Documents
Postoperative care in endoscopic sinonasal surgery
WOLF G.
ORL University.
Graz Hospital. Austria
New Concepts and New Strategies in Rhinosinusitis and Postoperative Care.
57th National Congress of the Spanish Society of Otorhinolaryngology.
Granada, 1 October 2006.
Keywords of 57th National Congress of SPO in Granada - PDF
PAPERS
In endoscopic sinonasal surgery, surgical treatment of the nasal passages and sinuses is performed under internal visual control by means of a flexible optical system that is inserted in the nostrils. This type of surgery has become increasingly popular in recent years, thanks to the improvements made in the technique and its acceptance by physicians and patients alike. It is often carried out in chronic conditions, which are usually associated with mucus production, such as nasal polyps, chronic sinusitis and surgery for tumours or sinonasal disorders.
The priority goal of postoperative care after this type of surgery is usually to restore the patency and ventilation of the nasal passages and paranasal sinuses and the mucociliary clearing mechanism, as well as speeding up the healing process. To achieve this goal and in order to prevent complications and risks (such as bleeding, scab formation, synechias and granulomas, closure of the ostium and accumulation of secretions in the immediate postoperative period), it is considered vital to establish an effective guideline for postoperative care. As Dr. Wolf pointed out at the start of his address, “these protocols vary from one centre to another and the efficacy associated with them also varies”. Given the success rate at Graz Hospital, it was particularly interesting to learn at this forum the premises used as the basis for their action protocol in such cases.
BASIC MEASURES
First of all, the Austrian expert stressed that “postoperative care, although it has sometimes been underrated, is essential for the operation’s ultimate success”. The outcome of postoperative care depends to a great extent on what is done during the preoperative period. Before performing the operation, a series of basic measures should be performed to guarantee that the final goal is accomplished (adequate pre-treatment, provision of information to the patient about the postoperative phase).
The goals of postoperative care
|
Basically, postoperative care seeks to accomplish a four-fold goal: facilitate the physiological healing process and rapid recovery of the ciliated mucosa and ciliary transport, obtain adequate ventilation and drainage of the nasal sinuses, reduce the risk of postoperative infection, oedema and stenosis and, above all, improve the patient’s comfort.
The priority goal of postoperative care after this type of surgery is usually to restore the patency and ventilation of the nasal passages and paranasal sinuses and the mucociliary clearing mechanism, as well as speeding up the healing process.
The treatment given in the preoperative period has an influence on the postoperative care that should be offered to the patient who has undergone endoscopic sinonasal surgery. The choice of medical treatment in the postoperative period will depend, to a great extent, on the previous treatment. It is currently accepted that topical steroids are the drugs of choice for polyposis and allergic rhinitis; the oral antihistamines are also drugs of choice in allergic rhinitis. As regards the systemic steroids, they may be indicated in patients with asthma or polyposis. Finally, the antibiotics would be indicated when there is infection.
During the perioperative period, success will depend on using the appropriate instruments. It is also vital to avoid causing unnecessary injury to the mucosa.
Dr. Wolf recommended preserving the mucosa as much as possible and avoiding any type of injury at this level (he recommended the use of microdebriders), not leaving the bone exposed without mucosa during surgery (this enables complications to be avoided in the postoperative period), avoiding combining septoplasty and other operations, and avoiding the so-called packing (using hyaluronic acid).
POSTOPERATIVE CARE
|
In order to optimise the wound healing process, there are certain important aspects that must be considered. During the lecture, Dr. Wolf reminded that for between 1 and 3 weeks after surgery, the surgical field is lined with a scab. About 8 hours after surgery, the ciliated cells start to migrate towards the area of the surgical wound and granulation tissue is seen after about 2-4 weeks. Oedema appears about 5 weeks after surgery. A clinically normal mucosa is usually seen between 4 and 18 weeks after surgery (scab formation usually continues until week 12). Microscopic studies have shown that full recovery of the ciliated cells usually takes about one year.
During the postoperative period, and following the Austrian expert’s recommendations, irrigations with saline are essential. Nasal cleansing is vital, in that it helps reduce the oedema, inflammation and congestion of the mucosa in the areas affected by the surgery, remove the secretions that have formed and avoid the formation of scabs and synechias, promoting normal re-epithelialisation of the mucosa. The current procedure is to use hypertonic saline solutions during the initial stages and saline solutions with a greater entraining power at a later stage. As Dr. Wolf said, “they have a positive influence on mucosal regeneration and help remove scabs, mucus and fibrin”. In addition, the Austrian expert stressed “the enormous future prospects opening in this field with the advent of new products containing plant extracts for nasal cleansing and drainage”.
Interleukin-3 (IL-3) also plays a role that has both positive and negative effects on the wound healing process. On one hand, it modulates multicellular activation but, on the other hand, it can also induce the so-called overrepair of the mucosa (which can only be stopped with topical corticoids). This is why, Dr. Wolf said, “we indicate use of these drugs immediately after surgery”. The drugs of choice are mometasone, budesonide and fluticasone. Generally speaking, these are drugs that reduce postoperative oedema, IL-3 production, scab formation and the overrepair process.
The possible occurrence of a postoperative infection may require, in many cases, the administration of antibiotic therapy. The antimicrobials of choice are the second-generation cephalosporins, amoxicillin/clavulanic acid or ciprofloxacin.
In some isolated cases where headache and intense pain is reported, anti-inflammatory drugs or systemic steroids are given.
SPECIFIC EXAMPLES
To help illustrate better the postoperative care programme in endoscopic sinonasal surgery, the speaker showed the procedures he used in different patient models.
Patient recommendations
|
In a non-complicated patient, with no clinical evidence of bacterial infection, he uses preventive intravenous antibiotic therapy administered three times (starting treatment 90 minutes before surgery and then every 12 hours). He also recommended irrigating with saline and administering topical steroids for periods exceeding three weeks (continuation of this treatment would be decided on the basis of the postoperative endoscopic findings), starting this treatment on day 1 after surgery.
In non-complicated patients with clinical evidence of bacterial infection (pus), treatment with oral antibiotics is continued for two weeks. Further continuation of this treatment guideline will depend on the endoscopic findings.
The speaker stressed “the enormous future prospects opening in this field with the advent of new products containing plant extracts for nasal cleansing and drainage”.
In a patient with nasal polyps, the normal postoperative care schedule at Graz University is to administer topical steroids for 6-18 weeks and prednisolone 5 mg for 3 weeks or 25 mg for 10 days. In some cases, the use of desloratadine may be considered. These patients must be monitored for an extended period, with follow-up visits after 3, 6 and 12 months, repeating the steroid therapy if the endoscopic findings so advise. In those patients in whom a bacterial infection is detected, antibiotic therapy (ciprofloxacin) should be begun promptly.
Dr. Wolf has numerous cases of postoperative aspergillosis among his personal case records. In such situations, he advises treating with amoxicillin/clavulanic acid for a period not less than 2 weeks.
Orbital decompression
|
A number of well-established guidelines are also applied at Graz Hospital for the mechanical management of patients after surgery. On average, the patients spend two nights in hospital. During this period, the floor of the nasal cavity is aspirated to remove any blood clots, mucus and fibrin. Intensive mechanical cleansing is avoided in order to avoid inflicting unnecessary discomfort on the patient. Fresh granulated epithelium is not manipulated either and bleeding is not induced. If there is any bleeding, the fibrin residues between the middle concha and the nasal wall are removed between days 7 and 14 after surgery.
The follow-up procedure is adapted to the endoscopic findings. In patients with aspergillosis, an endoscopic follow-up examination is performed after 3-6 months.
As final recommendation, Dr. Wolf assured that, on the basis of his personal experience, “one of the keys to success in postoperative care is to work closely with the patient”. In his opinion, “explaining a series of basic recommendations to them (which are also given in writing) not only helps improve their monitoring but also actively helps ensure the operation’s success.” As part of these recommendations, it is important to stress to the patient the necessity of performing frequent irrigations of the nasal passages and blowing the nose very gently (without pressing hard).
In those patients in whom orbital decompression has been performed, the postoperative care is different. In this case, the patient is advised to not practice sports such as scuba-diving or weight-lifting and that he/she not blow his/her nose. When there is sinusitis, antibiotic therapy is prescribed promptly. It is also very important in these patients to explain the postoperative situation and the risks if it should be necessary to re-operate.
One of the keys to success in postoperative care is to work closely with the patient. Explaining a series of basic recommendations to them not only helps improve their monitoring but also actively helps ensure the operation's success.
New Concepts and New Strategies in Rhinosinusitis and Postoperative Care - Index
Future prospects in rhinosinusitis and postoperative care - Next Article
privacy policy | 2010© Hartington Pharmaceutical, S.L.U. all rights reserved | INTRANET