The use of Silastic nasal splints in the treatment of chronic epistaxis and nasal septal ulceration.

Abstract

Some cases of epistaxis are chronic and resistant to treatment. We describe a novel method of treating persistent epistaxis with Silastic splints. This procedure is simple to perform and reverse, and it is much better tolerated than is total obstruction of the nostrils (Young's procedure). In addition, the presence of the splints reduces the likelihood of digital trauma, which can prevent healing. We describe the case of a 43-year-old man with a 5-year history of persistent epistaxis who was successfully treated with this procedure.

Introduction

Some cases of epistaxis are resistant to all traditional treatment methods. Digital trauma often contributes to the persistence of chronic epistaxis. We describe our use of a simple procedure involving the insertion of Silastic splints to successfully treat a case of persistent epistaxis with benign nasal septal ulceration and excoriation.

Case report

A 43-year-old man was referred to our department with a history of recurrent minor epistaxis. He complained of bleeding from both nostrils, more so from the left. Examination of the nose revealed mucosal dryness and ulceration with crusting in Little's area (Kiesselbach's area). Further investigation failed to uncover any evidence of an underlying cause of the epistaxis and ulceration. The patient underwent several treatments with silver nitrate cautery followed by the application of topical antibiotic creams and ointments without benefit.

After the patient had undergone 5 years of failed treatments, we attempted a new approach. With the patient under local anesthesia, we applied Silastic splints along each side of the septum. The splints were sutured in place with 2-0 silk. When the splints were removed 4 weeks later, the septal ulceration had healed and the mucosa appeared normal. At follow-up 4 months later, the patient had experienced no further epistaxis.

Discussion

Complete surgical closure of the nasal cavities for the treatment of atrophic rhinitis was first described by Young in 1967. (1) The underlying principle behind Young's procedure is that prevention of airflow through the nasal passages will prevent mucosal desiccation and crusting. (2) With the same principle in mind, surgeons have used Young's procedure to successfully treat chronic epistaxis secondary to hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber disease) (3-5) and granulomatous lesions of the septum (6) subsequent to persistent digital trauma. The obvious disadvantages of Young's procedure are complete nasal obstruction, anosmia and, in some patients, a sense of suffocation. (1) The procedure can be reversed with good results, and some patients achieve a satisfactory result with a partial reopening. (7,8)

As a less radical alternative to Young's procedure, individually molded Silastic obturators have been placed in the nasal vestibules for the treatment of atrophic rhinitis (9) and epistaxis secondary to coagulation deficiency (Bernard-Soulier syndrome). (10) The main disadvantage of this strategy is poor patient compliance secondary to discomfort.

In our patient, the septal ulceration was a large wound. Healing of this type of wound is achieved by secondary intention. (11) Such wounds occur as a result of significant trauma-induced tissue loss and as a complication of wound infection. The inflammatory process is more pronounced in cases of extensive tissue damage, and wound closure is prolonged secondary to a delay in epithelial union across the wound. Moreover, the formation of granulation tissue is more extensive in large wounds, although this helps reduce the surface area of the wound through myofibroblast contraction. At the end of the healing process, a wound surface is covered with intact epithelium and excessive scar tissue. Our patient had a large area of mucosal ulceration as a result of repeated airflow trauma, crust formation, and digital trauma.

Others have described the use of Silastic material to enhance the healing of large wounds. (12,13) The method we describe is simpler and less radical than Young's procedure. Silastic splints, which are normally used to prevent the occurrence or recurrence of postoperative adhesions, are readily available and easily insertable. They can be removed with only local anesthesia. Finally, this procedure is more cost-effective than other methods.

We believe that the principle behind our procedure is the same as that behind Young's procedure--that is, the splints block nasal airflow to the septal mucosa and also reduce the risk of self-inflicted digital trauma.

References

(1.) Young A. Closure of the nostrils in atrophic rhinitis. J Laryngol Otol 1967;81:515-24.

(2.) Serrano E, Percodani J, Pessey JJ. [Bilateral closure of the nasal cavity. An original surgical technique of treatment of severe recurrent epistaxis in Rendu-Osler disease]. Ann Otolaryngol Chir Cervicofac 1998;115:169-73.

(3.) Hosni AA, Innes AJ. Hereditary haemorrhagic telangiectasia: Young's procedure in the management of epistaxis. J Laryngol Otol 1994;108:754-7.

(4.) Gluckman JL, Portugal LG. Modified Yuung's procedure for refractory epistaxis due to hereditary hemorrhagic telangiectasia. Laryngoscope 1994;104:1174-7.

(5.) Lund VJ. Howard DJ. Closure of the nasal cavities in the treatment of refractory hereditary haemorrhagic telangiectasia. J Laryngol Otol 1997;111:30-3.

(6.) Brooker DS, Cinnamond MJ. Young's procedure in the treatment of epistaxis. J Laryngol Otol 1991;105:847-8.

(7.) Shah JT, Karnik PP, Chitale AR, Nadkami MS. Partial or total closure of the nostrils in atrophic rhinitis. Arch Otolaryngol 1974;100: 196-8.

(8.) Sinha SN, Sardana DS, Rajvanshi VS. A nine years' review of 273 cases of atrophic rhinitis and its management. J Laryngol Otol 1977; 91:591-600.

(9.) Lobo CJ, Hartley C, Farrington WT. Closure of the nasal vestibule in atrophic rhinitis--a new non-surgical technique. J Laryngol Otol 1998;112:543-6.

(10.) Lobo CJ, Hartley C, Farrington WT. Vestibular closure with a silastic obturator--an alternative to Young's procedure in bleeding diathesis. Rhinology 1999;37:131-2.

(11.) Young SR, Dyson M. Wound healing. In: KerrAG,ed. Scott-Brown's Otolaryngology. 6th ed. Oxford; Boston: Butterworth-Heinemann; 1997.

(12.) Burke JF. Yannas IV. Quinby WC Jr., et al. Successful use of a physiologically acceptable artificial skin in the treatment of extensive burn injury. Ann Surg 1981;194:413-28.

(13.) Prystowsky JH, Siegel DM, Ascherman JA. Artificial skin lot closure and healing of wounds created by skin cancer excisions. Dermatol Surg 2001:27:648-53.

Ausama Alaani, FRCSEd, FRCSI; Patrick Jassar, FRCS (ORL-HNS); Ian Smith, FRCS (ORL-HNS)

From the Department of Otorhinolaryngology--Head and Neck Surgery, Bradford Royal Infirmary Hospital, Bradford, U.K.

Reprint requests: Dr. Ausama Alaani, ENT Department, Warwick Hospital, Lakin Rd., Warwick CV34 5BW, UK. Phone: [phone]; fax: [phone]; e-mail: [e-mail]