What are the benefits and harms of postoperative debridement of the nasal and sinus cavities in patients who have had endoscopic sinus surgery for rhinosinusitis?
Endoscopic sinus surgery is often used for patients with recurrent acute or chronic rhinosinusitis when medical treatment has been unsuccessful. After surgery, several care measures have been suggested to help patients recover. One such measure is sinonasal debridement, which means removal of blood clots, crusts and secretions from the nasal and sinus cavities, a procedure that is usually performed under local anaesthesia.
We included four studies with a total of 152 adult participants. These studies were conducted in several countries (Norway, the United Kingdom and Canada). All of them compared debridement to no debridement after endoscopic sinus surgery. The minimum follow-up time in the studies ranged from 3 to 12 months. Only one study reported health-related quality of life scores and only one reported disease severity scores. However, all four studies reported scores for the appearance of the sinonasal cavities viewed through an endoscope. Adverse effects of this procedure and rates of revision surgery were not reported in any of these studies.
Health-related quality of life and disease severity scores were not significantly different between those patients who underwent debridement and those who did not. All four studies demonstrated better post-surgical endoscopic appearance in the debridement group, although the size of improvement was not statistically significant. A lower rate of intranasal scarring was noted in the patient group that underwent debridement. Nonetheless, the overall evidence for all of these outcomes is of low quality.
Quality of the evidence
We identified several problems or potential problems in these studies. The most important was that in each study a different protocol was used for the number of debridement interventions performed per patient and the time interval between each such intervention. In addition, the numbers of patients in the study groups were relatively small. We therefore determined the overall quality of the evidence to be low for all outcomes. The evidence in this review is up to date to May 2018.
We are uncertain about the effects of postoperative sinonasal debridement due to high risk of bias in the included studies and the low quality of the evidence. Sinonasal debridement may make little or no difference to disease-specific health-related quality of life or disease severity. Low-quality evidence suggests that postoperative debridement is associated with a significantly lower risk of adhesions at three months follow-up. Whether this has any impact on longer-term outcomes is unknown.
Endoscopic sinus surgery (ESS) is often recommended for symptomatic patients with recurrent acute or chronic rhinosinusitis who have failed conservative treatment. Postoperative care has been felt to be critical for both maintaining the surgical patency of the operated sinuses and improving patient symptoms. Debridement of the sinonasal cavities is one such postoperative care measure that has frequently been studied in the literature, often with conflicting conclusions.
To assess the effects of postoperative sinonasal debridement versus no debridement following endoscopic sinus surgery.
The Cochrane ENT Information Specialist searched the ENT Trials Register; Central Register of Controlled Trials (CENTRAL, via the Cochrane Register of Studies); PubMed; EMBASE; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 21 May 2018.
Randomised controlled trials comparing postoperative nasal debridement versus no debridement in adult patients with recurrent acute or chronic rhinosinusitis undergoing endoscopic sinus surgery. We included studies in which the patients acted as self-controls (i.e. one side of the nose underwent debridement and the other side did not) only for the secondary endoscopy outcomes.
We used the standard methodological procedures expected by Cochrane. Our primary outcome measures were: health-related quality of life, disease severity (patient-reported symptom scores) and significant adverse effects (bleeding requiring intervention, severe pain, iatrogenic injury). Secondary outcomes were: postoperative endoscopic appearance of the sinonasal surgical cavities (endoscopic scores), recorded use of postoperative medical treatment and rate of revision surgery. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics.
We included four studies (152 participants), with a follow-up duration ranging from three months to 12 months. In two studies patients acted as self-controls, i.e. one side of the nose underwent debridement and the other side did not ('split-nose' studies). The risk of bias in all studies was high, mostly due to the inability to blind the patients to the debridement procedure.
Disease-specific health-related quality of life scores
Only one study (58 participants) provided data for disease-specific health-related quality of life. At six months follow-up, lower disease-specific health-related quality of life scores, measured using the Sino-Nasal Outcome Test-22 (SNOT-22, range 0 to 110), were noted in the debridement group but the difference was not statistically significant (9.7 in the debridement group versus 10.3 in the control group, P = 0.47) (low-quality evidence).
Disease severity (patient-reported symptom score)
Only one study (60 participants) provided data for disease severity measured by visual analogue scale (VAS) score. No significant differences in total symptom score were observed between groups postoperatively (low-quality evidence).
Significant adverse effects
Significant adverse effects related to the debridement procedure were not reported in any of the included studies, however it is not clear whether data regarding adverse effects were not collected or if none were indeed observed in any of the included studies.
All four studies assessed the postoperative endoscopic appearance of the sinonasal cavities using the Lund-Kennedy score (range 0 to 10). A pooled analysis of endoscopic scores in the two non 'split-nose' studies revealed better endoscopic scores in the debridement group, however this was not a statistically significant difference (mean difference -0.31, 95% confidence interval (CI) -1.35 to 0.72; I² = 0%; two studies; 118 participants) (low-quality evidence). A sub-analysis of the adhesion formation component of the endoscopic score was available for all four studies and revealed a significantly lower adhesion rate in the debridement group (risk ratio 0.43, 95% CI 0.28 to 0.68; I² = 29%; four studies; 152 participants). Analysis of the number needed to treat to benefit revealed that for every three patients undergoing debridement, the endoscopic score would be decreased by one point in one patient. For every five patients undergoing debridement adhesion formation would be prevented in one patient.
Use of postoperative medical treatment was reported in all studies, all of which recommended nasal douching. Steroids (systemic or nasal) were administered in two studies. However, the data were very limited and heterogeneous, therefore we could not analyse the impact of concomitant postoperative medical treatment.
The rate of revision surgery was not reported in any of the included studies, however it is not clear whether these data were not recorded or if there were no revision surgeries in any of the included studies.