How Necessary are Postoperative Debridements After Endoscopic Sinus Surgery?

Background

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 three 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.

Best Practice

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. Read the full article in The Laryngoscope.