Postoperative Nasal Debridement in the Operating Room after Endoscopic Skull Base Surgery: When is it Indicated?

Introduction: The nasal debridement after endoscopic endonasal skull base surgery is a fundamental step in the overall postoperative patient care. The debridement aims to decrease the risk of infections improving the drainage of the sinuses and nasal breathing after the surgery. Depending on the degree of nasal structures resected for the approach, the type of reconstruction and comorbidities, some patients may require several office visits for the nasal cleaning. Most adult patients often tolerate the outpatient debridement with topical local anesthesia. However, some patients cannot tolerate debridement in the clinic and the procedure is performed in the operating room under general anesthesia or deep sedation. There is no study in the literature that clarifies this issue. The main objectives of the study are to determine the incidence of debridement performed in the operating room (inpatient) and to elucidate the factors associated with it. In addition, we sought to determine factors that are associated with increased nasal crusting, and the frequency of debridement in the outpatient setting.

Methods: The medical data of adult patients who had endoscopic endonasal skull base surgery at Albany Medical Center from January 2014 to December 2018 were reviewed retrospectively. Premorbid and operative data including the type of endoscopic approach and the type of reconstruction (none, mucosal grafts, and pedicled flap) were recorded. Postoperative data including the number of outpatient and inpatient debridement was recorded. Chi-square, t-test, Fisher’s analysis were used for statistical analysis

Results: Two hundred and thirty-five (235) patients who met the inclusion criteria had 246 surgeries. The average age was 55 years (range, 18–87 years). Female comprised 57.0%. Majority of the disease 65.4% was sella/suprasellar lesions including pituitary adenoma, and craniopharyngioma. Eleven percent of the cases involved anterior cranial skull base resections. Free mucosal graft from the nasal floor was used for reconstruction in 53.2% and a pedicled flap including either nasoseptal or pericranial flap was used in 22.8%. Fifty-eight cases (23.7%) were extradural procedures and did not require reconstruction. The rate of postoperative inpatient debridement was 4.90% with average of 37.6 ± 15.3 days from the primary surgery. The harvesting of pedicled flaps showed a statistical association with the need of inpatient debridement compared with free mucosal graft and no reconstruction (12.5 vs. 3.8 vs. 0.0% p < 0.05). Pedicled flap patients also required more outpatient nasal debridement than nonpedicled flap patients (2.6 vs. 1.7 vs. 1.5 debridement; p < 0.001). History of psychiatric disorder was also associated with need for inpatient debridement (9.52 vs. 3.30%, p < 0.05). Current tobacco smoking had higher rate of inpatient debridement but was not statistically significant (9.09 vs. 4.22%, p>0.05).

Conclusion: Nasal debridement performed in the operating room is a low occurrence in postoperative management of patients who underwent endoscopic skull base surgery. The harvesting of pedicled flaps, history of psychiatric disorders, and possibly smoking are the main factors associated with increased risk of need for inpatient debridement in the adult population. Patients with these risk factors should be counseled about that possibility during the initial evaluation.