Endoscopic view of the lateral nasal wall following sinonasal surgery.

Satisfactory postoperative healing of the lateral nasal wall following endoscopic sinonasal surgery depends greatly on a meticulous intraoperative atraumatic technique and careful postoperative debridement.

The injudicious use of biting forceps in removing diseased tissue can result in an inadvertent stripping of adjacent normal mucosa. Postoperatively, the resultant exposed underlying bone can lead to osteitis, granulation tissue, and crusts in the middle meatus. Since the use of microdebriders and through-cutting forceps became widespread in endoscopic sinonasal surgery, the incidence of postoperative crusting and synechiae has decreased noticeably. These instruments allow for the atraumatic excision of diseased tissues and help preserve normal mucosa during surgery. The judicious use of spacers in the middle meatus can also prevent middle meatal adhesions.

Postoperative intranasal crusting must be removed carefully to prevent synechiae formation, nasal and sinus obstruction, and recurrent sinus infection. Nasal crusts can be aspirated or removed manually. This is best accomplished under telescopic guidance. Instruments useful for the removal of crusts include 1)a 4-mm, O[degrees] telescope, 2) a Frazier suction tube, 3) cup or alligator forceps, and 4) a bulb syringe or other irrigation setup.

Figure A is a telescopic image (0[degrees] 4 mm) of a well-healed, patent left middle mental antrostomy window in the lateral nasal wall 4 months after surgery. Figure B is a close-up view with a 300 telescope of the same middle meatal window. Note the well-healed antral mucosa. Figure C is a 30[degrees] telescopic view of the left nasal cavity 3 months after surgery, and it shows a widely patent inferior meatal window. Note the large size of the window. Because the inferior meatal antrostomy is performed today for dependent drainage, the window should be large and its lower border should be at the same level as or close to the floor of the nasal cavity. Figure D is a 0[degrees] telescopic view of a most unusual appearance of the middle turbinate 2 weeks following endoscopic partial turbinectomy. This photograph is not enhanced or retouched. The image on the middle turbinate bears an uncanny resemblance to the President of the United States, Mr. Bill Clinton. Ironically, this photograph was taken in 1996, at the time of the most recent presidential election, and the patient had professed an inclination toward the Democratic Party. It has been said that political supporters show their colors in many ways. One might wonder what the patient's reaction was upon learning that the visage of her presidential candidate appears as a specter in her nasal cavity.

Optimal postoperative results after sinonasal surgery can be obtained with an atraumatic surgical technique, using the microdebrider and through-cutting instruments, and by careful postoperative debridement. Attention to meticulous technique and follow up cleaning will result in a well-healed mucosa and patent antrostomies.

From the Southern New England Ear, Nose, Throat, and Facial Plastic Surgery Group and the Hospital of St. Raphael, New Haven, Conn. (Dr. Yanagisawa), and the Section of Otolaryngology, Yale University School of Medicine, New Haven (Dr. Yanagisawa and Dr. Joe).