Product comparison model in otolaryngology: Equivalency analysis of absorbable hemostatic agents after endoscopic sinus surgery.
OBJECTIVE
Evidence-based medicine in otolaryngology literature continues to be lacking, especially with regard to new products brought to market. The marketing of products often includes statements of benefit that have limited objective support in research or literature. To address this, and to adequately determine product equivalency/superiority, careful evaluation must be made. In order to establish standards for this process in rhinology products, we directly compare three different absorbable hemostatic agents in patients with chronic rhinosinusitis (CRS) after undergoing endoscopic sinus surgery (ESS), using both objective and subjective outcomes.


METHODS
Double-blinded prospective (level 1) comparison and equivalency analysis of three plant-based absorbable hemostatic agents (carboxymethylcellulose [CMC] gel, mucopolysaccharide hemospheres (MPH), and potato starch wafer) in patients undergoing bilateral ESS.


METHODS
Patients with medically refractory CRS who underwent bilateral ESS were recruited and prospectively followed. At the conclusion of ESS, one of three different hemostatic agents was applied to each nasal passage. Subjective patient data was obtained using rated symptoms compared between the two sides (nasal obstruction, bleeding, pain, and nasal discharge) at baseline and on postoperative days 1, 7, and 14. Objective data was obtained by blinded endoscopic scoring to rate mucosal edema, inflammation, granulation, crusting, infection, and synechiae formation on postoperative weeks 1, 3, and 6.


RESULTS
Forty-eight patients who underwent ESS for CRS were included. There is no statistical difference in subjective scores for any of the variables measured, although (MPH) nearly reached statistical significance at postoperative day 7 for increased pain (P = 0.06) and obstruction (P = 0.22). Objective measures showed equivalency between all products, except the CMC gel approached significance at week 3 for increased crusting (P = 0.10), granulation (P = 0.24), and debridement (P = 0.07). At 6 weeks, increased debridement (P = 0.14) also approached significance.


CONCLUSIONS
Careful and deliberate consideration should be taken when choosing products to assist our surgical endeavors. Subjectively, patients treated with MPH showed near-significant increases in pain and obstruction. In objective measures, CMC gel nearly reaches significance for more postoperative debridement, with increased crusting and inflammation. Product choice could consider these factors, although it remains at the discretion of the surgeon. This model of comparison allows careful product comparison and should be applied to other hemostatics, as well as other materials in use in otolaryngology.


METHODS
1b. Laryngoscope, 126:S5-S13, 2016.
Department of Otolaryngology-Head and Neck Surgery, Saint Louis University, St. Louis, Missouri.
Jastin L
JL
Antisdel
Department of Otolaryngology-Head and Neck Surgery, Saint Louis University, St. Louis, Missouri.
Annika
A
Meyer
Department of Otolaryngology-Head and Neck Surgery, University of Kentucky, Lexington, Kentucky.
Brett
B
Comer
Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, Duke University, Durham, North Carolina.
David
D
Jang
Department of Otolaryngology-Head and Neck Surgery, University of Virginia, Charlottesville, Virginia.
Jose
J
Gurrola
Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.
Eyad
E
Khabbaz
Department of Otolaryngology-Head and Neck Surgery, Saint Louis University, St. Louis, Missouri.
Kara
K
Christopher
Department of Otolaryngology-Head and Neck Surgery, Georgia Regents University, Augusta, Georgia, U.S.A.
Stilianos
S
Kountakis
D000287:Administration, Topical; D000293:Adolescent; D000328:Adult; D000368:Aged; D002266:Carboxymethylcellulose Sodium / Q000008:administration & dosage; D004311:Double-Blind Method; D004724:Endoscopy / Q000009:adverse effects*; D005260:Female; D005500:Follow-Up Studies; D006025:Glycosaminoglycans / Q000008:administration & dosage; D006490:Hemostatics / Q000008:administration & dosage*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010256:Paranasal Sinuses / Q000601:surgery*; D011182:Postoperative Care / Q000379:methods*; D019106:Postoperative Hemorrhage / Q000628:therapy*; D011446:Prospective Studies; D012852:Sinusitis / Q000601:surgery*; D013213:Starch / Q000008:administration & dosage; D016896:Treatment Outcome; D055815:Young Adult
D006025:Glycosaminoglycans; D006490:Hemostatics; C052717:mucopolysaccharide polysulfate; D013213:Starch; D002266:Carboxymethylcellulose Sodium
Hemostasis; absorbable nasal packing; biomaterials; chronic rhinosinusitis; endoscopic sinus surgery