J Rhinol.  2020 May;27(1):21-27. 10.18787/jr.2019.00285.

The Antibiotic-Vaseline Soaked Cotton Pledget as an Adjuvant Material for Endoscopic Endonasal Fungal Ball Removal

• Kim YY
• Yang HC
• Kim JG
• Kim HY
• Park JM
• Nam KI
• Song MK
• Lim SC

• KMID: 2502790
• DOI: http://doi.org/10.18787/jr.2019.00285

Abstract

Background and Objectives
Treatment choice for fungal ball is endoscopic endonasal removal. However, it is not easy to remove fungal elements from the maxilla using only an endonasal approach. To overcome this difficulty, we introduced a cotton pledget technique and evaluated its efficacy through a cadaveric study and clinical research. Materials and Method: A cadaveric study was performed using 10 half heads of seven cadavers. The ease and safety of the cotton pledget technique were compared to those of a previously reported technique. In clinical research, we enrolled 52 patients who underwent surgery with the cotton pledget technique and 36 patients who underwent surgery using the conventional endoscopic approach. Demographic factors, preoperative Lund-Mackay (LM) score, sinonasal outcome test (SNOT) score, surgical morbidity, and incomplete removal rate were analyzed.
Results
The cadaveric study showed that the cotton pledget technique was easier (p=0.011) than the conventional technique. In addition, clinical evaluation showed that the cotton pledget group had significantly lower incomplete removal rate than that of the control group (p=0.010).
Conclusion
The cotton pledget technique is an easy and safe method that enables fungal ball removal more effectively than the conventional technique without need for inferior meatal antrostomy (IMA) or the Caldwell-Luc (CL) approach.

Keyword

Sinusitis; Mycetomas; Endoscopy; Paranasal sinuses; Minimally invasive surgical procedure; Maxillay

Figure

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  Fig. 1. Cadaveric feasibility study of endonasal fungal ball removal. Antibiotic-vaseline soaked cotton pledget was used as an adjuvant material. A: Vaseline coated cotton pledget holding with forceps. And packed cotton pledget formed a ball-shaped bulk with 90º frontal sinus recess giraffe forceps. B: The cadaver head was then cut at the level of the middle meatus to visualize the procedure. C: Without cotton pledget, the alveolar recess of maxillary sinus cannot be pushed. D: When cotton pledget was introduced to the maxillary sinus, a surgeon could push the alveolar recess of maxillary sinus.

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  Fig. 2. Phases of fungal ball removal. Cotton pledget was placed in the middle meatus (A) and introduced into the maxillary sinus (B). The maxillary sinus was loosely packed with cotton pledget (C). When pushing the packed cotton pledget into the maxillary sinus, it pushed the fungal material of alveolar recess toward the maxillary sinus ostium (D).

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  Fig. 3. Phases of endoscopic fungal ball removal. The fungal ball appeared as maxillary sinus ostium after middle meatus antrostomy (A). Cotton pledget was placed in the middle meatus (B) and introduced into the maxillary sinus (C). When pushing the packed cotton pledget into the maxillary sinus, it pushed the fungal material of alveolar recess toward the maxillary sinus ostium (D). Cheese-like fungal material spilled out from the maxillary sinus to the middle meatus via the antrostomy site (E). The postoperative image of the maxillary sinus showed that the fungal material was completely removed (F).

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