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: ahesham73@yahoo.com

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

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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

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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.

References

1. Fernandes SV (1999) Postoperative care in functional endoscopic

sinus surgery. Laryngoscope 109:945–948

2. Gross RD, Sheridan MF, Burgess LP (1997) Endoscopic sinus

surgery complications in residency. Laryngoscope 107:1080–1085

3. Van Duyne J, Coleman JA Jr (1995) Treatment of nasopharyn-

geal inlet stenosis following uvulopalatopharyngoplasty with the

CO2 laser. Laryngoscope 105:914–918

4. Levine HL (1989) Endoscopy and the KTP/532 laser for nasal

sinus disease. Ann Otol Rhinol Laryngol 98:46–51

5. Feyh J (1995) Endoscopic surgery of the nose and paranasal

sinuses with the aid of the holmium:YAG laser. Adv Otorhino-

laryngol 49:122–124

6. Muntz HR (1987) Pitfalls to laser correction of choanal atresia.

Ann Otol Rhinol Laryngol 96:43–46

7. Costa VP, Spaeth GL, Eiferman RA et al (1993) Wound healing

modulation in glaucoma filtration surgery. Ophthalmic Surg

24:152–166

8. Majmudar PA, Forstot SL, Dennis RF et al (2000) Topical

mitomycin C for subepithelial fibrosis after refractive corneal

surgery. Ophthalmology 107:89–94

9. Correa AJ, Reinisch L, Sanders DL et al (1999) Inhibition of

subglottic stenosis with mitomycin C in the canine model. Ann

Otol Rhinol Laryngol 108:1053–1060

10. Tom LWC, Palasti S, Potsic WP et al (1997) The effects of

gelatin film stents in the middle meatus. Am J Rhinol 229–232

11. Friedman M, Landsberg R, Tanyeri H (2000) Middle turbinate

medialization and preservation in endoscopic sinus surgery.

Otolaryngol Head Neck Surg 123:76–80

12. Miller RS, Steward DL, Tami TA et al (2003) The clinical effects

of hyaluronic acid ester nasal dressing (Merogel) on intranasal

wound healing after functional endoscopic sinus surgery. Oto-

laryngol Head Neck Surg 128(6):862–869

13. Chung JH, Cosenza MJ, Rahbar R, Metson RB (2002) Mitomycin

C for the prevention of adhesion formation after endoscopic sinus

surgery: a randomized, controlled study. Otolaryngol Head Neck

Surg 126(5):468–474

14. Lee JY, Lee SW (2007) Preventing lateral synechia formation

after endoscopic sinus surgery with a silastic sheet. Arch Oto-

laryngol Head Neck Surg 133(8):776–779

15. Shrime MG, Tabaee A, Hsu AK et al (2007) Synechia formation

after endoscopic sinus surgery and middle turbinate medialization

with and without FloSeal. Am J Rhinol 21(2):174–179

16. Konstantinidis I, Tsakiropoulou E, Vital I et al (2008) Intra- and

postoperative application of mitomycin C in the middle meatus

reduces adhesions and antrostomy stenosis after FESS. Rhinology

46(2):107–111

17. Anand VK, Tabaee A, Kacker A et al (2004) The role of mito-

mycin C in preventing synechia and stenosis after endoscopic

sinus surgery. Am J Rhinol 18(5):311–314

18. Kao SCS, Liao CL, Tseng JHS et al (1996) Dacryocystorhinostomy

with intraoperative mitomycin C. Ophthalmology 104:86–91

19. Hueman EM, Simpson CB (2005) Airway complications from

topical mitomycin C. Otolaryngol Head Neck Surg 133:831–835

20. Hu D, Sires BS, Tong DC et al (2000) Effect of brief exposure to

mitomycin C on cultured human nasal mucosa fibroblasts. Oph-

thal Plast Reconstr Surg 16:119–125

1292 Eur Arch Otorhinolaryngol (2011) 268:1289–1292

123