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News -> July, 2004 News
Andrew Lane, MD, FARS
As endoscopic sinus surgery has evolved over the past two decades, there have been tremendous advancements and refinements of the operative technique, facilitated by technological innovations such as mucosal sparing instrumentation, image guidance, and powered tissue dissectors. Peri-operative management has also progressed, albeit less dramatically, fueled by new pharmaceutical agents and shifting concepts of the underlying pathophysiology of rhinosinusitis. Pre-operative maximization of medical therapy, limitation of intranasal packing, and post-operative topical saline washes are examples of practices derived from the accumulated experiences of sinus surgeons suggesting a benefit in surgical outcomes. Although there have been very few studies that have addressed these issues in a scientific manner, much of the dogma associated with endoscopic sinus surgery has arguably been validated by its high rate of success. Over time, ESS has become increasingly safe and the results consistently better as practitioners incorporate new technologies and scientific discoveries into the time-proven fundamental principles.
One of the central tenets of post-operative care in ESS is that endoscopic surveillance should be performed on a regular and frequent basis in the early post-operative period. The goal of this practice is mainly to assess the status of healing in the sinonasal cavities and to guide medical therapy as necessary to control infection or persistent inflammation. In addition, nasal endoscopy provides an opportunity to débride devitalized bone, obstructing crusts, or developing synechiae that may impede proper healing or delay return of normal sinus function. To be performed successfully and properly, debridement frequently requires surgical instrumentation, additional topical or injected anesthetic, and adequate time. For this reason, debridement is justifiably a reimbursable procedure beyond and separate from nasal endoscopy. Unfortunately, the economic incentive associated with endoscopic debridement has led to exploitation of the billing code by some surgeons and, as a consequence, there have been recent calls from both within and outside the rhinology community for clarification of the term and limitation of its use. A few have even questioned whether endoscopic debridement should be performed at all as a routine aspect of post-operative care in ESS.
In the absence of case-controlled prospective studies comparing outcomes with and without debridement, the role of debridement is, in essence, a matter of philosophy and opinion, backed only by personal experience and educational bias. As with most diametrically opposed beliefs, the truth likely lies somewhere in-between the position of the "debrider" and the "non-debrider". In cases of minimal disease, particularly when strict mucosal-sparing technique is applied, it is correct that debridement is often not necessary. On the opposite end of the spectrum, it seems clear that in cases of polypoid pan-sinusitis with inflamed and infected mucosa, or revision surgeries with existing scarring, vigilant and proactive postoperative care is required. Regardless of the degree of mucosal disease or previous surgical history, every sinus surgeon strives to be as atraumatic as possible and to have minimal, if any, debridement to perform afterwards. That being said, imperfections do occur from time to time, and most patients develop at least some degree of crusting within the middle meatus. Although there is a theoretical case to be made that debridement in these circumstances is unnecessary and perhaps even counter-productive to healing of the sinonasal mucosa, the weight of nearly 20 years experience supports the opposite argument. Any proposed paradigm shift would need to be driven by compelling evidence that debridement is not critical to the success of ESS, rather than the other way around
Despite the fact that the purpose of debridement is to promote healing, it is not necessarily the act of debridement that accomplishes this aim. There are often areas, especially in the frontal recess, that may be difficult to evaluate postoperatively without first removing old blood, crusts, or fibrinous debris. If the goal of postoperative endoscopy is to assess the state of sinonasal mucosa and sinus cavities, that intent cannot be met if the mucosa is obscured. Common sense dictates that debridement be performed in the postoperative period as often and to whatever extent necessary to be able to completely evaluate the sinus cavities. This does not mean that every last crust has to be pulled off, nor that every time a suction is placed in the nose that it is to be considered a debridement. The message is to be judicious with the application of the procedure and ethical about the billing. For the future, prospective outcome studies concerning the role of postoperative debridement should be encouraged, and the results critically analyzed to ultimately shape recommended practice guidelines.
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