 |
|
 |
 |
| |
News -> July, 1999 News
Let's begin by discussing what surgeons do during sinus surgery
because this influences postoperative care. Many surgeons today
have converted to microdebriders to perform sinus surgery. These
instruments preserve mucosa, reduce bleeding, and scarring.
Therefore, patients may heal faster, require less packing,
and less postoperative care.
If turbinates are preserved, they must not lateralize. Prevention
of lateralization is done by the use of packing, adhesing the
middle turbinate to the septum (Bolgerizing), or suturing the
turbinate to the septum (Baluyoting). The adhesion procedure
can be performed using the microdebrider (Friedmanizing).
Packing placement for the adhesion procedure to allow the
scarring to heal and keep the turbinate medial is necessary
for 5 days to 2 weeks. A light small Telfa® or Merogel® just
at the anterior-most middle turbinate is all that is necessary.
Hematosis after surgery is essential to reduce postoperative
bleeding and reduce packing which patients detest. Routine
cautery of any significant bleeding area is important. If
turbinates are removed, cautery of the remnant is necessary.
If bleeding is controlled, only a small pack is used to act
as a spacer more than as a hemostatic agent. The author
routinely uses a small piece of Telfa® or Merogel® for most
patients. For extensive surgery with oozing, a Telfa® surrounding
a Merocel® sponge provides good hemostasis, comfort to the
patient, and easy postoperative packing retrieval. Packing
such as Surgicel® or Merocel® which is not plasticized is
difficult to remove and uncomfortable for the patient. Some
prominent surgeons in this country and in Australia don't
pack at all with the thought that blood clot and crust is
nature's "bandage" and should be left alone. It is understood
that these surgeons take steps to reduce turbinate lateralization
to accomplish their goal for healing.
Postoperative antibiotics depend on what is found at surgery.
If purulence or significant chronic infection is present,
several weeks of antibiotics are appropriate. If the sinuses
are relatively clean, 1 week is enough to cover any packing
present (toxic shock). Oral steroids are not routinely necessary.
Patients with asthma, polyps, and extensive disease will benefit
from the use of steroids. Pain medication needs are usually
minimal. Patients requiring large amounts of pain medication
with severe headache need consideration for a possible
complication. Nasal decongestant sprays (oxymetazalone) and
saline sprays used immediately postoperatively add to patient
comfort.
The first postoperative visit is variable depending on each
surgeon's philosophy. At major international centers such as
Graz, Austria, and the University of Pennsylvania, patients
are seen within 1 or 2 days to begin postoperative debridement
which consists of packing, clot and crust removals. Fixed
crusts are left until they soften and loosen to avoid hemorrhage.
These visits are repeated every few days until the cavity is
judged stable and healing properly. Then weekly or bi-weekly
visits continue until healing is achieved. The author's routine
is for the postoperative visit at 4-5 days with endoscopic
debridement and packing removal. At that time, the turbinate
is assessed. If an adhesion procedure was performed, a small
unobstructive pack (Telfa®, Merocel®, or Merogel®) is replaced.
The pack does not extend into the ethmoid or block the maxillary
sinus. At this visit all sinuses are gently unblocked and blood
suctioned. The next visit is scheduled at 2-3 weeks depending
on concern for healing or turbinate lateralization. The third
visit is 1 month later, then 4-6 weeks and 2-3 months. Endoscopic
debridement is used when necessary but is usually not needed
after 1 month since healing should be well on its way at that
time. Endoscopic exam is used at each visit. Crusting after
4-6 weeks may be due to small dehiscent areas of bone or
devitalized bone chips. Small forceps for endoscopic removal
usually takes care of the problem.
The last school of postoperative care is the "no postoperative
care" school. Patients are placed on medication and irrigations
at surgery on the first postoperative visit and are not seen
again for several weeks and then 3-4 weeks after that. Loose
debris, old clot, crust, and synechiae are removed as necessary.
From our Australian colleagues comes a recipe for Willy's
Inhalation (from Dr. Bill Coman) which is felt to greatly aid
self-debridement and healing. Of interest, all three groups
have reported their results in the literature and all are about
the same.
Other specific issues to be addressed postoperatively include
postoperative hemorrhage, stent removal, synechia management,
steroid use, and coding issues for debridement.
Postoperative hemorrhage usually occurs at 2-3 weeks from a
partial turbinectomy or sphenopalatine or posterior septal
artery trauma when removing polyps or entering the sphenoid.
Vigorous posterior epistaxis usually occurs and packing placed
posteriorly sometimes will work but an occasional endoscopic
cautery is needed. The key is telling patients about bleeding
and what to do if it occurs. Be aware that any patient going
to an unfamiliar doctor or ER may lose a lot of blood before a
posterior hemorrhage is controlled.
Stents in large openings usually can be removed endoscopically
within 1 month of surgery. Stents in small openings need to be
left long term (i.e., 1 year or more). If these stents are
removed early (within a few weeks), intensive endoscopic debridement,
dilation, irrigation (sometimes through a trephination made at
surgery or through the frontal recess) are necessary to keep the
ostia open. The use of medications such as oral (Prednisone) and
topical (Dexamethasone or Maxidex® ophthalmic) steroids drugs in
the Moffitt head down position may help to keep a small frontal
ostia open. It requires a lot of work to keep a small ostia open.
In revision cases where previous frontal osteoplasty has failed,
the stent is best left in for a year. It may be removed, cleaned,
and reinserted endoscopically in the office during that time. The
operated frontal recess without stent placement needs careful
observation, judicious debridement, and control of the middle
turbinate to prevent synechia. Synechia pulling the middle
turbinates laterally blocking and scarring the antrostomy, anterior
ethmoid and frontal recess must be controlled postoperatively or
failure will occur. Small forceps or scissors to cut these synechia
with a small spacer insertion (Gelfoam®, Telfa®, Gelfilm®,
Merocel®, Merogel®) are helpful. Repeat incisions may be necessary.
Judicious steroid use may be the difference between healing with
scarring and open draining sinuses. Depending on the underlying
problems, oral steroids can be used from several days (single or
repeated bursts) in routine sinus surgery or polyps to several
months in allergic fungal sinusitis. Every patient should be on
topical steroids and consideration as noted for topical ophthalmic
drops in severe polyps or difficult frontal ethmoid problems.
The last issue deals with coding problems for endoscopic postoperative
debridement (31237). The 31237 code has HCFA approval (0 day global)
attached to it which means it can be billed for after endoscopic sinus
surgery. The chart needs to have appropriate documentation that
endoscopic debridement was performed and was the focus of the visit.
While Medicare pays for this code without problem, HMO/PPO providers
have balked, which is illegal. Also, often times primary care approval
is not forthcoming in the postoperative period. The American Rhinological
Society (ARS) along with the AAO-HNS and AAOA are currently working to
solve this problem. Template letters are currently available through
the ARS and AAO-HNS which can be sent to insurers informing them of
the 0 day global period for endoscopic debridement and warning them
that non-payment is illegal.
It is hoped this brief synopsis is informative and beneficial. Taking
time at the end of an operation and in the early postoperative period
to prevent and correct problems will lead to better results and fewer
revisions.
James A. Stankiewicz, M.D.
Loyola University Medical Center
Department of Otolaryngology
Maywood, Illinois
|
|
|
|
|
