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The best outcome after endoscopic sphenoethmoidectomy follows frequent in-office endoscopic debridement of all crusts and old blood until healing is complete.
Endoscopic sinus surgery (ESS) has become the standard of care in the surgical management of chronic sinusitis over the last 2 decades. This has been due, in large part, to the careful introduction of its technique to otolaryngology by such pioneers as Messerklinger, Stammberger, Kennedy, and others. Traditional surgical approaches were devised around the concept of removing irreversibly diseased mucosa. In recent years, there has been recognition that denuded bone results in delayed healing.1.
Erica R. Thaler, MD
Instead, endoscopic technique emphasizes fidelity to the "function" of the sinuses, with preservation of as much of the native anatomy and mucosa as possible. As part of this, minimization of scar formation is deemed critical to retain normal ciliary function and thereby reestablish normal mucociliary clearance. A great deal of attention has been given how to best reestablish normal functioning sinuses while operating in the face of infection. The current understanding about this is 2-tiered. First, reestablishing drainage of the involved sinuses will help induce disease resolution. Second, removal of underlying infected bone is critical to the success of the postoperative result.2
Endoscopic technology has given us the ability to follow the progress of wound healing under direct visualization. Unlike traditional surgery, in which skin closure signaled the end of active participation on the part of the surgeon in the healing process, endoscopic visualization affords the opportunity—rightly or wrongly—to continue to try to intervene on behalf of the wound. There is only a very small amount of literature concerning postoperative mucosal healing after ESS. As a result of this paucity of understanding, there is a good deal of variation in postoperative management of patients who have undergone surgery. The variation in management style may be rather simply broken down into 2 camps: those who favor frequent debridement of the operated sinus cavities postoperatively and those who do not.
Most of the standard teaching regarding ESS includes a program of postoperative debridement. While this may vary from expert to expert, there is a common recommendation for at least 1 office debridement within the first week postoperatively and, from thereon, weekly or greater debridements for 4 to 6 weeks until the cavity is deemed healed.3-7 The rationale for this is 3-fold. First, it is believed that large crusting and clot may trap mucous, which in the setting of chronic infection will reinfect the sinuses. Further, the old blood itself may be a good culture medium for bacteria. Second, the crusts may act as bridges across which scar formation may occur, leading to an obstructed postoperative cavity. In particular, lateralization of the middle turbinate with synechial scar formation is frequently discussed. Third, retained bone fragments that are denuded of mucosa may be the nidus for reinfection. These must be removed at the postoperative "cleanouts."
Our literature is replete with articles that emphasize the importance of postoperative debridement. Senior et al8 attribute their excellent long-term results of ESS (98.4% of patients reporting improvement at 8 years' follow-up) to "careful postoperative medical management and weekly postoperative endoscopic debridement during the healing period." Bernstein et al9 report on their minimization of scar formation after ESS using a microdebrider. They report a 1.3% rate of synechiae formation using their regimen of ESS with a microdebrider and a postoperative routine of visits with debridements at days 1, 4, 7, and 21, with additional visits as necessary.
There may be a range of technique in postoperative debridement from surgeon to surgeon, though this is rarely discussed in great detail. The degree of aggressiveness in cleaning must certainly have an effect one way or another in aiding or hampering healing. Kuhn and Citardi10 go into this in some detail in their excellent review of postoperative care following ESS. Their regimen includes 3 visits within the first postoperative week, with cleaning and instruction in use of hypertonic saline irrigation. They describe "removing fibrin clot and polyps with debridement of devitalized bone," but do caution against starting any new bleeding. They also advise that revision procedures may be necessary, such as "breaking down synechiae, removing polyps, and placing spacers if a problem develops."10
The difficulty in interpreting these recommendations is that the authors have done no case-controlled studies to demonstrate the relative merits of postoperative debridement. It is simply pronounced as making good sense, sometimes backed up by evidence of excellent outcome.
There is evidence from several different vantage points that postoperative debridement may actually not make much sense, and in fact, may be counterproductive. The easiest place to look for this evidence is in the realm of pediatric rhinology. Children are not able to tolerate the postoperative cleanouts classically described after ESS. Pediatric otolaryngologists who have pursued this surgical technique in children have devised ways around the weekly visits. Mair's11 comprehensive article on pediatric ESS offers a typical regimen. Middle meatal splints are placed at the completion of surgery. Where able, children use a nasal douche or spray 3 times a day for the first 2 to 3 weeks. At 2 to 3 weeks after surgery, the patient is brought back to the operating room for "nasal endoscopy with toilette, debridement and removal of middle meatal splints."11 He further describes the gentle removal of granulation tissue if present near ostia, but cautions that extensive removal may promote future synechia formation. With some minor variation, these strategies are widely practiced by pediatric otolaryngologists. There is good evidence that pediatric ESS improves patients with chronic sinusitis. For example, Jiang and Hsu12 report their experience with ESS for 104 children, with postoperative improvement of 84%. Herbert and Bent13 report a meta-analysis of outcomes in pediatric ESS, with positive outcome rates of 88.7%.
Some otolaryngologists have taken the same approach to their adult patients, with reportedly good outcome. Fernandes14 describes a regimen devoid of postoperative debridement. He does not routinely use postoperative antibiotics and only sees the patient at 10 days after surgery to instruct about nasal douching. A follow-up visit at 1 month is done only to assess the nasal airway. He reports a synechiae rate of 11% and a success rate (defined as at least 50% subjective improvement of symptoms) of 95.5%.14 Brennan15 describes the use of the Boomerang Turbinate Glove (Zulou Medical Products Inc, Mystic, Conn), which is placed postoperatively to stent the septum and provide a spacer for the middle turbinate. He uses postoperative antibiotics while the stent is in place, and the patients are instructed to irrigate with physiologic saline. The stent is removed at the end of the second postoperative week, without debridement. He reports an incidence of 1.3% for adhesions after 234 procedures using this technique. Crusting is described as "virtually eliminated."15
Investigators have also looked at the effect of postoperative debridement on wound healing with some elucidating observations. Kuhnel et al16 took mucosal biopsy specimens from beneath crusts removed at postoperative cleanings. They found that local debridement of crusts avulsed epithelium in 23% of cases in the first postoperative week, though at the second-week debridement, no avulsed epithelium was identified. Their conclusion was that mechanical debridement of wounds should be time dependent and perhaps deferred to the second postoperative visit.16 Inanli et al17 have also looked at the healing of sinus mucosa after ESS. They found that histological, morphological, and mucociliary activity of the mucosa was not healed at 12 weeks after surgery, suggesting that the concept of debridement until healing is "completed" at 6 weeks after surgery may reflect what our eyes see, but not what is really happening at a cellular level.17
The conclusions to be drawn from the above information are necessarily muddy. It is clear that ESS is a good technique to improve chronic sinusitis. It also is clear that respecting the native anatomy of the sinuses, with as little disruption of mucosa as possible, is a better technique than more aggressive surgery. It appears rational to rid the sinus cavities of a many possible causes of infection (eg, obstructing crusts and clots that serve as culture medium), particularly in the healing phase after surgery. But there is compelling evidence that this may, at a minimum, be unnecessary, or worse, counterproductive. When patient discomfort (sometimes extreme) and the number of hours invested by both the physician and patient are added to the equation, it is hard not to consider that perhaps the early dictums about postoperative care of ESS have been overaggressive.
Much of this must be tailored to the particular patient and the particular surgery that has been done. In a case in which little surgery was performed (eg, anterior ethmoidectomy and maxillary antrostomy), little mucosa was disrupted, and little bleeding occurred, postoperative care can be minimized. In a patient with extensive disease (eg, allergic fungal sinusitis), who has rapid redevelopment of mucinous debris, debridement is critical and may accelerate mucosal healing.
My preference is to minimize endoscopic debridement in the first postoperative week and to focus on saline irrigation as a means to clear blood and crusting. An endoscopic look with or without debridement is important sometimes in the second postoperative week to assess the efficacy of perioperative antibiotics and to clean obstructing clot or crust. Thereafter, visits and debridements are entirely dependent on the patient pace of healing and the particular variety of chronic sinusitis. Patients may dictate the level of care they receive depending on their ability to tolerate postoperative debridement. As with many aspects of medicine, rigid adherence to a set of management protocols or a postoperative algorithm simply does not fit with the wide array of disease manifestation that is part of any busy clinician's practice.
Accepted for publication June 7, 2002.
Corresponding author and reprints: Erica R. Thaler, MD, 5 Silverstein Bldg, Department of Otorhinolaryngology, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 (e-mail: email@example.com).
Thaler ER. Postoperative Care After Endoscopic Sinus Surgery. Arch Otolaryngol Head Neck Surg. 2002;128(10):1204–1206. doi:10.1001/archotol.128.10.1204
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