Michael Schlewet* and Peter Catalano#
Department of Otolaryngology, Head and Neck Surgery, St Elizabeth’s Medical Center, 736 Cambridge Street, SMC-8 Brighton, MA 02135, USA
Received: 06 November, 2017; Accepted: 13 November, 2017; Published: 14 November, 2017
Department of Otolaryngology, Head and Neck Surgery, St Elizabeth’s Medical Center, 736 Cambridge Street, SMC-8 Brighton, MA 02135, USA, Tel: 617-779-6440; Fax: 617-779-8483; E-Mail:
Schlewet M, Catalano P (2017) Effects of a plant based Biodegradable Middle Meatal Dressing after Endoscopic Sinus Surgery: A Prospective Comparative Study. Arch Otolaryngol Rhinol 3(4): 121-125. DOI: 10.17352/2455-1759.000062
© 2017 Schlewet M, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Biodegradable; Middle meatal dressing; Intranasal stent; Endoscopic sinus surgery; NexPak; NasoPore
Background: The benefit from biodegradable middle meatal dressings is well established, and includes improved wound healing, stabilization of the middle turbinate, reduced granulation tissue, and improved patient comfort. This study compares the outcomes of a 100% plant-based nasal dressing to a popular fully synthetic dressing in patients undergoing endoscopic sinus surgery.
Design and Methods: A prospective study compared the clinical outcomes of two groups of patients undergoing endoscopic sinus surgery (ESS); the study group had a plant-based nasal dressing placed into the middle meatus, and the control group received a fully synthetic product. Outcome metrics included the degree of middle meatal crusting, amount of retained material during follow-up, need for debridement, wound healing, incidence of epistaxis, rate of post-operative infection, and patient comfort. Data was collected at 2 and 12 weeks after surgery. All patients underwent ESS for CRS and were matched for demographics and extent of disease.
Results: 25 patients were enrolled in the study group (50 dressings); the control group included 20 patients (40 dressings). The study group showed a statistically significant reduction (p<.05) in nasal crusting, amount of retained implant, patient comfort, and the need for debridement compared to the control group. However, the rate of infection was slightly higher in the study group at 2 weeks.
Conclusion: Plant based middle meatal dressings appear superior to fully synthetic dressings with regards to wound healing, crusting, rate of fragmentation, and patient comfort. A slightly elevated incidence of infection was noted.
Endoscopic sinus surgery (ESS) is widely accepted as the gold standard of surgical treatment for sinus disease . Optimal wound healing postoperatively is critical for successful outcomes. Common practice to optimize wound healing has been the use of middle metal dressings and postoperative debridement. Biodegradable middle meatal (MM) dressings have been shown to improve ESS outcomes by providing hemostasis, reducing synechia, and stabilizing the middle turbinate [2,3]. Suboptimal healing post ESS is associated with recurrent disease, scarring causing ostial or middle meatal obstruction, and recurrent infections.
Several studies have evaluated a number of biodegradable middle meatal dressings showing good clinical outcomes [3-6]. A few examples include carboxymethylcellulose foam, collagen-based Gelfoam, hyaluronic acid based film, and polyurethane sponges. However, some of these products have been associated with increased crusting, discomfort, and the need for aggressive debridement. One such example is a fully synthetic polyurethane sponge that has excellent biocompatibility and stabilizes the middle turbinate well, however, resorption is delayed (>7 days), the product is relatively stiff, and ease of use remains an issue among surgeons [4-6]. In particular, the polyurethane sponge is fully expanded at the time of insertion and therefore blocks the surgeon’s view of the target during placement.
A natural 100% plant-based middle meatal dressing (NexPak) is now available for use during ESS. Plant based polysaccharide dressings have been shown to have favorable wound healing and hemostatic properties [7-9]. We herein compare the clinical outcomes between a middle meatal dressing made with natural plant-based polysaccharides (Modified Amylopectin + Hydroxyethylcellulose) that is biocompatible, bioresorbable, and free of animal proteins, with a fully synthetic polyurethane foam dressing (NasoPore).
This is a prospective comparative study of 45 patients who required ESS due to medically refractory CRS with or without nasal polyps per AAO-HNS chronic rhinosinusitis diagnostic criteria guidelines .
45 patients who met the criteria of chronic rhinosinusitis with or without nasal polyposis (CRSw/sNP) were enrolled. Patient selection into the two different groups was by simple randomization. 25 patients were in the study group and received the plant-based dressing, and another 20 patients were in the control group and received the polyurethane dressing (Table 1). The dressing was placed intra-operatively in the middle meatus after completion of ESS and was hydrated with Bacitracin solution. Nasal saline irrigations were begun on post-op day #1 and continued BID in all patients for 30 days. No patient received oral antibiotics, antihistamine, oral or topical steroids during the study period.
As was previously shown [5,6,11], the topical targeted delivery of Bacitracin was as effective as oral antibiotics in the prevention of post-surgical sinusitis. Furthermore, the effect of topical Bacitracin on the healing process, infection, and hemostasis, if any, will be the same in both groups, and shall not be considered a confounding factor.
During their 2 and 12 weeks follow-up visits after surgery, patients underwent nasal endoscopic evaluation for the following parameters: degree of crusting, amount of retained implant, infection, allergic reaction to the dressing, and presence of adhesion/synechia. These parameters were graded as follow: Crusting -none (0), mild (1), moderate (2), severe (3). Retained implant was graded as either none (0) or present (1). A history was also taken with respect to post-op epistaxis and level of comfort.
To minimize observer bias, postoperative nasal endoscopic evaluations were performed by three independent otolaryngologists who were not directly involved with the primary surgery. Both groups underwent the same surgical procedure: septoplasty, bilateral uncinectomy, bilateral anterior ethmoidectomy, and bilateral radiofrequency ablation of inferior turbinates.
The assessment of degree of crusting was described as none (0), mild (1), moderate (2), and severe (3). (Table 2, Figures 1,2).