2018 Section 5 - Rhinology and Allergic Disorders

Orlandi et al.

TABLE III-8. Evidence-based recommendations for postoperative care following endoscopic sinus surgery

Benefit-harm assessment

Intervention

LOE

Benefit

Harm

Cost

Policy level

Saline irrigations

B Well-tolerated. Improved symptoms and endoscopic appearance B Improved symptoms and endoscopic

Local irritation, ear symptoms

Minimal

Preponderance of

Recommendation for use of nasal saline irrigation Recommendation for postoperative debridement

benefit over harm

Sinus cavity

Inconvenience, pain,

In-office procedure with cost

Preponderance of

debridements

epistaxis, syncope, and mucosal injury

benefit over harm

appearance, reduced risk of synechia and turbinate lateralization

Topical

A Improved symptoms and endoscopic appearance, reduced recurrence rate of polyps B Improved symptoms and endoscopic appearance, reduced crusting N/A Potential reduced mucosal swelling and bleeding

Epistaxis, headache

Moderate

Preponderance of

Recommendation for standard INCS

corticosteroids

benefit over harm

Oral antibiotics

GI upset, colitis,

Moderate to high

Balance of benefit and harm

Option for oral antibiotics

anaphylaxis, bacterial resistance

Topical

Increased pain, possible rhinitis medicamentosa

Minimal

Preponderance of

Recommendation against topical decongestants Option for packing or spacer

decongestants

harm over benefit

Packing/spacers without medication

B Improved symptoms and endoscopic

Pain, inconvenience,

Moderate to high, depending on material

Balance of benefit and harm; potential small benefit of

potential for creating synechia or granulation

appearance, reduced risk of synechia and turbinate lateralization

absorbable vs. nonabsorbable packing

Drug-eluting

A Reduction in inflammation, polyps, adhesions

Possible systemic absorption, pain, inconvenience

Moderate to high, depending on material and medication

Balance of benefit and cost

Consensus regarding recommendation

spacers/stents

cannot be reached at this point

Systemic

N/A Improvement in endoscopic

Insomnia, mood changes, hyperglycemia,

Minimal

Balance of benefit and harm

Option for systemic corticosteroids

corticosteroids

appearance, reduction in polyp recurrence

gastritis, increased intraocular pressure, avascular necrosis

Mitomycin C

B Reduction in synechia

Off-label use, systemic

Moderate to high

Balance of benefit and harm

Recommendation

formation, improvement in maxillary ostium patency

absorption, local toxicity

against mitomycin C

GI = gastrointestinal; INCS = intranasal corticosteroid; LOE = level of evidence; N/A = not applicable.

is limited and has not been compared to studies em- ploying early and frequent debridement. ◦ Policy Level: Option. ◦ Intervention: When bleeding cannot be controlled, packing may help achieve hemostasis, without sig- nificant adverse effects on postoperative wound healing. Drug-Eluting Packing, Stents, and Spacers : Corticos- teroid eluting materials appear to have promise in the postoperative period. Additional indications are on the

horizon. Clinical experience with this device is relatively narrow at this point and evidence, though at a high level, is limited to short-term outcomes.

◦ Aggregate Grade of Evidence: A (Level 1b: 2 studies; Level 2b: 1 study). ◦ Benefit: Reduction in polyposis and adhesions forma- tion, which translates to a reduction in postoperative interventions. ◦ Harm: Potential for misplacement and local reaction.

International Forum of Allergy & Rhinology, Vol. 6, No. S1, February 2016

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