Systematic review and metaanalysis of middle meatal packing after endoscopic sinus surgery Candace E. Hobson, M.D.,1 Garret W. Choby, M.D.,1 Eric W. Wang, M.D.,1 Sally C. Morton, Ph.D.,2 and Stella Lee, M.D.1

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ABSTRACT

Objective: The objective of this systematic review was to evaluate synechiae formation in patients who underwent packing in the middle meatus at the completion of endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) or recurrent acute rhinosinusitis. Data Sources: PubMed and Ovid. Review Methods: Prospective randomized controlled studies of ESS with the placement of middle meatal packing were reviewed and included for analysis. Metaanalysis of the pooled data was performed. Results: Eighteen prospective, randomized, controlled trials met inclusion criteria, resulting in a total of 925 subjects. Although there was a trend toward decreased risk of synechiae formation in the patients who underwent placement of middle meatal packing postoperatively (RR ⫽ 0.544), this did not achieve statistical significance on metaanalysis (p ⫽ 0.052). Conclusions: This systematic review and metaanalysis suggests that use of middle meatal packing does not significantly reduce the risk of synechiae formation after ESS. There was, however, significant heterogeneity of the data analyzed, and the difference between groups was just short of statistical significance in our metaanalysis. Additional prospective randomized studies on this topic will further elucidate the utility of middle meatal packing. (Am J Rhinol Allergy 29, 135–140, 2015; doi: 10.2500/ajra.2015.29.4153)

C

hronic rhinosinusitis (CRS) is a multifactorial inflammatory disorder that requires intensive medical therapy, and in patients who continue to be symptomatic, endoscopic sinus surgery (ESS) to remove polyps can reestablish natural drainage pathways and restore nasal airflow. Due to the potential risks of synechiae formation and resulting obstruction, sinus surgeons employ a variety of postoperative interventions to preserve sinus patency especially in the region of the middle meatus, or ethmoid cavity. Placement of packs, stents, and spacers into the middle meatus has been reported to prevent adhesion formation and middle turbinate lateralization, as well as achieve hemostasis.1,2 There are a vast number of products on the market currently available to the sinus surgeon, including both absorbable and nonabsorbable packing. The aim of this study was to compare clinical outcomes of ESS with and without the use of these devices.

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METHODS

Study Design

A systematic review of the English literature was performed comparing clinical outcomes after ESS with the placement of packing into the middle meatus postoperatively.

Inclusion and Exclusion Criteria Studies eligible for inclusion included prospective randomized controlled trials of adult and pediatric patients undergoing ESS with the placement of devices into the middle meatus for the treatment of CRS (with or without polyps) or recurrent acute rhinosinusitis in the 1

Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh School of Medicine, and 2Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pennsylvania Presented at the Combined Otolaryngology Spring Meetings, American Rhinologic Society, April 12–13, 2013, Orlando, Florida The authors have no conflicts of interest to declare pertaining to this article Address correspondence to Stella Lee, M.D., Otolaryngology-Head and Neck Surgery, University of Pittsburgh, 1400 Locust Street, Building B, Suite 11500, Pittsburgh, PA 15219 E-mail address: [email protected] Copyright © 2015, OceanSide Publications, Inc., U.S.A.

absence of systemic disease. Studies not meeting these criteria were excluded.

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Search Strategy

A computerized search of the PubMed and Ovid databases using the search terms, “chronic rhinosinusitis” or “chronic sinusitis” in combination with “middle meatus,” “synechiae,” “lateralization,” and “medialization,” was performed on April 15, 2012. We limited our search to English-language studies with human subjects. Additionally, we reviewed the references from all included studies to identify any further resources. Abstracts were reviewed by four of the authors (C.E.H., G.W.C., E.W.W., and S.L.) and assessed for inclusion or exclusion based on criteria detailed. Once this was accomplished, further full-text review was performed of the studies that met inclusion criteria.

Data Extraction The authors created a standardized data abstraction form a priori modeled after the Cochrane Collaboration templates. In addition to basic study data, the abstraction form documented the presence of synechiae and turbinate lateralization/middle meatal obstruction.

Statistical Analysis Metaanalysis was performed to compare the outcomes of the pooled studies. We used a DerSimonian and Laird random effects model for analysis of the pooled data using Stata version 12 software.3

RESULTS Our PubMed and Ovid searches resulted in a total of 712 references. In the initial screening, 643 articles were excluded that either did not meet search criteria or were duplicates. Three authors (C.E.H., E.W.W., and S.L.) independently reviewed each of the remaining 69 studies. Another 49 articles not meeting inclusion criteria were excluded, leaving 20 studies, and a total of 925 patients, for analysis (Table 1).1,4–22 The authors also scanned the references of these studies for other possible studies to include in the review. However, no further references were found. A Preferred Reporting Items for Systematic reviews and diagram of our study selection is provided in Fig. 1.23

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135

Table 1 Article Summary Year

n

Sepragel sinus (hylan B) as a postsurgical dressing for endoscopic sinus surgery

Title

Kimmelman et 2001 al.11

Author

10

Mitomycin C for the prevention of adhesion formation after endoscopic sinus surgery: A randomized, controlled study The clinical effects of hyaluronic acid ester nasal dressing (Merogel) on intranasal wound healing after functional endoscopic sinus surgery Effects of nonabsorbable packing in middle meatus after sinus surgery A randomized trial of Rapid Rhino Riemann and Telfa nasal packs following endoscopic sinus surgery Role of Mitomycin C in reducing adhesion formation following endoscopic sinus surgery

Chung et al.6

2002

55

Miller et al.13

2003

37

Absorbable Merogel (HA) in unilateral MM versus Merocel (NAP) in contralateral MM for 5–7 days

Bugten et al.1

2006

31

Bilateral NAP in MM for 5 days versus saline irrigation

Cruise et al.7

2006

45

A prospective single-blind randomized controlled study of use of hyaluronic acid nasal packs in patients after endoscopic sinus surgery Intra- and postoperative application of mitomycin C in the middle meatus reduces adhesions and antrostomy stenosis after FESS Long-term effects of postoperative measures after sinus surgery

Wormald et al.20

Effects of Meropack in the middle meatus after functional endoscopic sinus surgery in children with chronic sinusitis

30

2006

42

Konstantinidis et al.22

2008

30

Bugten et al.5

2008

31

Hu et al.9

2008

60

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136

Conclusions

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No statistically significant difference in synechiae, edema, or infection with the use of Merogel and unpacked, contralateral control

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No significant difference in symptoms of congestion, pain or HA; statistically significant decrease in adhesions in NAP group versus saline irrigation Nonabsorbable Rapid Rhino Rapid Rhino caused less pain on removal Reimann in unilateral MM versus compared with Telfa, mean VAS 2.0 versus nonabsorbable Telfa (control) in 3.7, less adhesions with the Rapid Rhino contralateral MM than Telfa pack (not significant)

T

O N 2006

Gupta and Motwani8

Intervention

Absorbable Sepragel sinus (hylan B: Statistically significant reduction in synechiae cross-linked hyaluronic acid gel) formation, middle meatal stenosis, mucosal into unilateral ethmoid cavity edema and improved mucosal regeneration versus no treatment on with Sepragel beginning 2 weeks contralateral side postoperatively; reduction remained statistically significant for outcomes of synechiae and stenosis Mitomycin for 4 minutes in Statistically significant decrease in mucosal unilateral MM versus salinehypertrophy and polypoid changes at one soaked cottonoid for 4 minutes in week, not significant beyond this time. contralateral MM. Both sides Decreased rate of adhesions with packed with a fingercot overnight mitomycin C (not significant)

Mitomycin C-soaked pledget into Statistically significant decrease in MM ⫻4 minutes (1 mL of 0.4 synechiae/adhesions and discharge in mg/mL) versus saline-soaked MMC group compared with saline. Also pledget in contralateral MM. Both significant decrease in residual disease and sides then packed with Merocel nasal obstruction (NAP) for 4 days Absorbable Merogel (HA) into No statistically significant difference in unilateral MM versus no incidence of synechiae, mucosal edema or treatment on contralateral side infection with the use of Merogel when compared with unpacked, contralateral control.

MMC-soaked pledget into MM for MMC application resulted in decreased 5 minutes (1 mL of 0.5 mg/mL) adhesion formation (not significant) and versus saline-soaked pledget in decreased antrostomy stenosis (statistically contralateral MM. Both sides then significant) compared with saline packed with Merocel (NAP) for 1 day; reapplication of MMC/saline at 4 weeks post-op Group 1. Bilateral NAP for 5 days Group 1. Improved symptoms of nasal versus saline irrigation congestion, HA, pain, discharge in patients with NAP over saline irrigation, although not statistically significant Group 2. Postoperative Group 2. Significant improvement in debridement versus saline symptoms in debridement group over irrigation saline irrigation group Absorbable Meropack into Meropack did not significantly reduce unilateral MM versus no synechiae formation as compared with the treatment on contralateral side unpacked control; however, it did reduce postoperative hemorrhage. No significant difference in adhesions, granulation, infection or patency of maxillary sinus

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Table 1 Continued Title Prevention of adhesion after endoscopic sinus surgery: Role of Mitomycin C

Author Baradaranfar et al.21

Year

n

2011

37 MMC-impregnated mesh (1.5 mL of MMC reduced postoperative adhesion 0.45 mg/mL) in to unilateral formation, but this difference was not MM, saline-soaked mesh into statistically significant contralateral MM for 5 minutes; both sides then packed with Merocel (NAP) for 72 hours 44 Absorbable Merogel (HA) into Statistically significant lower rate of bilateral MM or unilateral MM adhesions at both 4 and 12 weeks with versus NAP (antibiotic-coated greater reepithelialization, decreased Merocel sponge) into bilateral granulation tissue, and improved MM or unilateral MM appearance of nasal mucosa in MeroGel group

Intervention

Conclusions

Endoscopic outcomes of Berlucchi et resorbable nasal packing al.4 after functional endoscopic sinus surgery: A multicenter prospective randomized controlled study Effect of Kastl et al.10 carboxymethylcellulose nasal packing on wound healing after functional endoscopic sinus surgery Use of CMC foam sinus Szczygielski et dressing in FESS al.15

2009

The efficacy of a novel chitosan gel on hemostasis and wound healing after endoscopic sinus surgery Randomized controlled trial of hyaluronic acid/ carboxymethylcellulose dressing after endoscopic sinus surgery Safety and efficacy of a novel bioabsorbable, steroid-eluting sinus stent

Valentine et al.16

2010

Woodworth et al.19

2010

53 Absorbable HA/CMC into unilateral MM versus no treatment on contralateral side

2012

21 Absorbable Gelfoam into unilateral MM/ethmoid sinus with antibiotic ointment versus no treatment

Murr et al.14

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Topical Mitomycin C in functional endoscopic sinus surgery

2009

26 Absorbable CMC mesh or absorbable CMC gel in unilateral MM versus no treatment on contralateral side

2010

30 Absorbable CMC foam into unilateral MM versus NAP for 24 hours in contralateral MM

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No significant difference between the CMCpacked side and unpacked side with respect to wound healing

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Use of CMC foam resulted in statistically significant decrease in postoperative pain; decreased bleeding and synechiae formation (not significant). 36 Chitosan-dextran derivative gel into Statistically significant decrease in time to unilateral surgical site versus no hemostasis and number of adhesions with treatment on contralateral side chitosan gel

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Statistically significant decrease in nasal congestion with HA/CMC; significantly decreased synechiae formation in first 2 weeks postoperatively, although no difference in long-term synechiae formation between the two groups 2011 38 Absorbable, steroid-eluting stent in Statistically significant decrease in adhesions unilateral MM versus absorbable, and inflammation with steroid-eluting nondrug-eluting stent in stent. Decreased rate of MT lateralization contralateral MM with steroid-eluting stent, although not significant 2012 25 Mitomycin C- soaked pledget in MMC significantly reduced the incidence of unilateral MM for 5 minutes (1 synechiae in early post-op period (1 week), mL of 0.5 mg/mL) versus saline Statistical improvement in symptoms of pledget in contralateral MM; both nasal blockage and discharge at 1 month, sides then packed with acriflavin but no difference at 3 and 6 months and paraffin for 2 days 2012 105 Steroid-releasing, absorbable Steroid-eluting stent significantly reduces implant versus nondruginflammation, adhesions, and polypoid releasing, absorbable implant into tissue formation when compared with each MM nondrug-eluting stent

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Venkatraman et al.17

Advance II: A prospective, Marple et al.12 randomized study assessing safety and efficacy of bioabsorbable steroid-releasing sinus implants Comparison between Wee et al.18 Gelfoam packing and no packing after endoscopic sinus surgery in the same patients

No statistically significant difference between two groups based on symptom scores and endoscopic findings (synechiae, stenosis, and edema) 4 months after surgery

MM ⫽ middle meatus; NAP ⫽ nonabsorbable packing; VAS ⫽ visual analog scale; HA ⫽ hyaluronic acid; CMC ⫽ carboxymethylcellulose; MMC ⫽ mitomycin C.

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137

Idenficaon Screening

Addional records idenfied by reference review (n = 0 )

Titles and abstracts reviewed (n =712)

Duplicate or irrelevant arcles excluded (n = 643 )

Eligibility

Records idenfied via search of Ovid and PubMed database (n = 712 )

Full-text arcles assessed for eligibility (n = 69)

Arcles excluded (n = 49)

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Not prospecve, RCT* (n = 27)

No relevant intervenon (n = 12) No relevant outcomes (n=9)

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Included

Populaon undefined** (n = 1) Studies included in systemac review (n = 20)

Packing Versus No Packing

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Of the 18 studies, nine studies compared the outcomes of ESS followed by placement of middle meatal packing with outcomes without the placement of packing1,5,9–11,16,18–20. Eight of these nine studies reported synechiae formation as an outcome measure. Three studies reported a statistically significant decrease in synechiae formation with the use of middle meatal packing.1,11,16 One study reported a statistically significant decrease in the mean synechiae score (graded 0–3) with the use of middle meatal packing.18 And four studies did not show a statistically significant difference in synechiae formation with the use of middle meatal packing.9,10,19,20 The time period for endoscopic evaluation documenting the presence of synechiae varied between studies, and most studies evaluated this outcome at more than one time point. For our metaanalysis, we chose to perform our analysis at four weeks postoperatively, or the closest reported time point after surgery when synechiae formation could be reasonably assessed. Six studies were appropriate to be pooled for metaanalysis (Table 2). Metaanalysis revealed a decreased incidence of synechiae formation with the placement of packing in the middle meatus. However, this difference was just short of statistical significance (RR ⫽ 0.544; CI: 0.295–1.005; p ⫽ 0.052). The I2 value was 72%, indicating significant heterogeneity (X2 ⫽ 17.33, df ⫽ 5, p ⫽ 0.004). A forest plot of this outcome is documented in Fig. 2.

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Absorbable Versus Nonabsorbable Packing Three studies compared outcomes of ESS after the placement of absorbable versus nonabsorbable packing.4,13,15 All three studies reported a decrease in synechiae/adhesion formation with the use of

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Figure 1. Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) diagram of study selection. *, Randomized controlled trial; **, patients not defined as having CRS or recurrent acute rhinosinusitis.

Table 2 Comparison of synechiae formation with and without packing Incidence of Synechiae Formation Packing

No Packing

Author

Present

Absent

Present

Absent

Bugten et al. Bugten et al. Hu et al. Wormald et al. Kimmelman et al. Valentine et al. Kastl et al. Wee et al. Woodworth et al. Total

— 7 21 9 — 3 3 — 10 53

— 55 39 30 — 33 23 — 38 218

— 29 26 6 — 16 5 — 14 96

— 27 34 33 — 20 21 — 34 169

absorbable packing. However, this difference was only statistically significant in two of the studies.4,13

DISCUSSION Although a wide variety of middle meatal packs and devices is currently available to the sinus surgeon, evidence-based outcome measures are needed to direct treatment and surgical decision making. Sinus surgeons employ a variety of postoperative treatment regimens after ESS to prevent synechiae formation, middle turbinate lateralization, and stenosis.24–26

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RR (95% CI)

Study

Figure 2. Relative risk of synechiae formation with packing versus no packing.

Bugten et al. 2006

0.22 (0.10, 0.46)

18.33

Hu et al. 2008

0.81 (0.51, 1.27)

22.07

Wormald et al. 2006

1.50 (0.59, 3.81)

15.86

Valentine et al. 2010

0.19 (0.06, 0.59)

13.39

Kastl et al. 2009

0.60 (0.16, 2.26)

11.55

Woodworth et al. 2010 Overall (I-squared = 71.2%, p = 0.004)

0.71 (0.35, 1.45)

18.81

0.54 (0.29, 1.00)

100.00

.0598

2.

3. 4.

O N

6.

7.

8.

9.

10.

11.

12.

13.

This systematic review shows that the overall incidence of synechiae formation is decreased with the placement of middle meatal packing after ESS. However, this difference was just short of statistical significance in our metaanalysis (p ⫽ 0.052). Our analysis is limited by the heterogeneity of the types and methods of packing used, and further rigorous prospective studies are needed to determine whether middle meatal packing after ESS can improve outcome.

14.

15.

16.

REFERENCES Bugten V, Nordgård S, Skogvoll E, and Steinsvåg S. Effects of nonabsorbable packing in middle meatus after sinus surgery. Laryngoscope 116:83–88, 2006.

17.

1

16.7

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Valentine R, Wormald PJ, and Sindwani R. Advances in absorbable biomaterials and nasal packing. Otolaryngol Clin North Am 42:813– 828, ix, 2009. DerSimonian R, and Laird N. Meta-analysis in clinical trials. Controlled Clin Trials 7:177–188, 1986. Berlucchi M, Castelnuovo P, Vincenzi A, et al. Endoscopic outcomes of resorbable nasal packing after functional endoscopic sinus surgery: A multicenter prospective randomized controlled study. Eur Arch Otrhinolaryngol 266:839–845, 2009. Bugten V, Nordgard S, and Steinsvag S. Long-term effects of postoperative measures after sinus surgery. Eur Arch Otrhinolaryngol 265:531–537, 2008. Chung JH, Cosenza MJ, Rahbar R, and Metson RB. Mitomycin C for the prevention of adhesion formation after endoscopic sinus surgery: A randomized, controlled study. Otolaryngol Head Neck Surg 126: 468–474, 2002. Cruise AS, Amonoo-Kuofi K, Srouji I, et al. A randomized trial of Rapid Rhino Riemann and Telfa nasal packs following endoscopic sinus surgery. Clin Otolaryngol 31:25–32, 2006. Gupta M, and Motwani G. Role of mitomycin C in reducing adhesion formation following endoscopic sinus surgery. J Laryngol Otol 120: 921–923, 2006. Hu KH, Lin KN, Li WT, and Huang HM. Effects of Meropack in the middle meatus after functional endoscopic sinus surgery in children with chronic sinusitis. Int J Pediatr Otorhinolaryngol 72:1535–1540, 2008. Kastl KG, Betz CS, Siedek V, and Leunig A. Effect of carboxymethylcellulose nasal packing on wound healing after functional endoscopic sinus surgery. Am J Rhinol Allergy 23:80–84, 2009. Kimmelman CP, Edelstein DR, and Cheng HJ. Sepragel sinus (hylan B) as a postsurgical dressing for endoscopic sinus surgery. Otolaryngol Head Neck Surg 125:603–608, 2001. Marple BF, Smith TL, Han JK, et al. Advance II: A prospective, randomized study assessing safety and efficacy of bioabsorbable steroid-releasing sinus implants. Otolaryngol Head Neck Surg 146: 1004–1011, 2012. Miller RS, Steward DL, Tami TA, et al. The clinical effects of hyaluronic acid ester nasal dressing (Merogel) on intranasal wound healing after functional endoscopic sinus surgery. Otolaryngol Head Neck Surg 128:862–869, 2003. Murr AH, Smith TL, Hwang PH, et al. Safety and efficacy of a novel bioabsorbable, steroid-eluting sinus stent. Int Forum Allergy Rhinol 1:23–32, 2011. Szczygielski K, Rapiejko P, Wojdas A, and Jurkiewicz D. Use of CMC foam sinus dressing in FESS. Eur Arch Otrhinolaryngol 267:537–540, 2010. Valentine R, Athanasiadis T, Moratti S, et al. The efficacy of a novel chitosan gel on hemostasis and wound healing after endoscopic sinus surgery. Am J Rhinol Allergy 24:70–75, 2010. Venkatraman V, Balasubramanian D, Gopalakrishnan S, et al. Topical mitomycin C in functional endoscopic sinus surgery. Eur Arch Otrhinolaryngol 269:1791–1794, 2012.

T 5.

CONCLUSIONS

1.

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Note: Weights are from random effects analysis

There is a diverse spectrum of practices with regard to the use of postoperative middle meatal packing, and some surgeons may choose to not use any packing at all. Orlandi and Lanza argue that packing, as well as other hemostatic agents, is rarely necessary in routine ESS and that adhesions can be prevented by preserving the mucosa of the middle turbinate, removing the uncinate process completely and by suturing the middle turbinate to the nasal septum.27 Furthermore, some argue against the use of middle meatal packing, because it may be associated with nasal pain and obstruction, headaches, risk of dislodgement, aspiration, or toxic shock syndrome and may additionally cause pain or bleeding upon removal.1,18 Absorbable middle meatal packing does not require removal and thus avoids the latter complication. The decision to use nonabsorbable packing is not simple, however, because there are a variety of absorbable packing materials available. These include hyaluronic acid derivatives, carboxymethylcellulose, gelatin, polylactide-co-glycolide (stents), chitosan-dextran derivatives, and topical antifibrinolytics. In addition, with the advent of steroid-eluting stents, indications and patient selection for placement of these devices need to be further defined. In our review, we observed significant heterogeneity in studies evaluating the utility of nasal packing. The studies were heterogeneous in the type of packing (gels, foams, Merocel) used, the use of topical medications (steroids, mitomycin C), and the duration of packing. Furthermore, there was heterogeneity in not only the reported outcomes but also how those outcomes were reported. Additionally, we acknowledge that since the completion of this review, additional prospective studies on this topic have been completed, which may have changed our results.28,29 A recent metaanalysis evaluating the incidence of postoperative synechiae compared absorbable with nonabsorbable packing, yielding only two studies.30 No significant difference was seen between the two groups, but the small number of studies limits the conclusions that can be drawn. Our metaanalysis is unique in that only studies, which included a true control, i.e., no packing, were included.

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% Weight

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18.

19.

20.

21.

22.

23.

24.

Wee JH, Lee CH, Rhee CS, and Kim JW. Comparison between Gelfoam packing and no packing after endoscopic sinus surgery in the same patients. Eur Arch Otrhinolaryngol 269:897–903, 2012. Woodworth BA, Chandra RK, Hoy MJ, et al. Randomized controlled trial of hyaluronic acid/carboxymethylcellulose dressing after endoscopic sinus surgery. ORL J Otorhinolaryngol Relat Spec 72:101–105, 2010. Wormald PJ, Boustred RN, Le T, et al. A prospective single-blind randomized controlled study of use of hyaluronic acid nasal packs in patients after endoscopic sinus surgery. Am J Rhinol 20:7–10, 2006. Baradaranfar MH, Khadem J, Taghipoor Zahir S, et al. Prevention of adhesion after endoscopic sinus surgery: Role of mitomycin C. Acta Med Iranica 49:131–135, 2011. Konstantinidis I, Tsakiropoulou E, Vital I, et al. Intra- and postoperative application of mitomycin C in the middle meatus reduces adhesions and antrostomy stenosis after FESS. Rhinology 46:107–111, 2008. Moher D, Liberati A, Tetzlaff J, et al., PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. J Clin Epidemiol 62:1006–1012, 2009.

25. 26.

27. 28.

29.

30.

Musy PY, and Kountakis SE. Anatomic findings in patients undergoing revision endoscopic sinus surgery. Am J Otolaryngol 25:418– 422, 2004. Ramadan HH. Surgical causes of failure in endoscopic sinus surgery. Laryngoscope 109:27–29, 1999. Schaitkin B, May M, Shapiro A, et al. Endoscopic sinus surgery: 4-year follow-up on the first 100 patients. Laryngoscope 103:1117– 1120, 1993. Orlandi RR, and Lanza DC. Is nasal packing necessary following endoscopic sinus surgery? Laryngoscope 114:1541–1544, 2004. Baguley CJ, Stow NW, Weitzel EK, and Douglas RG. Silastic splints reduce middle meatal adhesions after endoscopic sinus surgery. Am J Rhinol Allergy 26:414–417, 2012. Matheny KE, Carter KB Jr, Tseng EY, and Fong KJ. Safety, feasibility, and efficacy of placement of steroid-eluting bioabsorbable sinus implants in the office setting: A prospective case series. Int Forum Allergy Rhinol 4:808–815, 2014. Wang TC, Tai CJ, Tsou YA, et al. Absorbable and nonabsorbable packing after functional endoscopic sinus surgery: Systematic review and meta-analysis of outcomes. Eur Arch Otorhinolaryngol doi: 10.1007/s00405–014-3107–2 June 14, 2014. [Epub ahead of print]. e

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Systematic review and metaanalysis of middle meatal packing after endoscopic sinus surgery.

The objective of this systematic review was to evaluate synechiae formation in patients who underwent packing in the middle meatus at the completion o...
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