Triological Society Best Practice
How necessary are postoperative debridements after endoscopic sinus surgery?1
The authors have no funding, financial relationships, or conflicts of interest to disclose.
Postoperative debridement after functional endoscopic sinus surgery has become an accepted part of the surgical management of chronic sinusitis. Debridements are traditionally stressed as an essential part of maintaining sinus ostium patency, reducing pooling of mucus, preventing infection, and critical to long-term success. This stress arose mostly from theoretical considerations, and from an association in the literature with excellent long-term outcomes. Impairment of mucociliary function persists for 3 to 12 weeks after surgery, and stagnant blood and mucus may act as a culture medium for microbes to perpetuate an immune response. During debridement procedures, blood and mucus are suctioned, bone chips are removed, fibrin clot and early synechiae are cleared, and residual bony partitions may be taken down as the mucosal edema resolves. The frequency of debridements is highly variable from one surgeon to the next and one case to another. Greater inflammation at the time of surgery is associated with greater postoperative scarring, and possibly higher rates of revision surgery. In these cases, frequent and aggressive debridement may be warranted.
However, postoperative debridements are uncomfortable for patients, time consuming for the surgeon and clinic staff, require specialized sinus instruments in the office, multiple patient visits, and carry potential for epistaxis. Additionally, removal of crusts within the first week can be a source of new epithelial injury. Despite these reservations, serial postoperative debridements are performed by many surgeons. Yet, little evidence supports its need or defines the extent to which it is necessary.
Currently available literature regarding postoperative debridements is poor at best. No controlled studies exist with groups of equally or severely diseased patients, and both subjective and objective outcomes vary from one study to the next, precluding any meaningful comparison. The extent of debridement is rarely discussed in any study. The assumption is that as much is done to achieve the aforementioned goals as the patient will allow. The most frequently cited study for regular weekly postoperative debridement is based on the long-term outcomes obtained by Senior et al.,1 where successful outcomes were attributed to proper patient selection and meticulous postoperative care. In a smaller study, Bernstein and colleagues2 achieved excellent results, attributing their success mostly to meticulous surgical technique. However, a mean of four debridements were performed over a roughly 3-week period. A generation of surgeons has been performing regular debridements with hopes of achieving similar results, despite a lack of control groups in these studies. Fernandes reported on patients undergoing surgery without any postoperative debridement or antibiotics.3 Regular nasal saline douching beginning 10 days postoperatively achieved a 50% overall symptomatic improvement in 95% of patients. However, disease severity was not addressed, and an 11% synechiae rate was identified at 6-month follow-up. The best study to date was a partially blinded, prospective comparison that reported on nearly 60 patients operated on by a single surgeon with a standard postoperative regimen of nasal saline douching without antibiotics and steroids. Debridements performed at days 6 and 12 significantly reduced crusting, obstruction, and adhesion formation, but were associated with pain and headache. With only a 14-week follow-up, it is not possible to assess the ultimate utility of this regimen.4 To determine the optimal frequency of debridements, Lee and Byun5 randomly separated patients into disease-matched groups that were debrided twice weekly, weekly, or every other week for 4 weeks after surgery. Antibiotics, oral and topical steroids, mucolytics, and saline douches were administered in all patients. All groups had similar outcomes on the 20-Item Sino-Nasal Outcome Test and endoscopic scoring at 6-month follow-up. The authors ultimately recommended weekly debridement, as the group who underwent less frequent debridement had significantly more pain, nasal obstruction, foul odor, and discharge on visual analog scores.
The need for postoperative debridement after endoscopic sinus surgery is supported by theory, anecdotal evidence, basic science, and clinical study. The limited evidence suggests the optimal regimen is weekly debridement until normalization, or at least stabilization, of the endoscopic exam. However, the timing, degree, and frequency of postoperative debridements is best left to clinical judgment based on patient factors, anatomic findings, degree of surgery performed, and the degree of inflammation present at the time of surgery.
LEVEL OF EVIDENCE
Overall there is a low level of evidence to support arguments for or against postoperative debridement. The best study available is level 2b, but the vast majority is level 4 evidence. Blinded, prospective, disease-matched, controlled studies with validated outcome measures at long-term follow-up will need to consider variables of disease severity, surgical technique, and postoperative medical management.