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.

modifications to existing dressings can also improve their tolerance and discomfort level during removal. The addi tion of lidocaine to Nasopore R , intra-operatively and 8 hours post-surgery appeared to be significantly reduced immediate post-operative pain for up to 16 hours after surgery, 1887 while gloved Merocel R packs were found to cause less discomfort on removal than standard Merocel R packs. 2178 In an RCT Yayik et al. showed that adding bupi vacaine and dexamethasone to the nasal pack decreased pain and analgesic requirements in the first 24 hours after surgery. 2199 In another RCT Garzaro et al. showed that adding 5 mL of lidocaine to a PVA sponge did not result in less pain then a saline soaked sponge in a gloved finger. 2200 Yan 2198 did a systemic review and meta-analysis of biodegradable vs standard packing and showed that biodegradable packing showed significant improvements in bleeding at the time of removal, pain in situ , pain on removal and nasal obstruction. No difference could be found in wound healing. Hobson et al. conducted another systemic review and meta-analysis in 2015 and showed that middle meatal packing did not significantly reduce the incidence of middle meatal adhesions. 2201 In summary, packing does not appear to be necessary in the majority of ESS cases. If packing is chosen, available evidence indicates packing achieves hemostasis without significant adverse effects on postoperative wound healing. Use of Packing in Sinus Surgery Aggregate Grade of Evidence: ∙ Intraoperative Hemostasis: A (Level 2: 6 studies; level 3: 1 study; level 4: 2 studies). ∙ Postoperative Hemostasis: A (Level 1: 2 stud ies; level 2: 14 studies; level 3: 1 study; level 4: 1 study). ∙ Wound Healing: A (Level 1: 2 studies; level 2: 27 studies; level 4: 1 study). ∙ Patient Comfort: A (Level 2: 14 studies; Table XII-21). Benefit: Rapid control of intra-operative bleed ing. Potential reduction in adhesion formation with some materials. CD (Chitogel R ) appears to improve ostial sizes postoperatively. Harm: Potential for increased discomfort while in situ and on removal. Rare risk of toxic shock syn drome. Potential for an increased rate of clinically significant adhesions with some materials. Cost: There is a cost associated with all packing materials, with absorbable materials being more costly than nonabsorbable packing. Benefits-Harm Assessment: Balance of risks and benefits.

Value Judgments: For the majority of sinus sur gical cases packing is not required for intraoper ative hemostasis and will not reduce the risk of post-operative epistaxis. Although evidence does exist suggesting packing may reduce adhesion for mation, it is limited and has not been compared to studies employing early and frequent debride ment. Policy Level: Option. Intervention: When bleeding cannot be controlled, packing may help achieve hemostasis, without sig nificant adverse effects on postoperative wound healing. XII.D.6 Inert Stents in Sinus Sugery Ostial stenosis, synechiae formation and middle turbinate lateralization (MTL) represent 3 of the most common complications following ESS, with up to 27% of patients being found to develop adhesions despite meticulous post operative care. 2205–2207 A 2004 review of 80 revision sinus surgeries found that 50% of frontal recesses and 39% of mid dle meati (MM) had stenosis. 2208 Moreover, a 2014 review of 66 patients requiring revision frontal sinus surgery found a 48% rate of MTL. 2209 The importance of pre venting post-operative adhesions was demonstrated in a 2013 multi-institutional study of 286 patients: patients with synechiae had less improvement in 2 QoL instruments even after controlling for differences in disease severity. 2210 To prevent the formation of synechiae formation and MTL, surgeons may deploy the use of non-medicated, non absorbable inert stents into the MM. 2211 Two double-blind RCTs 105,2212 (patient, reviewing surgeon), comparing MM silastic stents to no MM stenting, demonstrated that MM silastic stenting reduced MTL, synechia, and crusting, but had no effect on symptoms or other endoscopic scores. A DBRCT performed by Manji et al. 2213 compared a silastic MM stent to a gloved Merocel spacer (randomly placed, intrapatient control) and found no difference in synechiae between both sides although removal of silastic stents was rated more painful. Numerous case series 2214–2218 found silastic middle meatus stents to be well-tolerated and to reduce postoperative synechiae. A recently developed balloon-expandable polyurethane/nitinol alloy stent 2219 designed to be removed at 4 weeks has been proposed as a means of easily stenting the ethmoid cavity, prevent ing adhesions, and reducing MTL. A comparison of 14 to 28 days of a polyurethane/nitinol stent to 2 to 3 days of polyethylene terephthalate stenting revealed a 9.3 times greater risk of adhesions and a 44% (v 3.8%) risk of MTL