الفهرس 
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Abstract
Endoscopic sinus surgery (ESS) has become the standard
treatment for the management of medically refractory chronic
rhinosinusitis and nasal polyps. The common complications of ESS
include postoperative formation of synechiae in the middle meatus
and nasal bleeding. The former is considered the most common
complication of ESS, and the incidence of this complication ranges
from1%to 36%.1e3 Synechia in the middle meatus can block the
normal mucociliary drainage pathway of the sinuses and lead to
disease recurrence. Numerous techniques, including suture
medialization, partial resection of the middle turbinate, and nasal
packing in the middle meatus, have been used to prevent postoperative
synechia formation.
Nasal packing remains the most common procedure to prevent
synechia formation and postoperative bleeding. Conventional packing
products, such as Vaseline gauze strip and expandable polyvinyl
acetate (Merocel) are non-absorbable materials. New biodegradable
packing materials with various degrees of efficacy have also been
developed, for example, FloSeal, MeroGel and carboxy-Methyl-
Cellulose. However, the effects of these packing agents on mucosal
healing and postoperative bleeding have not been conclusively
determined.
Absorbable biomaterials are commonly used after endoscopic
sinus surgery, both for hemostatic and wound healing considerations.
Although removable nasal packing is the traditional method of
controlling ongoing bleeding and modulating wound healing, it is
uncomfortable for patients and associated with several complications.
Currently available absorbable agents frequently incite an inflammatory reaction and have been shown in animal and human
trials to adversely affect the wound healing process. Newer agents
offer distinct advantages because of their unique composition and
rapid clearance profiles.
The aim of this study is to compare the effect of absorbable
versus non-absorbable nasal packings on immediate postoperative
symptoms and wound healing after functional endoscopic sinus
surgery . Twenty patients with bilateral chronic rhinosinusitis were
enrolled for this study at Otorinolaryngology department at Menoufiya
Faculty of Medicine. The patients were subjected to functional
endoscopic sinus surgery using mucosal sparing technique. At the end
of procedure, the right nasal cavity of each patient was packed with
absorbable packing material (CMC based - Rapid Rhino Sinu Knit)
while packing the left nasal cavity with non-absorbable pack
(expandable polyvinyl acetate - Merocel). Assessment of immediate
postoperative symptoms including bleeding and patient discomfort at
day one postoperative was done. Follow up of the sinus mucosa was
done at 2, 4 and 12 weeks postoperative including endoscopic
assessment using POSE score and histopathological examination of
tissue biopsy materials using H & E, Masson Trichrome, Ki67, α
SMA, CD34 and CD117 stains.
In the present study, a significant difference can be shown
between the two types of packing regarding immediate postoperative
symptoms using patient questionnaire. This difference has shown
more benefit of non-absorbable packing in control of bleeding but
with more pain during removal. By endoscopic evaluation at early
healing (2 and 4 weeks) after FESS, absorbable packing has caused
significantly more oedema, MMA closure, maxillary sinus contents
and nasal secretions while non-absorbable packing has caused significantly more synechia. All turned to be of no significant
difference at late healing (12 weeks) except for MMA closure.
Regarding re-epithelialization by HP assessment, there was no
significant difference between the two types of packing at early and
late healing. Absorbable packing showed significantly more
inflammatory cells at both early and late healing with significantly
more oedema at early healing only. On the other hand, nonabsorbable
packing showed significantly more fibroblast and
myofibroblast proliferation, collagen fibers density and orientation,
Ki67 LI and α SMA H score at both early and late healing. Both types
of packing are associated with stem cell proliferation as detected by
CD117 staining but with no significant intergroup difference. So,
absorbable packing can induce more bleeding, oedema and
inflammation while non- absorbable packing induces more
discomfort, synechia and fibrosis. This difference is attributed to the
unique nature of each packing. As we always try to avoid abnormal
healing, we prefer absorbable packing due to the reversible nature of
its associated changes with no much impact on quality of healing.