Fibrin glue prevents complications of septal surgery: Findings in a series of 100 patients. (Original Article).

Abstract

Septal surgery is a common type of otolaryngology-head and neck surgery, and it is often performed in combination with other procedures. Complications of septal surgery include bleeding, hematoma, infection, abscess formation, and perforation. The most common methods of preventing these complications are the use of nasal packing, septal splints, and quilting sutures as a means of approximating the septalfiaps. In this article, we describe our study of an alternate method: fibrin glue. We used fibrin glue as the sole method of approximating flaps on 100 consecutive septal surgery patients. Our results indicate that the use offibrin glue is effective, rapid, comfortable, and inexpensive.

Introduction

Septal operations are common in otolaryngology--head and neck surgery, both alone and in combination with other procedures. Common ancillary procedures include inferior turbinoplasty, endoscopic sinus surgery, and rhinoplasty.

Complications of septal surgery include bleeding, hematoma, infection, abscess formation, and perforation. Rhinologic surgeons use a variety of techniques to prevent these potential complications. The most common are the use of nasal packing (with various materials left in place for various amounts of time), septal splints, and quilting sutures to approximate the septal flaps. In this article, we describe our study of fibrin glue as an alternative to these three methods.

Patients and methods

We used fibrin glue as the sole means of approximating septal flaps in 100 consecutive patients who underwent septal surgery alone or in combination with other procedures. Near the end of each procedure, we placed a thin layer of fibrin glue between the septal flaps, and we made certain that all surfaces were covered and enough glue was used to extend to the incision. The flaps were then pressed together for 30 seconds with an osteotome or other flat instrument. No packing or suture was used.

Results

Among the 100 patients, there were no hematomas, infections, or perforations. One patient developed bleeding at the incision site several hours postoperatively and required the temporary placement of Gelfoam. No other complications were observed.

Discussion

Little research has been done on the true effectiveness of septoplasty. Jang et al found a disparity in mucociliary transport between the convex and concave sides of the septum. (1) They demonstrated that the concave side has a longer saccharin clearance time, a more significant loss of cilia, fewer seromucous glands, and more inflammatory cells than does the convex side. Thus, mucociliary transport is impaired on the concave side. (1)

Rhinologic surgeons generally focus on the convex side as a cause of airway obstruction or as apredisposing factor in sinusitis. Although the latter point is widely believed, it is unproven scientifically. Pirila and Tikanto recently demonstrated that septoplasty resulted in an increase in nasal airflow and in the cross-sectional area on the convex side. (2) Interestingly, they found that these features deteriorated on the concave side following septoplasty.

Prevention of complications is important in such a common procedure. Nasal packing, septal splints, and quilting sutures work well in this regard, although each has its disadvantages.

Rhinologists consider packing a time-honored and well-accepted procedure, largely because of its ease and stellar effectiveness. Nevertheless, nasal packs are uncomfortable while they are in place and they cause pain and bleeding when they are removed. Ogretmenoglu et al recently reported that bilateral nasal packing leads to a significant decrease in oxygen saturation levels and heart rates in healthy young patients. (3) Toxic shock syndrome following nasal packing has been reported many times, first by Thomas et al in 1982 (4)

Septal splints can be used in lieu of packing to stabilize the septal flaps. However, in a prospective, randomized study, Malki et al found that patients who received splints experienced significantly more pain than did those who did not. (5)

Septal suturing has also been proposed as an alternative to packing, despite concerns about its inability to effectively stabilize the septal cartilage. (6,7) Stability was recently studied by Lemmens and Lemkens in a series of 226 consecutive patients who underwent septal suturing only. (8) In that series, only one patient experienced a recurrence of the deviation. Nevertheless, a notable disadvantage of suturing is the amount of time it requires.

The use of fibrin glue as an alternative to these three methods has several advantages. For example, while suturing requires 5 to 10 minutes to complete, even by expert hands, the placement of fibrin glue takes less than 60 seconds (including the compression time). Furthermore, at our institution, the cost of operating room time is $41 per minute, while fibrin glue costs $100/6 ml.

The use of fibrin glue in septoplasty has been reported only twice previously. In 1979, Wullstein described the first cases of septoplasty that were performed with the assistance of "biological adhesives." (9) In 1987, Hayward and Mackay reported on 30 patients who had been treated with fibrin glue. (10)

Fibrin glue is readily available in at least two forms. Under the trade name Tisseel, it has been commercially available in the United States for approximately 3 years, and it has been used in Europe for decades. Fibrin glue can also be compounded extemporaneously by mixing cryoprecipitate and thrombin. The latter formulation, which we used in our study, can be easily obtained and is less expensive than the commercial product.

We conclude that fibrin glue is a rapid and reliable method of approximating septal flaps and preventing complications associated with septoplasty.

References

(1.) Jang YJ, Myong NH, Park KH, et al. Mucociliaiy transport and histologic characteristics of the mucosa of deviated nasal septum. Arch Otolaryngol Head Neck Surg 2002;128:421-4.

(2.) Pirila T, Tikanto J. Unilateral and bilateral effects of nasal septum surgery demonstrated with acoustic rhinometry, rhinomanometry, and subjective assessment. Am J Rhinol 2001:15:127-33.

(3.) Ogretmenoglu O, Yilmaz T, Rahimi K, Aksoyek S. The effect on arterial blood gases and heart rate of bilateral nasal packing. Eur Arch Otorhinolaiyngol 2002:259:63-6.

(4.) Thomas SW, Baird IM, Frazier RD. Toxic shock syndrome following submucous resection and rhinoplasty. JAMA 1982;247:2402-3.

(5.) Malki D, Quine SM, Pfleiderer AG. Nasal splints, revisited. J Laryngol Otol 1999:113:725-7.

(6.) Stucker FJ, Ansel DG. A case against nasal packing. Laryngoscope 1978;88(8 Pt 1): 1314-7.

(7.) Reiter D, Alford E, Jabourian Z. Alternatives to packing in septorhinoplasty. Arch Otolaryngol Head Neck Surg 1989:115:1203-5.

(8.) Lemmens W, Lemkens P. Septal suturing following nasal septoplasty, a valid alternative for nasal packing? Acta Otorhinolaryngol Belg 2001;55:215-21.

(9.) Wullstein SR. [Septoplasty without postoperative nasal packing. Mucosal repair of the upper airway with human biological glue]. HNO 1979:27:3224.

(10.) Hayward PJ, Mackay IS. Fibrin glue in nasal septal surgery. J Laryngol Otol 1987:101:133-8.

From the Department of Otolaryngology--Head and Neck Surgery, Keck School of Medicine, University of Southern California, Los Angeles.

Reprint requests: Dale H. Rice, MD, 1200 N. State St., Box 795, Los Angeles, CA 90033. Phone: [phone]; fax: [phone]; e-mail: [e-mail]