Rhinologic Surgery Research Articles

Historical Instruments for the Modern Sinus Surgeon.

Despite a proliferation of technological advances in sinonasal surgery, "cold steel" instruments still comprise the core of the sinus surgeon's tools of the trade. Many of these implements retain eponyms that recall the legacies of prominent surgeons of the past. This review aims to familiarize the reader with the lives of 10 men who designed and popularized some of the most recognizable sinus instruments, without which the practice of rhinologic surgery would be unrecognizable. Ten individuals whose inventions are still used to this day and retain their names: Hartmann, Killian, Freer, Blakesley, Weil, Frazier, Grünwald, Hajek, Takahashi, and Cottle. Review of the history of these instruments helps demonstrate how sinus surgery has evolved to where it is today. The men described in this review transformed the practice of rhinologic surgery with their ingenuity and perseverance.

Opioid analgesic use and patient-reported pain outcomes after rhinologic surgery.

Opioid-based analgesics are routinely prescribed after elective rhinologic surgery. Balancing appropriate pain management while avoiding overprescription necessitates an evidence-based approach. Patients undergoing elective rhinologic surgery, including endoscopic sinus surgery (ESS), septoplasty, or ESS with septoplasty, were prospectively enrolled. Patients completed demographic and psychometric questionnaires assessing attitudes toward pain, baseline anxiety, and depression before surgery. Postoperatively, patients documented peak pain levels (0-100 visual analog scale) and daily prescription and nonprescription medication requirements over a 2-week period. Of the 42 patients enrolled, 15 underwent ESS, 14 septoplasty, and 13 ESS with septoplasty. Five patients (11.9%) reported a history of chronic pain before surgery. Patients were given a median of 30 opioid pain pills after surgery: acetaminophen with codeine 325/30 mg (10 patients) or oxycodone with acetaminophen 5/325 mg (32 patients). Patients had a median of 27 pills left over at the end of the study period. Median peak pain levels for all procedures were 22 (range, 0-94) on day 0, 26.5 (range, 0-86) on day 1, 8.5 (range, 0-85) on day 3, and 3 (range, 0-52) on day 7. Median opioid requirements measured in morphine milligram equivalents (MME) over those same days were 6.0, 4.1, 0, and 0, respectively. Postoperative pain after elective rhinologic surgery appears to peak over the first 3 days and decreases rapidly afterward. Most patients require a few doses of opioid analgesics. Opioid requirements and pain levels did not vary based on surgeon, type and extent of surgery, and demographic factors. Judicious prescribing of opioid medication after rhinologic surgery represents a practical opportunity for rhinologists and otolaryngologists to reduce opioid overprescription and abuse.

The Role of Quinine-Responsive Taste Receptor Family 2 in Airway Immune Defense and Chronic Rhinosinusitis.

Bitter (T2R) and sweet (T1R) taste receptors in the airway are important in innate immune defense, and variations in taste receptor functionality in one T2R (T2R38) correlate with disease status and disease severity in chronic rhinosinusitis (CRS). Quinine is a bitter compound that is an agonist for several T2Rs also expressed on sinonasal cells, but not for T2R38. Because of this property, quinine may stimulate innate immune defense mechanisms in the airway, and functional differences in quinine perception may be reflective of disease status in CRS. Demographic and taste intensity data were collected prospectively from CRS patients and non-CRS control subjects. Sinonasal tissue from patients undergoing rhinologic surgery was also collected and grown at an air-liquid interface (ALI). Nitric oxide (NO) production and dynamic regulation of ciliary beat frequency in response to quinine stimulation were assessed in vitro. Quinine reliably increased ciliary beat frequency and NO production in ALI cultures in a manner consistent with T2R activation (p < 0.01). Quinine taste intensity rating was performed in 328 CRS patients and 287 control subjects demonstrating that CRS with nasal polyps (CRSwNP) patients rated quinine as significantly less intense than did control subjects. Quinine stimulates airway innate immune defenses by increasing ciliary beat frequency and stimulating NO production in a manner fitting with T2R activation. Patient variability in quinine sensitivity is observed in taste intensity ratings, and gustatory quinine "insensitivity" is associated with CRSwNP status. Thus, taste tests for quinine may be a biomarker for CRSwNP, and topical quinine has therapeutic potential as a stimulant of innate defenses.

International survey and consensus (ICON) on ambulatory surgery in rhinology

ObjectivesDay-case surgery is the gold standard to several surgical procedures in Rhinology. However, few data and guidelines have been published except in the Anglo-Saxon countries and France. The aim of this survey was to propose a list of issues arising during day-case surgery in order to analyze the different constraints encountered around the world. Material and methodIt was a prospective multicenter international email survey. The method was based on the formalized expert consensus methodology. A list of 11 issues was based on literature data and was sent by e-mail to 265 key opinion leaders (KOL) who attended the IFOS congress. ResultsThe response rate was 20% from 27 countries without statistical difference between continents concerning the score on each item. The mean age of KOL was 50±10 years. Their mean length of experience was 21±10 years. Issues in relation with technical resources and experience showed that the last time at which ambulatory surgery in the day is possible was 4:00 PM but responses varied depending the availability of technical resources. Bleeding or hematoma occurred most frequently between the third and fourth postoperative day whatever the surgical procedure. A strong agreement and consensus was obtained concerning the nasal packing, septal contention and their schedule of removal which were not a contraindication of day-case. Also 75% of participants were agreeing with a therapeutic education program to improve the performance of postoperative care and decrease readmission rates. A relative agreement without consensus were obtained for the distance between the day-case unit and home, the role of surgery duration and the impact of anticoagulant and/or antiplatelet drugs in overnight admission and readmission rates. ConclusionPractice varies widely owing to local organization constraints and the availability of a dedicated day-case unit seems to be the main limiting factor.

Comparison between the Sinus and Gut Microbiome in Patients with Chronic Sinus Disease

Objectives: Associations between the gut microbiome and various non-GI related diseases have been detailed in recent studies. This investigation aims to directly compare the gut and sinus microbes in patients with chronic sinus disease and in control patients to determine if any link exists between the sinus and gut microbiota. Methods: This was a prospective study conducted from February 2016 to August 2017. It was conducted at a tertiary care academic rhinology practice on 16 patients undergoing rhinologic surgery. The primary outcome measure was to determine if any overlap exists between the gut and sinus microbiome in a given subject. A secondary outcome was to assess the effect of prior antibiotic therapy on the diversity of the gut microbiome. Results: There were 7 patients with chronic rhinosinusitis (CRS) with polyps, 6 patients with CRS without polyps and 3 control patients. Only one patient demonstrated an overlap of sinus and gut microbiotia. In patients receiving a reduced number of antibiotic courses over the past 24 months (0 or 1 course), there was a mean of 7.7 (SD 2.2) gut bacteria isolated from stool samples. In patients receiving more antibiotic courses (2+ courses), there was a mean of 5.1 (SD 2.3) gut bacteria isolated. This difference reached statistical significance (p=0.043). Conclusion: Minimal overlap between the sinus and gut microbiome was demonstrated, but further studies are needed to elucidate this potential association. This study supports the theory that antibiotics tend to reduce microbial diversity in the gastrointestinal tract.

A Retrospective Audit of Rhinosinusitis-inducing Medications in Rhinological Surgery

A Retrospective Audit of Rhinosinusitis-inducing Medications in Rhinological Surgery

Compatible Biomaterials Used In Rhinology Surgery – Our Expertise

Abstract In the last decades, rhinology has developed in a great manner concerning new surgical techniques and extending the use of compatible biomaterials in order to achieve normal morphology and normal functional aspect after surgery (endoscopic or open approach). Since biomaterials are integrated in biological active organs and systems, they have to be easily accepted by the receiver with no toxicity, inflammation or other side effects. The authors try to review all biocompatible materials used in several rhinological pathologies in order to obtain the best results after functional or reconstructive surgery. In rhinological surgery there are usually used homograft’s but the use of biomaterials like alloplastics (silicone, high density polyethylene, polytetrafluoroethylene, etc.) has widely increased. The authors present their experience in endoscopic approach of choanal atresia using nasal stents, closure techniques for septal perforation using nasal splints, endoscopic drainage and sinus ventilation using balloon sinuplasty, lacrimal pathway obstruction using double margin stent and some materials used in cosmetic and reconstructive rhinoplasty.

Predictors of unanticipated admission within 30 days of outpatient sinonasal surgery.

To identify predictive factors of readmission after day-case rhinologic surgery. A 2-year retrospective chart review of patients scheduled for ambulatory sinonasal surgery in a tertiary medical center was conducted. The operating room and the anesthetic files were screened to identify demographic data, types of procedure, comorbidities and post-operative complications. From January 2014 to January 2016, 924 outpatient sinonasal procedures were identified. The overall readmission rate within the 30-postoperative days was 5.1% (2.9% for overnight hospital stay, 2.2% for unplanned post procedure visit to the hospital via the emergency room, or directly to the surgical unit within 30 days of discharge). Age at least 50 years, surgical duration at least 80 min, endoscopic sinus surgery procedures and postoperative nasal packing were identified as negative predictive factors of readmission. Careful scheduling of those higher-risk patients undergoing sinonasal surgery and appropriate postoperative observation should be implemented to improve healthcare quality in an outpatient setting.

Office-based rhinologic surgery: A modern experience with operative techniques under local anesthetic.

Office-based rhinologic procedures have become popularized in recent years with the advent of several minimally invasive techniques. There is a paucity of literature, however, that supports more robust in-clinic procedures, e.g., true endoscopic sinus surgery (ESS). There is a high volume of this work being done at our center, and the objective of this article was to review the safety and tolerability of in-clinic surgeries. A retrospective chart review was conducted. All the adult patients who underwent in-clinic sinonasal procedures and surgery with a minimum of 3 months of follow-up were included. Information regarding intra- and postoperative complications and revision procedures were recorded. For the ESS procedures, the indication, sinuses operated on, and type of revision were also collected. A total of 315 patients met the inclusion criteria. There were 166 turbinoplasties, 118 ESS, 35 septoplasties, 34 rhinoplasties, and 4 septorhinoplasties performed. For the ESS procedures, 74 (62.7%) were bilateral, and experience was had operating in all paranasal sinuses. All ESS work involved opening diseased ostia and was more than just polypectomies. The mean follow-up for the ESS cases was 13.4 months (range, 12-65 months). Complication rates and tolerability measures were comparable with those of other reported in-office sinonasal procedures performed with the patient under local anesthetic. Office-based rhinologic surgery was safe and well tolerated by the patients. The need for revision ESS in our series was low when considering the extent of surgery that was performed. An in-clinic procedure may avoid a general anesthetic in the operating room for appropriately selected patients.

Predictors of unanticipated admission within 30 days of outpatient sinonasal surgery

To identify predictive factors of readmission after day-case rhinologic surgery. A 2-year retrospective chart review of patients scheduled for ambulatory sinonasal surgery in a tertiary medical center was conducted. The operating room and the anesthetic files were screened to identify demographic data, types of procedure, comorbidities and post-operative complications. From January 2014 to January 2016, 924 outpatient sinonasal procedures were identified. The overall readmission rate within the 30-postoperative days was 5.1% (2.9% for overnight hospital stay, 2.2% for unplanned post procedure visit to the hospital via the emergency room, or directly to the surgical unit within 30 days of discharge). Age at least 50 years, surgical duration at least 80 min, endoscopic sinus surgery procedures and postoperative nasal packing were identified as negative predictive factors of readmission. Careful scheduling of those higher-risk patients undergoing sinonasal surgery and appropriate postoperative observation should be implemented to improve healthcare quality in an outpatient setting.

Is nonabsorbable nasal packing after septoplasty essential? A meta-analysis.

Septoplasty is one of the most frequently performed rhinologic surgeries. Complications include nasal bleeding, pain, headache, septal hematoma, synechia, infection, residual septal deviation, and septal perforation. In this study, we aimed to compare complication rates among patients according to packing method. We performed a literature search using PubMed, Embase, and the Cochrane Library through August 2016. Our systematic review followed Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Random effect models were used to calculate risk differences and risk ratio with 95% confidence intervals (CIs). Cases referred to the nonpacking group included patients treated with transseptal sutures or septal splints. Cases referred to as the packing group included patients treated with nonabsorbable packing such as Merocel or gauze. Our search included 20 randomized controlled trials (RCTs) with a total of 1,321 subjects in the nonpacking group and 1,247 subjects in the packing group. There were no significant differences between packing methods regarding bleeding, hematoma, perforation, infection, and residual septal deviation. The risk differences of postoperative pain, headache, and postoperative synechia were -0.50 [95% CI: -0.93 to -0.07, P = .02], -0.42 [95% CI: -0.66 to -0.19, P = .0004], and -0.03 [95% CI: -0.06 to -0.01, P = .01], respectively. Nonabsorbable nasal packing is no more effective than treatments without packing after septoplasty. Septal splints and transseptal sutures reduce postoperative pain, headache, and synechia. 1B Laryngoscope, 127:1026-1031, 2017.

Geriatric Otolaryngologic Emergencies at a Teaching Hospital in Taiwan

Summary Background Many diseases are more common in older people than in younger people, and it may be more difficult to make a diagnosis because older patients often have nonspecific symptoms. The purpose of this study was to analyze the geriatric patients treated in an otolaryngology emergency room at a Taiwanese teaching hospital over a 5-year period. Methods A retrospective review was performed on patients older than 18 years of age who presented in otolaryngology emergency rooms from January 2010 to December 2014. A total of 4101 patients were enrolled in this study. Patients aged older than 65 years of age were defined as the elderly group. The retrieved data incvluded age, gender, clinical presentations, and treatment modalities for further analysis. Results A total of 502 patients (12.2%) were included in the elderly group. There were 287 males and 215 females ranging from 65 to 100 years of age with mean age of 75.7 ± 7.6. The most common need was pharyngolaryngology ( n = 274; 54.6%) followed by otology ( n = 128; 25.5%), rhinology ( n = 77; 15.3%), and head and neck surgery ( n = 23; 4.6%). Acute upper respiratory tract infection was the most frequent diagnosis. Foreign bodies were mostly found in the throat followed by the ears. Most patients with epistaxis sustained anterior nasal septum bleeding. More than 65% of the patients (335/502; 66.7%) were true emergencies. Conclusions The non-emergent disease, acute upper respiratory tract infection was the most frequent diagnosis. Although geriatric patients had a variety of medical conditions, most can be managed with a conservative treatment strategy.

Legal aspects in patients with complications and sequelae after rhinological surgery

AbstractBACKGROUND. In time, the field of surgery has developed, introducing new techniques for old diseases. Along with this evolution, postoperative complications occurred and patients denounced doctors for insufficient medical care or inappropriate surgical approach. We observed an increased number of reclamations from patients who underwent rhinological surgery. All of those patients considered that medical care and the surgical act were improper, with poor outcome.MATERIAL AND METHODS. The purpose of our presentation is to sum all the causes that motivate the patients to formulate claims and to start the legal prosecution, in order to obtain financial compensation and the doctor’s conviction. We included all the patients who referred to our clinic (even if they were first treated by us or another surgical team), complaining of postoperative: persistent purulent rhinorrhea, nasal obstruction, crusts, cacosmia or anosmia, epistaxis, epiphora, unaesthetic nasal aspect. Some of these patients, before or after receiving our care, denounced the initial caregiver.RESULTS. Their main complaints involved poor preoperative notifications regarding the surgical method, risks and potential complications, extensive surgery, wrong surgical indication, inexperienced surgical team, poor postoperative care. Even if they were first treated in our clinic or not, these patients received medical and surgical care to correct all the negative post operatory outcomes. Some of the patients still pursued the legal pathway, engaging all the resources to prove doctor’s medical guilt.CONCLUSION. To avoid medico-legal situations, guidelines need to be established for the ENT surgeons, in order to confer a healthier work environment with minimum risks and complications.

Transclival injury after routine transnasal rhinological surgery

ObjectivesRoutine transnasal rhinological procedures are widely practiced and are considered as safe, in general. Skull base lesions occur in less than 1% of procedures and typically involve the anterior or middle cranial fossa, while clivus lesions have not been well documented. Here we present a series of three patients with iatrogenic transclival lesions after routine transnasal rhinological procedures. Patients and methodsThree patients with penetrating clivus injuries after routine transnasal rhinological procedures were identified. All patients had undergone transnasal rhinological surgery at other hospitals and two of them were referred for emergency treatment. Patients were managed within an interdisciplinary context. ResultsThere were two women and one man. Mean age at surgery was 35 years. All operations had been performed under general anaesthesia. In only one instance, perforation of the clivus had been noticed during surgery by the ENT physician, while it went unnoticed in the other two patients. In one patient, no intracranial injury occurred secondary to the clivus fracture, while two patients had extensive brainstem lesions. The first patient survived without deficits, but one patient succumbed to the brainstem injury and the other remained with severe deficits. Risk factors including anatomical variants or distorted morphology were present in all patients. ConclusionTransnasal rhinological procedures can result in penetrating clivus injuries, which may not be noticed during surgery, but which can result in permanent morbidity or mortality. These lesions are obviously very rare and their true incidence remains unknown.

Effect of Septorhinoplasty on Olfactory Function: Assessment Using the Brief Smell Identification Test.

Septorhinoplasty (SRP), one of the most commonly performed rhinologic surgery procedures, can affect olfactory function; however, the findings of studies investigating smell following SRP are controversial. We used a culturally adapted modified Brief Smell Identification Test (B-SIT) to investigate the long- and short-term effects of SRP on olfactory function. We enrolled 59 patients admitted to the Ear-Nose-Throat Clinic, who were complaining of external nasal deformity and nasal obstruction. Functional SRP was performed on all cases. The B-SIT was administered prior to surgery and at 4 and 12 weeks post-surgery. The smell identification score (SIS) reflected the number of correct answers. In addition, we investigated the effects of gender and smoking on olfactory function and whether the SRP procedure changed these associations. The mean preoperative, 4-week, and 12-week postoperative SISs were 10.15±1.30, 10.21±1.52, and 10.92±0.95, respectively. The difference between the preoperative and 4-week postoperative SISs was not statistically significant; however, the 12-week postoperative score was significantly different from the preoperative and 4-week postoperative scores. Furthermore, the repeated measures analysis according to gender and smoking habit revealed a significant difference between the 4-and 12-week postoperative SISs. One patient developed postoperative anosmia; however, the patient recovered in the 12-week postoperative period. SRP surgery is a safe procedure in terms of olfactory function. In addition, olfactory function may increase following surgery as a result of improved nasal airflow.

Dilemma of Inferior Turbinate Surgery

Background and objectives: Inferiorturbinate surgery is considered as one of most commonly performed surgery in rhinology. It is usually done to reduce the bulk of inferior turbinates. It can be conducted for different indications such as relieving the mechanical nasal obstruction due to hypertrophied inferior turbinates, or to achieving a sufficient nasal surgical access during endoscopic sinus surgery, or removing the inferior turbinates as a part of wide and complete resection of rhino-sinus neoplastic lesions. The inferior turbinates have important role in the maintenance of nasal breathing function by providing the nasal valve mechanism necessary for the regulation of air flow through the nose. In spite of availability of well-established variable techniques for this surgery, the main goal of this surgery is yet not completely achieved. This could bean effect of different factors that are difficult to be predicted and controlled. Hence this pattern of surgery has become dilemmas in rhinology which need to be deeply evaluated and subsequently resolved. In order to evaluate and resolve this dilemma, this serial study was conducted prospectively. Patients and methods: 1337 patients aged 3 to -65 years suffering from hypertrophied inferior turbinates, presented with clinical pictures of mechanical nasal obstruction at ENT department – of Althowra central hospital and Al-tarahom private center Elbyda city- Libya between September 2005 to September 2014 they were operated by variable techniques of inferior turbinate surgery, namely sub-mucosal diathermy (SMD) (n=864 ), partial inferior turbinectomy (PIT) (n=427), CO2 laser vaporization of inferior turbinate (n=21), and turbinoplasty (n=25) . Post-operative atrophic rhinitis, and persistence, or recurrence of mechanical nasal obstruction the outcomes are that were studied in relation to different factors to shed-light on existing dilemma. Results and Conclusion: Proper selection of patient for this pattern of surgery is considered one of the main aspects of this issue and one of significant steps towards resolving of this dilemma. On the other hand, type of the technique for this surgery is an important selection criterion. In addition the amount of the inferior turbinate needed to be resected must be decided.

Book Review: Review of Rhinology and Endoscopic Skull Base Surgery (Otorhinolaryngology–Head and Neck Surgery Series)

Book Review: Review of <i>Rhinology and Endoscopic Skull Base Surgery</i> (Otorhinolaryngology–Head and Neck Surgery Series)

Office‐Based Surgical Procedures in Rhinology

Program Description: With continual advances in endoscopic instrumentation and technology, a burgeoning number of rhinologic procedures can now be effectively performed in the office environment. Such interventions have provided therapeutic alternatives in the management of primary and recalcitrant sinonasal disease. The purpose of this miniseminar is to describe the principles and techniques involved in successful implementation of rhinologic surgery in the clinic setting. Both fundamental (turbinate surgery, polypectomy) and advanced sinus procedures (frontal sinusotomy, revision surgery) will be discussed. Appropriate setup, anesthesia, and patient selection will be described. This miniseminar will be conducted by academic leading rhinologists using a multimedia, interactive, case-based format. Educational Objectives: (1) Discuss current office-based, rhinologic surgical procedures and their role in the management of sinonasal disease. (2) Describe appropriate patient selection, preparation, and optimal anesthetic and surgical techniques for rhinologic clinic procedures. (3) Assess recent technologic innovations and understand their proper application in rhinologic office-based surgical procedures.

Design of Dividable Colonoscope Sheath1

Design of Dividable Colonoscope Sheath1

A Prospective Double-Blinded Randomized Controlled Study Comparing the Efficacy of a Novel Biodegradable Synthetic Polyurethane Foam (Nasopore) vs Standard Polyvinyl Acetate Sponge (Merocel) as Packing Material after Functional Endoscopic Sinus Surgery: The First Indian Experience

ABSTRACT Background In Indian clinical practice, conventional nasal packing for hemostasis after routine rhinological surgery is usually performed with Vaseline (paraffin) gauze, and rarely with glove-finger packs or tamponade balloons. These materials are tedious to pack and cause discomfort to the patient on removal. Newer nasal packs which have recently emerged in the Indian scenario are found to be more user-friendly, equally effective for hemostasis and less traumatic to the operated nasal mucosa. Most rhinologists today, prefer to use polyvinyl acetate sponge packs (Merocel/Ivalon) for tamponade after nasal surgery. These packs are very effective but non-absorbable and need to be removed which does not augur well with many patients postoperatively. The recent entry of a biodegradable synthetic polyurethane foam (Nasopore) as an alternative nasal packing material, has evoked new interest, which initiated this study. Study method This prospective randomized double-blinded controlled study was aimed to compare the clinical efficacy and patient comfort level, while using Merocel and Nasopore as packing material after functional endoscopic sinus surgery (FESS). This study included thirty adults who were diagnosed with moderate to severe bilaterally comparable chronic rhinosinusitis, who underwent FESS under general anesthesia and received size-matched nasal packs randomly - Merocel on one side and Nasopore on the other. The assessment of clinical efficacy of both packs with regards to ease of packing, hemostasis, pressure effects, infections and adhesions was done with a Diagnostic Nasal Endoscopy at first postoperative day, first week and fourth week after surgery. All Merocel packs were removed on the first postoperative day. Patient comfort levels for both packs were recorded with a standard symptom questionnaire marked on a visual analogue scale of ten and the results were statistically compared between the two groups. Results Comparable outcomes were found while using Merocel or Nasopore with regards to ease of nasal packing and control of postoperative bleeding. There was a statistical difference in the hemostatic property between the two materials in the immediate postoperative period. Five out of 30 patients developed reactionary bleeds with Nasopore, which required repacking with same material within the first 24 hours, but no further bleeds were noted. Two out of these five patients on the first postoperative day had migration of Nasopore toward the choana and had to be repacked with additional Nasopore. Sequential postoperative nasal endoscopy revealed that Nasopore is more mucosal friendly with lesser incidence of adhesions, synechiae, infection and edema, with better biocompatibility and safety. The major success with Nasopore was found to be, the fact that no pack removal was necessary, which immensely improved patient satisfaction and willingness to use the material when compared to Merocel. This was proved by the patient's symptom questionnaire which showed significant benefits of Nasopore over Merocel with regards to compliance and comfort levels. Conclusion Nasopore is a novel biodegradable synthetic material which is clinically as efficacious and patient-friendly as Merocel and is suitable for postoperative nasal packing after functional endoscopic sinus surgery. The clinical benefits of Nasopore and its outcomes among patients as recorded in our study, stands proof to support Nasopore as a successful packing material in rhinological surgery. How to cite this article Raghunandhan S, Kameswaran M, Thomas JK. A Prospective Double-Blinded Randomized Controlled Study Comparing the Efficacy of a Novel Biodegradable Synthetic Polyurethane Foam (Nasopore) vs Standard Polyvinyl Acetate Sponge (Merocel) as Packing Material after Functional Endoscopic Sinus Surgery: The First Indian Experience. Clin Rhinol An Int J 2014;7(3):105-111.