Postoperative Management

We will have aimed by this point to have explained to the patient enough about their disease process that they will understand that their treatment is a combined effort from both the medical team and themselves to try to improve their symptoms. The patient should not feel that their treatment and surgery is something that the surgeon has done to them as a passive recipient. As part of an effort to improve their symptoms, they need to know that they also must take some action. The key issues are: The need to irrigate stagnant mucus and altered blood and stop it from collecting on the lining of the paranasal sinuses until ciliary function has returned. Local medical treatment is usually needed to reduce inflammation present in the mucosa. (This may be the result of an unresolved preoperative infection, allergy, or nonspecific inflammation resulting from the persistent production of cytokines.) The patient should be aware that local debridement of their nose may be needed at about one week after surgery in order to avoid adhesions and to hasten recovery of the mucosa. Removal of a nasal dressing is often very unpleasant for the patient because of a dragging sensation or the moderate discomfort that pulling it out causes. The patient needs to be prepared for this. If the patient is aware that it is likely to be uncomfortable, if the staff are sympathetic, and if moderate analgesia is given beforehand, this problem can be reduced. Patients should be aware that after sinus surgery it is important to continue to look after the lining of their paranasal sinuses. The lining of the sinuses is like a lawn and often weeding, or even a weedkiller (organic!), is needed. Compliance with medical treatment is needed to maximize the benefit that surgery can offer through helping drainage, reducing the surface area, allowing access for topical treatment, and debulking diseased tissue. Pain control is vital for the patients short-term and long-term wellbeing. All trauma, whether it is surgical or through injury, alters a patients peripheral and central pain perception through neuroplasticity.

Thankfully, in most cases the repair processes mean that after a few days the patients pain subsides. In a small proportion of patients, the pain persists. It is worth controlling patients postoperative pain so as to minimize the possibility that their trigeminal nucleus may become sensitized and their postoperative pain perpetuated. The Postoperative Course In the first few days, the nasal airway can collect a fibrinous exudate that sets like jelly in a mold. We encourage our patients to sniff and douche in order to avoid this. The postoperative recovery period can be plagued by the repeated formation of crusts, which result from mucosal damage. Mucosal damage may be superficial, partial thickness, or full thickness. Most nasal dressings cause superficial mucosal damage that results in mucus stagnation as there are few remaining functioning cilia that remain to clear any secretions. If there is full-thickness mucosal damage it may take up to a year for the cilia start to function synchronously again. With superficial mucosal damage it may take 23 weeks for the mucosa to recover. Similarly, if there has been a marked infection, (e.g., Staphylococcus within the mucosa in these patients pus can be seen oozing out of the mucosa minutes after it has been cleaned and

irrigated), it may take months of douching before the cilia start to work well. Continued douching is needed to clear the stagnant mucus otherwise it will become superinfected and the bacterial toxins produced will further damage the cilia and produce a self-perpetuating cycle of stagnation. In the Hospital Nasal Packs The most uncomfortable experience for the patient is that of having a nasal pack removed; accordingly, if packs can be avoided, it is best to do so. If there is a moderate amount of bleeding at the end of surgery, then a pack soaked in 1:10000 epinephrine can be placed and then removed in the recovery room just before the laryngeal mask is taken out. If there is a little oozing, it will usually stop when the patient is placed 30 head-up after extubation. The bleeding often increases temporarily when the patient wakes up and coughs, as this raises the venous pressure. Any more marked bleeding is best dealt with before the end of surgery; it is usually due to one of the branches of the sphenopalatine artery and is best stopped using suction diathermy. Douching Ideally, patients are supervised in the douching technique before they are discharged. It is well worth spending some time with the patient to make sure they know how to douche, both to see that they are doing it properly and to help them through the first time they do it. This will greatly help compliance. Most patients are advised to douche at least twice daily for 2 weeks and particularly before taking any topical medication. Often patients are advised to douche four times a day in the first week if the mucosa is very unhealthy. In patients with severe polyposis, or those who have had a long history of infective rhinosinusitis, it may take weeks or months for the cilia to recover and protracted douching over this period may be required. In patients who have ciliary dysmotility or cystic fibrosis, douching is needed in the long term. Some studies have shown that adding antibiotics such as tobramycin to the douching can help patients with cystic fibrosis. It is interesting that studies have shown that douching, in its own right; helps relieve the symptoms of rhinosinusitis and the endoscopic appearance of mucosa. Medical Management Patients who have evidence of purulent secretions at surgery are advised to take a broad-spectrum antibiotic with anaerobic cover for 2 weeks, unless a culture suggests a different spectrum of sensitivity. Patients are advised that they may have loose stools toward the end of the course of treatment. Women are warned that they may get vaginal thrush toward the end of treatment and require an antifungal pessary. They are also warned that antibiotics can interfere with the absorption of the contraceptive pill. Patients with allergic rhinitis are advised to continue their topical nasal steroid therapy after douching and to follow their preoperative treatment strategy (e.g., allergen avoidance, antihistamines). Nasal drops enter the frontal sinus best if they are given with the patient lying flat and with their head cocked back over the edge of the bed. It is often difficult for a patient to gauge how many drops they have instilled in this position and it can be helpful to keep the drops in the fridge, so as to provide more sensation when they are put in. As with all patients with allergic rhinitis, the importance of compliance should be explained. In patients with nasal polyposis, topical nasal steroids are given for 3 months and then reduced if the mucosa looks healthy (Fig. 13.4). In patients with allergic aspergillosis or invasive aspergillosis, itraconazole is preferable to amphotericin as it is associated with fewer side effects. Nevertheless, liver function and morning cortisol levels should be monitored monthly.

Outpatient Visit at One Week Debridement In the early days of endoscopic sinus surgery, debridement was advocated in the first few days after surgery. This has not been shown to help, and patients dislike it. We do as little suction and instrumentation to patients as possible as they find it very uncomfortable. It is our practice to see patients after one week and not to remove any eschar unless adhesions are starting to form between two adjacent surfaces. Under these circumstances, the nasal airway is anaesthetized with a topical local anesthetic and the adhesions are divided; the patient is encouraged to douche more frequently and enthusiastically. We find that inserting cotton wool soaked in cophenylcaine for 3 minutes and then gradually advancing it is a good way to anaesthetize the nose and clear the eschar with a minimum amount of bleeding. Sometimes huge casts of altered blood can be removed to the satisfaction of the patient, as their airway is immediately improved. A further appointment in the following week may be indicated if there are concerns that adhesions may reform, so that any fibrinous strands can be cleared. Normally a further appointment at 610 weeks is given to check the state of the mucosa. We reinforce the need for douching and advise that patients should continue this until their airway feels clear and they have not irrigated out any debris for several days. We are happy for patients to blow their nose after approximately 4 days. Patients with ciliary disorders will have been told preoperatively that they will need to douche in the long term. Medical Management We are aware that some surgeons give steroids postoperatively to complement their surgery. We like to give them preoperatively rather than postoperatively in order reduce the extent of surgical manipulation and mucosal damage. For the first few days after surgery the patient will be more blocked than if they have postoperative steroids, but after that they will recover better because a smaller surface area of mucosa has been damaged. Postoperative Problems Crusting Where mucosa has been removed, it may take months for the cilia to return and any mucus that is produced will dry and collect. In this case, the following measures may help: regular douching, staying well hydrated, facial saunas or steam inhalations (advise patients to leave boiled water to stand for 5 minutes before inhaling as otherwise the steam will be too hot and will cause damage), and humidifying the environment (placing a damp flannel on a radiator in the bedroom or having a hot bowl of water in one corner). In a small proportion of patients, particularly those who have had several procedures or who live in a dry and dusty climate, areas of mucosa can become dry and atrophic. These patients may need to follow all of the above advice for an extended period. Various ointments have been used to stop the lining drying out. It is our experience that a greasy ointment such as petroleum jellyworks best. Glucose and glycerin drops disperse too quickly, as do water-miscible agents. Patients who have had radiotherapy or who have ciliary dyskinesia will need to douche indefinitely. Bleeding It is normal for the nose to produce blood-stained mucus for several days after surgery.

Pain The postoperative discomfort that patients experience is normally from bony damage; a combination of a nonsteroidal anti-inflammatory drug with either acetaminophen or codeine phosphate helps. The regular combination of these may be needed for a fewdays. It is good to give the nonsteroidal anti-inflammatory drug as a suppository or parenterally on induction so that it is active before the patient wakes up. Nasal Obstruction In the first few days after surgery, the accumulation of secretions and dried mucus tends to fill any airway that remains after the swollen turbinates have encroached on it. Douching can help considerably, but in a moderate proportion of patients the eschar builds up no matter how much douching the patient does. Local sympathomimetic sprays can provide some help for an hour or two, but it is important to tell patients not to take these for more than a few days in order to avoid habituation developing in the turbinate vasculature. Douching and humidification are the mainstay of treatment until mucosal edema settles. Oral steroids in the postoperative period may help reduce the edema that results from surgery, but the riskbenefit analysis of this strategy remains uncertain. A patient with the stress of surgery, and possibly with a reduced appetite for a day or two, may be more liable to gastric erosions if they take oral steroids. There is insufficient evidence available for the authors to have a clear idea whether the benefits of taking postoperative oral steroids outweigh the risks. Patients with allergic rhinitis, whether they have hay fever within season or perennial allergic rhinitis, will be helped by taking antihistamines up to and after surgery, in order to reduce the amount of secretions they produce and the amount of mucosal swelling following surgery.