Abstract
Postoperative débridement is a crucial aspect of optimizing results in endoscopic sinus surgery. Careful and thorough débridements require precise knowledge of sinonasal anatomy and the surgical procedure. This chapter highlights the key steps in successful sinonasal débridement and postoperative management. Postoperative débridements remove synechiae, crusts, and mucus collections that can impair recovery, while improving patients’ postoperative symptoms and the appearance of the healing sinonasal cavity.
Keywords
débridement, post-op, postoperative care, medical therapy
Introduction
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For many, postoperative débridement is considered a crucial aspect of optimizing endoscopic surgical results.
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The most widely cited study supporting the practice of postoperative débridement is that of Senior et al., which suggested that weekly postoperative débridement was integral to the long-term improvement of symptoms in their series.
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Several advantages to postoperative débridement have been described:
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Impairment of mucociliary function persists for 3 to 12 weeks after surgery. Stagnant blood and mucus may act as a culture medium for microbes to perpetuate an immune response. Débridement reduces such colonization.
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The removal of postoperative blood, fibrinous clot, mucus and bone fragments, and residual partitions may diminish the amount of postoperative inflammation and the potential for synechiae formation and middle turbinate lateralization.
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Débridement improves patients’ postoperative symptoms and the endoscopic appearance of a healing sinus cavity.
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The timing of postoperative débridements varies from surgeon to surgeon. In general, the patient returns for the first postoperative visit 5 to 7 days following surgery. A second postoperative visit is scheduled in 1 to 2 weeks, depending on the healing status of the sinonasal cavity. A third postoperative visit is often needed 4 to 5 weeks after surgery when the sinonasal cavity is nearly healed.
Preoperative Considerations
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Patient discomfort may limit the extent of débridement. The use of topical anesthetics and vasoconstrictive agents is recommended.
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Topical 4% cocaine solution can act as a potent anesthetic and vasoconstrictive agent.
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It is often recommended that patients take a narcotic pain reliever before the initial postoperative débridement.
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Minimal débridement should be undertaken if the indication for surgery included repair of cerebrospinal fluid leaks or skull base tumor resections.
Pearls and Potential Pitfalls
Pearls
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If a frontal sinus dissection has been performed, it is often easier to identify the natural recess in the office if a frontal sinus stent has been placed intraoperatively ( Fig. 12.1 ).
Fig. 12.1
View through a 30-degree endoscope with a malleable, curved suction tube. With this device, the left natural frontal recess can easily be identified by following a stent placed intraoperatively (asterisk). MT, Middle turbinate.
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It is recommended that a full set of functional endoscopic sinus surgery instruments be available in the clinic for resection of retained bone fragments and recurrent polyps.
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When instrumentation of the sinonasal cavity is performed, the nasal septum should be avoided, because it is often the most sensitive to the healing patient. Moving the instruments along the lateral nasal wall is generally better tolerated than moving them along the septum.
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Talking to the patient while performing the débridement helps ease patient anxiety and improve patient comfort. A more comfortable patient often translates into a more compliant patient and more effective débridement.
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For example, when the maxillary sinus is débrided, the patient should be warned that discomfort may be experienced in the teeth.
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Potential Pitfalls
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Crusting at or near the sphenopalatine foramen or a resected middle turbinate should initially be left alone for at least 10 days to avoid a potential sphenopalatine arterial bleed in the office setting.
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Although removal of denuded bone is recommended, care must be taken in aggressively removing bone from the skull base, especially in cases in which the anterior ethmoid artery is in a mesentery and may potentially be injured.
Surgical Procedure
Step 1
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Remove any nonabsorbable nasal pack or space.
Step 2
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Aggressively apply a topical decongestant or anesthetic.
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Allow adequate time for the topical decongestant or anesthetic to take effect.
Step 3
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Under endoscopic visualization, use a straight Frazier suction tube to suction the nasal cavity and nasopharynx of blood and debris.
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Using a 30-degree endoscope initially angled inferiorly avoids the need to change to angled endoscopes later in the débridement process.
Step 4
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Identify the sphenoid sinus (if surgically opened) or the face of the sphenoid and suction debris to identify the posterior limit of débridement ( Fig. 12.2 ).
