The Laryngoscope V C 2017 The American Laryngological, Rhinological and Otological Society, Inc. Nose Blowing After Endoscopic Sinus Surgery Does Not Adversely Affect Outcomes Noel Ayoub, BS ; Wirach Chitsuthipakorn, MD; Jayakar V. Nayak, MD, PhD; Zara M. Patel, MD ; Peter H. Hwang, MD Objective: Patients frequently are advised to abstain from nose blowing following endoscopic sinus surgery (ESS), despite a lack of evidence supporting this recommendation. This randomized study assessed whether nose blowing in the first postoperative week affects subjective and objective clinical outcomes. Methods: Forty patients undergoing ESS were randomized into an interventional arm in which patients blew their nose at least twice daily for the first 7 postoperative days, or a control arm in which patients refrained from nose blowing. All patients were allowed to blow their nose after 7 days. The frequency and degree of epistaxis was documented by daily diary and visual analog scale (VAS). At 1 and 4 weeks postoperatively, Nasal Obstruction Symptom Evaluation (NOSE) and Sino- Nasal Outcome Test-22 (SNOT-22) were collected, and endoscopies were recorded for blinded Lund-Kennedy scale scoring. Results: There were no differences between the two groups in terms of frequency and duration of bleeding events, VAS epistaxis scores, SNOT-22 scores, and NOSE scores at every postoperative timepoint. Lund-Kennedy scores also were similar at the 1-week (P 5 0.0762) and 4-week (P 5 0.2340) postoperative visits, but the nose-blowing group had improved nasal discharge subscores at the first (P 5 0.0075) and second (P 5 0.0298) postoperative visits. Conclusion: Nose blowing after ESS does not appear to measurably improve symptoms of nasal congestion or general sinonasal quality of life, nor does it seem to adversely affect the frequency or severity of postoperative epistaxis during the first postoperative week. Judicious nose blowing may be permissible immediately after uncomplicated ESS. Key Words: Endoscopic sinus surgery, chronic rhinosinusitis, postoperative care, epistaxis, quality of life, nose blowing, ESS, SNOT-22. Level of Evidence: 1b. Laryngoscope, 00:000–000, 2017 INTRODUCTION Since endoscopic sinus surgery (ESS) was first described, a number of technical innovations have trans- formed the capabilities of sinus surgeons, yet recommen- dations regarding optimal postoperative care have remained relatively static. 1–3 One of the core tenets of postoperative care after ESS has been to restrict patients from nose blowing in the days or weeks follow- ing ESS. 3 Concerns regarding nose blowing after surgery often relate to its potential to instigate bleeding or cause air to transgress into the skull base or orbit. A casual review of institutional websites suggests that most sur- geons advise patients to refrain from nose blowing for periods ranging from 3 days to 2 weeks following ESS. With the advent of evidence-based medicine, many of the treatment options for medically refractory chronic rhi- nosinusitis (CRS) have undergone rigorous assessment. 4 However, evidence-based assessments of postoperative care have remained more limited. In particular, the recommen- dation of restricting nose blowing postoperatively has to our knowledge never been directly assessed. Although restricting nose blowing postoperatively remains a practice standard, the benefits to the patient of such a recommenda- tion have not been proven relative to the potential inconve- nience and discomfort associated with such a restriction. Our objective with this study was to determine whether nose blowing in the immediate postoperative period following ESS is associated with any changes in typical subjective or objective outcome measures. MATERIALS AND METHODS Approval for this study was obtained from the Stanford University Institutional Review Board. Overall study design was a prospective, randomized, single-blinded clinical trial, with endpoint assessments of severity and frequency of postop- erative epistaxis, as well as nasal obstruction scores, sinonasal symptom scores, and endoscopy scores. Patient Characteristics Subjects were eligible for the study if they were 18 years or older and were scheduled to undergo ESS for CRS or From the Division of Rhinology and Endoscopic Skull Base Sur- gery, Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine (N.A., W.C., J.V .N., Z.M.P ., P .H.H.), Stanford, California, U.S.A. Editor’s Note: This Manuscript was accepted for publication August 16, 2017. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Peter H. Hwang, MD, Division of Rhinol- ogy and Endoscopic Skull Base Surgery, Department of Otolaryngology– Head and Neck Surgery, Stanford University School of Medicine, 801 Welch Road, Stanford, CA 94305; email: hwangph@stanford.edu DOI: 10.1002/lary.26907 Laryngoscope 00: Month 2017 Ayoub et al.: Nose Blowing Following Sinus Surgery 1