Postoperative care following endoscopic sinus surgery (ESS) for medically refractory chronic rhinosinusitis (CRS) is believed to be important to optimize clinical outcomes. There is no standardized approach to postoperative care and, because of the numerous reported strategies, there remains a debate as to what constitutes the optimal postoperative care protocol. This article reviews the evidence and describes an evidence-based approach for postoperative care following ESS for medically refractory CRS.
The following points present level of evidence as based on grading by the Oxford Centre for Evidence-Based Medicine.
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Postoperative care following endoscopic sinus surgery (ESS) is important to optimize clinical outcomes.
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Nasal saline irrigations should be used following ESS (Grade: B).
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In-office endoscopic sinus cavity debridement after ESS improves both short-term and long-term clinical outcomes (Grade: B).
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Topical steroid therapy is integral for control of postoperative mucosal inflammation and should be started following ESS (Grade: A).
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Off-label topical steroid solutions may be considered in cases with severe mucosal inflammation (Grade: D).
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Perioperative systemic corticosteroids improve endoscopic outcomes following ESS in patients with nasal polyposis (Grade: not available; 1 level 1b study).
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Systemic antibiotics improve short-term symptoms and reduce crusting following ESS (Grade: B).
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Drug-eluting middle meatal spacers and stents improve endoscopic outcomes in patients with nasal polyposis (Grade: A).
Overview
Chronic rhinosinusitis (CRS) is a disabling inflammatory condition of the sinonasal mucosa that produces symptoms of nasal congestion, discharge, facial pressure, and olfactory dysfunction. Furthermore, several studies have demonstrated that CRS produces a significant reduction in both disease-specific symptoms and general quality of life (QoL). Management of CRS is focused on reducing mucosal inflammation and improving sinonasal function. The use of topical and systemic medical therapy remains the mainstay of treatment; however, a subset of patients will have persistent symptoms despite best medical efforts, and become candidates for endoscopic sinus surgery (ESS). Several studies have demonstrated the positive impact of ESS on both symptom-related and health-related QoL (HRQoL) outcomes in patients with medically refractory CRS. With more than 250,000 ESS procedures performed in the United States every year, it is important for the surgeon to optimize factors that improve postoperative success, which can produce positive long-term clinical outcomes. Although there are several minor technical variations, the fundamentals of ESS are to preserve mucosal lining while removing diseased tissue, creating an accessible sinus cavity, and ventilating the natural draining sinus pathways.
The primary goals of early postoperative care are to reduce mucosal inflammation and infection, improve short-term patient symptoms, promote early return of ciliary function, and prevent complications. Optimizing these goals should incur the best chance to maintain long-term HRQoL improvement and minimize the need for revision ESS. There is no standardized approach to postoperative care and, because of numerous reported strategies, there remains a debate regarding what constitutes the optimal postoperative care protocol. The most commonly described postoperative care modalities include: nasal saline irrigations, in-office sinus cavity debridement, topical nasal steroid sprays, off-label topical steroids, short-course systemic steroids, systemic antibiotics, and middle meatal drug-eluting spacers and stents ( Box 1 ).
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Nasal Saline Irrigations
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Low-volume
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High-volume
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Endoscopic nasal and sinus cavity debridement
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Topical corticosteroid therapies
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Sprays
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Drops
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Irrigations
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Systemic corticosteroid therapy
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Systemic antibiotic therapy
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Middle meatal drug-eluting spacers
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Middle meatal drug-eluting stents
Following a successful ESS procedure, an open and accessible sinus cavity will allow for continued topical medical therapy, which is critical for long-term success by minimizing mucosal inflammation. This article discusses the evidence pertaining to the different postoperative care strategies, and provides an evidence-based approach to postoperative care following ESS.
Evidence-based clinical assessment
Following ESS, the milieu of old blood, exposed bone, unresorbed packing, and retained secretions can predispose to infection and inflammation, and provide a potential framework for scarring and early disease recurrence. Although there may be a minority of surgeons who believe postoperative care following ESS is un-necessary, most experts believe that despite careful patient selection and meticulous surgery, a failure of dedicated postoperative care likely predisposes to potentially avoidable complications, such as synechiae, middle turbinate lateralization, ostial stenosis, and rapid polyp recurrence ( Fig. 1 ). The return of normal mucosal histology and ciliary function often takes longer than 12 weeks following surgery, therefore, postoperative follow-up is often recommended to ensure an adequate healing sinus cavity.
In a recent multi-institutional evidence-based review with recommendations article by Rudmik and colleagues, the recommended postoperative care treatments were: nasal saline irrigations, in-office sinus cavity debridement, and topical nasal steroid sprays. Because of a relative balance of harm and benefit, options were made for systemic steroids, systemic antibiotics, and drug-eluting spacers. Because of increased pain and the risk of rhinitis medicamentosa, the only recommendation against was for the routine use of topical decongestants. To further refine the optimal postoperative care strategy, further research is needed to confirm the evidence-based protocol that is proposed and elucidate the ideal frequency and timing of postoperative follow-up visits. The following sections discuss the different postoperative care strategies and present the evidence for each topic.
Evidence-based clinical assessment
Following ESS, the milieu of old blood, exposed bone, unresorbed packing, and retained secretions can predispose to infection and inflammation, and provide a potential framework for scarring and early disease recurrence. Although there may be a minority of surgeons who believe postoperative care following ESS is un-necessary, most experts believe that despite careful patient selection and meticulous surgery, a failure of dedicated postoperative care likely predisposes to potentially avoidable complications, such as synechiae, middle turbinate lateralization, ostial stenosis, and rapid polyp recurrence ( Fig. 1 ). The return of normal mucosal histology and ciliary function often takes longer than 12 weeks following surgery, therefore, postoperative follow-up is often recommended to ensure an adequate healing sinus cavity.
In a recent multi-institutional evidence-based review with recommendations article by Rudmik and colleagues, the recommended postoperative care treatments were: nasal saline irrigations, in-office sinus cavity debridement, and topical nasal steroid sprays. Because of a relative balance of harm and benefit, options were made for systemic steroids, systemic antibiotics, and drug-eluting spacers. Because of increased pain and the risk of rhinitis medicamentosa, the only recommendation against was for the routine use of topical decongestants. To further refine the optimal postoperative care strategy, further research is needed to confirm the evidence-based protocol that is proposed and elucidate the ideal frequency and timing of postoperative follow-up visits. The following sections discuss the different postoperative care strategies and present the evidence for each topic.
Evidence-based management
Nasal Saline Irrigations
Nasal douching with saline solutions has been well established as a treatment adjunct in CRS. However, the role of saline irrigations in the early postoperative period remains controversial. Advocates for early postoperative nasal saline irrigations hypothesize that nasal douching aids with debris removal and softens crusting, which may produce improved mucociliary clearance and potentially easier in-office debridement. There is significant variation is the delivery mode, volume, and frequency of saline irrigations:
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Delivery modes include squeeze bottles, atomization sprays, and electrical fluid delivery devices.
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The volume of saline douching varies from atomized 2 mL to 240 mL and the frequency varies from once daily to 4 times daily.
There are no studies that evaluate the optimal postoperative saline irrigation protocol. Although saline irrigations are safe and well tolerated, potential adverse effects include local irritation, epistaxis, nasal burning, headaches, ear plugging, and unexpected nasal drainage.
Nasal saline irrigation studies
Six randomized studies have evaluated the impact of saline irrigations on clinical outcomes following ESS. All study methodologies were heterogeneous, as they used different postoperative care protocols with different saline irrigation volumes and frequencies. Two studies evaluated low-volume postoperative nasal saline irrigations.
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A randomized trial (level 2b) by Freeman and colleagues demonstrated that the benefits of postoperative saline irrigations were limited to early endoscopic appearance, specifically a reduction in discharge and crusting, while they failed to demonstrate any long-term endoscopic improvement such as a reduction in synechiae or adhesions. However, one criticism of this study was the low-volume saline irrigation protocol (2 mL atomization 3 times a day), which questions whether it provided a strong enough mechanical debridement to make a difference.
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Another randomized (level 2b) trial by Pinto and colleagues evaluated 3 postoperative patient groups (no irrigations, normal saline irrigations, hypertonic saline irrigations), which irrigated 30 mL 4 times a day following ESS. The results demonstrated that hypertonic saline produced increased postoperative pain scores whereas the normal saline irrigations did not offer any additional benefit compared with the control group. Again, this study used a low-volume irrigation protocol (30 mL), making it difficult to draw conclusions about the commonly used large-volume (240 mL) irrigation strategy.
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One randomized (level 1b) trial by Liang and colleagues evaluated a large-volume (240 mL daily) saline irrigation protocol and demonstrated that the benefits were limited to patients with mild CRS, with those patients with moderate to severe CRS failing to demonstrate a difference in symptoms and endoscopic appearance. This finding may suggest that patients with moderate to severe CRS often require additional postoperative medical therapy to control inflammation and reduce symptoms.
Despite some controversy in the literature, most experts agree that there is a preponderance of benefit over harm, and nasal saline irrigations should be started within the early postoperative period, usually 24 to 48 hours after ESS. Although large volume saline irrigation has been demonstrated to be superior to low volume saline irrigation in the management of CRS, the effects of saline volume in the early postoperative period have not yet been evaluated.
Postoperative In-Office Sinus Cavity Debridement
The sinus cavity following ESS often has a large amount of crusting, old blood, unresorbed dissolvable packing, and retained secretions. This postoperative local environment is thought to provide a framework for scarring, ostial stenosis, and middle turbinate lateralization. Debridement of the postoperative sinus cavity is thought to optimize early mucosal healing by reducing the inflammatory load and lowering the risk of infection. Debridement technique often includes a rigid nasal endoscope scope for visualization, and the use of a suction instrument for soft debris and endoscopic graspers for harder crusts. Most surgeons agree that postoperative sinus debridement is a useful adjunct to maximizing long-term ESS outcomes. Arguments against debridement include exposing patients to increased pain, potential for mucosal stripping, and other rare adverse events such as epistaxis and syncope.
Postoperative debridement studies
There have been 4 randomized trials evaluating the role of postoperative debridement after ESS.
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An early pilot study (level 2b) by Nilssen and colleagues failed to demonstrate a clinical benefit of sinus debridement; however, it had several limitations including being underpowered.
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A recent randomized trial (level 1b) by Bugten and colleagues demonstrated that early postoperative sinus cavity debridement resulted in reduced crust and middle meatal adhesion rates at 3 months follow-up, and their long-term follow-up study in 2008 reported that the initial short-term improvements were stable after a mean of 56 weeks.
Although most experts agree that postoperative debridement is a useful adjunct to optimizing ESS outcomes, the timing and frequency of debridement is somewhat controversial.
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A study by Kuhnel and colleagues demonstrated that early crust debridement was associated with underlying mucosal avulsion in 23% of cases, although this risk was negligible after 2 weeks.
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Two subsequent level 1b randomized trials have demonstrated that the optimal timing for the first postoperative debridement is 1 week following the ESS procedure.
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The randomized trial (level 1b) by Lee and Byun demonstrated that patients who received multiple debridements within the first week received similar short-term (4 weeks) and long-term (6 months) symptom outcomes compared with patients with debridement(s) at 1-week intervals. Furthermore, the patients who received multiple debridements within the first week after ESS reported the greatest disturbances in socioeconomic activities and had the highest rate of omitting postoperative clinic visits.
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The randomized trial (Level 1b) by Kemppainen and colleagues demonstrated that patients who received 3 sinus cavity debridements within the first week after ESS had reduced nasal discharge scores compared with patients who received a debridement at 1 week after ESS.
When evaluating the evidence, the most accepted practice would include a sinus cavity debridement at 1 week after ESS, while subsequent debridements are often surgeon dependent and based on the degree of crusting and inflammation ( Figs. 2 and 3 ).
Topical Nasal Steroids
Topical nasal corticosteroid therapy is an integral component of anti-inflammatory CRS medical therapy. Application techniques include nasal sprays, atomizers, drops, and irrigations. Common CRS approved topical nasal steroid sprays include fluticasone, mometasone, and budesonide, while common off-label solutions include budesonide irrigations (0.5 mg/2 mL or 1 mg/2 mL mixed into 240 mL of saline), prednisolone 1% ophthalmic drops, dexamethasone 0.1% ophthalmic drops, and ciprofloxacin/dexamethasone 0.3%/0.1% otic drops ( Table 1 ). Although these higher-potency off-label formulations provide increased concentrations of local steroid therapy, the major disadvantage is the unknown systemic absorption profile with potential for adrenal suppression and other long-term systemic steroid effects. Standard first-line therapy typically uses approved nasal steroid sprays while reserving the off-label formulations for cases of severe postoperative mucosal inflammation. Furthermore, nasal sprays tend to provide more “nasal” coverage, whereas irrigations and drops tend to provide improved “sinus” penetration and may be a better postoperative topical therapy delivery technique. Unlike the use of systemic steroids, standard nasal steroid sprays have minimal systemic effects and therefore can be used as long-term corticosteroid therapy.
