Functional endoscopic sinus surgery (FESS) is currently the most effective treatment for chronic sinusitis refractory to medical therapy, with symptomatic improvements reported by approximately 90% of patients. In addition to meticulous and careful surgical technique, the management of the postsurgical patient is instrumental to optimizing success following FESS. The reported complications following FESS can be classified broadly into immediate postoperative complications such as bleeding and crusting; short-term complications such as infection, synechiae formation, and turbinate lateralization; and long-term complications such as ostial stenosis, refractory disease, and disease recurrence. This article highlights currently available data for postsurgical management strategies and briefly discusses additional techniques and tools under development for managing these complications.
In the past 25 years, there has been widespread adoption of functional endoscopic sinus surgical (FESS) techniques among otolaryngologists. In addition to the management of medically refractory chronic rhinosinusitis (CRS), these same techniques are currently applied to the management of acute complications of acute rhinosinusitis, resection of intranasal tumors, occuloplastic procedures, and approaches to the anterior skull base. Since its initial description by Messerklinger, and throughout its subsequent evolution, the underlying surgical philosophy of FESS has utilized endoscopic visualization to identify obstructed or inflamed natural drainage pathways of the paranasal sinuses and restore drainage and ventilation of these sinuses using meticulous mucosal-sparing techniques. These techniques have resulted in an effective therapy for CRS with intermediate and long-term symptomatic improvement reported by over 90% of patients undergoing FESS. Despite excellent surgical technique, however, postoperative complications and disease recurrence requiring revision surgery are reported in 18% of patients in long-term follow up.
Even following technically precise surgery, postoperative complications such as bleeding and excessive crusting can arise both in the immediate postoperative period, while other complications such as synechia formation, middle turbinate lateralization ,and infection may manifest within weeks of surgery. Underlying host factors, anatomy, surgical technique, and post-operative care ultimately dictate long-term complications such as ostial stenosis and disease recurrence. Hence, it is critical for the otolaryngologist to carefully evaluate post-FESS patients using postoperative course, nasal endoscopy, and even computed tomography scanning for the occurrence of such complications, since early recognition of such complications may facilitate outpatient interventions to stave off subsequent complications.
As the popularity of FESS has grown, there is an increasing interest in interventions and therapies targeted at optimizing outcomes. These interventions frequently are grounded in, and simultaneously limited, by the understanding about the pathogenesis of the inflammation associated with chronic rhinosinusitis. Traditionally, theories on the pathogenesis of CRS include obstruction of the osteomeatal complex, impaired mucociliary clearance, osteitis, atopy, and microbial resistance, including biofilm formation. These potential pathogenic mechanisms form the underpinnings of most current therapies for CRS, including antimicrobials, antihistamines, leukotriene antagonists, topical and systemic corticosteroids, and nasal rinses. More recently, research into host factors such as an aberrant host response to ubiquitous environmental mould and Staphylococcus aureus colonization and host barrier dysfunction have inspired clinical trials of therapeutics aimed at eliminating these potential agents in post-FESS patients. In a separate line of research, clinical trials have been conducted on various biomaterials and biological agents that may facilitate wound healing and reduce scarring in the post-FESS patient. This article reviews the available literature examining the role of operative or postoperative management strategies for reducing postoperative complications.
Prevention of post-FESS complications using intraoperative measures
Prevention of postoperative complications begins in the operating room itself, immediately following dissection of the cavity.
Nasal Packing
Nonabsorbable nasal packing traditionally has been the method of controlling ongoing bleeding after surgery to the paranasal sinuses and reduction of clot in the surgical bed. Additional theoretical benefits of nasal packing include preventing adhesion formation, middle turbinate lateralization, and restenosis after surgery. Unfortunately, the presence of nasal packing and its subsequent removal is frequently uncomfortable and is often rated by patients as the most unpleasant aspect of the FESS surgical experience. This has spurred development of absorbable hemostatic nasal packing materials that obviate the need for removal but need to degrade in an appropriate time frame without inducing an inflammatory reaction. Orlandi and Lanza have argued that the routine placement of hemostatic nasal packing for hemostasis is unnecessary, with 87% of their series of 165 patients not requiring any hemostatic agent packed in their nose without any increase in postoperative bleeding. A comprehensive review of the data and types of nasal packing in the literature, recently was published; however, the authors have selected a few specific studies in this article to highlight some of the more salient studies on nasal packing in the post-FESS patient.
Nonabsorbable packing
An excellent randomized, blinded controlled clinical trial was performed on the effect of middle meatus Merocel packing for 5 days in 61 patients after FESS. Contrary to the experience of the authors of this article, patients with Merocel packing did not experience any differences in the mean scores for nasal pain, headache, nasal congestion or postoperative bleeding. The primary benefit this study found from the placement of nasal packing was the reduction of synechia or adhesions that was seen in none of the 31 patients with nasal packing but 10 of those who did not receive nasal packing. In a separate study, Lee demonstrated thee use of silicone elastomer sheeting as a middle turbinate spacer in cases of a floppy middle turbinate following FESS and showed a reduction in synechiae formation from 44% to 6% in the treated side.
Absorbable packing
One of the absorbable hemostatic agents studied extensively in post-FESS patients is the Floseal matrix consisting of bovine-derived gelatin particles and human thrombin (Floseal, Baxter, Deerfield, IL, USA). A prospective uncontrolled study on 18 patients on using Floseal as a means of controlling bleeding post-FESS found it effective in providing postoperative hemostasis, with only one patient requiring additional postsurgical intervention for bleeding. Another study compared their prospective experience with Floseal on 50 patients with 50 controls receiving Merocel packing and found equal efficacy in postoperative hemostasis but less patient discomfort. However, a randomized study performed by the authors’ group on Floseal compared with thrombin-soaked gelatin foam and an additional larger retrospective study performed by a separate investigator, demonstrate an increased propensity of patients in the Floseal group to form early granulation tissue and subsequent adhesions.
Other groups have reported a prospective study utilizing microporous hemispheres, controlled-porosity spherical particles manufactured from bioinert plant polysaccharide, for use in the post-FESS setting with no differences noted in the immediate postoperative period when compared with the untreated control side. However, they did not report the presence of adhesion formation as one of their measured outcomes. Dissolvable carboxymethyl cellulose (CMC) foam was reported in a recent prospective study of 60 patients to reduce adhesion formation. Specifically, adhesions were observed in 35.7% of those receiving cotton gauze wrapped in latex glove fingers versus 6.7% in patients receiving CMC foam, with decreased levels of localized pain in the latter cohort. It was unclear from the methods whether the decision to place CMC-foam was randomized. A study examining hyaluronic acid nasal packs (Merogel, Medtronic, Jacksonville, FL, USA) failed to demonstrate any benefit of the spacer on bleeding, synechia formation, or edema when compared with the unpacked side.
Together, these studies demonstrate that the routine use of nasal packing, whether absorbable or nonabsorbable, has little effect on postoperative bleeding but more importantly, plays a more important role in postoperative healing. Definitive reductions in synechiae appear to be reported in studies involving nonabsorbable packs or splints, while the data regarding absorbable materials is more equivocal, and further studies and new materials will need to be developed for this purpose.
Middle Turbinate Stabilization
In addition to the operative placement of nasal packing, other intraoperative techniques to promote post-FESS healing include techniques to encourage the middle turbinate to heal in the medialized position, maintaining the patency of the ostia lateral to the middle turbinate. Published techniques include suture stabilization of the middle turbinate to the septum, metal clips, biological glue, and a controlled synechiae (Bolgerization).
Mitomycin C
Mitomycin C is a DNA cross-linking antineoplastic agent that has been used in ophthalmologic surgery to reduce scar tissue. Several groups have examined the application of mitomycin C via a middle meatal pledget at the end of surgery to reduce the formation of lateral synechiae. Chung applied mitomycin C at 0.4 mg/mL unilaterally in 55 patients and found a nonsignificant decrease of unilateral adhesions on the side receiving mitomycin C but also excluded the patients who formed bilateral adhesions from this analysis. Similarly, separate studies by Anand and Kim of similar design and mitomycin C concentration also failed to find significant benefit of mitomycin C in their studies. Conversely Konstantinidis applied mitomycin C to the middle meatus both at the conclusion of FESS and once in the postoperative period and was able to demonstrate a reduction in adhesions (4 of 30 moderate on the control side vs none on the treated side) and ostial stenosis. Together, these studies suggest that there may be a role mitomycin C in postoperative synechiae prevention; however, the effect probably is relatively small.
Frontal Sinus Stents
The use of indwelling stents has been described for the middle meatus, but in clinical practice, stenting generally is applied to the frontal sinus, where there has been significant debate about several related issues, including type of material, duration, and the basic need for stenting. A recent review has summarized the data behind frontal sinus stenting, but unfortunately to date, there are no controlled studies examining the effect of frontal sinus stenting. Weber retrospectively reviewed a series of 12 patients with refractory disease who had received frontal sinus stents for more than 6 months and found a patency rate of 70% and advocated for the placement of stents for that duration. Orlandi recently reviewed a series of nine patients on whom the frontal sinusotomy was felt to be tenuous, with a diameter less than 5 mm, and a Rains frontal sinus stent was placed. He has followed these patients for a mean duration of 33 months and has had to remove only one of these stents for infection.
Prevention of postoperative complications using postoperative techniques
Debridement
Throughout the development of FESS, debridement of the postoperative surgical cavity has been advocated for optimizing surgical outcomes. Several randomized controlled trials have directly examined the effect of postsurgical debridements on the outcome of surgery. Bugten has published short- and long-term follow-up to a prospectively enrolled study of 60 patients randomized to postoperative debridement or not. Each patient underwent debridements at 6 days and 2 weeks after surgery, and the study found that patients who received endoscopic debridement showed a more rapid resolution of the sensation of nasal congestion and reduced the number of middle meatal adhesions (11 adhesions vs 29 in control) when examined 12 weeks postoperatively. Lee randomized his patients into three groups receiving postoperative debridement ranging from twice weekly to every other week and concluded that once weekly debridement for 4 weeks was optimal for reducing patient discomfort from debridement or nasal crusting.
Postoperative Nasal Irrigation
The use of nasal irrigation in the postoperative period has been investigated, with several studies varying the use of nasal irrigation, the nature and tonicity of nasal irrigation, and even positioning during nasal irrigation. Freeman randomized his post-FESS nasal polyp patients to unilateral saline irrigation and found symptomatic improvements in his patients but few differences in crusting or edema. A rather exhaustive randomized study that included extensive postoperative biopsies on 80 patients who were randomized to receive either sulfurous-arsenical-ferruginous thermal water from the (Levico Spa, Trento, Italy) or isotonic sodium chloride solution for 6 months demonstrated a reduction in tissue eosinophilia in the group receiving spa water. Unfortunately, the authors did not report any endoscopic or clinical parameters in their paper. A controlled study examined hypertonic nasal saline spray, isotonic nasal spray, and no spray on a group of 60 patients in the post-FESS period and found that hypertonic nasal sprays had a detrimental effect of increasing the amount of nasal discharge and postoperative pain, but the study found no beneficial effect of either nasal saline spray. Nasal irrigation and douching techniques were not examined by this study.
Several other studies relevant to the discussion of irrigation in the post-FESS patient are Wormald’s study, in which the distribution of a nasal saline irrigation containing Technetium 99 m sulfur colloid was examined following nasal irrigation using a metered nasal spray, nebulization, and nasal douching with the head on the floor. This study found nasal douching to be most effective in distributing irrigant solution into the frontal recess and maxillary sinus. All techniques studied were unable to access the sphenoid sinus or frontal sinus well. In a separate study by the same group, a higher volume of irrigant (200 cc) was better able to penetrate the frontal sinus. The effect of tonicity of the nasal solution was shown to only transiently affect ciliary beat frequency in a study of either 0.9% saline spray or 3.0% saline spray. There has been no clinical trial demonstrating a sustained improved effect of hypertonic nasal irrigation or spray in the clinical setting.
In a cautionary note, Welch recently published a study of the irrigation bottles used by patients after FESS and found that bacteria could be cultured from the irrigation bottles in 29% of studied patients including Pseudomonas aeruginosa , Acinetobacter baumannii, and Klebsiella pneumoniae, although fortunately no clinically significant postoperative infections were noted. Frequent changing and sterilization of nasal irrigation bottles is advocated.
Prevention of postoperative complications using postoperative techniques
Debridement
Throughout the development of FESS, debridement of the postoperative surgical cavity has been advocated for optimizing surgical outcomes. Several randomized controlled trials have directly examined the effect of postsurgical debridements on the outcome of surgery. Bugten has published short- and long-term follow-up to a prospectively enrolled study of 60 patients randomized to postoperative debridement or not. Each patient underwent debridements at 6 days and 2 weeks after surgery, and the study found that patients who received endoscopic debridement showed a more rapid resolution of the sensation of nasal congestion and reduced the number of middle meatal adhesions (11 adhesions vs 29 in control) when examined 12 weeks postoperatively. Lee randomized his patients into three groups receiving postoperative debridement ranging from twice weekly to every other week and concluded that once weekly debridement for 4 weeks was optimal for reducing patient discomfort from debridement or nasal crusting.
Postoperative Nasal Irrigation
The use of nasal irrigation in the postoperative period has been investigated, with several studies varying the use of nasal irrigation, the nature and tonicity of nasal irrigation, and even positioning during nasal irrigation. Freeman randomized his post-FESS nasal polyp patients to unilateral saline irrigation and found symptomatic improvements in his patients but few differences in crusting or edema. A rather exhaustive randomized study that included extensive postoperative biopsies on 80 patients who were randomized to receive either sulfurous-arsenical-ferruginous thermal water from the (Levico Spa, Trento, Italy) or isotonic sodium chloride solution for 6 months demonstrated a reduction in tissue eosinophilia in the group receiving spa water. Unfortunately, the authors did not report any endoscopic or clinical parameters in their paper. A controlled study examined hypertonic nasal saline spray, isotonic nasal spray, and no spray on a group of 60 patients in the post-FESS period and found that hypertonic nasal sprays had a detrimental effect of increasing the amount of nasal discharge and postoperative pain, but the study found no beneficial effect of either nasal saline spray. Nasal irrigation and douching techniques were not examined by this study.
Several other studies relevant to the discussion of irrigation in the post-FESS patient are Wormald’s study, in which the distribution of a nasal saline irrigation containing Technetium 99 m sulfur colloid was examined following nasal irrigation using a metered nasal spray, nebulization, and nasal douching with the head on the floor. This study found nasal douching to be most effective in distributing irrigant solution into the frontal recess and maxillary sinus. All techniques studied were unable to access the sphenoid sinus or frontal sinus well. In a separate study by the same group, a higher volume of irrigant (200 cc) was better able to penetrate the frontal sinus. The effect of tonicity of the nasal solution was shown to only transiently affect ciliary beat frequency in a study of either 0.9% saline spray or 3.0% saline spray. There has been no clinical trial demonstrating a sustained improved effect of hypertonic nasal irrigation or spray in the clinical setting.
In a cautionary note, Welch recently published a study of the irrigation bottles used by patients after FESS and found that bacteria could be cultured from the irrigation bottles in 29% of studied patients including Pseudomonas aeruginosa , Acinetobacter baumannii, and Klebsiella pneumoniae, although fortunately no clinically significant postoperative infections were noted. Frequent changing and sterilization of nasal irrigation bottles is advocated.
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