ORIGINAL ARTICLE

Early postoperative care following endoscopic sinus surgery:

an evidence-based review with recommendations
Luke Rudmik, MD1 , Zachary M. Soler, MD2 , Richard R. Orlandi, MD3 , Michael G. Stewart, MD, MPH4 ,
Neil Bhattacharyya, MD5,6 , David W. Kennedy, MD7 , Timothy L. Smith, MD, MPH1

Background: Early postoperative care following endoscopic sinus surgery (ESS) has been suggested to minimize
avoidable complications and optimize long-term outcomes.
Several postoperative care strategies have been proposed
but a formal comprehensive evaluation of the evidence has
never been performed. The purpose of this article is to provide an evidence-based approach to early postoperative
care following ESS.
Methods: A systematic review of the literature was
performed and the Clinical Practice Guideline Manual,
Conference on Guideline Standardization (COGS), and the
Appraisal of Guidelines and Research Evaluation (AGREE)
instrument recommendations were followed. Study inclusion criteria were: adult population >18 years old; chronic
rhinosinusitis (CRS) based on published diagnostic criteria;
ESS following failed medical therapy; primary study objective was to evaluate an ESS early postoperative care strategy; and clearly dened primary clinical end-point.
Results: This review identied and evaluated the literature on 7 early postoperative care strategies following
ESS: saline irrigations, sinus cavity debridements, systemic

1
Division of Rhinology and Sinus Surgery, Department of
OtolaryngologyHead and Neck Surgery, Oregon Health and Science
University, Portland, OR; 2 Division of Rhinology and Sinus Surgery,
Department of OtolaryngologyHead and Neck Surgery, Medical
University of South Carolina, Charleston, SC; 3 Division of
OtolaryngologyHead and Neck Surgery, University of Utah, Salt Lake
City, UT; 4 Department of Otorhinolaryngology, Weill Medical College
of Cornell University, New York City, NY; 5 Division of Otolaryngology,
Brigham and Womens Hospital, Boston, MA; 6 Department of Otology
and Laryngology, Harvard Medical School, Boston, MA; 7 Department
of Otorhinolaryngology, University of Pennsylvania School of Medicine,
Philadelphia, PA

steroids, topical steroids, oral antibiotics, topical decongestants, and drug-eluting spacers/stents.
Conclusion: Based on the available evidence, use of nasal
saline irrigation, sinus cavity debridement, and standard
topical nasal steroid spray are recommended early postoperative care interventions. Postoperative antibiotic, systemic steroid, nonstandard topical nasal steroid solution,
and/or drug-eluting spacers/stents are options in postoperative management. These evidence-based recommendations should not necessarily be applied to all postoperative
patients and clinical judgment, in addition to evidence, is
C 2011
critical to determining the most appropriate care. 
ARS-AAOA, LLC.

Key Words:
endoscopy; evidence-based medicine; postoperative care;
sinusitis; surgery
How to Cite this Article:
Rudmik L, Soler ZM, Orlandi RR, et al. Early postoperative care following endoscopic sinus surgery: an evidencebased review with recommendations. Int Forum Allergy
Rhinol, 2011; 1:417430

hronic rhinosinusitis (CRS) is a common disabling illness characterized by diffuse sinonasal inflammation,
resulting in symptoms of congestion, nasal drainage, facial pain, and olfactory dysfunction. Despite comprehensive medical therapy, a subgroup of patients with refractory disease often requires surgical treatment, usually in
the form of endoscopic sinus surgery (ESS). The surgical
treatment of CRS has been increasing steadily, with an

Correspondence to: Timothy L. Smith, MD, MPH, Division of Rhinology and

Sinus SurgeryThe Oregon Sinus Center, Department of
OtolaryngologyHead and Neck Surgery, Oregon Health and Science
University, 3181 SW Sam Jackson Park Rd. PV-01, Portland, OR 97239;
e-mail: smithtim@ohsu.edu

Medical Director and shareholder of Medtronic Xomed (Minneapolis, MN);

T.L.S. is a consultant for Intersect ENT and ENTrigue Surgical Inc. (San
Antonio, TX). None of these consultant sources provided any funding or
compensation for this investigation.

Potential conflict of interest: R.R.O. is a consultant for Entellus Medical

(Maple Grove, MN); D.W.K. is a consultant for Intersect ENT (Palo Alto, CA),
a member of the Medical Advisory Board for ENTCare (Dothan, AL), and the

Received: 1 March 2011; Accepted: 2 May 2011

DOI: 10.1002/alr.20072
View this article online at wileyonlinelibrary.com.

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Rudmik et al.

TABLE 1. Review characteristics

Purpose
Outline the evidence evaluating commonly utilized ESS early postoperative care strategies.
Promote an evidence-based strategy for ESS early postoperative care.
Goal
Provide focused summaries and, when possible, recommendations for specific ESS early postoperative care strategies in order to assist clinicians with optimizing
ESS outcomes. These evidence-based recommendations should not necessarily be applied to all patients and clinician judgment, in addition to the evidence, is
critical to determining the most appropriate care.
Focus
Disease: Chronic rhinosinusitis with and without nasal polyps
Population: Adults >18 years old
Intervention: ESS early postoperative care (within 12 weeks of ESS)
Intended users
Surgeons who perform ESS procedures on adult patients with chronic rhinosinusitis
Clinicians who care for patients after ESS
ESS = endoscopic sinus surgery.

estimated 250,000 paranasal sinus surgical procedures performed yearly in the United States.1
To optimize patient care and manage finite health care resources, strategies that optimize clinical outcomes and minimize subsequent revision surgery must be recognized and
implemented. Many experts have suggested that early postoperative care is a critical determinant of surgical success.
However, the definition of surgical success following ESS is
poorly defined. Most experts would agree that the ultimate
goal of early postoperative care is optimizing long-term
quality of life (QoL). However, postoperative care strategies which improve short-term clinical outcomes without
affecting the long-term QoL are still important for optimizing patient care. For example, postoperative antibiotics
may improve short-term symptoms; however, they may not
alter the long-term QoL outcomes following ESS. Improving short-term symptoms, even without long-term benefit,
is still an important aspect of patient care. Furthermore,
an early postoperative care intervention may compromise
short-term outcomes but improve long-term outcomes. For
example, postoperative sinus cavity debridement may result in temporary procedural-related pain while improving long-term healing outcomes. Since different postoperative care strategies often target different clinical goals, the
challenge is deciding which outcome is the most clinically
relevant. Therefore, we have not recommended a best
outcome assessment for each treatment. Instead, when reviewing the evidence, the reader should consider which specific outcome might be optimal for the case(s) under consideration and determine whether the studies addressed that
outcome.
Postoperative care is not standardized and a formal
evidence-based review of common clinical practices has
never been performed for ESS. The purpose of this review
is to identify early postoperative strategies commonly utilized after ESS and promote an evidence-based approach

to their use (Table 1). For each postoperative care strategy,

this article provides a focused summary of the literature and
when possible, recommendations are introduced based on
the supporting evidence. Since there are several indications
for ESS, this article focuses on adult patients with CRS (with
and without nasal polyps) and addresses only early postoperative care (defined as care incurred in the first 12 weeks after ESS), rather than long-term medical management, which
has been the topic of several prior articles.24 This review
is not intended to replace professional judgment, rather it
is meant to assist clinicians with understanding the available evidence and the potential tradeoffs associated with
each treatment strategy. It must be highlighted that clinical
studies, by their nature, report on mean characteristics of
the study population and yet the clinician in practice is often faced with individual patients who are not represented
by the mean. Therefore, these evidence-based recommendations should not be applied to all patients and clinician
judgment is critical to determining the most appropriate
care.

Materials and methods

The Clinical Practice Guideline Manual,5 Conference on
Guideline Standardization (COGS),6 and the Appraisal of
Guidelines and Research Evaluation (AGREE) instrument7
recommendations were followed to improve quality, transparency, and reporting of results in this review. We defined
early postoperative care as therapeutic interventions performed within the first 12 weeks after the ESS procedure.8
A systematic review of the literature was performed using Medline, EMBASE (www.embase.com), and Cochrane
Review Databases up to December 2010. A screening literature search, which was used to identify ESS postoperative care strategies, was performed using keywords:
Endoscopic, Sinus, Surgery, Postoperative, and

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Early postoperative care following ESS

TABLE 2. Endoscopic sinus surgery early postoperative

care strategies
Potential strategies

Saline irrigations

Recommendations incorporate both the quality of research

methodology and the balance of benefit vs harm. When the
evidence was sufficient to develop a recommendation for a
specific early postoperative care strategy, a suggested role
for the intervention was provided.

Sinus cavity debridement

Systemic steroids

Results

Topical steroids

Postoperative care strategies

Nasal saline irrigations

Oral antibiotics
Topical decongestants
Drug-eluting spacers/stents

Care. The resulting 311 abstracts were evaluated and 7

potential ESS postoperative care strategies were identified
(Table 2).
A second focused literature search for each individual strategy listed in Table 2 was performed using the
keywords: Endoscopic, Sinus, Surgery, Postoperative, and Strategy from Table 2. All abstracts were
reviewed and the following study inclusion criteria were applied: adult population >18 years old; CRS based on published diagnostic criteria;9,10 ESS for failed medical therapy of CRS; primary study objective was to evaluate an
ESS early postoperative care strategy; and clearly defined
primary clinical end-point.
Included studies were evaluated and level of evidence
was applied based on reported research methodology.11
After quality evaluation for each study, a summary was
produced which includes the aggregate grade of evidence
(Table 3) and recommendations based on the American
Academy of Pediatrics (AAP) guidelines.12 When there was
only a single study evaluating a postoperative care strategy, an aggregate grade of evidence was not provided since
grades are derived from the findings of multiple studies.
Two authors (L.R. and T.L.S.) reviewed the literature and
produced the initial manuscript. One at a time, subsequent authors (Z.M.S., R.R.O., M.G.S., N.B., and D.W.K.)
were asked to review and critically appraise the recommendations based on the literature. Areas of controversy
were debated in an electronic forum until a consensus was
achieved for every early postoperative care strategy. Author selection was based on a literature review, identifying individuals with an interest in evidence-based medicine
and/or prior participation with guideline development.

A total of 6 studies were identified where the primary objective was to evaluate the effects of nasal saline (NS) irrigation
on early ESS postoperative clinical outcomes (Table 4).1318
All study designs were randomized controlled trials and at
least single-blinded. When evaluating postoperative symptoms, 3 of the 4 studies demonstrated improved symptom
scores with saline irrigations.13,15,16 The highest quality article was a level 1b study by Liang et al.15 that compared
saline irrigations combined with postoperative debridement
to debridement alone. They demonstrated that NS irrigations combined with sinus debridement significantly improved both patient symptoms and endoscopic appearance
in the mild CRS patient cohort, while the addition of NS
irrigation to sinus debridement failed to demonstrate any
improvement in the moderate-severe CRS group.
When evaluating the impact of saline irrigations on
postoperative endoscopic appearance, a level 2b study by
Freeman et al.14 demonstrated that NS irrigations improved early (3 weeks) endoscopic appearance and mucociliary clearance; however, there was minimal difference
at 3 months after the ESS procedure. One disadvantage of
this study was the utilization of a low volume saline irrigation protocol (2 mL atomized). Conclusions from this
study cannot be directly applied to patients who utilize a
common high volume (240 mL) NS irrigation protocol. The
ideal volume and frequency of postoperative saline irrigation is poorly defined and future studies will be required to
evaluate this topic.
The only study evaluating hypertonic NS irrigations on
early postoperative care demonstrated that it increases
postoperative pain.17 Other general side-effects of saline
irrigations have been described including local irritation,
ear pain, nose bleeds, headache, nasal burning, and
nasal drainage.19 Recently, it has been shown that bacterial contamination of saline irrigation bottles is common. A

TABLE 3. Recommendations based on defined grades of evidence12

Grade

Research quality

Preponderance of benefit over harm

Balance of benefit and harm

Well-designed RCTs

Strong recommendation

Option

RCT with minor limitations; Overwhelming consistent evidence from

observational studies

Strong recommendation/recommendation

Option

Observational studies (case control and cohort design)

Recommendation

Option

Expert opinion; Case reports; Reasoning from first principles

Option

No recommendation

RCT = randomized controlled trial.

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2008

Staffieri et al.18

Study

RCT

RCT

RCT

RCT

RCT

RCT

design

2b

1b

2b

1b

2b

2b

LOE

80

77

23

128

60

20

subjects

Number of

Began POD
#1; 20 mL;
4 daily

Began POD
#1; 240 mL;
1 daily

1) NS +
debridement;
2) Debridement
alone
1) NS;
2) SFT water

Began POD
#1; atomization
of 2 mL; 3
daily

Began POD
#1; 2
daily

Began POD
#1; 30 mL;
4 daily

Began POD
#2; 3 daily

protocol

Saline irrigation

1) NS;
2) No irrigations

1) NS;
2) Dexpanthenol
spray

1) NS;
2) HS;
3) No irrigations

1) Sea salt;
2) Sea salt +
mucolytic +
antiseptic

Study groups

1) Postoperative
mucosal
histomorphology

1) Symptoms;
2) Endoscopic
appearance

1) Endoscopic
appearance

1) Symptoms;
2) Mucociliary
clearance

1) Symptoms

1) Weight of
ethmoid crusts;
2) Symptoms

end-point

Primary ESS

SFT water had a greater reduction in mucosal

eosinophil count; no difference in other
histomorphology findings; SFT should be
considered for allergic patient postoperative
irrigations

NS group, with mild CRS, had better symptom and

endoscopy scores; no difference in patients with
moderate-severe CRS

NS provided early endoscopic improvement (reduced

discharge and edema); no difference in
long-term endoscopic findings (adhesions,
crusting, polyps)

Both groups improved postoperative symptom score

and mucociliary clearance

No difference in postoperative symptoms between

NS and no irrigation; HS produces worse pain and
nasal drainage

Improved postoperative symptoms with sea salt

irrigations alone; no difference in weight of
ethmoid crusts or symptom score with addition of
mucolytic and antiseptic

Conclusion

CRS = chronic rhinosinusitis; ESS = endoscopic sinus surgery; HS = hypertonic saline; LOE = level of evidence; NS = normal saline; POD = postoperative day; RCT = randomized controlled trial; SFT = sulfurous
ferruginous-thermal.

2008

2008

Fooanant et al.13

Liang et al.15

2006

Pinto et al.17

2008

1996

Pigret and
Jankowski16

Freeman et al.14

Year

Study

TABLE 4. Summary of postoperative nasal saline irrigation studies

Rudmik et al.

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Early postoperative care following ESS

study by Lewenza et al.20 demonstrated 32 different bacterial species colonizing sinus rinse bottles with no correlation
between the duration of bottle use and degree of colonization. Although bacterial colonization is prevalent, the role it
plays on ESS outcomes is unclear as multiple studies including Lee et al.21 have failed to demonstrate that colonization
leads to increased post-ESS infection rates.
Summary:
1.
2.

3.

4.
5.
6.
7.
8.

Aggregate quality of evidence: B (Level 1b: 2 studies; Level 2b: 4 studies)

Benefit: Generally well tolerated. Improved
early post-operative symptoms and endoscopic
appearance.
Harm: Local irritation, nasal burning, headaches,
ear pain (predominantly with hypertonic
solutions).
Cost: Minimal; patient time for application
Benefits-Harm assessment: Preponderance of benefit over harm
Value Judgments: None
Policy level: Recommendation for use of nasal
saline irrigations
Intervention: Begin daily normal saline irrigations
between 24 and 48 hours after ESS

Postoperative debridement
Postoperative sinonasal cavity debridement has been advocated to prevent potential synechiae and sinus ostial
stenosis, and to improve patient symptoms. Removal of old
blood, nasal secretions, unresorbed packing, and exposed
bony lamellae are thought to reduce the inflammatory load
and remove potential framework for scarring.22,23
This review identified 4 randomized controlled studies evaluating ESS postoperative debridement on clinical
outcomes (Table 5).2427 Three trials were level 1b studies and demonstrated significant symptom and endoscopic
improvement with postoperative debridement. The study
by Bugten et al.24 (level 1b) demonstrated that postoperative sinus cavity debridement resulted in reduced crust
and middle meatal adhesion rates at 3 months follow-up.
In 2008, Bugten et al.28 reported the long-term results of
their debridement group and demonstrated that the initial short-term improvements were stable after 56 weeks.
The remaining 2 level 1b studies identified in this review
attempted to elucidate the ideal timing of postoperative debridement. The study by Lee and Byun26 demonstrated that
patients who received multiple debridements within the first
week received similar short-term (4 weeks) and long-term
(6 months) symptom outcomes compared to patients with
debridement(s) at 1-week intervals. However, the patients
who received multiple debridements within in the first week
after ESS reported the greatest disturbances in socioeconomic activities and had the highest rate of omitting postoperative clinic visits. As a result, Lee and Byun26 concluded
that the optimal frequency of post-ESS sinus cavity debridements was at 1-week intervals. The study by Kemppainen

421

et al.25 demonstrated that patients who received 3 sinus

cavity debridements within the first week after ESS had
reduced nasal discharge scores compared to patients who
received a debridement at 1-week after ESS. The only study
that failed to demonstrate a benefit from postoperative
debridement was an early pilot study by Nilssen et al.27
(level 2b); however, it was underpowered and failed to use
a standardized endoscopic grading system.
Although the ideal frequency and timing of debridement
is likely quite variable depending on a number of diseaserelated and patient factors, all 3 level 1b studies demonstrated statistically significant improvements in both symptom and endoscopic outcomes with postoperative sinus
cavity debridement. Due to the paucity of current literature regarding the ideal frequency, duration, extent, and
timing of debridement, future studies will need to elucidate
these topics before an optimal debridement schedule can be
recommended.
Summary:
1.
2.

3.

4.
5.
6.

7.
8.

Aggregate quality evidence: B (Level 1b: 3 studies;

Level 2b: 1 study)
Benefit: Improved postoperative symptoms and endoscopic appearance. Minimizes risk of synechiae
and middle turbinate lateralization.
Harm: Inconvenience of office visit. Procedurerelated epistaxis, pain, and syncope. Mucosal
avulsion.
Cost: It is a surgical procedure (in-office) and has
associated costs
Benefits-Harm assessment: Preponderance of benefit over harm
Value Judgments: Relating the surgeons assessment of healing into the clinical need for
debridement.
Policy level: Recommendation for postoperative
debridement
Intervention: Perform sinus cavity debridement after ESS.

Postoperative systemic steroids

CRS is an inflammatory disease and therefore, systemic
steroids have long been utilized in the management of
CRS symptoms due to their potent anti-inflammatory properties. One randomized, double-blind, placebo-controlled
study was identified which evaluated the effect of perioperative systemic steroids on ESS clinical outcomes
(Table 6).29 The study population was comprised of patients with CRS and nasal polyposis. The steroid protocol
used in this study started patients on prednisone (30 mg)
5 days before surgery and continued for 9 day postoperatively, without a taper. Although systemic steroids failed
to improve postoperative symptoms, there was a significant postoperative endoscopic improvement compared to
the placebo group, which was most evident at the 2-week
postoperative time point.

International Forum of Allergy & Rhinology, Vol. 1, No. 6, November/December 2011

2002

2006

2008

2008

Nilssen et al.27

Bugten et al.24

Kemppainen et al.25

Lee and Byun26

Study

RCT

RCT

RCT

RCT

design

1b

1b

1b

2b

LOE

30

90

60

17

subjects

Number of

1) Frequent
debridement;
2) Standard
debridement;
3) Delayed
debridement

1) Frequent
debridement +
saline irrigations;
2) Standard
debridement +
saline
irrigation

1) Debridement alone;
2) Saline irrigation
alone

1) Debridement;
2) No debridement

Study groups

1) Endoscopic
appearance

1) Symptoms;
2) Endoscopic
appearance

end-point

Primary ESS

Frequent debridement
1) Early symptoms;
2) Late HRQoL;
= 2 per week;
Standard debridement 3) Late endoscopic
appearance
= 1 per week;
Delayed debridement =
1 every 2
weeks

Frequent debridement
1) Symptoms
= 3 within
first week post-ESS;
Standard debridement
= 1 at
week 1 post-ESS

Debridement on
POD# 6 and 12

Single-side debridement
on: POD# 3, weeks
1, 2, 4, and month 3

protocol

Debridement

2007

Wright and Agrawal29

Study

RCT; doubleblind;
placebocontrolled

design

1b

LOE

24

subjects

Number of

Study

1) Perioperative
systemic steroids;
2) Placebo

groups

PO prednisone 30 mg:
Beginning 5 days
preoperatively and
continuing for 9 days
post-ESS; placebo:
same schedule
as above

protocol

Systemic steroid

ESS = endoscopic sinus surgery; LOE = level of evidence; PO = per os (oral medication); RCT = randomized controlled trial.

Year

Study

1) Technical ease of
surgery;
2) Symptoms;
3) Endoscopic
appearance

end-point

Primary ESS

TABLE 6. Summary of the postoperative systemic steroid study

ESS = endoscopic sinus surgery; HRQoL = health-related quality of life; LOE = level of evidence; POD = postoperative day; RCT = randomized controlled trial.

Year

Study

TABLE 5. Summary of postoperative debridement studies

Technically easier surgery in

prednisone-treated group; no difference
in post-ESS symptoms between
groups; significantly improved post-ESS
endoscopic appearance in
prednisone-treated group.

Conclusion

Delayed debridement had the worst early

symptoms scores; frequent debridement
group had the worst compliance and
social interruption scores; no difference in
late outcomes between the 3 groups.

3 per week ESS debridements provided

symptom improvement compared to
1 per week

Debridement group had reduced adhesions

and crusts

No difference between groups.

Conclusion

Rudmik et al.

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Early postoperative care following ESS

Despite convincing evidence from this level 1b study by

Wright and Agrawal,29 the potential side-effects of short
term systemic steroid use must be balanced with the proven
benefit in postoperative endoscopic appearance. A recent
article by Poetker and Reh30 provides a comprehensive review of the adverse effects of systemic steroids. Although
serious side-effects from short-term steroid use are rare, potential adverse events include psychiatric/mood changes, insomnia, hyperglycemia, stomach ache (gastritis), increased
intraocular pressure, and avascular necrosis of the hip.
Summary:
1.
2.
3.

4.
5.
6.

7.

Aggregate quality of evidence: N/A (Level 1b: 1

study)
Benefit: Improvement in endoscopic appearance
compared to placebo.
Harm: Side effects of systemic steroids including: Insomnia. Psychiatric/mood changes. Hyperglycemia. Gastritis. Increased intraocular pressure.
Avascular necrosis of the hip.
Cost: Minimal
Benefits-Harm assessment: Relative balance of benefit and harm.
Value Judgments: Difficult to develop a postoperative recommendation based on 1 study where
the clinical benefit was limited to endoscopic
appearance.
Recommendation level: Option

Topical nasal steroid sprays and other topical

steroid applications
Intranasal application techniques can deliver topical steroid
medication without the systemic side effects of oral steroid
therapy. Due to their localized anti-inflammatory effects
and excellent safety profile, standard topical nasal steroid
sprays have become a common treatment modality for CRS.
This review identified 4 randomized, double-blind,
placebo controlled trials evaluating the role of standard
topical nasal steroid sprays on post-ESS clinical outcomes
(Table 7).3134 All studies were level 1b quality and the
3 most recent studies demonstrated significant clinical improvements with standard topical steroid sprays following
ESS. Most benefit appears to be in CRS patients with nasal
polyps, as time to recurrence of polyps was lengthened and
recurrence rate was significantly reduced. The study by
Dijkstra et al.34 compared fluticasone nasal spray to
placebo and failed to demonstrate a clinical improvement 1
year after ESS. Although strong in some areas, the Dijkstra
et al.34 study had several important limitations: it was
single-institutional, they failed to use a validated rhinosinusitis health-related QOL (HRQoL) instrument, and reported a low number of nasal polyp patients comprising
their study cohort (68/162 patients). Despite this negative
study, there is still significant evidence to support the clinical benefits of topical nasal steroids following ESS for refractory CRS.

423

The timing of intranasal steroid spray initiation is not

well defined; however, most studies suggest commencing
therapy in the early postoperative period. Potential side effects of topical nasal sprays occur in <5% of patients and
most commonly include headache, epistaxis, and cough.35
The panel of authors on this evidenced-based review noted
1 important caveat: that there is likely a subset of patients
with CRS who undergo ESS for primarily anatomic abnormalities with minimal underlying mucosal inflammation.
The role of topical nasal steroids in this subset of patients
has not been specifically explored.
Nonstandard, off-label intranasal steroid solutions have
been used to deliver higher amounts and higher concentrations of topical steroid to the sinonasal mucosa. A retrospective study by DelGaudio and Wise36
(level 3b) evaluated intranasal dexamethasone ophthalmic
drops (0.1%), prednisolone ophthalmic drops (1%), and
ciprofloxacin/dexamethasone otic drops (0.3/0.1%) in patients who underwent revision ESS with a high risk for
sinus ostial stenosis and polyp recurrence. They concluded
that nonstandard, high-dose nasal steroid drops may reduce sinus ostial stenosis, need for revision sinus surgery,
and reduce oral steroid rescue episodes. It is important
to recognize that off-label steroid solutions were not used
routinely following primary ESS; rather, they were studied in patients with severe inflammatory disease who were
felt to be at high-risk for sinus ostial stenosis and revision sinus surgery. Since the study had no comparison group, future controlled studies will need to be performed before definitive conclusions can be made regarding
efficacy.
The predominant risk of off-label topical steroid therapy
is the potential systemic absorption, resulting in the sideeffects associated with systemic steroid therapy. Although
there is likely higher systemic absorption with the use of
off-label steroid drops, the study by DelGaudio and Wise36
reported that only 1 patient out of 36 required medication
discontinuation due to a drop in morning cortisol level. Additionally, a study by Bhalla et al.37 evaluating the safety
of off-label topical budesonide irrigations demonstrated no
significant adrenal suppression. A recent study by Welch
et al.38 demonstrated that twice daily budesonide nasal irrigations (0.5 mg/2 mL in 240 mL saline) following ESS did
not alter the serum cortisol or 24-hour urine cortisol levels.
Although it appears that short-term use is likely safe, future
studies will need to assess the safety of long-term off-label
topical nasal steroid preparations. Furthermore, there is the
theoretical consideration that in the immediate period after
ESS, mucosal barriers may be disrupted allowing for higher
levels of systemic absorption, ocular absorption and, theoretically, potential negative interactions between higher
concentration steroids and wound healing in the sinonasal
cavity. Oftentimes the therapeutic alternative in high-risk
CRS patients is a course of systemic steroids; in these instances, using off-label topical nasal steroid solutions may
be a viable alternative to systemic steroid therapy, thereby
potentially avoiding large systemic doses.

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2009

2009

2006

Jorissen et al.32

Stjarne et al.33

DelGaudio and Wise36

Retrospective

RCT doubleblind
placebo
controlled
multicenter

RCT doubleblind
placebocontrolled

RCT doubleblind
placebocontrolled

RCT doubleblind
placebocontrolled

Study design

3b

1b

1b

1b

1b

LOE

36

104

99

109

162

subjects

Number of

Steroid nasal
drops:
1) Dexamethasone
ophthalmic;
2) Prednisolone
ophthalmic;
3) Ciprofloxacin/
dexamethasone

1) Mometasone
nasal spray;
2) Placebo

1) Mometasone
nasal spray;
2) Placebo
spray

1) Fluticasone
nasal spray;
2) Placebo
spray

1) Fluticasone
nasal spray;
2) Placebo
spray

Study groups

Started steroid
nasal drops
within 3 months
of ESS

Started QD nasal
spray 2 weeks
after ESS

Started BID nasal

spray 2 weeks
after ESS
6 months

Started nasal
sprays 6 weeks
post-ESS

Started nasal spray

1 week after
ESS

Protocol

Topical Steroid

BID = twice a day; ESS = endoscopic sinus surgery; LOE = level of evidence; QD = once daily; RCT = randomized controlled trial.

2005

2004

Year

Rowe-Jones et al.31

Dijkstra et al.

Study

1) Ostial patency;
2) Oral steroid
rescue
episodes;
3) Revision
sinus surgery

1) Days to polyp
recurrence

1) Endoscopic
appearance;
2) Number of
oral steroid
rescue
episodes

1) Symptoms;
2) Endoscopic
appearance;
3) Number of
oral steroid
rescue episodes

1) Patients
withdrawn from
study because
of recurrent
disease

end-point

Primary ESS

TABLE 7. Summary of the postoperative topical nasal steroid studies

Topical nasal drops may reduce sinus

ostial stenosis and decreased the need for
revision ESS; topical nasal drops may reduce
oral steroid rescue episodes

Mometasone spray significantly lengthened

the duration before polyp recurrence

Mometasone spray group had better healing

scores, especially in nasal polyp
subgroup; no difference in oral steroid
rescue episodes

Fluticasone spray group had better symptoms

and endoscopic scores at 5 years;
Fluticasone spray group required
significantly fewer oral steroid rescues

No difference in the patient withdrawal rate

between groups

Conclusion

Rudmik et al.

International Forum of Allergy & Rhinology, Vol. 1, No. 6, November/December 2011

424

Early postoperative care following ESS

Summary: Standard Topical Nasal Steroid Spray

1.
2.
3.
4.
5.
6.
7.
8.

Aggregate quality of evidence: A (Level 1b:

4 studies)
Benefit: Improved symptoms and endoscopic appearance. Lengthen time to polyp recurrence.
Harm: Headache. Epistaxis. Cough.
Cost: Moderate; depends on preparation
Benefits-Harm assessment: Preponderance of benefit over harm
Value Judgments: none.
Recommendation level: Recommendation for standard nasal steroid spray
Intervention: Begin standard topical nasal steroid
spray after ESS

Summary: Non-Standard, Off-label Topical Nasal

Steroid Therapy
1.
2.

3.

4.
5.
6.

7.

Aggregate quality of evidence: N/A (Level 3b: 1

study)
Benefit: Potentially reduce risk of ostial stenosis.
May reduce systemic steroid rescue episodes. Potential alternative to course of systemic steroids.
Harm: Poorly defined risks. Potential adrenal suppression, ocular absorption, wound healing, and
other systemic steroid effects.
Cost: Minimal to moderate, depends on
preparation
Benefits-Harm assessment: Equal balance of benefit
to harm.
Value Judgments: Lack of data regarding systemic
absorption is concerning but the only other option
in many cases is systemic steroid.
Recommendation level: Option in patients with severe mucosal inflammatory disease.

Postoperative antibiotics
Bacterial infection following ESS is thought to contribute to prolonged healing time, worse patient symptoms,
and potential local complications. Traditionally, a shortcourse of postoperative antibiotic (710 days) has been
recommended22,39 ; however, the literature regarding their
use is conflicting.
This review identified 3 randomized trials evaluating the role of postoperative antibiotics following ESS
(Table 8).4042 The earliest study, a randomized doubleblind, placebo controlled trial (level 1b) by Annys and
Jorissen,40 evaluated a short-course of postoperative antibiotics (2 days) and demonstrated it had no benefit on ESS
clinical outcomes. This provides convincing evidence that
a short-course of antibiotics after ESS has minimal value.
However, conclusions regarding the benefit of longer, more
traditional, postoperative antibiotic courses (ie, 714 days)
cannot be made from this study. A level 2b study by
Jiang et al.41 utilized a randomized methodology to assign
patients to a longer course of antibiotic group (Amoxicillin/Clavulante 375 mg 3 times a day [TID] 3 weeks)

425

or control group (no antibiotics) and demonstrated no

clinical difference between the groups. However, there was
no placebo and investigators were not blinded to the treatment groups. Additionally, endoscopic scoring was performed at 3 weeks post-ESS, which would have missed
the early postoperative period when antibiotics would have
their greatest benefit. A recent level 1b study by Albu and
Lucaciu42 performed a randomized, double-blind, placebocontrolled trial which evaluated a longer postoperative antibiotic schedule (Amoxicillin-Clavulanate 625 mg 2 times
a day [BID] 2 weeks). The results from this study demonstrate that postoperative antibiotics improve both patient
symptoms within the first 5 days and endoscopic appearance at the 12 day period. Additionally, there was a significant reduction in sinonasal crust formation.
There are several reported potential adverse effects from
prophylactic antibiotics. The most commonly discussed
side-effects include gastrointestinal symptoms (cramping and diarrhea). Less common adverse effects include
clostridial difficile colitis, anaphylaxis, and increased bacterial resistance. Antibiotic choice must take into account
common sinonasal pathogens and usually involves the use
of a penicillin-based agent or macrolide.
The level 1b study by Albu and Lucaciu42 presents the
most convincing evidence for the beneficial effects of a
longer course of postoperative antibiotic therapy following ESS, as they demonstrated improved early patient
symptoms and endoscopic appearance along with reduced
crust formation. There does not appear to be any benefit
from a short course (2 days) of postoperative antibiotics.
Future studies will need to elucidate the ideal duration and
agent used for postoperative antibiotic therapy.
Contrary to considerations for standard antibiotic prophylaxis for clean surgical cases, surgeons are often faced
with concurrent bacterial infection at the time of ESS. To
date, no studies have examined the benefit of antibiotic
prophylaxis when purulence is found at the time of sinus
surgery. In these instances, surgeons may be able to target specific pathogens based on intraoperative cultures and
sensitivities. Finally, the panel noted that in a substantial
fraction of cases, septoplasty is performed in conjunction
with ESS and may result in placement of septal splints or
other foreign sinus materials such as spacers or hemostatic
agents. In these instances, anti-staphylococcal prophylactic
antibiotics have traditionally been prescribed to theoretically prevent rare instances of toxic shock syndrome.43
The evidence evaluating these circumstances is beyond the
scope of this guideline.
Summary:
1.
2.

3.

International Forum of Allergy & Rhinology, Vol. 1, No. 6, November/December 2011

Aggregate evidence: B (Level 1b: 2 studies; Level

2b: 1 study)
Benefit: Improved early postoperative symptoms
and endoscopic appearance. Reduced sinonasal
crusting.
Harm: GI upset. Clostridial difficile colitis. Anaphylaxis. Bacterial resistance.

6.

7.

Cost: Generally Moderate to high

Benefits-Harm assessment: Relative balance of benefit and harm.
Value Judgments: Reducing early postoperative
symptoms is important; active bacterial infection
may trigger inflammation postoperatively
Recommendation level: Option

Topical decongestant

BID = twice a day; ESS = endoscopic sinus surgery; LOE = level of evidence; QD = once daily; RCT = randomized controlled trial; TID = 3 times a day.

Albu and Lucaciu42

Jiang et al.41

4.
5.

Antibiotics reduced nasal obstruction and

drainage in early (first 5 days)
post-ESS period; antibiotics improved
endoscopic scores within first 12 days;
antibiotics reduced crust formation
AmoxicillinClavulanate
625 mg BID
2 weeks after
ESS
1b
RCT doubleblind
placebocontolled
2010

75

1) Oral antibiotic;
2) Placebo

1) Symptoms
2) Endoscopic
appearance
3) Crust formation

No difference in symptoms, endoscopic

appearance, or culture rates between
groups at 3-week time point.
AmoxicillinClavulanate
375 mg TID
3 weeks
2b
RCT; no
placebo;
no blinding
2008

71

1) Oral antibiotic;
2) No antibiotic

1) Symptoms
2) Endoscopic
appearance
3) Culture rates

No difference in symptoms or endoscopic

appearance between groups
1) Symptoms;
2) Endoscopic
appearance
Cefuroxime 250
mg QD
2 days
1) Oral antibiotic;
2) Placebo
1b
RCT doubleblind
placebocontrolled
Annys and Jorissen

40

2000

202

end-point
protocol

Primary ESS
Oral antibiotic

subjects

Study groups
Number of

LOE
Study design
Year
Study

TABLE 8. Summary of postoperative prophylactic antibiotic studies

Conclusion

Rudmik et al.

Following sinus surgery, mucosal edema is expected and

contributes to early postoperative symptoms of congestion
and nasal discharge. Although not commonly utilized, the
use of topical decongestants in the early postoperative period has the theoretical potential to reduce mucosal edema
by inducing vasoconstriction. However, prolonged use can
lead to rhinitis medicamentosa and worse symptoms of
nasal obstruction upon decongestant discontinuation.44
This review identified 1 study, which evaluated the role
of topical decongestant on ESS early postoperative care
(Table 9).45 The randomized trial by Humphreys et al.45
compared topical decongestant, xylometazoline, to a normal saline spray in the ESS early postoperative period.
There was no difference in sinonasal symptom scores or
bleeding events between groups and the topical decongestant group had worse postoperative pain scores. The major
flaw of the study was a lack of patient blinding to their respective treatment group. One caveat is that decongestants
are commonly used for minor postoperative bleeding. A
short decongestant course (24 hours) may be considered to
control mild epistaxis; however, a thorough discussion on
the management of postoperative epistaxis is beyond the
scope of this review.
Summary:
1.
2.
3.
4.
5.
6.

7.

Aggregate evidence: N/A (level 2b: 1 study)

Benefit: Potential for reduced mucosal swelling and
reduced bleeding.
Harm: Increased pain. Potential for rhinitis
medicamentosa.
Cost: Minimal; over the counter medication
Benefits-Harm assessment: Preponderance of harm
over benefit
Value Judgments: Increased pain and risk of rhinitis
medicamentosa is concerning despite only 1 study
evaluating this intervention.
Recommendation level: Recommendation against;
Caveat: this recommendation against does not relate to management of postoperative epistaxis.

Drug-eluting stents or spacers

Issues of noncompliance and adequate drug delivery surround traditional topical medical therapy techniques. With
the introduction of drug eluting spacers and stents, the potential for a slow release of continuous therapy is possible while removing the potential for noncompliance. Drugeluting stents are being developed for CRS and they may
have significant benefit in the treatment of this chronic

International Forum of Allergy & Rhinology, Vol. 1, No. 6, November/December 2011

426

427

No difference in sinonasal symptoms or

bleeding events between groups; higher
pain scores in Xylometazoline group
1) Symptoms;
2) Pain

ESS = endoscopic sinus surgery; LOE = level of evidence; RCT = randomized controlled trial.

Xylometazoline 0.1%
2 puffs 4 per
day; saline spray
6 per day
Humphreys et al.45

2009

120
2b
RCT

1) Topical
decongestant;
2) Normal saline
spray

Primary ESS

end-point
protocol
Study groups
subjects
LOE
design
Study

Year

Topical

decongestant
Number of
Study

TABLE 9. Summary of the postoperative topical decongestant study

Conclusion

Early postoperative care following ESS

inflammatory disease.46 This potential benefit is balanced

against the risk of inducing inflammation as a foreign material and the potential for unintended systemic absorption of
the medication.47 It is important to recognize that there are
no U.S. Food and Drug Administration (FDA)-approved
steroid eluting or antibiotic eluting stents currently available on the market. Rather the current stents are primarily
drug delivery vehicles and the treating surgeon determines
the type and dosage of steroid to utilize in an off-label formulation. Early topical therapy after ESS can be limited
by nasal crusting, retained secretions, and mucosal edema.
The use of ethmoid cavity spacers or sinus ostial stents,
which elute local topical drugs can potentially aid in drug
delivery to the affected mucosa in the early postoperative
period.
This review identified 3 studies evaluating the role of
drug-eluting spacers and stents after ESS (Table 10).4850
One study evaluated a frontal sinus drug eluting stent,
while the other 2 studies evaluated ethmoid cavity drug
eluting spacers. The study by Huvenne et al.48 (level 3b)
demonstrated that a frontal sinus stent eluting doxycycline
could improve local frontal sinus symptoms and reduce matrix metalloproteinase (MMP)-9 levels, a molecule thought
to contribute to osteoneogenesis. The studies by Kang et
al.49 (level 2b) and Cote and Wright50 (level 1b) evaluated
postoperative ethmoid cavity packing soaked with topical
steroid (triamcinolone) in CRS patients with nasal polyps.
The studies demonstrated significant improvements in the
endoscopic appearance at both early and late postoperative
periods as well as reduced polyp recurrence. The specific
protocol used in the level 1b study by Cote and Wright50
included a triamcinolone soaked spacer (Nasopore, Stryker
Canada, Hamilton, Ontario, Canada) placed within the
ethmoid cavity at the completion of ESS and removed at
the week 1 debridement.
Overall, since the current studies were small and ethmoid cavity eluting spacers are relatively new treatment
modalities, the balance of harm to benefit is unclear. The
systemic absorption of drug eluting spacers and stents
is poorly defined. Larger future studies will be required
to confirm the safety and clinical benefit of these early
studies.
Summary:
1.
2.
3.
4.
5.
6.

International Forum of Allergy & Rhinology, Vol. 1, No. 6, November/December 2011

Aggregate evidence: B (level 1b: 1 study; level 2b: 1

study; level 3b: 1 study)
Benefit: Improved endoscopic appearance. Reduced
polyp recurrence.
Harm: Potential for systemic steroid absorption.
Potential for ocular absorption.
Cost: Variable depending on the stent/spacer selected and medication utilized
Benefits-Harm assessment: Relative balance of benefit and harm.
Value Judgments: Standard topical steroids have
a proven role in postoperative management but
nonstandard topical steroids require further study.

2008

2008

2010

Huvenne et al.48

Kang et al.49

Cote et al.50
RCT doubleblind
placebocontrolled

RCT

Prospective
cohort

Study design

1b

2b

3b

LOE

19

32

10

subjects

Number of

1) Ethmoid cavity
steroid-soaked
dressing;
2) Placebo

1) Ethmoid cavity
steroid-soaked
dressing;
2) Steroid nasal
spray

1) Drug eluting
frontal sinus
stent;
2) Placebo frontal
sinus stent

Study groups

Nasopore soaked in
Triamcinolone
packing;
Nasopore
soaked in saline

Triamcinalone
(40 mg)-soaked
gauze packing
qWeekly
2 months

DC-releasing stent

Drug-eluting device

1) Endoscopic
appearance

1) Nasal polyp
recurrence

1) Frontal sinus
symptoms;
2) Local MMP-9
levels

end-point

Primary ESS

Improved early (POD 7 and 14) and late

(month 3 and 6) endoscopic scores

Reduced nasal polyp rate

DC stent side had better symptom scores and

lower MMP-9 levels (suggesting less
osteoneogenesis)

Conclusion

International Forum of Allergy & Rhinology, Vol. 1, No. 6, November/December 2011

B
N/A
A
D
B
N/A
B

Debridement

Systemic steroids

Topical nasal steroid spray

Off-label topical steroid

Postoperative antibiotics

Topical decongestants

Ethmoid cavity eluting spacers

and stents

Grade of
evidence

Equal

Harm

Equal

Equal

Benefit

Equal

Benefit

Benefit

Balance of benefit
to harm
Recommendation

ESS postoperative protocol

N/A
Single level 1b study protocol: Nasopore packing soaked with triamcinolone steroid
placed with ethmoid cavity after ESS. Removed at the 1 week postoperative
debridement

Recommendation against
Option

Single level 1b study protocol: Amoxacillin/Clavulante 625 mg BID 14 days

Single level 3b nasal drop options used: Dexamethasone ophthalmic, Prednisolone

ophthalmic, or Ciprofloxacin/Dexamethasone otic drops

Topical nasal sprays started after ESS

Single level 1b study protocol was: Prednisone (30 mg) started 5 days preoperatively
and continued for up to 9 days after ESS (no taper) in CRS patients with nasal polyps

Sinus cavity debridement(s) after ESS

Normal saline irrigation starting within 24 to 48 hours after ESS

Option

Option

Recommendation

Option

Recommendation

Recommendation

BID = twice a day; CRS = chronic rhinosinusitis; ESS = endoscopic sinus surgery; N/A = not applicable.

Saline irrigation

Postoperative treatment
strategy

TABLE 11. Summary of ESS early postoperative treatment summaries

ESS = endoscopic sinus surgery; DC = doxycycline; LOE = level of evidence; MMP = matrix metalloproteinase; POD = postoperative day; qWeekly = every week; RCT = randomized controlled trial.

Year

Study

TABLE 10. Summary of postoperative drug eluting spacers/stents studies

Rudmik et al.

428

Early postoperative care following ESS

7.

Although some trials have been conducted, sample

sizes are small and data is considered insufficient to
extrapolate to larger populations, particularly with
respect to safety concerns.
Recommendation level: Option

Overall summary
Based on the best available evidence, an evidenced-based
early postoperative care protocol after ESS would include
nasal saline irrigation, sinus cavity debridement, and initiation of a standard topical nasal steroid spray (Table 11).
Postoperative antibiotics are an option, which reflects the
tradeoff between short-term clinical benefit and the downside of medication side-effects and costs. There is 1 highlevel evidence study to support the use of postoperative
systemic steroids to improve both early and long-term endoscopic appearance; however, given the potential adverse
effects, the use of systemic steroids remains an option
until further evidence is available. In such instances, the
option level assignment for this intervention would typically require shared decision-making and discussion with
the patient prior to prescribing.
Off-label topical steroid therapy and ethmoid cavity
steroid eluting spacers/stents are both options that may
be considered in special cases, such as sinus ostial stenosis,
severe inflammatory disease, and/or rapid polyp recurrence.
The literature recommends against the routine use of early
topical decongestants. This review is not intended to supersede clinical judgment, but rather to assist clinicians
with understanding the available evidence and develop
an evidence-based approach to early postoperative care
after ESS.

based postoperative treatment protocol after ESS would

include the use of nasal saline irrigation, sinus cavity debridement, and initiation of standard topical nasal steroid
spray. Due to a relative balance between possible therapeutic advantages and potential adverse effects, the use of
postoperative antibiotics, systemic steroids, off-label topical steroid medications, and drug eluting materials are
all options for postoperative care. These evidence-based
recommendations should not necessarily be applied to all
postoperative patients and clinical judgment, in addition
to available evidence, is critical to determining the most
appropriate care.
The data on interventions and postoperative care following ESS are rather sparse in many areas, with several notable
evidence gaps. Potential future research topics include:
1.
2.
3.
4.
5.
6.
7.
8.
9.

Conclusion

10.

This review evaluated the literature on 7 different ESS early

postoperative care strategies based on a specific protocol for
evidence-based review and recommendation. An evidence-

11.

Evaluation of small and large volume saline irrigations on ESS postoperative outcomes.
Evaluation of the frequency of saline irrigations on
ESS postoperative outcomes.
Evaluation of adverse effects of postoperative systemic steroid use.
Evaluation of postoperative systemic steroids in patients with CRS without nasal polyps.
Evaluation of the systemic and ocular effects of
long-term off-label topical nasal steroid drops.
Evaluation of the ideal duration of prophylactic
antibiotics.
Evaluation of the ideal antimicrobial agent used for
postoperative antibiotics.
Evaluation of the safety and systemic effects of
drug-eluting middle meatal spacers.
Evaluation of multiple early sinus cavity debridements and their timing.
Evaluation of long-term clinical outcomes of
early postoperative care strategies.
Evaluation of the wound healing effects of higherdose topical steroid concentration irrigations and
drug-eluting middle meatal spacers.

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