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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International consensus statement on rhinosinusitis

hemodynamic effects, but studies comparing this treat ment to no packing have not yet been performed. A recent systemic review and meta-analysis compared fibrin tissue adhesive (FTA) vs nasal packing in which 4 studies were identified. 2182 Bleeding trended toward improvement in the packing group but not statistically significantly. Nasal obstruction, granulations were better in the FTA group. Wound Healing. Critical to good surgical outcomes is optimal wound healing. Various studies have inves tigated the effects of different packing materials on adhesion formation, crusting, mucosal edema, inflam mation, and cilia regeneration. Packing materials that have been evaluated against not packing at all include Merocel R 2183 and absorbable materials such as Floseal R , 2170 HemoStase R 2184 carboxymethylcellulose (CMC), 2185 Merogel R , 2186 Sepragel R 2187 and CD gel (Chitogel R ). 2159 Only CD gel (Chitogel R ),Merocel R and Sepragel R were shown to confer an advantage over not packing at all, with both showing lower adhesion rates in their active treatment arms. 2159,2183 CD gel (Chitogel R ) was also shown, in another RCT, to be associated with significantly larger sinus ostial sizes at 3 months, although this study did not report any difference in adhesion rates between treated and untreated cavities. 2188 In a more recent study CD gel (Chitogel R ) showed a significant improvement in frontal, maxillary and sphenoid ostial size at 12 months. 2189 A small noncontrolled study by Kim et al., suggests that gloving the Merocel R pack prior to insertion may further reduce its post-operative adhesion rate, however this finding has yet to be validated in a controlled study. 2178 Given the perceived benefits of Merocel R in reducing adhesion formation, several RCTs have evaluated different packing materials directly against Merocel R .Floseal R , 2171 fibrin sealant, 2174 oxidized cellulose, 2177 and Nasopore R 2179,2180 have all been found to have similar effects on postsurgical wound healing, including rate of adhesion formation. Contrasting results exist in RCTs comparing Merogel R toMerocel R however. While an RCT by Berlucchi et al. 2190 suggested better early and long-term wound healing for Merogel R , no difference between these agents was observed in 2 other independent RCTs. 2191,2192 A RCT by Park et al. 2016 comparing Cal cium alginate (Algi-pack R ) and carboxymethylcellulose (Sinu-knit R ) showed a statistically better outcome with respect to adhesions and edema for the calcium alginate pack. Interestingly an RCT by Shi et al. evaluating a hyaluronan-based gel, PureRegen Gel R (BioRegen Bio medical, Changzhou, China), observed improved wound healing in terms of adhesion formation, edema and crusting when the gel was applied to Merocel R prior to packing. 2193 This does suggest a possible benefit of hyaluronan gel.

Floseal R and CMC have also been extensively investi gated for their effect on wound healing. Although stud ies by Jameson et al. 2170 and Baumann et al. 2171 reported no difference in wound healing or adhesion rates when Floseal R was compared to no treatment or packing with Merocel R , concerns have been raised regarding Floseal R ’s possible pro-adhesion properties. Two studies by Chan draet al., 2194,2195 suggest that Floseal R may actually incite early granulation tissue formation, with a higher rate of symptomatic adhesion formation. Their histopathological finding of incorporated foreign material within a mature synechiae supports this concern. 2195 Like Floseal R , CMC has not been shown to confer any significant benefit on wound healing compared to leaving a cavity unpacked. 2185 Two separate RCTs do suggest however that CMC dress ings may be associated to a lower rate of adhesion forma tion when compared to commonly used non-absorbable dressings. 2196,2197 Yan et al. in a systemic review and meta-analysis of biodegradable packing showed that biodegradable packing was better than removable packing for bleeding on removal of packs, pain and nasal obstruction but could not deter mine whether biodegradable packing was better than no packing at all. 2198 Stern-Shavit et al. did a decision analysis model which showed that packing was not advantageous for patients undergoing ESS but that absorbable packing had less adverse effects than non-absorbable packing. 2166 Patient Comfort. Sinus surgery itself is not characteristi cally associated with significant amounts of pain, although patients do frequently report discomfort from nasal pack ing and its removal. Level 1 evidence suggests that pack ing with absorbable dressings such as Nasopore R , 2181 HemoStase R , 2161 Sepragel R 2187 and Floseal R 2170 is not associated with any increase pain, compared to unpacked cavities. In fact in the studies that evaluated Sepragel R and Floseal R , patients reported less subjective discomfort on the treated side. 2170,2187 Both studies were small in num ber however and did not use validated pain scoring sys tems. Bugten et al. 2183 also reported no significant differ ence in pain scores between patients packed bilaterally with Merocel R and those left unpacked, although a patient self-controlled study has not yet been performed to val idate this observation. Several RCTs have directly com pared pain and comfort levels of packing using absorbable vs non-absorbable materials. Nasopore R and Merogel R (Medtronic, Jacksonville, Florida, USA) have both been found to better tolerated than non-absorbable Merocel R while insitu , 2179,2180,2190 with Merogel causing less discom fort on removal. 2190 Park et al. in a single blinded random ized controlled study found no difference in pain when comparing calcium alginate packing to carboxymethyl cellulose but showed less edema and adhesions with the latter. 2164 Finally, studies have also investigated whether