The Laryngoscope

Lippincott Williams & Wilkins, Inc., Philadelphia

0 1999 The American Laryn ological,
Rhinological and Otological lociety, Inc.

Postoperative Care in Functional Endoscopic

Sinus Surgery?
Sylvester Valentine Fernandes, FRCSEd, FRACS, FACS

Objective: To assess the value of nonintervention inability to carry out the procedure without anesthesia-
after FESS.Study Design: Prospective study.Methods: have been more reluctant to intervene after surgery, but
Fifty-five patients with diagnosed chronic rhinosi- without significant deterioration in their results. Most
nusitis who failed adequate medical therapy were recommend a cleaning out under anesthesia approxi-
subjected to FESS.No postoperative care, apart from mately 2 to 3 weeks after surgery.
nasal douching with hypertonic saline after the tenth However, a recent study by Walner et aL7 questions
postoperative day, was done. No antibiotics or ste-
roids were administered routinely. Because 10 pa- the value of a “second-look” endoscopy in children. The
tients were not available for follow-up, only 46 pa- purpose of cleaning is to debride clots, remove granula-
tients were included in the study. Results: Success tions, and lyse synechiae. However, this external manip-
ratejudged by at least 50% subjective improvementof ulation interferes with rational surgical judgment. How
symptoms was 96.5%. However, all patients derived many of us would succumb to the thought of having a scab
some benefit. The occurrence of postoperative syn- picked off a wound every so often? How often is an exter-
echiae is discussed. Conclusions: The usefulness of nal ethmoidectomy subject to such treatment?
postoperative care of the FESS cavity needs reap- Such postoperative care also taxes patients, doctors,
praisal. Key Words: Postoperative care in FESS,func- and health care money. Patients despise every moment of
tional endoscopic sinus surgery, FESS. the postoperative visit and are glad when the routine is
hryngoscope, lO!M4i%948,1999
over. Apart fkom the time spent in such postoperative care
INTRODUCTION by the doctor (and patient), it is difficult to sufficiently
Most rhinologists no longer doubt the value and re- anesthetize the cavity with local anesthetics in view of the
sults of FESS. However, postoperative care is not yet debris already present. Pain and bleeding, especially
standardized. Various authors recommend differing rou- when imposed by the doctor, are not welcome.
tines dictated by personal experience and convenience.
Stammbergerl recommends cleaning the cavity 2 to 4 days MATERIALS AND METHODS
after surgery and thereafter every 3 to 5 days for the next A prospective study was scheduled to be conducted on 55
10 days. Kennedy2begins on the first and third or fourth consecutive patients with a diagnosis of chronic rhinosinusitis.
Adequate medical therapy included antibiotics and topical ste-
day following surgery. Cleaning is then performed weekly roids for at least 4 weeks. Preoperative nasal endoscopy and
until normal epithelialization of the cavity. Unless aggres- computed tomography scans provided diagnostic confirmation.
sive, he predicts the mucoceles of tomorrow. The protocol Ten patients were excluded because they were not able to return
recommended by Smith et al.3 includes endoscopic clean- for follow-up. This left a total of 45 patients available for review.
ing 2 to 4 days after surgery and weekly for 4 to 6 weeks. The 30 men and 15 women ranged in age from 18 to 71 years at
The patients are then followed closely with frequent en- the time of surgery. There were 13 asthmatics (28.9%) and 16
doscopy.Wigand4 commences cavity toilet daily for 1week tobacco users (35.6%). Eleven patients (24.4%) had a known al-
after surgery. Lund and McKay6 begin between 5 and 10 lergy and employed relevant measures for amelioration.
days after surgery and later a t 1 to 2 weekly intervals. Ten patients (22.2%)had a history of previous rhinosinus
Ryan et a1.6 perform cavity toilet at 2 weeks after surgery surgery. “his included septal surgery, nasal polypectomy, intra-
nasal (headlight) ethmoidectomy, maxilloturbinectomy, antrum
and in most cases a second and final visit a t 3 months is
washout, inferior meatal antrostomy, and one each of Caldwell-
scheduled. Antibiotics and local steroids are used rou- Luc surgery and removal of antrochoanal polyp. There were three
tinely. Paediatric rhinologists- obviously limited by their patients whose extent of nasal surgery was not decipherable. One
patient (2.2%) had a history of recent dental complaints and
treatment.
From Kurri Kurri District Hospital, Kum Kurri, New South Wales,
Australia.
Significant symptomatology volunteered included nasal ob-
Editor’s Note: This Manuscript was accepted for publication Febru-
struction (62.2%), postnasal drip (51.1%), facial pain including
ary 1, 1999. headaches (35.6%),and snoring (40%). Gastroesophageal reflw
Send Reprint Requests to Sylvester Valentine Fernandes, FRCSEd, symptoms (44.4%) were also noted. Specific questioning revealed
FRACS, FACS, 46 Fairfax Road, Warners Bay, NSW 2282, Australia. nasal obstruction in 1008,postnasal drip in 97.8%, facial pain in

Laryngoscope 109:June 1999 Fernandes: Postoperative Care in FESS?

945
 62.2%, snoring in 71.1% and gastroesophageal reflux in 44.4%. relief. Only one patient (2.2%)reported no improvement at
"his implies that patients attach significance to some symptoms all. Clinical examination in this patient revealed an adhe-
and not others. Nasal endoscopy revealed polyposis in 12 patients sion between the leR middle turbinate and septum.
(26.7%).Smell impairment, although noted before surgery in four Postnasal discharge improved 100% in 25% of pa-
patients (8.9%), was difficult to evaluate after surgery on the
visual analog scale.8
tients with the symptom; 70.5% had 50% or more relief.
The computed tomography scans revealed bilateral involve- Only one patient (2.3%)had no relief a t all.
ment of the ethmoids in 40 cases (88.9%),with sole involvement Facial pain improved 100%in 46.4% of patients with
in 1case. Bilateral involvement of the maxillary sinuses was seen the symptom; 82.1%had 50%or more relief. Four patients
in 42 cases (93.3%),with sole involvement in 3 cases. It is possible (14.3%)were not relieved a t all. Two patients with mi-
that bilateral involvement of the maxillary sinuses alone may be graine and one with temporomandibular joint dysfunction
related to allergic tendencies. Involvement of the sphenoids was were not included in this category and as expected were
seen in 14 cases (31.1%)and involvement of the frontal sinuses in not relieved of this symptom.
22 (48.9%).Unilateral involvement of the ethmoid and maxillary Snoring was improved 100%in 3.1% of patients with
sinuses only was seen in two cases only. One of these had had
the symptom; 65.6% had 50%or more relief. Nine patients
dental treatment recently. Seven of the above cases would score
(28.1%)had no relief at all.
24 on the Lund-Kennedy scale9 for radiologic staging. Three cases
of concha bullosa, one of Haller cell, one of agger nasi pneumati- Gastroesophageal reflux symptoms abated com-
zation, and one ethmoid mucocele were identified, pletely (100%) in 10% of patients with the symptom.
All cases were operated on by the author under general Thirty percent of such patients had 50% or more relief
anesthesia with local vasoconstrictor and anesthesia injection. from the symptom. Ten patients (50%)had no relief at all.
Surgery was accomplished to achieve the best possible nasal Asthma subsided completely (100%) in one patient
airway and establish ostiomeatal patency and mucosal integrity. (7.7% of patients with such tendencies); 46.1% had 50%or
To this end the procedures included total uncinectomy, middle more relief, indicated by decreasing frequency of attacks
meatal antrostomy, total ethmoid bullectomy (and anterior eth- and/or decreased dosage of asthma medications. Five pa-
moidectomyf, partial middle lamellectomy, posterior ethmoidec- tients (38.5%)had no improvement at all.
tomy, sphenoidotomy, and frontal reccessotomy. Lateral lamel-
lectomy of concha bullosa and Haller and agger nasi cellectomy
Overall improvement of 100% was claimed by 28.9%
were performed as necessary. There was no hesitation to improve of patients; 95.5%had 50%or more overall improvement.
the airway with septoplasty particularly in the region of the No patients had an overall improvement of less than 30%.
perpendicular plate of the ethmoid. Also maxilloturbinectomy No major complications either during or after surgery
and rhinoplasty were added as necessary. In general the surgery were encountered. Among the minor complications, or-
was meant to be functional rather than cosmetic. The middle bital fat was exposed in one patient who was not included
turbinate was never sacrificed and no middle meatal spacers in these results, as she was unable to attend follow-up. In
were used. The nose was routinely packed overnight. the original study group of 55 patients, this complication
Powered instrumentation was used in the latter part of the translates into an incidence of 1.8%.This patient was last
study and this may have contributed to a lesser incidence of seen 3 months after surgery and had no problems. No
synechiae during this period. Unless specifically indicated, no
nasolacrimal duct injury was noted in this series.
postoperative antibiotics were used routinely. No topical nasal
steroids were allowed until 3 months after surgery on a need Synechiae were the main concern of this study. Be-
basis. The patient was seen 10 days after surgery to air com- tween the right middle turbinate and lateral wall three
plaints and to learn about nasal douching with hypertonic saline. synechiae were encountered, between the leR middle tur-
Douching commenced after this visit. binate and lateral wall two, between both middle turbi-
The next visit took place in 1 month's time. An anterior nates and septum two, and one between the right middle
rhinoscopy was done at this stage mainly to assess the airway turbinate and septum. There were no adhesions involving
and to provide answers to pending questions. The next visit took the maxilloturbinals. This leads to a total of 10 uninten-
place 3 months later, at which time nasal endoscopy was per- tional synechiae, of which five occurred between middle
formed and a decision to further medicate was made if necessary. turbinates and septum (which may be beneficial in some
cases). In one patient an adhesion that was present be-
RESULTS tween the right middle turbinate and the lateral wall up to
Forty-five patients ranging in age from 18 to 71 years 3 months after surgery had disappeared by the 6 month's
were included in this study. The follow-up period ranged review! This case is not included in the total. Other post-
from 6 to 29 months. A modification of the symptom scor- operative endoscopy findings include middle meatal pol-
ing method as expressed by Lund et a1.S was used after yps on the right side in two cases, mucosal edema in two
surgery. Assuming that the symptom's preoperative score cases, and discharge in one case. Sixteen patients (35.6%)
was 10, the patient was asked to grade the same symptom used postoperative topical steroids on a regular basis.
after surgery on a visual analog scale. If there was no
improvement, the score remained at 10; if the symptom
improved loo%, the score was 0. If the symptom wors- DISCUSSION
ened, the patient was told to say so. Olfaction was difficult Patient discomfort during postoperative toilet follow-
to assess, as most patients are only able to volunteer a ing FESS is undeniable.6 Local anesthesia is difficult to
positive or negative response, although an intermittency achieve and pain and bleeding are frequent accompani-
of the response may be acknowledged. ments, contributing to patient dissatisfaction with the
On this basis nasal blockage improved 100%in 44.4% procedure. There is no universal protocol for postoperative
of patients with the symptom and 88.9%had 50%or more care apart from the fact that it must be meticulous. This is

Laryngoscope 109: June 1999 Fernandes: Postoperative Care in FESS?

946
interpreted by various authorities in various ways and
TABLE 1.
various protocols have evolved. Postoperative Results.
Pediatric rhinologists bound by anesthetic limita- ~ ~~~

tions are now restricting postoperative cleaning of the 100% Better >50% Better No Improvement
(%) (%) (%)
cavity to once only after approximately 2 weeks and have
encountered comparable resultslo-12 to adults.1,3*5J3J4 Nasal obstruction 44.4 88.9 2.2
Even this once only cleaning is under threat.7 Despite the Postnasal discharge 25 70.5 2.3
once only cleaning, success rates of 80% to 92% are re- Facial pain 46.4 82.1 14.3
ported. If anything, children should fare worse than Snoring 3.1 65.6 28.1
adults in view of the absolute dimensions of the nose and Esophageal reflux 10 30 50
sinuses and increased frequency of allergies and asth- Asthma 7.7 46.1 38.5
ma.2J4 This is not the case. Overall improvement 28.9 95.5
Postoperative synechiae between the middle turbi-
Percentages relate to the incidence of individual symptoms.
nate and the lateral wall have been blamed for FESS
failures.3J5 Meticulous postoperative care is advocated to
reduce synechiae formation. Studies addressing synechiae
formation after meticulous postoperative care report an Initial FESS surgery should include a total uncinectomy,
incidence of 1%to ll%.16-19 This study reports an inci- total ethmoid bullectomy, middle meatal antrostomy and
dence of 11%synechiae between the middle turbinates frontal recessotomy. Agger cellectomy and Haller cellec-
and lateral wall. A similar incidence of unintentional syn- tomy, if such lesions were present, should be done. Other
echiae between the middle turbinates and septum also surgery as indicated should be performed. If, inspite of the
occurred. Some studies advocate the beneficial nature of above surgery, further symptoms arise, then a systemic
the latter and advise on how to incur the same.20 A total of problem is probably present.
eight patients had unintentional synechiae (including The incidence of mucoceles rising is questionable.
beneficial). Thirty-seven patients (82.2%) had no syn- Although ostial obstruction and inflammation may be fac-
echiae and would have been grateful to have been in- tors in etiology, given the frequency of such, the incidence
cluded in the study to escape “meticulous” postoperative of mucoceles is relatively uncommon in general. Various
care! other conditions-some still unknown-must be present.
Preservation of mucous membrane by utilizing Lund27 showed higher concentrations of prostaglandin E,
through-cutting forceps and microdebriders is ideal, al- in mucoceles. Schenk et a1.28 were unable to provoke mu-
lowing healing to take place in 2 to 6weeks. Posttraumatic cocele formation in dogs experimentally. Canalis et aLz9
healing is best left alone. Intervention causes removal of found an incidence of mucoceles of 35% in postnasal sur-
granulations with bleeding and poor visualization, caus- gery cases, some of whom may have had allergy and nasal
ing further granulations and delay in healing. Steroids polyposis. The use of hypertonic saline appeared to be
cause suppression of the inflammatory response and col- salutary in this study, cleansing the cavity of debris with-
lagen lysis, impairing healing during the early days after out significant complaints from patients.
injury.
Middle turbinate resection has been advocated, both
to relieve nasal obstruction,3,21 and to reduce the inci-
dence of synechiael7.22 (although statistical significance is CONCLUSION
The success rates of FESS exceed 80% in most re-
not attained in these studies). Nasal obstruction was im-
ported series. However postoperative care needs reap-
proved in 93.3%of patients in this series without middle
praisal. The results of a postoperative nonintervention
turbinate resection. Attendance to the nasal septum and
study are presented in Table I.
maxilloturbinectomy in requisite cases may be contribu-
tory. This latter intervention may also account for the
adhesions between the middle turbinate and septum (ben-
eficial ones). Partial middle turbinectomy actually may BIBLIOGRAPHY
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Tinnitus:
New Perspectives on Diagnosis and Management
Dartmouth-Hitchcock Medical Center
Lebanon, New Hampshire
August 14,1999
Program Directors: Dudley J. Weider, MD, and Frank E. Musiek, PhD. There will be an evening reception for program
faculty and attendees on August 13, 1999. For information contact the Center for Continuing Education in the Health
Sciences, Darmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756-0001 (603-650-1526.

Laryngoscope 109: June 1999 Fernandes: Postoperative Care in FESS?

948