xRead - Nasal Obstruction (September 2024) Full Articles

20426984, 2021, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/alr.22741 by Stanford University, Wiley Online Library on [01/07/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License

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Orlandi et al.

XII.D.5 Use of Packing in Sinus Surgery Absorbable and non-absorbable materials are commonly used to pack the sinus cavities in the peri-operative period. Proponents of their use suggest that they facilitate hemostasis and improve wound healing while opponents argue that they increase patient discomfort and may increase scarring. This area has been well studied in recent years, with numerous well-performed RCTs. Evidence exists to support the position that pack ing for hemostasis is not essential for the vast major ity of sinus cases. 2159–2167 Five RCTs comparing pack ing to no-packing reported no evidence of significant post-operative bleeding requiring intervention in their unpacked arms. 2159–2161,2165,2167 This is further supported by a large retrospective series by Orlandi and Lanza of 165 patients undergoing ESS. 2162 This study observed that only 11.2% of patients required packing at the end of their sinus procedure, with no reports of significant post-operative bleeding in those left unpacked. Intraoperative Hemostasis. Level 1 evidence now exists to support the findings of earlier case series that pack ing with absorbable biomaterials can help achieve rapid hemostasis within the sinuses. 2168–2171 Both Floseal R (Bax ter Inc, Deerflied, Illinois, USA), an absorbable matrix of bovine-derived gelatin with human-derived thrombin and HemoStase R (CryoLife Inc, NW Kennesaw, USA), a purified plant polysaccharide, resulted in complete ces sation of intra-operative bleeding within 5 minutes of application. 2168,2169 Although Jameson et al. 2170 reported a slower mean time to hemostasis of 16.4 minutes in their RCT using Floseal, hemostasis was still consid erably faster than no intervention. When compared to Merocel (Medtronic ENT, Jacksonville, Florida, USA), a non-absorbable, highly porous polyvinyl acetyl sponge, Floseal did not appear to achieve significantly faster hemostasis. 2171 Other absorbable agents that have been evaluated include chitosan-dextran (CD) gel (Chitogel R ), a biopolymer derived from the treatment of crustaceans (Chitogel Pty ltd, Wellington New Zealand); Sepragel R , a hyaluronan-derived gel (Genzyme Co, Cambridge, USA); Quixil R , a fibrin-based glue (OMRIX Biopharmaceuticals Ltd, Nes-Ziona, Israel); and Surgiflo R hemostatic matrix (Johnson & Johnson, Ethicon division Somerville, NJ, USA) used in combination with thrombin (King Phar maceuticals, Bristol, TN, USA). 2159,2160,2172,2173 AnRCT by Valentine at al. 2159 showed CD gel (Chitogel R ), to achieve hemostasis in a mean time of 2 minutes, which was sig nificantly lower than the average time of 10 minutes in untreated sinuses cavities. Sepragel R has also been com pared to no intervention, but did not appear to confer the same advantage in the time to hemostasis. 2160 Vaiman et al.

showed Quixil R to be significantly superior to Merocel R in the control of intra-operative bleeding and bleeding on pack removal, but no significant difference was observed in post-surgical bleeding > 30 hours after the procedure. 2172 Although Surgiflo R with thrombin was shown in 1 case series to have an impressive time to hemostasis (median = 61 seconds) and success in 95% of patients, these findings have not yet been validated in a well-designed RCT. 2173 Post-Operative Hemostasis. For situations where pack ing is necessary, a number of trials have compared various materials. Vaiman et al. reported significantly less bleeding in sinus cavities treated with fibrin sealant (Quixil R ) com pared to Merocel R , within the first 24 hours post surgery but not beyond. 2172 Yu et al.’s study 2174 did not replicate this finding in their study of an aerosolized form of a fibrin sealant but did report a decreased rate of bleeding on pack removal in favor of the fibrin sealant. Raghunandhan et al. (2014) in a DBRCT compared Nasopore R (Stryker, Hamil ton, ON, Canada) with Merocel and showed that the Mero cel had better hemostasis in the first 24 hours. Floseal R , 2171 Surgicel R , 2175 Cutanplast R 2176 (Mascia Brunelli S.p.A., Milan, Italy), and oxidized cellulose 2177 have also been found in RCTs to be associated with less bleeding than Merocel R at the time of pack removal. Al-Shaikh et al.’s 2177 study also showed oxidized cellulose to be associated with significantly less bleeding than Merocel R , immediately after surgery and on post-operative days 4,6 and 7. Kim et al. 2178 investigated whether gloving Merocel R prior to its insertion had any effect on hemostasis and found that sinus cavities packed with the gloved Merocel R had40gm less bleeding on removal than sides packed with ungloved Merocel R . Mehan et al. performed an RCT with polyvinyl acetate (PVA) packing on 1 side for a day after which it was removed and compared this to no packing. There was significantly more bleeding on the unpacked side on day 1 but significantly more bleeding after pack removal on the packed side on days 2 and 3 with no difference thereafter. 2167 Nasopore R , a fully synthetic absorbable dressing, has also been studied extensively. Two different RCTs com paring Nasopore R to Merocel R have shown contrast ing results. While Verim et al. 2179 showed a benefit of Nasopore R in all areas of post-operative morbidity includ ing bleeding on packing removal, this was not replicated in Shoman et al.’s RCT. 2180 More recently a DBRCT by Kastl et al. 2181 showed no post-operative hemostatic ben efit of Nasopore R over not packing at all. Jung et al. in an RCT compared aerosolized fibrin sealant to Nasopore R and found no difference post-operative bleeding. 2165 There is some evidence to suggest that pre-soaking Nasopore R with lidocaine may improve its hemostatic effect within the first 24 hours after surgery, 1887 without causing adverse