1

Introduction

Epistaxis is the most frequent complication after functional endoscopic sinus surgery (FESS) . It may occur in a postoperative period up to 15 days after the surgery. Many rhinologists adopt nose packing as a routine measure for preventing postoperative bleeding. Although typically effective, nasal packing causes pain, rhinorrhea, nasal obstruction, and inconvenience, and its removal is painful and often associated with rebleeding . Such considerations have started different studies that are finalized to demonstrate the uselessness of the routine appeal of nasal packing, especially after FESS in relation to the low incidence of postoperative epistaxis and the relationship between costs and benefits .

Nevertheless, there are pathologic conditions that require a more aggressive FESS approach to achieve results with the consequence of an increased risk of postoperative epistaxis. For example, extensive nasal polyposis could involve the middle turbinate, inducing the surgeon to partially remove it ( Fig. 1 ). In fact, many rhinologists agree that a diseased, destabilized, or obstructive middle turbinate should be partially removed because of the postoperative decreased incidence of synechiae formation, long-term patency of middle meatus antrostomy, improved nasal airflow, decreased nasal resistance, and improved intraoperative and postoperative access to the ethmoidal labyrinth .

Extensive nasal polyposis involving middle turbinate.

However, other studies report significant complications after a partial middle turbinectomy (PMT) as anosmia, hyposmia, frontal sinusitis, crusting, atrophic rhinitis, and epistaxis .

The advances of endoscopic procedures have also brought along the possibility of a surgical solution to nasal bleeding by using very precise hemostatic techniques. These procedures include endoscopic cautery of bleeding points and more difficult techniques of endoscopic ligation of the sphenopalatine artery (SPAL) or of the anterior ethmoidal artery .

We initiated this retrospective study to evaluate (1) the effect of PMT on postoperative epistaxis in patients without nasal packing and (2) the possibility that SPAL could reduce the risk of bleeding in these patients.

2

Materials and methods

In this retrospective study, we reviewed the cases of extended nasal polyposis (graded as stage III according to the Lund-MacKay classification) that underwent primary FESS with PMT at the Ospedali Riuniti University Hospital, Foggia. For all patients, each surgical side was evaluated independently.

We then selected the last consecutive 27 patients (15 women and 12 men; age range, 22–61 years; mean, 39.1 years) who underwent PMT on 40 sides (13 patients bilateral). Functional endoscopic sinus surgery with PMT was planned in all sides with evidence of concha bullosa and/or polypoid degeneration of the middle turbinate ( Fig. 1 ), and/or flail turbinate, and/or obstruction of access to the middle meatus.

The study group was compared with a control group of 27 patients (13 women and 14 men; age range, 22–54 years; mean, 34.4 years) with extended bilateral nasal polyposis who underwent FESS with middle turbinate preservation on 40 sides (13 bilateral and 14 unilateral with PMT on the other side, belonging to the study group).

Patients with other systemic diseases involving nasal structures (primary ciliary dyskinesia, cystic fibrosis, Wegener granulomatosis, etc) or coagulation problems treated with anticoagulants or submitted to additional nasal procedures (septoplasty, inferior turbinoplasty, etc) were excluded from the study.

All patients underwent a preoperative fiber endoscopic examination and a computed tomography scan of paranasal sinuses to evaluate the extension of the nasal polyposis.

The surgical procedure was determined by the extent and location of the disease. In the study group, PMT was performed as described by LaMear et al , after injecting the middle turbinate with 2 mL of 2% lidocaine solution with 1:80 000 epinephrine. During surgery, discrete bleeding was controlled positioning 2 intranasal cotton pads with naphazoline for a few minutes or using a bipolar cautery.

The study group was further divided into 2 subgroups based on the SPAL: 21 patients (52.5%) were submitted to this procedure, whereas 19 (47.5%) were not. Sphenopalatine artery ligation was executed according to the technique described by Budrovich and Saetti .

After surgery, 2 intranasal cottonoid pads are left in each nostril until the trachea is extubated to minimize bleeding that could be brought on by coughing or by other Valsalva maneuvers. They are generally removed in the postanesthesia care unit. Only if diffused bleeding occurs that cannot be controlled with cauterization of the bleeding points, we use anterior nasal packing done with open cell foam polymer of hydroxylated polyvinyl acetyl (Merocell sinus pack from Medtronic Xomed, Jacksonville, FL).

The same treatment is expected in cases of epistaxis in the following period of hospitalization during recovery. It is also advisable for the patients to avoid blowing their nose or to do unnecessary efforts, which can augment the pressure (contraction of the abdominal wall, coughing, sneezing). Patients are told that they may expect to see many tissues spotted with blood for several days after surgery. Antibiotic therapy is prescribed with amoxicillin and clavulanic acid (1 g twice a day orally) and tranexamic acid (1 g twice a day orally) starting the night of the surgery. Starting the next day, nasal lavages are frequently performed with lukewarm sterile saline solution. Upon discharge, the patient receives a written list of rules to prevent eventual bleeding (sneeze with open mouth, avoid blowing nose, washing with warm water, avoid eating very hot foods, and avoid drugs that have anticoagulatory effects such as aspirin and its derivatives). If significant bleeding occurs, the patient is instructed to return to the hospital immediately.

A postoperative checkup is performed a week after surgery, in particular, to remove the scabs or the clots and to evaluate the postoperative healing and the eventual postoperative bleeding. Subsequent checkups are performed weekly until the full integrity of the mucosa is restored. In each visit, patients are questioned regarding nasal bleeding and symptoms of acute sinusitis, frontal headache, nasal dryness, or nasal obstruction. The patients are followed for a minimum of 1 year after surgery, recording endoscopic findings of mucosal disease, synechiae, lateralization of middle turbinate, and stenosis of frontal recess.

Patients submitted to FESS with PMT and without PMT were compared in relation to the risk of bleeding using the Fisher exact test. The same test was used to compare the study group patients submitted to SPAL and patients who did not undergo this procedure, in relation to the risk of postoperative bleeding. A P value of less than .05 was considered significant.

2

Materials and methods

In this retrospective study, we reviewed the cases of extended nasal polyposis (graded as stage III according to the Lund-MacKay classification) that underwent primary FESS with PMT at the Ospedali Riuniti University Hospital, Foggia. For all patients, each surgical side was evaluated independently.

We then selected the last consecutive 27 patients (15 women and 12 men; age range, 22–61 years; mean, 39.1 years) who underwent PMT on 40 sides (13 patients bilateral). Functional endoscopic sinus surgery with PMT was planned in all sides with evidence of concha bullosa and/or polypoid degeneration of the middle turbinate ( Fig. 1 ), and/or flail turbinate, and/or obstruction of access to the middle meatus.

The study group was compared with a control group of 27 patients (13 women and 14 men; age range, 22–54 years; mean, 34.4 years) with extended bilateral nasal polyposis who underwent FESS with middle turbinate preservation on 40 sides (13 bilateral and 14 unilateral with PMT on the other side, belonging to the study group).

Patients with other systemic diseases involving nasal structures (primary ciliary dyskinesia, cystic fibrosis, Wegener granulomatosis, etc) or coagulation problems treated with anticoagulants or submitted to additional nasal procedures (septoplasty, inferior turbinoplasty, etc) were excluded from the study.

All patients underwent a preoperative fiber endoscopic examination and a computed tomography scan of paranasal sinuses to evaluate the extension of the nasal polyposis.

The surgical procedure was determined by the extent and location of the disease. In the study group, PMT was performed as described by LaMear et al , after injecting the middle turbinate with 2 mL of 2% lidocaine solution with 1:80 000 epinephrine. During surgery, discrete bleeding was controlled positioning 2 intranasal cotton pads with naphazoline for a few minutes or using a bipolar cautery.

The study group was further divided into 2 subgroups based on the SPAL: 21 patients (52.5%) were submitted to this procedure, whereas 19 (47.5%) were not. Sphenopalatine artery ligation was executed according to the technique described by Budrovich and Saetti .

After surgery, 2 intranasal cottonoid pads are left in each nostril until the trachea is extubated to minimize bleeding that could be brought on by coughing or by other Valsalva maneuvers. They are generally removed in the postanesthesia care unit. Only if diffused bleeding occurs that cannot be controlled with cauterization of the bleeding points, we use anterior nasal packing done with open cell foam polymer of hydroxylated polyvinyl acetyl (Merocell sinus pack from Medtronic Xomed, Jacksonville, FL).

The same treatment is expected in cases of epistaxis in the following period of hospitalization during recovery. It is also advisable for the patients to avoid blowing their nose or to do unnecessary efforts, which can augment the pressure (contraction of the abdominal wall, coughing, sneezing). Patients are told that they may expect to see many tissues spotted with blood for several days after surgery. Antibiotic therapy is prescribed with amoxicillin and clavulanic acid (1 g twice a day orally) and tranexamic acid (1 g twice a day orally) starting the night of the surgery. Starting the next day, nasal lavages are frequently performed with lukewarm sterile saline solution. Upon discharge, the patient receives a written list of rules to prevent eventual bleeding (sneeze with open mouth, avoid blowing nose, washing with warm water, avoid eating very hot foods, and avoid drugs that have anticoagulatory effects such as aspirin and its derivatives). If significant bleeding occurs, the patient is instructed to return to the hospital immediately.

A postoperative checkup is performed a week after surgery, in particular, to remove the scabs or the clots and to evaluate the postoperative healing and the eventual postoperative bleeding. Subsequent checkups are performed weekly until the full integrity of the mucosa is restored. In each visit, patients are questioned regarding nasal bleeding and symptoms of acute sinusitis, frontal headache, nasal dryness, or nasal obstruction. The patients are followed for a minimum of 1 year after surgery, recording endoscopic findings of mucosal disease, synechiae, lateralization of middle turbinate, and stenosis of frontal recess.

Patients submitted to FESS with PMT and without PMT were compared in relation to the risk of bleeding using the Fisher exact test. The same test was used to compare the study group patients submitted to SPAL and patients who did not undergo this procedure, in relation to the risk of postoperative bleeding. A P value of less than .05 was considered significant.