plant. The therapeutic efficacy of halofuginone in parasitic infections, scleroderma, inflammation, and fibrosis-related diseases, as well as in some types of cancer, has been previously reported. The effects of halofuginone on nasal mucosal damage are not yet known.

Objective

The aim of this study was to investigate the potential effect of topically applied halofuginone on wound healing in the mechanically injured nasal mucosa of rats.

Methods

A unilateral mucosal wound was created in the nasal cavity of 32 rats (aged 4 weeks) using the brushing technique. These rats were randomly divided into 4 groups. Although the control group did not receive an intervention, a dry pad, a saline-impregnated pad, or a pad impregnated with halofuginone were placed in the rats of the other 3 groups and left for 5 minutes. Rats were sacrificed on the 14th day, and a histological examination was performed. The nasal mucosa was assessed via hematoxylin-eosin and Masson’s trichrome staining.

Results

There were no statistically significant differences in epithelial thickness, inflammation, goblet cell formation, and epithelial disarray values between the halofuginone group and the control group ( P > .05). The subepithelial thickness was significantly decreased in the saline-treated group and the halofuginone-treated group ( P < .05), but a significantly lower level of subepithelial fibrosis was only observed in the halofuginone group compared to the other groups ( P < .05).

Conclusions

Topical halofuginone administration reduces the development of fibrosis and subepithelial edema after experimentally induced nasal mucosal injury, but it does not exert therapeutic or preventive effects on epithelial damage, inflammation, and goblet cell hyperplasia.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusion

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

Influence of chitosan-based dressing on prevention of synechia and wound healing after endoscopic sinus surgery: A meta-analysis

INTRODUCTION

Endoscopic sinus surgery (ESS) has had many complications, e.g., synechia formation. This meta-analysis investigated the effect of a novel chitosan-based dressing on prevention of synechia and wound healing after ESS.

METHODS

We systematically searched various medical literature data bases and included the randomized controlled trials (RCT) regarding the effect of novel chitosan-based dressing on ESS. The study outcomes included synechia, granulations, hemostasis, crusting scores, and infection.

RESULTS

Six RCTs, which involved 337 patients, were included in the meta-analysis. Compared with control intervention after ESS, chitosan-based gel dressing substantially inhibited synechia (risk ratio [RR] 0.28 [95% confidence interval {CI}, 0.15-0.54]; p = 0.0001), improved granulations (RR 1.47 [95% CI, 1.07-2.03]; p = 0.02), and hemostasis (RR 1.47 [95% CI, 1.07-2.03]; p = 0.02) but demonstrated no effect on crusting scores (standard mean difference -0.41 [95% CI, -1.06 to 0.23]; p = 0.21) and infection (RR 0.88 [95% CI, 0.51-1.52]; p = 0.64).

CONCLUSION

Compared with control intervention, chitosan-based dressing was associated with significantly reduced synechia and with increased granulations and hemostasis but showed no influence on crusting and infection after ESS.

The clinical outcomes of using a new cross-linked hyaluronan gel in endoscopic frontal sinus surgery

In endoscopic sinus surgery (ESS) synechiae formation and ostial stenosis are frequently encountered. This is not uncommon after frontal recess and ostium interventions due to the narrow recess and difficult anatomy of the region. The goal of this study is to evaluate the efficacy of the new cross-linked hyaluronan gel-PureRegen^® Gel Sinus-on wound healing and synechiae prevention in endoscopic frontal sinus surgery. The study consists of two groups of patients who underwent ESS, including frontal sinus surgery. In the study group of 37 patients, PureRegen^® Gel Sinus was applied to both the frontal recess and ostium at the end of the procedure. The control group consisted of 28 patients. In this group, nasal dressing material was not applied at the end of surgery-neither to the frontal recess nor to the ostium. Postoperatively, epithelization was found to be significantly better at 2 and 4 weeks in the study group when compared with the findings in patients where no postoperative dressing was applied. In the eighth week, there was no significant difference found between the two groups in terms of epithelization. Synechiae formation was significantly lower in the PureRegen^® Gel Sinus group than the control group at all 2, 4 and 8 weeks postoperative evaluations. The effects of PureRegen^® Gel Sinus on wound healing, especially in reepithelization, have shown to occur earlier in the postoperative period. Rapid reepithelization and control of infection related granulation tissue formation with antibiotics in the early postoperative period may explain the low stenosis rate in frontal sinus ostia in PureRegen^® Gel Sinus applied patients.

Middle meatal packing in endoscopic sinus surgery-to pack or not to pack?-a decision-analysis model

BACKGROUND

Packing of the middle meatus and ethmoid cavities is a common practice in endoscopic sinus surgery (ESS), but its necessity recently has been challenged. The aim of this study was to formulate a decision-analysis model to determine the need for packing in ESS and identify variables affecting the decision.

METHODS

A systematic review of the literature was conducted for all randomized control trials comparing packing to no packing in ESS, and a decision-analysis model was generated. Probabilities and utilities were derived from the literature. Sensitivity analysis was used to determine which variables most affected the model.

RESULTS

No packing was associated with better expected utilities than packing. On sensitivity analysis, packing was preferred when the disutility of no packing outweighed the disutility of packing, and when the probability for synechiae was greater than 35% without packing or lower than 2% with packing. When the component of packing removal was subtracted from the overall disutility simulating absorbable packing, the results favored packing.

CONCLUSION

Our decision-analysis model indicates that middle meatal packing is not advantageous for patients undergoing ESS. Absorbable packing materials have a less adverse effect on quality of life than nonabsorbable materials.

LEVEL OF EVIDENCE

1a. Laryngoscope, 127:1506-1512, 2017.

Healing of the nasal septal mucosa in an experimental rabbit model of mucosal injury

Objective

The aim of this study was to investigate the regeneration process of the nasal mucosa after a surgically created mucosal defect in the rabbit nasal septum, and to evaluate the effects of different interventions.

Methods

A 7 mm-diameter circular mucosal defect was made in the septum of forty New Zealand white rabbits. The rabbits were divided into four groups (ten rabbits in each group) according to the type of intervention; no treatment (control), silastic sheet (SS), hyaluronic acid (HA), and silastic sheet and hyaluronic acid (SS + HA) group. The diameter of the defect, mucosal thickness, epithelial thickness, and ciliated cell count were evaluated every week for five weeks.

Results

The average diameter of the defect in the control group were 5.1, 3.65, 1.2, 0.75, and 0.05 mm at postoperative 1, 2, 3, 4, and 5 weeks. In the SS group, the diameter decreased to 4.35, 2.1, 0.35, 0.15, and 0 mm at postoperative 1, 2, 3, 4, and 5 weeks, respectively, in which the mean diameter of the postoperative week 2 was significantly smaller compared to control (3.65 mm vs. 2.1 mm, P = 0.039). For the HA group and SS + HA group, the diameter of the defect did not show a significant difference from the control group during the five weeks. The mucosal thickness, epithelial thickness, and ciliated cell count of the regenerated mucosa were not significantly different among the groups.

Conclusion

The regeneration process of the nasal septal mucosa was identified using a novel rabbit model. Mucosal regeneration can be accelerated by applying silastic sheets.

Advances in Absorbable Biomaterials and Nasal Packing

Nasal biomaterials have been developed to improve postoperative outcomes after functional endoscopic sinus surgery (FESS). These products have been designed to overcome certain common complications in FESS, and to maximize patient comfort. This article evaluates the performance of nonabsorbable and absorbable packing with respect to these outcomes. The collected trials suggest superior performance of bioabsorbable packs compared with absorbable packs with respect to patient comfort. For hemostasis and wound healing, variation in performance metrics makes interstudy comparison difficult. Before further trials are conducted, consensus must be reached among rhinologists as to the proper method of evaluating these products.

Electrocauterization and no packing may be comparable with nasal packing for postoperative hemorrhage after endoscopic sinus surgery

BACKGROUND

Nasal packing is commonly performed after functional endoscopic sinus surgery (FESS). However, nasal packing is associated with higher cost (owing to the cost of packing materials), patient discomfort, delayed wound healing, and concern about toxic shock syndrome. Some surgeons have been performing FESS without packing, but there are few studies that show its safety.

OBJECTIVE

The purpose of this study was to evaluate the safety of electrocauterization and no packing.

METHODS

A total of 490 patients who underwent bilateral FESS for chronic rhinosinusitis were included in this retrospective study, 242 in the nasal packing group and 248 in the electrocauterization and no-packing group. Electrocauterization was performed by using a suction coagulator. Rates of immediate (first 24 hours after surgery) and delayed postoperative bleeding were compared. Patient characteristics, including concomitant disease and medication history, and Lund-Mackay computed tomography score were also assessed Results: There were no significant differences in age; sex; Lund-Mackay score; use of anticoagulant drugs; or prevalence of hypertension, diabetes, or asthma between the two groups. In the electrocauterization and no-packing group, there were fewer patients with allergic rhinitis and more smokers. Primary bleeding did not occur in the nasal packing group, but 11 patients (4.4%) had delayed bleeding. Primary bleeding occurred in four patients (1.7%) in the electrocauterization and no-packing group, and five patients (2.1%) had delayed bleeding. There were no significant differences in primary (p = 0.058) and secondary bleeding (p = 0.142) between the two groups. All bleeding was minor and easily controlled. Multivariate logistic regression analysis ruled out significant correlation between no packing and postoperative bleeding.

CONCLUSION

This study provided evidence that, in terms of postoperative hemorrhage, the safety of the electrocauterization and no-packing technique after FESS was comparable with that of nasal packing.

Efficacy and Safety of Guardcel Nasal Packing After Endoscopic Sinus Surgery: A Prospective, Single-Blind, Randomized Controlled Study

OBJECTIVES

Nasal packing after endoscopic sinus surgery is frequently used to control postoperative bleeding, enhance the wound healing process, and prevent lateralization of the middle turbinate, which causes insufficient ventilation. Many biodegradable materials have been developed to reduce pain and mucosal damage during packing removal. The purpose of this study was to compare the efficacy of Guardcel (Genewel Co.) middle meatal packing with a traditional nonabsorbable middle meatal packing, Merocel (Medtronic Xomed), on wound healing and patient satisfaction.

METHODS

In this prospective, single-blind, randomized controlled study, we enrolled 32 consecutive patients (64 nostrils) undergoing bilateral endoscopic sinus surgery at Korea University Guro Hospital from February 2015 to August 2015. Guardcel and Merocel were inserted postoperatively into a randomly assigned side. Objective findings about bleeding, hemostasis, adhesion, and infection were evaluated with nasal endoscopy. Patients' symptoms including pain and nasal obstruction were evaluated with a visual analog scale. Each evaluation was done at 2-3 days, 1 week, 2 weeks, and 4 weeks after surgery.

RESULTS

At 2-3 days after endoscopic sinus surgery, the Guardcel side had a significantly less hemostasis time than the Merocel side (P=0.001). During this period, the pain during packing removal was significantly lower on the Guardcel-inserted side than the Merocel-inserted side (P=0.002). At two weeks after surgery, the adhesion score on the Guardcel side was significantly lower than that of the Merocel side (P=0.011). Other parameters during the study follow-up periods were not statistically significant. There were no severe adverse reactions.

CONCLUSION

Guardcel, a newly developed packing material, appeared to shorten the hemostasis time and reduce pain sensation at 2-3 days after surgery; it also prevented adhesion formation 2 weeks after surgery when compared with the control. Guardcel can be an effective and safe candidate to replace conventional packing materials after endoscopic sinus surgery.

Budget impact analysis of bioabsorbable drug-eluting sinus implants following endoscopic sinus surgery

OBJECTIVE

Propel is a bioabsorbable drug-eluting sinus implant inserted following an endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS). The objective of this study was to estimate the budget impact of incorporating Propel post-ESS for CRS patients from a self-insured employer or third-party payer perspective.

METHODS

An Excel-based budget impact model was developed. Estimates of the prevalence of CRS, rates of ESS, and effectiveness outcomes, along with direct and indirect costs from CRS were obtained from published literature. A total population of 1.5 million members was hypothesized for the analysis. All cost data were adjusted to October 2015 US dollars using the Medical Care Component of the Consumer Price Index. The cost and clinical/economic characteristics of Propel were compared to other treatments commonly used to minimize post-operative complications. The primary outcome was the incremental budget impact reported using per-member-per-month (PMPM) costs. Scenario-based, probabilistic, and one-way sensitivity analyses were performed to gauge the robustness of the results and identify the parameters with the most influence on the results.

RESULTS

For a US self-insured employer or a commercial health plan of 1.5 million members, the incremental PMPM impact of incorporating Propel was estimated to range from -$0.003 to $0.036, respectively, for all members in the health plan. Sensitivity analyses identified the cost of Propel, probability of polyposis recurrence requiring medical intervention, probability of adhesion formation requiring surgical intervention, and the treatment costs for polyposis as the primary parameters influencing the results.

CONCLUSION

This study has demonstrated the use of Propel following ESS procedures has a negligible impact on the budget of a US self-insured employer or payer. The upfront cost of Propel was offset by savings associated with reduced probability for polyp recurrence, adhesion formation, and their subsequent treatment.

Biomaterials in Rhinology

Introduction

Many different kinds of rhinologic biomaterials, both nonabsorbable and absorbable, have been developed over the years to improve outcomes following endoscopic sinus surgery (ESS) for patients with chronic rhinosinusitis. In particular, these products have been designed to prevent postoperative bleeding, optimize the wound healing process, and reduce inflammation. This review evaluates the most recent evidence on biomaterials used in rhinology, focusing on these outcomes after ESS.

Data Sources

MEDLINE, Scopus, Google Scholar, and Clinicaltrials.gov.

Review Methods

A primary literature search based on the listed databases was performed with combinatorial search terms. Studies were considered for review if they met a set of inclusion and exclusion criteria.

Conclusions

Some products have performed better than others in clinical trials, although significant heterogeneity among studies does not allow for selection of a clearly superior biomaterial. While nonabsorbable biomaterials are still effective in achieving certain outcomes, newer, absorbable substances may be just as effective and avoid the morbidity associated with nasal packing removal. Steroid-eluting biomaterials have shown promising early results in reducing inflammation and promoting wound healing.

Implications for Practice

Certain absorbable biomaterials, such as chitosan gel and fibrin glue, have performed well with respect to postoperative hemostasis and wound healing, although they do not address mucosal inflammation. Steroid delivery systems may play an increasingly important role in reducing disease recurrence after ESS, although more studies are needed to assess long-term outcomes.

Systematic review and metaanalysis of middle meatal packing after endoscopic sinus surgery

OBJECTIVE

The objective of this systematic review was to evaluate synechiae formation in patients who underwent packing in the middle meatus at the completion of endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) or recurrent acute rhinosinusitis.

DATA SOURCES

PubMed and Ovid.

REVIEW METHODS

Prospective randomized controlled studies of ESS with the placement of middle meatal packing were reviewed and included for analysis. Metaanalysis of the pooled data was performed.

RESULTS

Eighteen prospective, randomized, controlled trials met inclusion criteria, resulting in a total of 925 subjects. Although there was a trend toward decreased risk of synechiae formation in the patients who underwent placement of middle meatal packing postoperatively (RR = 0.544), this did not achieve statistical significance on metaanalysis (p = 0.052).

CONCLUSIONS

This systematic review and metaanalysis suggests that use of middle meatal packing does not significantly reduce the risk of synechiae formation after ESS. There was, however, significant heterogeneity of the data analyzed, and the difference between groups was just short of statistical significance in our metaanalysis. Additional prospective randomized studies on this topic will further elucidate the utility of middle meatal packing.

How effective is postoperative packing in FESS patients? A critical analysis of published interventional studies

The present study aimed to assess the clinical effectiveness of absorbable packing alone, non-absorbable packing alone, and absorbable versus non-absorbable packing in the postoperative care of FESS patients, regarding bleeding control, adhesion formation, wound healing, and overall patient comfort. Systematic literature review in Medline and other database sources until July 2013, and critical analysis of pooled data were conducted. Blinded prospective randomized control trials, prospective, and retrospective comparative studies were included in study selection. The total number of analyzed studies was 19. Placing packs in the middle meatus after endoscopic procedures does not seem to be harmful for postoperative patient care. Regarding the postoperative bleeding rate, absorbable packing is not superior to no postoperative packing (strength of recommendation A). Comparing absorbable to non-absorbable packing, the former one seems slightly more effective than the latter in the aforementioned domain (strength of recommendation C). Absorbable packing was also found more effective than non-absorbable packing as a means of reducing the postoperative adhesion rate (strength of recommendation B), and more effective in comparison with not placing any packing material at all (strength of recommendation C). Non-absorbable packing also proves more effective than no postoperative packing in preventing the appearance of such adhesions (strength of recommendation A). Absorbable packing is also more comfortable compared to non-absorbable materials (strength of recommendation A), or no postoperative packing in FESS patients (strength of recommendation B). The comparative analysis between the different packing modalities performed in the present study may help surgeons design a more individualized postoperative 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.

Product comparison model in otolaryngology: Equivalency analysis of absorbable hemostatic agents after endoscopic sinus surgery

OBJECTIVES/HYPOTHESIS

Evidence-based medicine in otolaryngology literature continues to be lacking, especially with regard to new products brought to market. The marketing of products often includes statements of benefit that have limited objective support in research or literature. To address this, and to adequately determine product equivalency/superiority, careful evaluation must be made. In order to establish standards for this process in rhinology products, we directly compare three different absorbable hemostatic agents in patients with chronic rhinosinusitis (CRS) after undergoing endoscopic sinus surgery (ESS), using both objective and subjective outcomes.

STUDY DESIGN

Double-blinded prospective (level 1) comparison and equivalency analysis of three plant-based absorbable hemostatic agents (carboxymethylcellulose [CMC] gel, mucopolysaccharide hemospheres (MPH), and potato starch wafer) in patients undergoing bilateral ESS.

METHODS

Patients with medically refractory CRS who underwent bilateral ESS were recruited and prospectively followed. At the conclusion of ESS, one of three different hemostatic agents was applied to each nasal passage. Subjective patient data was obtained using rated symptoms compared between the two sides (nasal obstruction, bleeding, pain, and nasal discharge) at baseline and on postoperative days 1, 7, and 14. Objective data was obtained by blinded endoscopic scoring to rate mucosal edema, inflammation, granulation, crusting, infection, and synechiae formation on postoperative weeks 1, 3, and 6.

RESULTS

Forty-eight patients who underwent ESS for CRS were included. There is no statistical difference in subjective scores for any of the variables measured, although (MPH) nearly reached statistical significance at postoperative day 7 for increased pain (P = 0.06) and obstruction (P = 0.22). Objective measures showed equivalency between all products, except the CMC gel approached significance at week 3 for increased crusting (P = 0.10), granulation (P = 0.24), and debridement (P = 0.07). At 6 weeks, increased debridement (P = 0.14) also approached significance.

CONCLUSION

Careful and deliberate consideration should be taken when choosing products to assist our surgical endeavors. Subjectively, patients treated with MPH showed near-significant increases in pain and obstruction. In objective measures, CMC gel nearly reaches significance for more postoperative debridement, with increased crusting and inflammation. Product choice could consider these factors, although it remains at the discretion of the surgeon. This model of comparison allows careful product comparison and should be applied to other hemostatics, as well as other materials in use in otolaryngology.

LEVEL OF EVIDENCE

1b. Laryngoscope, 126:S5-S13, 2016.

Effect of aerosolized fibrin sealant on hemostasis and wound healing after endoscopic sinus surgery: a prospective randomized study

BACKGROUND

The purpose of this study was to investigate the effect of aerosolized fibrin sealant (FS) compared with that of polyvinyl acetal sponge packing on hemostasis and wound healing after functional endoscopic sinus surgery (FESS).

METHODS

We conducted a prospective randomized controlled trial of the use of aerosolized FS in 41 consecutive patients who underwent bilateral FESS between February 2011 and March 2012. The patients were randomized to receive FS applied via an aerosol spray in one nasal cavity and polyvinyl acetal sponge packing in the opposite cavity. The patients were followed up at 1, 2, 4, 8, and 12 weeks postoperatively. Crusting, adhesion, bleeding, granulation tissue formation, infection, and frontal sinus ostium stenosis after endoscopic surgery were assessed using a grading scale. Subjective symptoms related to nasal packing were evaluated using questionnaires quantified by visual analog scales.

RESULTS

The degree of granulation and crusting was significantly reduced in the side treated with FS compared with the polyvinyl acetal sponge side, as were bleeding and pain during nasal packing removal (p < 0.05). In addition, general satisfaction and willingness to reuse the material were significantly higher for the FS-treated side than for the polyvinyl acetal sponge-packed side (p < 0.001).

CONCLUSIONS

Compared with polyvinyl acetal sponge, aerosolized FS shows beneficial effects on hemostasis and wound healing after FESS. The application of FS resulted in a high degree of patient satisfaction without additional morbidity.

Biodegradable nasal packings for endoscopic sinonasal surgery: a systematic review and meta-analysis

OBJECTIVES

To assess biodegradable nasal packing effectiveness for improving postoperative symptoms and mucosal healing after endoscopic sinonasal surgery as compared with conventional/non-packing groups.

METHODS

Relevant articles were searched on PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials. We included randomized controlled trials (RCTs) that compared biodegradable packings with conventional packings or no packing, reporting postoperative symptoms and/or mucosal healing outcomes.

RESULTS

This review included 19 studies, of which 11 compared biodegradable packings with conventional packings. Meta-analysis found that biodegradable packings significantly improved postoperative symptoms: bleeding at removal, pain at removal, pain in situ, and nasal blockage. Mucosal healing outcomes were inconsistent within studies, with no data could be pooled. Eight studies compared biodegradable packings with non-packing group. Postoperative symptom data in this comparison could not be pooled: A protective or equal effect on postoperative bleeding was reported in different studies; no difference was reported in pain status and nasal blockage. As for mucosal healing, meta-analysis showed that two arms of comparison had similar effect on synechiae, edema, infection and granulation at each time point.

CONCLUSION

The limiting evidence suggests that biodegradable nasal packings are statistically better than conventional packings in postoperative symptoms, and probably comparable to non-packing group, as in this comparison we could not carry out meta-analysis. No beneficial or detrimental effect on postoperative mucosal healing could be determined based on existing evidence.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Absorbable and nonabsorbable packing after functional endoscopic sinus surgery: systematic review and meta-analysis of outcomes

The purpose of the study was to perform a systematic review and meta-analysis of the literature to compare the efficacy (and other postoperative outcomes) of nonabsorbable versus absorbable nasal packing after functional endoscopic sinus surgery (FESS) for the treatment of chronic rhinosinusitis. Studies were considered for inclusion if they were published in English language, were randomized clinical trials, and reported on outcomes following postoperative synechia. The primary outcome for meta-analysis was the incidence of postoperative synechia; pooled odds ratios (ORs) and 95 % confidence intervals (CIs) were calculated using fixed-effects models. Five studies, involving 241 nasal cavities in each treatment group, were included in the systematic review. The prevalence of synechia ranged from 4.6 to 8.0 % in the absorbable groups and from 8.0 to 35.7 % in the nonabsorbable groups. Postoperative bleeding was lower in the absorbable groups, whereas there was no clear finding regarding postoperative pain. Postoperative edema was generally similar between groups. There were no consistent findings regarding bleeding and pain on packing removal. Two studies using the same type of packing material were included in the meta-analysis. The combined OR (0.33, 95 % CI 0.04–2.78) for postoperative synechia did not significantly favor (P = 0.308) absorbable packing over nonabsorbable packing. Although there is some evidence in the available literature that absorbable nasal packing may provide superior outcomes to nonabsorbable packing after FESS, the lack of homogeneity between studies makes definitive conclusions impossible. Further randomized clinical trials are needed to compare the efficacy of different types of absorbable nasal packing for preventing synechia after FESS.

Merocel versus Nasopore for nasal packing: a meta-analysis of randomized controlled trials

Objective

To compare the clinical outcomes, including efficacy and complications, of Merocel versus Nasopore as a nasal packing material after nasal surgery.

Methods

Relevant randomized controlled trials were identified from electronic databases (The Cochrane Library, PubMed, EMBASE, China National Knowledge Infrastructure and Chinese Biomedical Database). Conference proceedings and references from identified trials and review articles were also searched. Outcome measures were pain during nasal packing, pain and bleeding upon packing removal, pressure sensation, nasal blockage, formation of synechiae, mucosal healing, and patients' general satisfaction.

Results

Seven randomized controlled trials met criteria for analysis. Compared with Merocel, Nasopore significantly reduced patients' subjective symptoms including in situ pain (pain experienced while packing is in place), nasal pressure, pain and bleeding during packing removal, and increased patients' general satisfaction with nasal packing. There were no significant differences in nasal obstruction, adhesion and mucosal healing between the Merocel and Nasopore groups.

Conclusions

Preliminary evidence suggests that Nasopore may be superior to Merocel as a nasal packing material with regard to in situ pain, pain and bleeding upon removal, pressure, and general satisfaction and does not differ from Merocel in terms of nasal obstruction, tissue adhesion, and long-term mucosal healing.

Effects of cryotherapy on the maxillary antrostomy patency in a rabbit model of chronic rhinosinusitis

It is acknowledged that many causes of failures in endoscopic sinus surgery are related to scarring and narrowing of the maxillary antrostomy. We assessed the effect of low-pressure spray cryotherapy in preventing the maxillary antrostomy stenosis in a chronic rhinosinusitis (CRS) rabbit model. A controlled, randomized, double-blind study was conducted on 22 New Zealand rabbits. After inducing unilateral rhinogenic CRS, a maxillary antrostomy was performed and spray cryotherapy was employed on randomly selected 12 rabbits, while saline solution was applied to the control group (n = 10). The antrostomy dimensions and the histological scores were assessed 4 weeks postoperatively. The diameter of cryotreated antrostomy was significantly larger at 4 weeks than that in the control group. At 4 weeks, the maxillary antrostomy area in the study group was significantly larger than the mean area in the control group (103.92 ± 30.39 mm² versus 61.62 ± 28.35 mm², P = 0.002). Submucosal fibrous tissues and leukocytic infiltration in saline-treated ostia were more prominent than those in cryotreated ostia with no significant differences between the two groups regarding the histological scores. Intraoperative low-pressure spray cryotherapy increases the patency of the maxillary antrostomy at 4 weeks postoperatively with no important local side effects.

The clinical outcomes of new hyaluronan nasal dressing: a prospective, randomized, controlled study

BACKGROUND

Poor postoperative wound healing after endoscopic sinus surgery (ESS) remains a significant problem. This study evaluates the efficacy and safety of a new absorbable hyaluronan hydrogel.

METHODS

A prospective, randomized, controlled trial was conducted. Fifty-five patients with bilateral ESS were recruited and randomized to receive absorbable hyaluronan hydrogel in one side as treated and the opposite side without absorbable hyaluronan hydrogel as control. Clinical outcome measures were assessed at postoperative 1, 2, 4, 8, and 12 weeks.

RESULTS

Fifty-four patients completed the study. Overall, absorbable hyaluronan hydrogel significantly promotes the reepithelization process and reduces the presence of obstructing synechia, nonobstructing synechia, edema, crust, and mild mucopurulent drainage (all p ≤ 0.0002). At all postoperative follow-up visits, the promotion in reepithelization is statistically significant at 2, 4, and 8 weeks, and the reductions in the presence of nonobstructing synechia, edema, crust, and mild mucopurulent drainage are all statistically significant except for the presence of crust at 12 weeks and mild mucopurulent drainage at 1 and 12 weeks. Although the presence of obstructing synechia at each follow-up visit between groups does not reach statistical significance, the incidence ranges from 5.56 to 12.96% in the control group and from 0 to 3.70% in the treated group. No adverse event related to treatment was observed.

CONCLUSION

In this clinical study, data analyses suggest that this new absorbable hyaluronan hydrogel, as nasal dressing/packing after ESS is safe and promotes the postoperative reepithelization process and reduces the presence of synechia, edema, crust, and mild mucopurulent drainage.

Antibodies directed against integration host factor mediate biofilm clearance from Nasopore

OBJECTIVES/HYPOTHESIS

Intranasal resorbable packing, such as Nasopore, is commonly used during sinus surgery despite a paucity of evidence that demonstrates clinical benefit. We theorized that Nasopore supports bacterial growth and biofilm formation. The DNABII family of bacterial nucleic acid binding proteins stabilizes the extracellular polymeric substance of the biofilm, thus protecting bacteria from host defenses and traditional antibiotics. We tested the hypothesis that use of anti-IHF antibodies in conjunction with antibiotics would enhance biofilm eradication from Nasopore.

STUDY DESIGN

In vitro experiments.

METHODS

Nontypeable Haemophilus influenzae (NTHI) biofilms were grown on Nasopore. Following 24-hour incubation, biofilms were incubated for an additional 16 hours with either medium alone, naïve rabbit serum, rabbit anti-IHF serum, amoxicillin/clavulanate, or anti-IHF serum + amoxicillin/clavulanate. Computer statistics (COMSTAT) analysis was performed on images of biofilms obtained via confocal microscopy.

RESULTS

NTHI readily formed a biofilm on Nasopore. Treatment with amoxicillin/clavulanate alone mediated an increase in biomass by 92% to 6.63 μ(2) /μ(3) compared to incubation in sterile medium alone (3.46 μ(2) /μ(3)). Treatment with anti-IHF alone reduced the biomass by 77% to 1.29 μ(2) /μ(3) compared to incubation with naïve rabbit serum (5.53 μ(2) /μ(3)). Anti-IHF + amoxicillin/clavulanate reduced biomass by 88% to 0.66 μ(2) /μ(3) (P <0.02) compared to incubation with naïve rabbit serum.

CONCLUSION

Antibiotics alone were ineffective in eradicating NTHI biofilms that had formed on Nasopore in vitro. Anti-IHF antibodies plus amoxicillin/clavulanate therapy synergistically reduced biofilm biomass by 88%. These data support clinical studies for the use of anti-IHF combined with antibiotics to reduce biofilm formation on intranasal packing.

Effect of polyvinyl acetal sponge nasal packing on post-operative care of nasal polyposis patients: a randomised, controlled, partly blinded study

OBJECTIVE

To compare the effects of routine nasal packing with polyvinyl acetal sponge (Merocel) versus no packing, after endoscopic sinus surgery for nasal polyposis.

SUBJECTS AND METHODS

This clinical, randomised, controlled trial was performed in an academic tertiary referral centre between 2008 and 2011. Sixty patients with resistant nasal polyposis underwent endoscopic sinus surgery, and were then randomly divided into two groups: packed and non-packed. The amount of bleeding and pain in each group during pack removal was documented.

RESULTS

There was no significant difference between the two groups in the outcome of surgery and complications. One patient in each group needed extra packing. In the packed group, the mean ± standard deviation pain score on pack removal was 61 ± 3 (using a visual analogue scale in which 0 = no pain and 100 = worst pain imaginable).

CONCLUSION

This study found no significant difference between polyvinyl acetal packed and non-packed groups, following endoscopic sinus surgery for nasal polyposis. This confirms the findings of similar studies, and supports the reconsideration of routine post-operative packing in selected cases.

Effect of a dexamethasone Sinu-Foam™ middle meatal spacer on endoscopic sinus surgery outcomes: a randomized, double-blind, placebo-controlled trial

BACKGROUND

Off-label drug eluting middle-meatal spacers have shown promising results for improving clinical outcomes following endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS). This study evaluates a dexamethasone Sinu-Foam™ spacer following ESS for CRS without nasal polyposis (CRSsNP).

METHODS

Patients with CRSsNP (n = 36) were enrolled into a double-blind, placebo-controlled trial and randomized into either a treatment arm (dexamethasone Sinu-Foam™ mixture; n = 18) or placebo arm (Sinu-Foam™ alone; n = 18). Therapeutic outcomes were evaluated at 1 week, 4 weeks, and 3 months using sinonasal endoscopy and graded using the Lund-Kennedy scoring system. Postoperative care included nasal saline irrigations and a short course of systemic steroids.

RESULTS

All patients completed the study follow-up period. Both study arms experienced significant improvement in endoscopic grading over the study duration (p < 0.001). There was no difference in average endoscopic scores between the treatment and placebo groups at 1 week, 4 weeks, and 3 months (all p > 0.489).

CONCLUSION

This study demonstrated that an off-label drug-eluting middle-meatal spacer of dexamethasone and Sinu-Foam™ does not improve endoscopic outcomes in the early postoperative period following ESS when combined with postoperative saline irrigations and a short course of systemic steroids.

The evaluation of two new hyaluronan hydrogels as nasal dressing in the rabbit maxillary sinus

BACKGROUND

The postoperative scaring, ostial stenosis, and adhesions after functional endoscopic sinus surgery for chronic rhinosinusitis remains a major problem. This study was designed to evaluate two new hyaluronan (HA) hydrogels for neo-ostium antistenosis and promoting wound healing in a rabbit maxillary sinus model.

METHODS

The anterior wall of the maxillary sinus of 48 rabbits was removed to create a 4-mm circumferential wound both on the nasal and on the sinus sides. A rapid-gelling HA hydrogel or preformed HA hydrogel was filled randomly into the right or left sinus, while the opposite sinus served as blank control or was treated with Merogel (Medtronic Xomed Surgical Products, Jacksonville, FL) as control. The neo-ostium diameter and histological scores were evaluated and analyzed postoperatively.

RESULTS

The neo-ostium diameter in the rapid-gelling HA hydrogel-treated side was significantly larger than that in the blank control side with a mean difference of 1.46 ± 0.99 mm (p = 0.03), 1.30 ± 0.61 mm (p = 0.0087), and 1.60 ± 0.25 mm (p = 0.00015) at 2, 3, and 4 weeks, respectively; the neo-ostium diameter in the preformed HA hydrogel-treated side at 2 weeks was significantly larger than that in the blank control side or Merogel control side with a mean difference of 1.46 ± 0.76 mm (p = 0.002) or 0.54 ± 0.36 mm (p = 0.007), respectively. The preformed HA hydrogel-treated side showed better histology scores at 2 weeks in heterophils, fibrosis, and osteogenesis than the blank control, and the chronic inflammation (lymphocyte/plasmacyte infiltration) was not prevalent.

CONCLUSION

During the postoperative follow-up period both of the two HA hydrogels significantly prevented neo-ostium stenosis and the preformed HA hydrogel promoted wound healing.

Microporous polysaccharide hemospheres do not increase synechiae after sinus surgery: randomized controlled study

BACKGROUND

Many surgeons use absorbable packing materials after endoscopic sinus surgery (ESS). Despite their popularity, some of these agents have been shown to contribute to synechiae formation. Microporous polysaccharide hemospheres (MPH) is a plant-based hemostatic powder that does not interfere with regenerating sinus mucosa in the animal model. The goal of this study was to examine the impact of MPH on healing and synechiae formation after ESS in human subjects.

METHODS

A prospective, randomized, controlled, double-blind study was performed. Forty consenting adult patients with chronic sinusitis requiring symmetric ESS were randomized to receive MPH unilaterally at the conclusion of surgery. The opposite side was untreated. Standard postoperative care was performed bilaterally. Outcomes measured included blinded observer ratings for synechiae formation, edema, and infection. Each side was examined endoscopically and scored at postoperative days 7, 14, and 30.

RESULTS

Twenty men and 20 women with an average age of 48.2 years were included. There were no complications and all patients were discharged home the same day. There was no significant difference in synechiae formation at any point postoperatively. The rate of synechiae formation was determined to be 10% (4/40) on the MPH-treated side versus 7.5% (3/40) on the untreated side (p = 0.7639). In addition, there were no significant differences observed in edema (p = 0.7480) or infection (p = 0.5533).

CONCLUSION

The use of MPH after sinus surgery does not increase synechiae formation and does not appear to deleteriously affect the healing of postoperative sinus cavities.

Effect of dexamethasone on wound healing of the septal mucosa in the rat

BACKGROUND

Postoperative treatment after functional endoscopic sinus surgery (FESS) aims to modulate the wound healing process. Systemic or topically applied corticosteroids have been reported to be beneficial for improving nasal wound healing after FESS. However, few studies have investigated the effects of postoperative systemic steroids on nasal wound healing with regard to histological changes. The aim of this study was to evaluate the effect of systemic dexamethasone on nasal wound healing after mechanical injury in the rat.

METHODS

A unilateral wound in the nasal cavity was induced using the brushing technique in 4-week-old, Sprague-Dawley rats (n = 70). Dexamethasone (0.15 mg/kg daily for 7 days) and normal saline were administered i.p. to the experimental and control groups (n = 35 for each) after the injury. The rats (n = 7 for each) were killed on days 2, 5, 14, 28, and 42 after the injury. Histological changes in the nasal mucosa were examined and compared using hematoxylin and eosin and Masson's trichrome staining.

RESULTS

The experimental group showed less subepithelial edema formation and epithelial disarray at the early phase of the wound healing period. There were statistically significant differences in the subepithelial thickness and epithelial thickness indices between the experimental and control groups (p < 0.05). Ciliary and goblet cell indices were lower in the experimental group, which means that ciliary and goblet cell regeneration may be delayed by dexamethasone (p < 0.05). There were no differences in the subepithelial fibrosis index between the two groups. Adhesion formation between the nasal septum and turbinate were found only in the control group.

CONCLUSION

Systemic dexamethasone after mucosal injury may lessen subepithelial edema, goblet cell hyperplasia, and adhesion formation; however, it may cause delayed mucosal ciliary regeneration.

Advances in the surgical management of chronic sinusitis and nasal polyps

Current research has only reinforced the belief that chronic rhinosinusitis is a multifactorial and idiosyncratic disease process. Most basic science research on the topic focuses on delineating the many proposed contributing factors and attempting to establish therapeutic targets. In patients whose symptoms do not respond to medical therapy, endoscopic sinus surgery may be offered. Several surgical techniques have been proposed, and it would appear that certain techniques are ideal for certain situations. Recent clinical research has focused on the introduction of new technology and new techniques. Additionally, investigators have looked for ways to optimize current techniques and to determine which patient populations may expect to benefit from which types of interventions.

Evaluation of symptoms and QOL with calcium alginate versus chitin-coated gauze for middle meatus packing after endoscopic sinus surgery

OBJECTIVE

Nasal packing is used to control postoperative bleeding and wound healing, and it also exerts a very strong influence on the comfort of the patient. Sorbsan(®) (calcium alginate) is an absorbent packing that shows a potent hemostatic effect and is able to maintain wound surfaces in a moist environment by absorbing and gelling the wound exudate. The aim of this study was to evaluate the early symptoms and QOL with Sorbsan(®) versus Beschitin-F(®) (chitin-coated gauze) for middle meatus packing after endoscopic sinus surgery (ESS).

METHODS

We performed a cohort study of 40 patients who underwent ESS. Following ESS, the patients were randomly allocated into two groups of 20 patients each who underwent insertion of either Sorbsan(®) or Beschitin-F(®) into the middle meatus. A daily diary was used to record the symptoms and QOL, measured using visual analogue scales, before the ESS and on each day thereafter. Postoperative bleeding and local infection were also recorded.

RESULTS

The scores for each of the symptoms of nasal pain, headache, nasal bleeding and postnasal drip were statistically significantly lower in the Sorbsan(®) group. The scores for each of the QOL parameters, including the effect on their stay in the hospital and sleep disturbance, were also significantly lower in the Sorbsan(®) group. There were no findings of postoperative hemorrhage or local infection in either group.

CONCLUSION

Sorbsan(®) packing did not cause any major complications and has the potential to reduce nasal pain and suffering in post ESS patients compared with gauze packing.

Nasal packing and stenting

Nasal packs are indispensable in ENT practice. This study reviews current indications, effectiveness and risks of nasal packs and stents. In endoscopic surgery, nasal packs should always have smooth surfaces to minimize mucosal damage, improve wound healing and increase patient comfort. Functional endoscopic endonasal sinus surgery allows the use of modern nasal packs, since pressure is no longer required. So called hemostatic/resorbable materials are a first step in this direction. However, they may lead to adhesions and foreign body reactions in mucosal membranes. Simple occlusion is an effective method for creating a moist milieu for improved wound healing and avoiding dryness. Stenting of the frontal sinus is recommended if surgery fails to produce a wide, physiologically shaped drainage path that is sufficiently covered by intact tissue.

Perioperative and intraoperative maneuvers to optimize surgical outcomes in skull base surgery

There are many approaches to obtaining a workable endoscopic surgical field in sinus surgery. With extended sinus and transdural endoscopic surgery, a more rigid approach must be taken. There are 3 main factors that invariably lead to poor surgical outcomes in endoscopic sinus and skull base surgery: bleeding, inadequate access, and unidentified anatomic anomalies. Bleeding is arguably the most common reason for incomplete resection. An understanding of microvascular and macrovascular bleeding allows a more structured approach to improve the surgical field in extended endoscopic surgery. The endoscopic surgeon should always be comfortable in performing the same procedure as an open operation. However, converting or abandoning an endoscopic procedure should rarely occur because much of this decision making should take place preoperatively. Along with poor hemostasis, inadequate access is an important cause of poor outcome. Evaluation of the anatomy involved by pathology but also the anatomy that must be removed to allow adequate exposure is important. This article reviews the current techniques used to ensure optimal surgical conditions and outcomes.

Nasal morbidity following endoscopic skull base surgery: a prospective cohort study

BACKGROUND

Nasal morbidity following skull base surgery necessitates follow-up for postoperative care. We describe nasal morbidity following endoscopic skull base surgery.

METHODS

Patient and operative data and postoperative subjective and objective measures of morbidity were prospectively collected for 1 year. Time to absence of crusting and remucosalization were determined. Risk factor analyses for crusting and nasal discharge were performed.

RESULTS

Nasal crusting (98%) and discharge (46%) were the most common postoperative symptoms. Median time to absence of crusting was 101.0 days, with longer times for complex cases (p = .033) but not for patients with septal flaps or fat grafts. Median time to remucosalization after nasoseptal flap was 89.0 days. There were no risk factors for crusting, although surgical complexity was a risk factor for postoperative discharge (odds ratio [OR] = 5.17).

CONCLUSIONS

Nasal morbidity following endoscopic skull base surgery is common and may be affected by surgical complexity and use of the nasoseptal flap.

Looking after local nasal and sinus mucosa in health, disease and after surgery

The paper emphasises the need for looking after of nasal and sinus mucosa in health, disease and after nasal surgery. It is a systematic arrangement of steps required to restore nasal mucosa to healthy state. These steps have been arranged to co relate them to diseases and symptoms for symptomatic and curative treatment. It can rationalise the need for surgery in cases non responsive to maximum medical treatment. It can improve postoperative surgical results after functional endoscopic sinus surgery (FESS) and other endoscopic assisted procedures.

The efficacy of a novel chitosan gel on hemostasis and wound healing after endoscopic sinus surgery

BACKGROUND

Postoperative bleeding and adhesion formation are the two most common complications after endoscopic sinus surgery (ESS). Continued bleeding risks airway compromise from the inhalation of blood clots and from the aspiration of blood-stained vomitus. Additionally, adhesion formation is the most common reason for patients requiring revision surgery. This study aimed to determine the efficacy of a novel chitosan/dextran (CD) gel on hemostasis and wound healing after ESS.

METHODS

A randomized controlled trial was performed involving 40 patients undergoing ESS for chronic rhinosinusitis. Immediately after surgery a baseline Boezaart Surgical Field Grading Scale was taken. Computer randomization was performed with one side receiving CD gel and the other side receiving no treatment (control). Boezaart bleeding scores were then calculated for each side every 2 minutes. Patient's endoscopic features of wound healing were assessed at 2, 6, and 12 weeks after surgery.

RESULTS

CD gel achieved rapid hemostasis with the mean time to hemostasis at 2 minutes (95% CI, 2-4 minutes) compared with 10 minutes (95% CI, > or =6 minutes) for the control (p < 0.001). There were significantly less adhesions at all time points with CD gel versus control: 2 versus 18 at 2 weeks (p < 0.001), 3 versus 16 at 6 weeks (p < 0.001), and 2 versus 12 at 3 months (p < 0.001). There was no significant difference between CD gel and control with respect to crusting, mucosal edema, infection, or granulation tissue formation.

CONCLUSION

CD gel is rapidly hemostatic immediately after ESS and prevents adhesion formation, addressing two of the most common complications of sinus surgery.

[Revision of surgical treatment of rhinosinusitis]

The aim of this revision paper is to provide an update of available resources to achieve the best endoscopic sinus surgery outcomes of adult rhinosinusitis. The cause and mechanisms of rhinosinusitis remain unknown, and curative treatment does not exist. Recent new insights into paranasal sinus pathophysiology, along with technical advances in imaging and endoscopy, have revolutionised surgical treatment of rhinosinusitis. Since an increasing number of patients undergo functional endoscopic sinus surgery as a therapeutic regimen for their disease, appropriate use of computed tomography is critical in providing a "roadmap" for the surgeon to delimit the surgical procedure, as well as to ensure safety and accuracy. With proper training and technique, endoscopic surgery is quite safe, but prevention and management of complications must be known.

Nasal dressings after endoscopic sinus surgery: what and why?

PURPOSE OF REVIEW

Nasal dressings are commonly used following endoscopic sinus surgery in an attempt to prevent ongoing bleeding and to modulate the wound healing process. Experience with nasal dressings in the otolaryngologic literature spans more than half a century; however, despite this, there is still little agreement between surgeons on the optimal choice of nasal dressings following endoscopic sinus surgery, or whether nasal dressings are required at all. This paper briefly reviews the past research and examines recent advances in the area of nasal dressings.

RECENT FINDINGS

The ideal nasal dressing is one that is absorbable, hemostatic and improves healing. Although a number of currently available materials may address one of these features, none address all. Currently available dressings that achieve hemostasis worsen wound healing outcomes. However, recent research shows promise with microporous polysaccharide hemospheres and chitosan gel having promising effects on hemostasis, and chitosan gel showing a significant adhesion prevention effect.

SUMMARY

The sinus surgeon must be aware of the potential advantages and limitations of currently available nasal dressings. The area of wound healing and adhesion prevention remains an area of active research and more prospective controlled trials are needed to define any benefits biomaterials may have.