Debridement Sinus

Sinonasal debridement versus no debridement for the
postoperative care of patients undergoing endoscopic sinus

surgery (Protocol)
Tzelnick S, Alkan U, Leshno M, Hwang P, Soudry E
This is a reprint of a Cochrane protocol, prepared and maintained by The Cochrane Collaboration and published in The Cochrane
Library 2016, Issue 1
http://www.thecochranelibrary.com
Sinonasal debridement versus no debridement for the postoperative care of patients undergoing endoscopic sinus surgery (Protocol)
Copyright 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
TABLE OF CONTENTS
HEADER . . . . . . . . . .
ABSTRACT . . . . . . . . .
BACKGROUND . . . . . . .
OBJECTIVES . . . . . . . .
METHODS . . . . . . . . .
ACKNOWLEDGEMENTS
. . .
REFERENCES . . . . . . . .
APPENDICES . . . . . . . .
CONTRIBUTIONS OF AUTHORS
DECLARATIONS OF INTEREST .
SOURCES OF SUPPORT . . . .
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[Intervention Protocol]
Sinonasal debridement versus no debridement for the

postoperative care of patients undergoing endoscopic sinus
surgery
Sharon Tzelnick1 , Uri Alkan1 , Moshe Leshno2 , Peter Hwang3 , Ethan Soudry1,4
1
Department of Otolaryngology - Head and Neck Surgery, Rabin Medical Center, Petah Tikva, Israel. 2 Tel Aviv Universitys Faculty
of Management and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel. 3 Division of Rhinology, Department of Otolaryngology, Stanford University School of Medicine, Stanford, California, USA. 4 Sackler Faculty of Medicine, Tel Aviv University, Tel
Aviv, Israel
Contact address: Ethan Soudry, Department of Otolaryngology - Head and Neck Surgery, Rabin Medical Center, Petah Tikva, Israel.
ethanso@clalit.org.il.
Editorial group: Cochrane ENT Group.
Publication status and date: New, published in Issue 1, 2016.
Citation: Tzelnick S, Alkan U, Leshno M, Hwang P, Soudry E. Sinonasal debridement versus no debridement for the postoperative
care of patients undergoing endoscopic sinus surgery. Cochrane Database of Systematic Reviews 2016, Issue 1. Art. No.: CD011988.
DOI: 10.1002/14651858.CD011988.
ABSTRACT
This is the protocol for a review and there is no abstract. The objectives are as follows:
To assess the effects (benefits and harms) of postoperative sinonasal debridement versus no debridement following endoscopic sinus
surgery.
BACKGROUND
Description of the condition

Rhinosinusitis has been defined as a group of disorders characterized by mucosal inflammation of the paranasal sinuses. According
to a recent analysis of US national health interview survey data
(Blackwell 2014), the prevalence of rhinosinusitis is 12% among
adults. It imparts a significant disease burden both within and
outside of the health system (Bhattacharyya 2009).
Rhinosinusitis is classified temporally as acute rhinosinusitis (ARS)
when symptoms last up to 12 weeks. Recurrent acute sinusitis is
defined as four or more episodes of ARS per year without signs
or symptoms of rhinosinusitis between episodes. Chronic rhinosinusitis (CRS) is defined by symptoms of nasal congestion, facial
pain/pressure, anterior or posterior nasal drainage and reduced or
absent sense of smell, lasting more than 12 weeks and associated
with objective findings on nasal endoscopy or imaging (Fokkens
2012; Rosenfeld 2007). CRS is further subtyped as CRS with nasal
polyps (CRSwNP) and CRS without nasal polyps (CRSsNP). CRSwNP and CRSsNP are now considered unique disease subsets
that share some common clinical features but often differ on a
molecular level, and they can differ with regard to treatment outcomes. Whereas the etiology and pathogenesis of acute rhinosinusitis are typically linked to an infectious process, CRS comprises
a group of disorders that arise from complex inflammatory processes triggered by an array of exogenous agents. At present, fac-
tors that have been associated with the etiology and pathogenesis
of CRS include fungi, resistant bacteria, superantigens, biofilms,
atopy, mucociliary dysfunction, environmental irritants, acquired
sinonasal obstruction (especially of the ostiomeatal complex), osteitis, and genetic or epigenetic variation of the host.
Treatment of CRS most commonly involves pharmacological therapy, with surgery generally reserved for those patients whose symptoms persist after appropriate medical therapy. Guidelines for the
conservative treatment of CRS lack consensus. Treatment alternatives commonly include nasal saline lavages, intranasal glucocorticoids, systemic glucocorticoids and oral or topical antibiotics
(Hamilos 2011). For those patients refractory to comprehensive
medical management, the current literature provides compelling
evidence that those patients who undergo endoscopic sinus surgery
(ESS) for CRS will on average have improved quality of life outcomes after surgery (Rudmik 2014).
First reports of ESS came out in the 1970s but it was only in
1985 that the principles of ESS were published in the English
literature (Kennedy 1985). Since then ESS has become one of the
most common procedures performed by ENT physicians, with
an estimated 250,000 ESS procedures performed yearly in the
United States alone (Bhattacharyya 2010), for the indication of
chronic sinusitis as well as other indications (Luong 2006). The
aim of ESS in CRS is to clear inflammation and infection, to
restore mucociliary function by re-establishing physiological sinus
ventilation and drainage, and to allow improved topical delivery
of medications.
Short- and long-term (eight years of follow-up) results of ESS
have shown excellent subjective improvement and stability over the
years with respect to symptoms such as headache, nasal discharge,
congestion, change in sense of smell and recurrent infections (
Senior 1998). An improvement in quality of life was reported in
85% of patients (Damm 2002).
Recent literature demonstrates that patients who elect for surgical
management report more improvement than medically managed
patients on quality of life instruments. In addition, they report
less use of oral antibiotics and oral steroids and fewer missed days
of work or school. Followed up to one year, the surgical cohort
still reported improved quality of life outcomes compared with
the medical cohort (Smith 2005; Smith 2013).
Intranasal synechiae, the most common complication of ESS, can
occur in up to 20% of operated patients (Henriquez 2013). These
can lead to impaired nasal airflow, contribute to ostial blockage and
impair delivery of topical medications. The presence of synechiae
has been shown to be associated with significantly decreased postoperative disease-specific quality of life scores, such as the physical
and emotional Rhinosinusitis Disability Index (RSDI) score and
Chronic Sinusitis Survey (CSS) score compared with patients who
did not develop synechiae (Henriquez 2013). Lateralization of the
middle turbinate and synechiae to the lateral nasal wall, another
very common postoperative complication, may impair adequate
postoperative endoscopic follow-up and delivery of topical medi-
cations. One study has shown that patients who developed middle turbinate lateralization may have had higher revision surgery
rates compared to patients who did not develop middle turbinate
lateralization (Bassiouni 2015).
Several postoperative measures have been suggested to reduce postoperative infection, inflammation and synechiae and ultimately
to improve patient outcome. Most commonly these include saline
irrigations, topical and systemic steroids, oral antibiotics, middle
meatal spacers and intranasal debridement (Dautremont 2014;
Low 2014; Rudmik 2011).
It is suggested that nasal saline irrigations assist in softening and
removing postoperative nasal crusting and thus improve mucociliary clearance (Jorissen 2004). Topical nasal steroids have been
shown to reduce mucosal edema and decrease the risk of disease
recurrence, with the advantage of reducing the use of systemic
steroids (DelGaudio 2006). Although used commonly, there is
controversy in the literature regarding the efficacy of antibiotics in
the postoperative period (Albu 2010; Annys 2000; Jiang 2008).
Absorbable and non-absorbable nasal packing, specifically in the
middle meatus, is also often used to control immediate postoperative bleeding and as spacers to prevent lateralization of the middle
turbinate. Recently, the use of drug-eluting stents has been introduced, as temporary spacers offering slow-release steroid therapy
to the middle meatus (Huang 2015; Rudmik 2011).
A recent survey of the members of the American Academy of Otolaryngology - Head and Neck Surgery showed that the majority
of surgeons recommend saline irrigations and antibiotics in the
immediate postoperative period, and conduct postoperative nasal
debridement (Portela 2012).
Description of the intervention

The postoperative period after sinus surgery is critical to the outcome of surgery. Blood clots, crusts and secretions are frequent in
the postoperative sinonasal cavities and are considered by many to
serve as a framework for the development of infections and scar
tissue that can obstruct the sinus ostia. Nasal debridement, considered by many to be the cornerstone of postoperative care (Bugten
2006), can be performed in an outpatient clinic with a local anesthetic and a vasoconstrictor agent, or in the operating room under
general anesthesia. After an inspection of the operated sinonasal
cavities using a rigid endoscope, blood clots, crusts and secretions
are evacuated by suction and other gentle instruments, such as
forceps. Fixed clots or crusts are typically left alone. Nonetheless,
despite the many advantages there are several difficulties. The procedure is time-consuming and obliges the patient to attend more
frequent clinic visits. In addition, it may cause inconvenience and
bleeding. Furthermore, logistically, a clinic set-up with appropriate equipment is mandatory. The contribution of postoperative
debridement of the sinonasal cavities to ESS outcomes has been
questioned in the literature. In addition it may have direct impli-
cations for the cost of care in terms of more frequent postoperative

patient visits and increased expenditure per visit.
tools are more difficult to interpret as these do not typically assess

laterality.
How the intervention might work
Types of participants
The aim of postoperative nasal debridement is to minimize the

complication rate and improve postoperative outcome. It is believed that the evacuation of crusts, clots and granulation tissue,
mainly in the immediate postoperative period, helps remucosalization and prevents ostial stenosis, intranasal scarring and synechiae.
Thus, it may improve overall surgical success, reduce the recurrence rate, reduce the need for revision surgery and allow better
postoperative follow-up and endoscopic visualization of the sinus
cavities.
Inclusion criteria
Adult patients (aged over 18 years) who underwent primary

endoscopic sinus surgery, with a diagnosis of recurrent acute or
chronic rhinosinusitis.
Exclusion criteria
Why it is important to do this review

Adequate postoperative care following ESS is thought by many
practitioners to be of great significance in guaranteeing satisfactory results, both in terms of endoscopic appearance and patient
quality of life. Nonetheless, in addition to the short-term patient
inconvenience and the logistical requisites of this procedure, the
role of postoperative nasal debridement in improving postoperative patient outcome is controversial in the literature (Alsaffar
2013; Bugten 2006). Therefore, the value of postoperative nasal
debridement merits further investigation in order to provide evidence-based data and recommendations.
OBJECTIVES
To assess the effects (benefits and harms) of postoperative sinonasal
debridement versus no debridement following endoscopic sinus
surgery.
METHODS
Criteria for considering studies for this review
Types of studies
Randomized controlled trials. We will exclude any study in which
patients had less than three months follow-up. We will consider
studies in which the patients acted as self controls, i.e. one side of
the nose underwent debridement and the other side did not (splitnose studies), only for the secondary endoscopy outcomes. This
study design, although important in terms of objective outcomes,
can introduce a high risk of bias, as patient-reported outcome
Revision cases.
Concomitant septoplasty.
Types of interventions
Postoperative nasal debridement versus no debridement.
Types of outcome measures

We will analyze the following outcomes in the review, but they
will not be used as a basis for including or excluding studies.
Primary outcomes
Health-related quality of life, using disease-specific healthrelated quality of life scores, such as the Sino-Nasal Outcome
Test-22 (SNOT-22), Rhinosinusitis Outcome Measures-31
(RSOM-31) and SNOT-20.
Disease severity, as measured by patient-reported symptom
score (such as the Chronic Sinusitis Survey (CSS) questionnaire
and visual analogue scales).
Significant adverse effect(s): significant bleeding requiring
intervention, severe pain, iatrogenic injury.
Secondary outcomes
Postoperative endoscopic appearance of the sinonasal

surgical cavities (adhesions, synechiae, ostial stenosis, purulence)
as measured or described by endoscopic scores such as the LundKennedy score.
Recorded use of postoperative medical treatment.
Rate of revision surgeries.
Search methods for identification of studies

The Cochrane Ear, Nose and Throat Disorders Group Trial Search
Co-ordinator will conduct systematic searches for randomized
controlled trials and controlled clinical trials. There will be no
language, publication year or publication status restrictions. We
may contact original authors for clarification and further data if
trial reports are unclear and we will arrange translations of papers
where necessary.
Data collection and analysis
Selection of studies
Two authors (TS and AU) will independently assess the titles and
abstracts retrieved by the search strategy, blinded to decisions made
by each other. We will obtain in full text any studies that could
potentially meet the inclusion criteria and review these independently. We will settle any differences in opinion by discussion with
the senior authors ES and PHH.
Electronic searches
Published, unpublished and ongoing studies will be identified by
searching the following databases from their inception:
the Cochrane Register of Studies ENT Disorders Group
Trials Register (search to date);
the Cochrane Central Register of Controlled Trials
(CENTRAL, current issue);
PubMed (1946 to date);
Ovid EMBASE (1974 to date);
EBSCO CINAHL (1982 to date);
LILACS (search to date);
KoreaMed (search to date);
IndMed (search to date);
PakMediNet (search to date);
Web of Knowledge, Web of Science (1945 to date);
CNKI (searched via Google Scholar to date);
ClinicalTrials.gov, www.clinicaltrials.gov (search via the
Cochrane Register of Studies to date);
ICTRP (search to date);
ISRCTN, www.isrctn.com (search to date);
Google Scholar (search to date);
Google (search to date).
The subject strategies for databases will be modeled on the search
strategy designed for CENTRAL (Appendix 1). Where appropriate, these will be combined with subject strategy adaptations of
the highly sensitive search strategy designed by Cochrane for identifying randomized controlled trials and controlled clinical trials
(as described in the Cochrane Handbook for Systematic Reviews of
Interventions Version 5.1.0, Box 6.4.b. (Handbook 2011)).
Searching other resources

We will scan the reference lists of identified publications for additional trials and contact trial authors if necessary. In addition,
the Trial Search Co-ordinator will search PubMed, TRIPdatabase,
The Cochrane Library and Google to retrieve existing systematic
reviews relevant to this systematic review, so that we can scan their
reference lists for additional trials. We will search for conference abstracts using the Cochrane Ear, Nose and Throat Disorders Group
Trials Register and EMBASE.
Data extraction and management

We will extract data from the included studies using a standardized form. TS will perform the data extraction and this will be
rechecked by AU. We will extract data in order to allow an intention-to-treat analysis. We will settle any differences in opinion by
discussion with the senior authors ES and PHH.
For each study we will extract the following data:
year of publication and country of origin;
demographic characteristics of the participants;
primary diagnosis of the participants, i.e. recurrent acute
rhinosinusitis, CRSsNP or CRSwNP;
extent of disease as assessed by the Lund Mackay CT score
and endoscopic scores;
indication for ESS;
extent of surgery;
postoperative management other than debridement;
details of debridement - timing and frequency;
details of quality of life outcome assessments, assessed by
symptom score (visual analogue scale (VAS) or Lund-Mackay) or
with more complex tools such as SNOT questionnaire or the SF
questionnaire;
details of endoscopic score as documented by LundKennedy or equivalent scores;
length of follow-up time.
Assessment of risk of bias in included studies

AU and TS will undertake assessment of the risk of bias of the
included trials independently, with the following taken into consideration, as guided by theCochrane Handbook for Systematic Reviews of Interventions (Handbook 2011):
sequence generation;
allocation concealment;
blinding;
incomplete outcome data;
selective outcome reporting; and
other sources of bias.
We will use the Cochrane Risk of bias tool in Review Manager 5.3
(RevMan 2014), which involves describing each of these domains
We will use RevMan 5.3 for data analysis. We will assess dichotomous data by calculating the risk ratio (RR) and continuous data
by calculating the mean difference (MD) for outcomes measured
on the same scale and/or the standardized mean difference (SMD)
for outcomes measured on different scales, with 95% confidence
intervals (CI).
available). We will address multiple publication bias by combining

papers that describe different results from the same study, and by
excluding papers that reported results that have already been published. We will address language bias by including all languages
in the search strategy and obtaining a translation when possible.
We will address outcome reporting bias by assessing the risk of
bias from within-study selective reporting and selective under-reporting of data. We will assess reporting biases (publication bias
and other reporting biases) using a funnel plots as recommended
by the Cochrane Handbook for Systematic Reviews of Interventions
(Handbook 2011).
Unit of analysis issues
Data synthesis
We will only include randomized controlled trials, as recommended by the Cochrane Handbook for Systematic Reviews of Interventions (Handbook 2011). In the included studies the unit of
randomization will be the individual participant. We will consider
studies in which the patients acted as self controls, i.e. one side
of the nose underwent debridement and the other side did not
(split-nose studies), only for the secondary endoscopy outcomes.
Where studies present results at multiple time points during follow-up (repeated observations such as one month, three months,
six months), we will analyze the longest follow-up from each study
in order to avoid a unit of analysis error.
We will analyze data by including all available data and analyzing

patients according to the group randomized. If data are comparable
we will combine data in order to give a summary measure of effect.
If meta-analyzable data are not available, we will report the results
of individual studies. We will collect data to compare trials using
different scoring systems. We will present continuous data as mean
difference or standardized mean difference (with 95% confidence
intervals) and express binary outcomes as a risk ratio/odds ratio,
with 95% confidence intervals.
as reported in the trial and then assigning a judgement about the

adequacy of each entry: low, high or unclear risk of bias.
Measures of treatment effect
Subgroup analysis and investigation of heterogeneity

Dealing with missing data
We will handle any missing data by contacting the study investigators with open-ended questions in order to reduce the risk of
positive answers. In the circumstance that contacting the author
is not possible, we will assume that missing data are missing at
random and we will perform data analysis using the available data
(i.e. ignoring the missing data).
Assessment of heterogeneity
We will test heterogeneity using the Chi test and the I statistic for
quantifying inconsistency, which are included in the forest plots in
Cochrane reviews. We will use the rough guide to interpretation
of the I value as recommended by the Cochrane Handbook for
Systematic Reviews of Interventions (Handbook 2011):
0% to 40%: might not be important;
30% to 60%: may represent moderate heterogeneity;
50% to 90%: may represent substantial heterogeneity;
75% to 100%: considerable heterogeneity.
We intend to assess clinical heterogeneity by examining the:

types of participants and indications for surgery - patients
with a diagnosis of CRS versus CRSwNP versus recurrent acute
sinusitis;
extent of disease as measured by preoperative Lund Mackay
scores and endoscopic scores;
extent of surgery - uncinectomy and maxillary antrostomy
only versus uncinectomy and maxillary antrostomy with anterior
ethmoidectomy versus uncinectomy and maxillary antrostomy
with total ethmoidectomy; frontal recess surgery;
sphenoidotomy;
use of concomitant other postoperative measures: saline
irrigations; topical nasal steroids; systemic steroids; systemic
antimicrobials; placement of packing material in the middle
meatus.
As needed, in the presence of statistical heterogeneity, we will use a
random-effects model as recommended by the Cochrane Handbook
for Systematic Reviews of Interventions (Handbook 2011).
Summary of findings table

Assessment of reporting biases
We will address publication bias by including trial databases in
the electronic search, looking for published, unpublished and ongoing trials. Where potentially eligible but unpublished trials are
identified, we will contact the authors to ask for the results (where
We will use the GRADE approach to rate the overall quality of

evidence. The quality of evidence reflects the extent to which we
are confident that an estimate of effect is correct and we will apply
this in the interpretation of results. There are four possible ratings:
high, moderate, low and very low. A rating of high quality of
evidence implies that we are confident in our estimate of effect

and that further research is very unlikely to change our confidence
in the estimate of effect. A rating of very low quality implies that
any estimate of effect obtained is very uncertain.
The GRADE approach rates evidence from RCTs that do not have
serious limitations as high quality. However, several factors can
lead to the downgrading of the evidence to moderate, low or very
low. The degree of downgrading is determined by the seriousness
of the these factors:
study limitations (risk of bias);
inconsistency;
indirectness of evidence;
imprecision; and
publication bias.
We will include a Summary of findings (SOF) table, constructed

according to the recommendations described in Chapter 11 of
the Cochrane Handbook for Systematic Reviews of Interventions (

Handbook 2011).
The outcomes that will be presented in the SOF table are patientreported disease-specific symptom scores, health-related quality
of life scores (measured by SNOT-22 and SF-36), endoscopic
appearance, endoscopic score, complications and rate of revision
surgeries.
ACKNOWLEDGEMENTS
This project was supported by the National Institute for Health
Research, via Cochrane Infrastructure, Cochrane Programme
Grant or Cochrane Incentive funding to Cochrane ENT. The
views and opinions expressed therein are those of the authors and
do not necessarily reflect those of the Systematic Reviews Programme, NIHR, NHS or the Department of Health.
REFERENCES
Additional references
Albu 2010
Albu S, Lucaciu R. Prophylactic antibiotics in endoscopic
sinus surgery: a short follow-up study. American Journal of
Rhinology & Allergy 2010;24(4):3069.
Alsaffar 2013
Alsaffar H, Sowerby L, Rotenberg BW. Postoperative nasal
debridement after endoscopic sinus surgery: a randomized
controlled trial. Annals of Otology, Rhinology and Laryngology
2013;122(10):6427.
Bugten 2006
Bugten V, Nordgrd S, Steinsvg S. The effects of
debridement after endoscopic sinus surgery. Laryngoscope
2006;116(11):203743.
Damm 2002
Damm M, Quante G, Jungehuelsing M, Stennert E. Impact
of functional endoscopic sinus surgery on symptoms and
quality of life in chronic rhinosinusitis. Laryngoscope 2002;
112(2):3105.
Annys 2000
Annys E, Jorissen M. Short term effects of antibiotics
(Zinnat) after endoscopic sinus surgery. Acta Oto-RhinoLaryngologica Belgica 2000;54:238.
Dautremont 2014
Dautremont JF, Mechor B, Rudmik L. The role of
immediate postoperative systemic corticosteroids when
utilizing a steroid-eluting spacer following sinus surgery.
Otolaryngology - Head and Neck Surgery 2014;150(4):
68995.
Bassiouni 2015
Bassiouni A, Chen PG, Naidoo Y, Wormald PJ. Clinical
significance of middle turbinate lateralization after
endoscopic sinus surgery. Laryngoscope 2015;125(1):3641.
DelGaudio 2006
DelGaudio JM, Wise SK. Topical steroid drops for the
treatment of sinus ostia stenosis in the postoperative period.
American Journal of Rhinology 2006;50:5637.
Bhattacharyya 2009
Bhattacharyya N. Contemporary assessment of the disease
burden of sinusitis. American Journal of Rhinology & Allergy
2009;23:3925.
Fokkens 2012
Fokkens WJ, Lund VJ, Mullol J, Bachert C, Alobid I,
Baroody F, et al. European Position Paper on Rhinosinusitis
and Nasal Polyps 2012. Rhinology. Supplement 2012;3:
1298.
Bhattacharyya 2010
Bhattacharyya N. Ambulatory sinus and nasal surgery in the
United States: demographics and perioperative outcomes.
Laryngoscope 2010;120(3):6358.
Blackwell 2014
Blackwell DL, Lucas JW, Clarke TC. Summary health
statistics for U.S. adults: national health interview survey,
2012. Vital Health Statistics 10 2014;260:1161.
Hamilos 2011
Hamilos DL. Chronic rhinosinusitis: epidemiology and
medical management. Journal of Allergy and Clinical
Immunology 2011;128(4):693707.
Handbook 2011
Higgins JPT, Green S (editors). Cochrane Handbook
for Systematic Reviews of Interventions Version 5.1.0
[updated March 2011]. The Cochrane Collaboration,

2011. Available from www.cochrane-handbook.org.
International Forum of Allergy & Rhinology 2012;2(1):

2733.
Henriquez 2013
Henriquez OA, Schlosser RJ, Mace JC, Smith TL, Soler
ZM. Impact of synechiae after endoscopic sinus surgery on
long-term outcomes in chronic rhinosinusitis. Laryngoscope
2013;123(11):26159.
RevMan 2014 [Computer program]

The Nordic Cochrane Centre, The Cochrane Collaboration.
Review Manager (RevMan). Version 5.3. Copenhagen:
The Nordic Cochrane Centre, The Cochrane Collaboration,
2014.
Rosenfeld 2007
Rosenfeld RM, Andes D, Bhattacharyya N, Cheung D,
Eisenberg S, Ganiats TG, et al. Clinical practice guideline:
adult sinusitis. Otolaryngology - Head and Neck Surgery
2007;137(3):S131.
Huang 2015
Huang Z, Hwang P, Sun Y, Zhou B. Steroid-eluting sinus
stents for improving symptoms in chronic rhinosinusitis
patients undergoing functional endoscopic sinus surgery.
Cochrane Database of Systematic Reviews 2015, Issue 6.
[DOI: 10.1002/14651858.CD010436.pub2]
Jiang 2008
Jiang RS, Liang KL, Yang KY. Postoperative antibiotic care
after functional endoscopic sinus surgery. American Journal
of Rhinology 2008;22:60812.
Jorissen 2004
Jorissen M. Postoperative care following endoscopic sinus
surgery. Rhinology 2004;42(3):11420.
Kennedy 1985
Kennedy DW. Endoscopic sinus surgery: evolution and
technical innovations. Archives of Otolaryngology 1985;111:
6439.
Low 2014
Low TH, Woods CM, Ullah S, Carney AS. A doubleblind randomized controlled trial of normal saline, lactated
Ringers, and hypertonic saline nasal irrigation solution after
endoscopic sinus surgery. American Journal of Rhinology &
Allergy 2014;28(3):22531.
Luong 2006
Luong A, Marple BF. Sinus surgery: indications and
techniques. Clinical Reviews in Allergy and Immunology
2006;30(3):21722.
Portela 2012
Portela RA, Hootnick J, McGinn J. Perioperative care
in functional endoscopic sinus surgery: a survey study.
Rudmik 2011
Rudmik L, Soler ZM, Orlandi RR, Stewart MG,
Bhattacharyya N, Kennedy DW, et al. Early postoperative
care following endoscopic sinus surgery: an evidence-based
review with recommendations. International Forum of
Allergy & Rhinology 2011;1(6):41730.
Rudmik 2014
Rudmik L, Mace J, Soler ZM, Smith TL. Long-term utility
outcomes in patients undergoing endoscopic sinus surgery.
Laryngoscope 2014;124(1):1923.
Senior 1998
Senior BA, Kennedy DW, Tanabodee J, Kroger H, Hassab
M, Lanza D. Long-term results of functional endoscopic
sinus surgery. Laryngoscope 1998;108(2):1517.
Smith 2005
Smith TL, Batra PS, Seiden AM, Hannley M. Evidence
supporting endoscopic sinus surgery in the management of
adult chronic rhinosinusitis: a systematic review. Journal of
Rhinology 2005;19:53743.
Smith 2013
Smith TL, Kern R, Palmer JN, Schlosser R, Chandra RK,
Chiu AG, et al. Medical therapy vs surgery for chronic
rhinosinusitis: a prospective, multi-institutional study with
1-year follow-up. International Forum of Allergy & Rhinology
2013;3(1):49.
Indicates the major publication for the study
APPENDICES
Appendix 1. CENTRAL search strategy

#1 MeSH descriptor: [Sinusitis] explode all trees
#2 rhinosinusitis or nasosinusitis or sinusitis or pansinusitis or ethmoiditis or sphenoiditis
#3 inflamm* and sinus*
#4 #1 or #2 or #3
#5 MeSH descriptor: [Chronic Disease] explode all trees
#6 chronic or persis* or recur*
#7 MeSH descriptor: [Recurrence] explode all trees and with qualifier(s): [Prevention & control - PC]
#8 #5 or #6 or #7
#9 #4 and #8
#10 CRSwNP or CRSsNP or ARS or RARS or ARR
#11 #10 or #9
#12 MeSH descriptor: [Endoscopy] explode all trees
#13 endoscop* or uncinectomy or antrostomy or antrotomy or ethmoidectomy or sphenoidotomy
#14 sinus and surg*
#15 fess or ess
#16 MeSH descriptor: [Surgical Procedures, Operative] explode all trees
#17 #12 or #13 or #14 or #15 or #16
#18 #11 and #17
#19 MeSH descriptor: [Sinusitis] explode all trees and with qualifier(s): [Surgery - SU]
#20 #11 and #19
#21 #18 or #20
#22 MeSH descriptor: [Debridement] explode all trees
#23 debridement*
#24 MeSH descriptor: [Tissue Adhesions] explode all trees and with qualifier(s): [Prevention & control - PC, Surgery - SU]
#25 MeSH descriptor: [Postoperative Care] explode all trees
#26 MeSH descriptor: [Postoperative Complications] explode all trees and with qualifier(s): [Prevention & control - PC]
#27 MeSH descriptor: [Suction] explode all trees
#28 (suck or suction* or removal or evacuat* or forcep* or clean* or clear* or aspirat* or drain*) and (blood or clot* or crust* or
adhesion* or fibrin or secretions or granulation* or synechia)
#29 MeSH descriptor: [Wound Healing] this term only
#30 wound heal*
#31 #22 or #23 or #24 or #25 or #26 or #27 or #28 or #29 or #30
#32 #21 and #31
CONTRIBUTIONS OF AUTHORS
Ethan Soudry initiated the review and will select eligible studies, analyze and interpret the data, assess trial quality, revise the review
and approve the final content.
Tzelnick Sharon will select eligible studies, assess trial quality, perform data extraction, analyze and interpret the data, draft and revise
the review.
Alkan Uri will select eligible studies, assess trial quality, perform data extraction, draft and revise the review.
Peter Hwang will analyze and interpret the data, revise the review and approve the final content.
Moshe Leshno will analyze and interpret the data, revise the review and approve the final content.
DECLARATIONS OF INTEREST
Ethan Soudry: none known.
Tzelnick Sharon: none known.
Alkan Uri: none known.
Peter Hwang: consultancy for Intersect ENT, Medtronic and Sinuwave. Consultancies are unrelated to the subject matter of the
manuscript.
Moshe Leshno: none known.
SOURCES OF SUPPORT
Internal sources
No sources of support supplied
External sources
National Institute for Health Research, UK.
Infrastructure funding for Cochrane ENT

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Debridement Sinus

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Sinonasal debridement versus no debridement for the

postoperative care of patients undergoing endoscopic sinus

Sinonasal debridement versus no debridement for the

Description of the condition

Description of the intervention

cations for the cost of care in terms of more frequent postoperative

tools are more difficult to interpret as these do not typically assess

How the intervention might work

The aim of postoperative nasal debridement is to minimize the

Adult patients (aged over 18 years) who underwent primary

Why it is important to do this review

Criteria for considering studies for this review

Types of outcome measures

Postoperative endoscopic appearance of the sinonasal

Search methods for identification of studies

Data collection and analysis

Searching other resources

Data extraction and management

Assessment of risk of bias in included studies

available). We will address multiple publication bias by combining

Unit of analysis issues

We will analyze data by including all available data and analyzing

as reported in the trial and then assigning a judgement about the

Subgroup analysis and investigation of heterogeneity

We intend to assess clinical heterogeneity by examining the:

Summary of findings table

We will use the GRADE approach to rate the overall quality of

evidence implies that we are confident in our estimate of effect

We will include a Summary of findings (SOF) table, constructed

the Cochrane Handbook for Systematic Reviews of Interventions (

[updated March 2011]. The Cochrane Collaboration,

International Forum of Allergy & Rhinology 2012;2(1):

RevMan 2014 [Computer program]

Indicates the major publication for the study

Appendix 1. CENTRAL search strategy

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