The use of spacers to prevent postoperative middle meatal adhesions.

The importance of mucosal preservation during functional endoscopic sinus surgery (FESS) has been well described to prevent postoperative synechiae formation. Postoperative scar formation results from the creation of opposing raw surfaces during sinonasal surgery. [1] Should synechiae impair mucociliary transport within the middle meatus, recurrent sinus disease can result.

Anatomic variations in the middle turbinate can narrow the middle meatus and predispose patients to postoperative middle meatal scarring. Such middle turbinate configurations include concha bullosa and large middle turbinates in close proximity to the lateral nasal wall. [2]

Surgical technique during FESS is critical to prevent middle meatal synechiae. Excessive removal of mucous membranes or insufficient debridement of clotted blood can lead to the formation of granulation tissue and subsequent scarring. [3] The key to preventing such undesirable postoperative synechiae is to pay meticulous attention to intraoperative technique. Blood clots and bone fragments should be debrided carefully. Aggressive removal of the mucosa and the creation of opposing raw surfaces should be avoided. The judicious use of a microdebrider and through-cutting punches help minimize synechiae formation.

To prevent wound surfaces from opposing each other within the middle meatus, a variety of spacers is available. Gelfilm can be rolled into a multilayered stent and placed in the middle meatus (figure, A). Care should be taken to prevent inadvertent dislocation of the Gelfilm, because it might be difficult for the surgeon to keep it tucked into the middle meatus. Nonabsorbable sutures secured to the Gelfilm can minimize the risk of aspiration if the spacer should fall into the nasopharynx. A small Merocel sponge, such as a Kennedy intraoperative surgical sponge, will swell when it is exposed to moisture and therefore might better maintain its position in the middle meatus (figure, B). Strings attached to these sponges facilitate their removal postoperatively.

A stiff sheet of plastic, Silastic, or Teflon can be cut to size and inserted into the middle meatus (figure, C). These sheets maintain their shape and can be secured in position by suturing them to the nasal septum. Similarly, a small sheet of Telfa can be cut to size, rolled into a cigar-shaped stent, and placed in the middle meatus.

An alternative to placing a middle meatal spacer is to secure the medial surface of the middle turbinate to the nasal septum, which improves the patency of the middle meatus. A technique called "Bolgerizing" the middle turbinate is particularly useful when there is a question of stability at its insertion to the skull base. The mucosa of the medial surface of the middle turbinate is denuded, as is the opposing nasal septum. The middle turbinate is then positioned with nasal packing against the nasal septum in order to induce scar formation between the nasal septum and middle turbinate. [3]

Another method of securing an unstable middle turbinate is to attach it to the nasal septum via endoscopic suturing (figure, D). This prevents undesirable lateralization of the turbinate.

Even when the surgical technique has been meticulous, the importance of postoperative care cannot be overemphasized. Endoscopic debridement in the office setting and mechanical self-debridement with intranasal saline irrigation should minimize synechiae. Thorough preoperative planning, careful intraoperative technique, and postoperative endoscopic debridement are all integral parts of the multistep regimen for treating sinus disease.

References

(1.) Stankiewicz JA. Complications of endoscopic sinus surgery and malpractice. In: Stankiewicz JA, ed. Advanced Endoscopic Sinus Surgery. St. Louis: Mosby Year Book, 1995:151-60.

(2.) Stammberger HR. Functional Endoscopic Sinus Surgery-- Messerklinger Technique. Philadelphia: B.C. Decker, 1991.

(3.) Kuhn FA, Citardi MJ. Advances in postoperative care following functional endoscopic sinus surgery. Otolaryngol Clin North Am 1997;30:479-90.