Skip to main content

Hyaluronic acid for post sinus surgery care: systematic review and meta-analysis

  • E Fong (a1) (a2), M Garcia (a1), C M Woods (a1) and E Ooi (a1)

Wound healing after endoscopic sinus surgery may result in adhesion formation. Hyaluronic acid may prevent synechiae development. A systematic review was performed to evaluate the current evidence on the clinical efficacy of hyaluronic acid applied to the nasal cavity after sinus surgery.


Studies using hyaluronic acid as an adjunct treatment following endoscopic sinus surgery for chronic rhinosinusitis were identified. The primary outcome was adhesion formation rates. A meta-analysis was performed on adhesion event frequency. Secondary outcome measures included other endoscopic findings and patient-reported outcomes.


Thirteen studies (501 patients) met the selection criteria. A meta-analysis of adhesion formation frequency on endoscopy demonstrated a lower risk ratio in the hyaluronic acid intervention group (42 out of 283 cases) compared to the control group (81 out of 282) of 0.52 (95 per cent confidence interval = 0.37–0.72). Hyaluronic acid use was not associated with any significant adverse events.


Hyaluronic acid appears to be clinically safe and well tolerated, and may be useful in the early stages after sinus surgery to limit adhesion rate. Further research, including larger randomised controlled trials, is required to evaluate patient- and clinician-reported outcomes of hyaluronic acid post sinus surgery.

Corresponding author
Address for correspondence: Dr Eric Fong, ENT Department, Flinders Medical Centre, Flinders Drive, Bedford Park, SA 5042, Australia Fax: +61 8 8204 7524 E-mail:
Hide All

Presented at the Australian Society of Otolaryngology – Head and Neck Surgery 65th Annual Scientific Meeting, 7–9 March 2015, Sydney, Australia.

Hide All
1 Australian Institute of Health and Welfare. Chronic Respiratory Diseases in Australia: Their Prevalence, Consequences and Prevention. Canberra: Australian Institute of Health and Welfare, 2005
2 Pleis, JR, Lucas, JW, Ward, BW. Summary health statistics for U.S. adults: National Health Interview Survey, 2008. Vital Health Stat 10 2009;(242):1157
3 Van Cauwenberge, P, Van Hoecke, H, Bachert, C. Pathogenesis of chronic rhinosinusitis. Curr Allergy Asthma Rep 2006;6:487–94
4 Fokkens, WJ, Lund, VJ, Mullol, J, Bachert, C, Alobid, I, Baroody, F et al. European Position Paper on Rhinosinusitis and Nasal Polyps 2012. Rhinol Suppl 2012;(23):3 p preceding table of contents, 1298
5 Musy, PY, Kountakis, SE. Anatomic findings in patients undergoing revision endoscopic sinus surgery. Am J Otolaryngol 2004;25:418–22
6 Henriquez, OA, Schlosser, RJ, Mace, JC, Smith, TL, Soler, ZM. Impact of synechiae after endoscopic sinus surgery on long-term outcomes in chronic rhinosinusitis. Laryngoscope 2013;123:2615–19
7 Bassiouni, A, Chen, PG, Naidoo, Y, Wormald, PJ. Clinical significance of middle turbinate lateralization after endoscopic sinus surgery. Laryngoscope 2015;125:3641
8 Jorissen, M. Postoperative care following endoscopic sinus surgery. Rhinology 2004;42:114–20
9 Rudmik, L, Soler, ZM, Orlandi, RR, Stewart, MG, Bhattacharyya, N, Kennedy, DW et al. Early postoperative care following endoscopic sinus surgery: an evidence-based review with recommendations. Int Forum Allergy Rhinol 2011;1:417–30
10 Brody, HJ. Use of hyaluronidase in the treatment of granulomatous hyaluronic acid reactions or unwanted hyaluronic acid misplacement. Dermatol Surg 2005;31(8 Pt 1):893–7
11 Fraser, JR, Laurent, TC, Laurent, UB. Hyaluronan: its nature, distribution, functions and turnover. J Intern Med 1997;242:2733
12 Chen, WY, Abatangelo, G. Functions of hyaluronan in wound repair. Wound Repair Regen 1999;7:7989
13 Goa, KL, Benfield, P. Hyaluronic acid. A review of its pharmacology and use as a surgical aid in ophthalmology, and its therapeutic potential in joint disease and wound healing. Drugs 1994;47:536–66
14 King, SR, Hickerson, WL, Proctor, KG. Beneficial actions of exogenous hyaluronic acid on wound healing. Surgery 1991;109:7684
15 Voigt, J, Driver, VR. Hyaluronic acid derivatives and their healing effect on burns, epithelial surgical wounds, and chronic wounds: a systematic review and meta-analysis of randomized controlled trials. Wound Repair Regen 2012;20:317–31
16 Souza-Fernandes, AB, Pelosi, P, Rocco, PR. Bench-to-bedside review: the role of glycosaminoglycans in respiratory disease. Crit Care 2006;10:237
17 Soldati, D, Rahm, F, Pasche, P. Mucosal wound healing after nasal surgery. A controlled clinical trial on the efficacy of hyaluronic acid containing cream. Drugs Exp Clin Res 1999;25:253–61
18 Casale, M, Sabatino, L, Frari, V, Mazzola, F, Dell'Aquila, R, Baptista, P et al. The potential role of hyaluronan in minimizing symptoms and preventing exacerbations of chronic rhinosinusitis. Am J Rhinol Allergy 2014;28:345–8
19 Chen, Q, Sun, G, Wang, Y, Zhong, W, Shu, XZ. The evaluation of two new hyaluronan hydrogels as nasal dressing in the rabbit maxillary sinus. Am J Rhinol Allergy 2012;26:152–6
20 Orlandi, RR, Shu, XZ, McGill, L, Petersen, E, Prestwich, GD. Structural variations in a single hyaluronan derivative significantly alter wound-healing effects in the rabbit maxillary sinus. Laryngoscope 2007;117:1288–95
21 Proctor, M, Proctor, K, Shu, XZ, McGill, LD, Prestwich, GD, Orlandi, RR. Composition of hyaluronan affects wound healing in the rabbit maxillary sinus. Am J Rhinol 2006;20:206–11
22 Yildirim, A, Turgut, B, Bebek, AI, Gumus, C, Kocaturk, S, Kunt, T. Early effect of exogenous Na hyaluronate on mucociliary clearance. Am J Rhinol 2005;19:244–7
23 Zhao, X, Grewal, A, Briel, M, Lee, JM. A systematic review of nonabsorbable, absorbable, and steroid-impregnated spacers following endoscopic sinus surgery. Int Forum Allergy Rhinol 2013;3:896904
24 Wu, W, Cannon, PS, Yan, W, Tu, Y, Selva, D, Qu, J. Effects of Merogel coverage on wound healing and ostial patency in endonasal endoscopic dacryocystorhinostomy for primary chronic dacryocystitis. Eye 2011;25:746–53
25 Smith, TL, Hwang, PH, Murr, AH, Lavigne, F, Koreck, A. Interrater reliability of endoscopic parameters following sinus surgery. Laryngoscope 2012;122:230–6
26 Smith, TL, Mendolia-Loffredo, S, Loehrl, TA, Sparapani, R, Laud, PW, Nattinger, AB. Predictive factors and outcomes in endoscopic sinus surgery for chronic rhinosinusitis. Laryngoscope 2005;115:2199–205
27 Chang, EH. New insights into the pathogenesis of cystic fibrosis sinusitis. Int Forum Allergy Rhinol 2014;4:132–7
28 Anfuso, A, Ramadan, H, Terrell, A, Demirdag, Y, Walton, C, Skoner, DP et al. Sinus and adenoid inflammation in children with chronic rhinosinusitis and asthma. Ann Allergy Asthma Immunol 2015;114:103–10
29 Joanna Briggs Institute. Reviewers' Manual. Adelaide: Joanna Briggs Institute, 2014
30 Review Manager (RevMan) [computer program]. Version 5.2. Copenhagen: Nordic Cochrane Centre, Cochrane Collaboration, 2012
31 Miller, RS, Steward, DL, Tami, TA, Sillars, MJ, Seiden, AM, Shete, M et al. The clinical effects of hyaluronic acid ester nasal dressing (Merogel) on intranasal wound healing after functional endoscopic sinus surgery. Otolaryngol Head Neck Surg 2003;128:862–9
32 Franklin, JH, Wright, ED. Randomized, controlled, study of absorbable nasal packing on outcomes of surgical treatment of rhinosinusitis with polyposis. Am J Rhinol 2007;21:214–17
33 Berlucchi, M, Castelnuovo, P, Vincenzi, A, Morra, B, Pasquini, E. Endoscopic outcomes of resorbable nasal packing after functional endoscopic sinus surgery: a multicenter prospective randomized controlled study. Eur Arch Otorhinolaryngol 2009;266:839–45
34 Shi, R, Zhou, J, Wang, B, Wu, Q, Shen, Y, Wang, P et al. The clinical outcomes of new hyaluronan nasal dressing: a prospective, randomized, controlled study. Am J Rhinol Allergy 2013;27:71–6
35 Wormald, PJ, Boustred, RN, Le, T, Hawke, L, Sacks, R. A prospective single-blind randomized controlled study of use of hyaluronic acid nasal packs in patients after endoscopic sinus surgery. Am J Rhinol 2006;20:710
36 Kimmelman, CP, Edelstein, DR, Cheng, HJ. Sepragel sinus (hylan B) as a postsurgical dressing for endoscopic sinus surgery. Otolaryngol Head Neck Surg 2001;125:603–8
37 Woodworth, BA, Chandra, RK, Hoy, MJ, Lee, FS, Schlosser, RJ, Gillespie, MB. Randomized controlled trial of hyaluronic acid/carboxymethylcellulose dressing after endoscopic sinus surgery. ORL J Otorhinolaryngol Relat Spec 2010;72:101–5
38 Catalano, PJ, Roffman, EJ. Evaluation of middle meatal stenting after minimally invasive sinus techniques (MIST). Otolaryngol Head Neck Surg 2003;128:875–81
39 Cantone, E, Castagna, G, Sicignano, S, Ferranti, I, Rega, F, Di Rubbo, V et al. Impact of intranasal sodium hyaluronate on the short-term quality of life of patients undergoing functional endoscopic sinus surgery for chronic rhinosinusitis. Int Forum Allergy Rhinol 2014;4:484–7
40 Macchi, A, Terranova, P, Digilio, E, Castelnuovo, P. Hyaluronan plus saline nasal washes in the treatment of rhino-sinusal symptoms in patients undergoing functional endoscopic sinus surgery for rhino-sinusal remodeling. Int J Immunopathol Pharmacol 2013;26:137–45
41 Kim, JH, Lee, JH, Yoon, JH, Chang, JH, Bae, JH, Kim, KS. Antiadhesive effect of the mixed solution of sodium hyaluronate and sodium carboxymethylcellulose after endoscopic sinus surgery. Am J Rhinol 2007;21:95–9
42 Gelardi, M, Guglielmi, AV, De Candia, N, Maffezzoni, E, Berardi, P, Quaranta, N. Effect of sodium hyaluronate on mucociliary clearance after functional endoscopic sinus surgery. Eur Ann Allergy Clin Immunol 2013;45:103–8
43 Gouteva, I, Shah-Hosseini, K, Meiser, P. Clinical efficacy of a spray containing hyaluronic acid and dexpanthenol after surgery in the nasal cavity (septoplasty, simple ethmoid sinus surgery, and turbinate surgery). J Allergy (Cairo) 2014;2014:635490
44 Lee, JY, Lee, SW. Preventing lateral synechia formation after endoscopic sinus surgery with a silastic sheet. Arch Otolaryngol Head Neck Surg 2007;133:776–9
45 Shrime, MG, Tabaee, A, Hsu, AK, Rickert, S, Close, LG. Synechia formation after endoscopic sinus surgery and middle turbinate medialization with and without FloSeal. Am J Rhinol 2007;21:174–9
46 Turner, L, Shamseer, L, Altman, DG, Weeks, L, Peters, J, Kober, T et al. Consolidated standards of reporting trials (CONSORT) and the completeness of reporting of randomised controlled trials (RCTs) published in medical journals. Cochrane Database Syst Rev 2012;(11):MR000030
47 Wang, TC, Tai, CJ, Tsou, YA, Tsai, LT, Li, YF, Tsai, MH. Absorbable and nonabsorbable packing after functional endoscopic sinus surgery: systematic review and meta-analysis of outcomes. Eur Arch Otorhinolaryngol 2015;272:1825–31
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

The Journal of Laryngology & Otology
  • ISSN: 0022-2151
  • EISSN: 1748-5460
  • URL: /core/journals/journal-of-laryngology-and-otology
Please enter your name
Please enter a valid email address
Who would you like to send this to? *



Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed