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RHINOLOGY
Laser and topical mitomycin C for management of nasal synechiaafter FESS: a preliminary report
Ahmed Hesham • Ahmed Fathi • Mahmoud Attia •
Sherif Safwat • Ahmed Hesham
Received: 8 September 2010 / Accepted: 15 March 2011 / Published online: 30 March 2011
� Springer-Verlag 2011
Abstract The objective of the study is to assess the role
of diode laser coupled with topical mitomycin C (MMC)
in the management of synechia after endoscopic sinus
surgery. Twenty-five patients with recurrent sinusitis due to
synechia between the middle turbinate and lateral nasal
wall after endoscopic sinus surgery were included in this
study. Diode laser was used to divide the synechia and
MMC was applied topically in the area of the middle
meatus for 5 min. Patients were followed for 6 months to
assess symptoms improvement, recurrence of synechia and
CT scan changes. Most of our patients reported improve-
ment of their symptoms, recurrent synechia occurred in
15% of the patients with significant improvement of the CT
scan findings. In conclusion, the diode laser with topical
MMC is an outpatient procedure which is simple, safe and
effective in managing postoperative nasal synechia.
Keywords Nasal synechia � Diode laser � Mitomycin C �FESS � Postoperative
Introduction
Functional endoscopic sinus surgery (FESS) is frequently
performed for chronic rhinosinusitis refractory to medical
management. Despite advances in instrumentation and
surgical technique, postoperative synechia formation
continues to occur in between 1 and 27% of patients [1].
When synechia occur in the middle meatus, the maxillary,
ethmoid and frontal sinuses may become obstructed
resulting in recurrent problems [2].
Lasers are excellent instruments for dividing granulation
tissue, scar, adhesions and membranous stenosis [3]. The
CO2, argon, Ho:YAG, KTP, diode, and Nd:YAG lasers
have been all successfully used for this purpose [4]. In
many cases, it is enough simply to divide the tissue. In
some cases, it is also advisable to vaporize the peripheral
tissue to gain additional space [5]. Stent insertion is gen-
erally unnecessary, but regular postoperative care with
removal of fibrin deposits should be maintained to prevent
recurrence [6].
Mitomycin C (MMC) is an alkylating antineoplastic
antibiotic that prevents replication of fibroblasts and epi-
thelial cells. It has been demonstrated in several clinical
studies to prevent healing by selectively interrupting DNA
replication, and inhibiting mitosis and protein synthesis
[7]. It has been used extensively in ophthalmology as an
adjunctive treatment in pterygium and glaucoma surgery to
prevent scarring and bleb failure [8].
In the field of otolaryngology, MMC is currently under
inquiry for the prevention of laryngotracheal stenosis in
high risk patients and as an adjunct to FESS to prevent
closure of the maxillary sinus antrostomy [9].
The aim of the study was to assess the role of diode laser
coupled with topical MMC in the management of synechia
after endoscopic sinus surgery.
A. Hesham � A. Fathi � M. Attia
Department of Otorhinolaryngology,
Faculty of Medicine, Cairo University,
Cairo, Egypt
S. Safwat
Laser Institute of Enhanced Laser Sciences,
Cairo University, Cairo, Egypt
A. Hesham (&)
Magrabi Eye and Ear Hospital, P.O. Box 513,
112 Muscat, Sultanate of Oman
e-mail: [email protected]
123
Eur Arch Otorhinolaryngol (2011) 268:1289–1292
DOI 10.1007/s00405-011-1587-x
Materials and methods
This prospective study was conducted at the Laser Institute
of Enhanced Laser Sciences, Cairo University during the
period from January 2009 to 2010. The study was approved
by the local ethics committee with informed consent being
taken from the patients. This study was done in accordance
with the ethical standards laid down in 1964 Declaration of
Helsinki.
This study included 25 patients with recurrent sinusitis
due to synechia between the middle turbinate and lateral
nasal wall (interfering with sinus ventilation and drainage)
after endoscopic sinus surgery. Inclusion was based on the
history taking, endoscopic examination and CT scan of the
paranasal sinuses [opacification of any of the anterior
group of sinuses with obstruction of the ostiomaetal com-
plex (OMC) area].
Patients were excluded based on the following criteria:
1. Synechia between the middle turbinate and the septum.
2. Synechia due to other causes, e.g., trauma and
granulomatous diseases.
3. Complete scarring between middle turbinate and
lateral nasal wall.
4. Synechia with no obvious interference with sinus
ventilation.
5. Involvement of the sphenoid or posterior ethmoid
sinuses on CT scan.
Surgical procedure
All the procedures were done under local anesthesia
(1% lidocaine with 1:100,000 epinephrine). With the aid of
nasal endoscopes (Karl Storz Hopkin telescopes 0� and
30�), the diode laser (Quanta System, class 4 product,
wavelength 980 nm) was used to deliver the laser energy
through flexible 400-nm optical fiber coupled with suction
tube to allow for smoke evacuation during the surgery.
The laser was set at power of 20 W, in a continuous or
pulsed mode, producing spot size of 0.4–0.8 mm to cut the
synechia. Small cottonoid soaked in 1 ml of MMC in a
concentration of 0.4 mg/ml was left in the area of the
middle meatus for 5 min, after which the area was washed
with 60 ml normal saline.
An eye safety filter was attached to the nasal telescope
to protect the surgeon’s eye from the laser beam while the
other eye was protected with eye safety monocle. The other
staff, as well as the patients’ eyes, were protected with
goggles.
The patients were discharged on the same day with no
packs and only saline nasal wash was prescribed for
2 weeks.
Follow-up visits were done weekly in the first month,
then monthly for 6 months to check for subjective
improvement and for synechia recurrence on endoscopic
photography. CT scan of the paranasal sinuses was repe-
ated after 6 months to confirm resolution of the sinusitis.
Data were statistically described in terms of frequencies
(number of cases) and percentages. Comparison between
preoperative and postoperative results was done using
McNemar test. A probability value (p value) less than
0.05 was considered statistically significant. All statistical
calculations were done using computer programs Stats
Direct statistical software version 2.7.2 for MS Windows,
StatsDirect Ltd., Cheshire, UK
Results
Among the 25 patients included in this study, 5 patients
were lost for follow-up, so they were excluded from the
study. The study group (20 patients) included 12 males
(60%) and 8 females (40%) with a mean age of 40 years.
The most frequent symptoms among those patients were
nasal obstruction (80%), nasal discharge (70%) and head-
ache (50%), which were not responding to medical treat-
ment after a mean of 1.7 sinus surgeries (34 procedures).
The synechia between the middle turbinate and lateral
nasal wall was confirmed by endoscopic examination.
Photography was obtained and the results were compared
with the postoperative one (Fig. 1). Synechia was bilateral
in 12 patients and unilateral in 8 patients, making a total of
32 sides.
CT scan of the paranasal sinuses was done and only
those involved with synechia were analyzed. The OMC,
maxillary sinus, anterior ethmoids and frontal sinus were
involved in 32, 26, 20, 10 sides, respectively (Fig. 2).
The patients tolerated the procedure well with an
uneventful recovery. No complications were encountered
in the immediate or early postoperative period.
Fig. 1 Endoscopic view. a Synechia between the right middle
turbinate and lateral nasal wall. b 2 months after successful division
of the synechia
1290 Eur Arch Otorhinolaryngol (2011) 268:1289–1292
123
During follow-up endoscopy, only synechia interfer-
ing with sinus drainage were considered as recurrence.
Endoscopic examination revealed recurrent synechia in 3
patients (15%), 4 sides including 1 bilateral case (all
occurred within 2 months). Recurrent synechia were divi-
ded again and patients were followed up with no evidence
of recurrence until the end of the study. None of our
patients required revision of the original endoscopic sinus
surgery.
At the end of the 6 months, most of our patients had
reported improvement of their symptoms (Table 1).
Postoperative CT scan revealed involvement of the
OMC, maxillary sinus, anterior ethmoids and frontal sinus
in 8, 6, 4 and 2 sides, respectively (Table 2).
Discussion
When injured mucosal surfaces are in close proximity at
the completion of sinonasal surgery, regenerating epithe-
lium and fibrous tissue may grow between these surfaces to
create an adhesion. If the adhesion is of sufficient size and
proper location, it can lead to recurrence of obstruction of
an adjacent sinus ostium and consequently sinus infection.
Attempts to limit such adhesion formation with anatomic
barriers have been met with limited success [10].
This study was conducted in a prospective manner to
assess the efficacy of diode laser coupled with topical
MMC in the management of nasal synechia after endo-
scopic sinus surgery.
Previous reports on nasal synechia were focusing on the
prevention [11–17], while the management was not suffi-
ciently addressed, so we conducted our study to tackle this
issue.
We conducted this study on 20 patients who developed
symptoms suggestive of chronic sinusitis after endoscopic
sinus surgery due to synechia interfering with sinus
drainage. The analysis of the CT scan of the sides only
involved with synechia and exclusion of involvement of
the posterior group of sinuses ensure proper correlation
between nasal synechia and CT scan findings.
Diode laser was used to divide the synechia and topical
MMC was used to prevent synechia reformation based on
reports of previous studies [13, 16].
No complications were reported in our study related to
MMC use. Complications, including glaucoma, corneal
ulcers, cataracts, scleral calcifications, and endophthalmitis
were reported in the ophthalmology literature [18], these
complications occurred from cumulative use in patients
taking MMC as eye drops for several days and not similar
to the one time topical application used in our study. No
serious complications from topical mitomycin use in the
nose and ear were reported in the literature. On the other
hand, life-threatening airway obstruction necessitating
emergent airway intervention associated with the use of
topical MMC in endoscopic management of laryngotra-
cheal stenosis was reported by Hueman and Simpson [19].
Airway obstruction was caused by the characteristic
accumulation of obstructing fibrinous exudate at the oper-
ative site.
Most of our patients reported significant improvement of
their symptoms. Recurrent synechiae were observed in
Fig. 2 Coronal CT scan.
a Opacification of the left
maxillary, ethmoid sinuses and
blockage of the OMC due to
left-sided nasal synechia.
b Clear sinuses and patent OMC
6 months after division of the
nasal synechia
Table 1 Postoperative symptoms vs preoperative ones
Symptoms Percentage
of patients
(pre operatively)
Percentage
of patients
(postoperatively)
p
Nasal obstruction 80 20 0.004
Nasal discharge 70 15 \0.001
Headache 50 10 0.008
Table 2 Postoperative CT findings as compared to the preoperative
ones
Sinus involved Number of sides
(preoperatively)
Number of sides
(postoperatively)
p
Ostiomaetal complex 32 8 \0.001
Maxillary 26 6 \0.001
Anterior ethmoids 20 4 \0.001
Frontal 10 2 0.008
Eur Arch Otorhinolaryngol (2011) 268:1289–1292 1291
123
15% of patients within the first 2 months. As reported by
Chung et al. [13], this recurrence could be attributed to the
conclusion reported by one study that 70% of fibroblasts
were still alive after a 5 min of exposure to 0.4 mg/ml
MMC and exhibited evidence of regrowth within 2–3 days
[20]. CT scan repeated after 6 months showed significant
improvement as compared to the preoperative one.
One of the limits of our study is the small number of
patients, but based on the encouraging preliminary results,
we recommend conducting further studies on a larger scale.
Conclusions
The diode laser with topical MMC is an outpatient proce-
dure which is simple, safe and effective in managing
postoperative nasal synechia.
Acknowledgments The authors would like to thank Dr Ahmed
Saada, MD, for his help in photography.
Conflict of interest The authors declare that they have no conflict
of interest.
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