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News -> July, 2001 News
Discussions of post-op care and sinus packing in FESS tend to be filled with equal parts science, experience, and hocus pocus. Despite this, however, since the popularization of functional endoscopic sinus surgery began about 15 years ago, most surgeons have found that successful outcome mandates post-operative care in the clinic setting, though what this exactly means is controversial and surgeon-dependent. In order to clarify these issues and enlighten our readers, we asked several of our colleagues on the Board of Directors of the American Rhinologic Society the following questions: "What kind of packing do you use and for what duration?" and " What is your usual schedule of post-op care?"
Regarding packing:
Winston Vaughan, MD: No packing if minimal bleeding, or finger cot wrapped Merocel sponge if moderate oozing and/or to stabilize the middle turbinate. Packs removed on day 3.
Brent Senior, MD: FloSeal applied to the cavity, one cartridge to each side. Material is debrided out of the cavity at the first post-op visit approximately one week following surgery.
Donald Lanza, MD: No packing in 90% of cases; Merocel (Kennedy) in 10% removed on post-op day one.
Jim Stankiewicz, MD: Small Telfa packing for 2-5 days.
Martin Citardi, MD: Use of packing is variable and decreasing. When used, it functions more as a spacer than as a tight pack, minimizing blood/mucus accumulation by simply taking up space. Standard spacer is a Merocel cut to size and wrapped in a latex glove finger and secured with a blue prolene suture. It is left in place for several days.
Jim Hadley, MD: Merocel packing (Kennedy) trimmed to approximate the ethmoid cavity. These are sometimes wrapped with a "U" of gelfilm to facilitate removal and left in place for 4-5 days. FloSeal is being evaluated to determine its merits.
J. David Osguthorpe, MD: Small Merocel (Kennedy) pack saturated with Cipro HC (3/4) and oxymetazoline (1/4) in the ethmoid defect for 5 days.
Mike Sillars, MD: Nothing or Merogel. Merogel dissolves by 10 days to 2 weeks. Merogel is unlikely to be used if a frontal sinusotomy has been performed because the frontal sinus cannot be visualized at the first visit (5-7 days) requiring its debridement.Occasionally to tamponade bleeding, a Merocel in a finger cot secured to the nasal septum with a 4.0 prolene suture is used.
Regarding regimens for post-op care, the following responses were noted:
Winston Vaughan, MD: Day 3 packs are removed and debridement with straight and curved suctions performed. Day 10 debride with suctions and pediatric forceps. Day 17 endoscopic evaluation; consider adding prednisone or singulair. Day 30-35 endoscopic evaluation.
Brent Senior, MD: Culture directed antibiotics for about 21 days. No irrigations. Oral steroids in polyp patients and asthma patients. Patients are seen for their initial post-op visit approximately 7-10 days post-op and debridement under local anesthesia and/or conscious sedation. Second visit about day 14-17 and debridement is performed. Subsequently endoscopic exams are performed post-op week 4, 8, and 12. Debridements at those times are individually tailored.
Donald Lanza, MD: At the day of surgical booking, post-op care appointments are scheduled at 1 week and 3 weeks post-op. Then depending upon the surgery, nature/severity of the disease, patients are seen more frequently in the first two months.
Jim Stankiewicz, MD: For patients living near, pack removal and endoscopic debridement are performed 4-5 days post-op, along with initiation of irrigations and topical dexamethasone drops. Next return is 3-4 weeks later for endoscopic evaluation. For out of town patients, the day after surgery, packing is removed, debridement performed and irrigations begun along with dexamethasone drops. Patients return in one month for endoscopic evaluation.
Martin Citardi, MD: Culture documented antibiotics. Prednisone for polyps with a slow taper. Hypertonic saline irrigations. Post-op visits are scheduled routinely for days 3 and 10. The third visit is about 6-8 weeks after surgery.
Jim Hadley, MD: One week endoscopic debridement; two weeks endoscopic debridement; endoscopic exam 6weeks and three months following surgery.
J. David Osguthorpe, MD: Antibiotics while packs in place. Oral decongestants, and saline sprays or irrigations, for 4 weeks; resume topical steroid sprays in those with inhalant allergies or polyps. Following pack removal, inspection and cleaning at 5 days, and further office visits occur at 2 and 6 weeks.
Mike Sillers, MD: Nasal irrigations with a bulb syringe begun on post-op day 1 and continue until the irrigant returns clear i.e. no clots or discolored mucus (~ 3 weeks). First visit 5-7 days post-op and again at 2 weeks with subsequent visits determined by pathology, extent of dissection, and healing process.
Obviously the proverbial cat can be skinned in many ways. While a variety of opinions exist regarding these issues, several points of similarity can be identified. First, though some are moving away from it, packing remains commonplace following sinus surgery with a variety of materials both absorbable and non-absorbable. Non-absorbable packing is typically removed 1-5 days post-op. Interestingly six respondents noted that they use no packing, or are using (experimenting) with absorbable packing.
Regarding post-op care, a consensus continues to exist that post-op care including frequent dŽbridements and endoscopic examinations remains an axiom of successful endoscopic sinus surgery. The exact number of procedures and examinations varies among different respondents ranging from 3 to 7 during the post-op period. Most suggest about 5 visits. While so many procedures performed by otolaryngologist/head and neck surgeons are complete when complete, clearly sinus surgery remains unique in its requirement for close ongoing surveillance and "tweaking" of the surgical field to ultimately improve healing and outcome.
Brent A. Senior, MD, FACS
University of North Carolina, Chapel Hill, NC
P.S. Per the SAHP Update on another page of the Newsletter, a group of us met with BC/BS of Illinois re. post-op nasal endoscopy and cleaning. They have had claims for up to 27 consecutive weekly endoscopies/cleanings after routine sinus surgery. We thought such a routine of post-op care was highly unusual, hence this survey by Brent Senior. The upshot of our meeting is that BC/BS of Illinois seems to accept a zero global period for transnasal sinus surgery, and up to 3 endoscopic cleanings in the first 30 days post-op. In excess of such will likely require written justification.
J.D. Osguthorpe, SAHP Board Member
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