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Comparative study of intranasal septal splints and nasal packs in patients undergoing nasal septal surgery.

Abstract

We conducted a prospective, comparative, interventional study to evaluate the role of intranasal septal splints and to compare the results of this type of support with those of conventional nasal packing. Our study population was made up of 60 patients, aged 18 to 50 years, who had undergone septoplasty for the treatment of a symptomatic deviation of the nasal septum at our tertiary care referral hospital. These patients were randomly divided into two groups according to the type of nasal support they would receive: 30 patients (25 men and 5 women, mean age: 23.3 yr) received bilateral intranasal septal splints and the other 30 (26 men and 4 women, mean age: 22.4 yr) underwent anterior nasal packing. Outcomes parameters included postoperative pain and a number of other variables. At 24 and 48 hours postoperatively, the splint group had significantly lower mean pain scores (p < 0.05). At 48 hours, the splint group experienced significantly fewer instances of nasal bleeding (p < 0.01), swelling over the face and nose (p < 0.01), watering of the eyes (p < 0.01), nasal discharge (p = 0.028), nasal obstruction (p < 0.001), and feeding difficulty (p = 0.028). Likewise, mean pain scores during splint or pack removal were significantly lower in the splint group (p < 0.01). At the 6-week follow-up, only 2 patients (6.7%) in the splint group exhibited a residual deformity, compared with 8 patients (26.7%) in the packing group (p = 0.038). Finally, no patient in the splint group had an intranasal adhesion at follow-up, while 4 (13.3%) in the packing group did (p < 0.05). We conclude that intranasal septal splints result in less postoperative pain without increasing postoperative complications, and thus they can be used as an effective alternative to nasal packing after septoplasty.

Introduction

The true prevalence of nasal septal deviation is unknown, and numerous studies have revealed a wide range of prevalence. This can be explained in part by the fact that different age groups have been studied and that several classification systems have been used. In adults, a recent international study found a prevalence of 89.2%. (1) In some of these individuals, the irregularity was significant enough to produce symptoms. The major symptom of septal deviation is nasal obstruction.

Significant septal deviations are generally treated with septoplasty. Postoperatively, many surgeons routinely administer nasal packing to achieve internal stabilization of the cartilaginous/bony skeleton of the nose and to prevent complications such as bleeding, hematoma, infection, and abscess formation. Other complications associated with postoperative intranasal swelling are disturbances in endonasal lymph and venous drainage, the nasal-vagal reflex, mucosal injury, septal perforation, sleep respiratory disturbances, decreased arterial oxygen saturation during sleep, allergy, toxic shock syndrome, eustachian tube dysfunction, and pack granuloma. Moreover, nasal packs are uncomfortable while they are in place, and they often cause severe pain and bleeding when they are removed.

Some rhinologists use intranasal septal splints as an alternative to nasal packing. However, there is considerable controversy regarding the efficacy of splints. To shed some light on the topic, we conducted a study to evaluate the role of intranasal septal splints and to compare the results of splinting with those of conventional nasal packing after nasal septal surgery.

[FIGURE 1 OMITTED]

Patients and methods

We conducted a prospective, comparative, interventional study to evaluate the role of intranasal septal splints and to compare the results of this type of treatment with those of conventional nasal packing. Our study population was made up of 60 patients, aged 18 to 50 years, who had undergone septoplasty for the treatment of a symptomatic deviation of the nasal septum at our tertiary care referral hospital.

Nasal obstruction was present in all 60 patients. Other preoperative complaints included sneezing (n = 8), headache (n = 5), and nasal discharge (n = 3). Exclusion criteria for this study included a history of previous nasal septum surgery and the presence of any skin disease in the external nasal pyramid, features of acute or chronic sinusitis, bleeding disorders, and nasal polyps or any other nasal mass.

Prior to septoplasty, the 60 patients were randomly divided into two groups according to the type of nasal support they would receive: 30 patients (25 men and 5 women, mean age: 23.3 yr) received bilateral intranasal septal splints and the other 30 (26 men and 4 women, mean age: 22.4 yr) underwent anterior nasal packing. All patients were taken up for surgery with local anesthesia after providing written informed consent.

The patients in the splint group received Reuter-type fluoroplastic bivalve intranasal septal splints with prepunched holes of standard 0.50-mm thickness (Medtronic; Jacksonville, Fla.). These splints are made of clear medical-grade fluoroplastic that is flexible and nonadherent. One splint was inserted into each nasal cavity and fixed with a 3-0 Mersilk suture that crossed both septal flaps and splints anteriorly and posteriorly; a through-and-through mattress suture was used to cross the remaining septal cartilage if possible (figure 1). Excessive tightening of the sutures was avoided. No antibiotic pack was used.

[FIGURE 2 OMITTED]

The patients in the packing group received antibiotic-soaked nasal packs in both nasal cavities (figure 2).

Postoperatively, all patients were given oral amoxicillin/clavulanate at 625 mg three times a day and oral diclofenac at 50 mg three times a day for 7 days. Patients were assessed for pain and discomfort at 24 and 48 hours postoperatively; pain was rated on a visual analogue scale of 0 (no pain) to 10 (the most pain imaginable). Patients were also evaluated for other postoperative complications.

The nasal packs were removed after 48 hours and the splints were removed after 1 week. Pain scores during removal in both groups were recorded.

All patients were followed up at 1 and 6 weeks. At 6 weeks, patients were asked for their subjective assessment of complaints. In addition, all patients were examined endoscopically to look for residual deformity, intranasal adhesions, nasal discharge, nasal obstruction, nasal crusting, and septal perforation.

Statistical analysis was performed with the Statistical Package for the Social Sciences software (v. 16; SPSS; Chicago), and the level of significance was set at p < 0.05.

Approval for this study was granted by our departmental board of postgraduate studies.

Results

At 24 hours postoperatively, mean pain scores were 2.53 in the splint group and 5.7 in the packing group. At 48 hours, the respective scores were 1.36 and 2.9. Both differences were statistically significant (p < 0.05).

At 48 hours, the splint group had significantly fewer cases of nasal bleeding, swelling over the face and nose, watering of the eyes, nasal discharge, nasal obstruction, and feeding difficulty (table 1). There was no significant difference between the two groups in tip cellulitis, and no patient in either group experienced a septal hematoma.

During removal of their respective supports, the mean pain scores were 2.06 in the splint group and 4.63 in the packing group. Again, the difference was statistically significant (p < 0.01).

At the 1-week follow-up, there were no significant differences in pain scores (p = 0.584) and cases of nasal bleeding (p = 0.688), nasal discharge (p = 0.184), vestibulitis (p = 0.739), and crust formation (p = 0.197).

At the 6-week follow-up, the splint group had significantly fewer cases of residual deformity --and intranasal adhesions (table 2). There were no significant differences in nasal discharge, nasal obstruction, nasal crusting, and septal perforation.

Discussion

In our study, the men outnumbered the women by a ratio of 5.7:1. Similar findings have been observed by Campbell et al, (2) Cook et al, (3) and Al-Mazrou and Zakzouk. (4) The preponderance of men in these studies might be explained by the fact that men engage in more physical activities than do women and are thus more prone to injury. Septal deviations are more likely to be acquired secondary to trauma than to occur congenitally, a fact that has been substantiated by studies of identical twins with respect to deformities of the anterior septum. (5)

The traditional rationale for routine nasal packing following septal surgery is that it results in good flap apposition and minimizes the risks of postoperative bleeding, septal hematoma, and adhesion formation. Packing supports the unstable fragments of the newly formed septum until sufficient stability has been obtained by the clotting of fibrin between the fragments. The final stabilizing effects of fibrosis and scar-tissue formation are obtained at a far later stage.

Most patients complain that the presence of nasal packing is quite distressing, and some say that its removal was the most painful experience of their lives. In fact, Yavuzer and Jackson quoted a significant number of new patients as saying, I have come to have surgery from you because I hear that you don't pack the nose!" (6)

Besides pain, nasal packing is also associated with several other complications. In view of these concerns, surgeons have debated the advisability of nasal packing, and alternatives to traditional packing have been proposed. Nasal splints are an effective alternative to nasal packing in terms of supporting the septum and preventing adhesions, while at the same time allowing for nasal respiration postoperatively. (7) Nevertheless, their use is still a source of considerable debate and controversy, and studies conducted from time to time have yielded conflicting results.

The postoperative pain scores in our study took into account associated headache. The patients in the packing group had a greater incidence of headache because of the fact that packing stretches the nasal walls and causes pain. This finding was in accordance with those of Nunez and Martin, who studied pain in 59 patients undergoing septal surgery. (8) They reported a mean pain score of 4.1 in their packing group and a score of 2.9 in a group that received no packing (mucosal sutures only); the difference was statistically significant (p < 0.05).

In a study of 110 patients, Malki et al found no significant difference in pain at 48 hours between patients who received a splint and those who did not. (9) Mean pain scores were 2.1 in the splinted group and 1.8 in the nonsplinted group (p = 0.5).

Our findings that nasal bleeding, swelling over the face and nose, watering of the eyes, nasal discharge, nasal obstruction, and feeding difficulty during first 48 hours were significantly less common in the splint group (table 1) are in accordance with the findings of Nayak et al. (10) They studied 100 patients and concluded that postoperative comfort was greatly enhanced by the use of septal splints instead of nasal packing.

Our finding that pain during removal of the two types of support was significantly less severe in the splint group is supported by other investigators, as well. Von Schoenberg et al studied the use of Silastic nasal splints and nasal packing and recorded mean pain scores during removal. (11) The mean score during splint removal at 1 week postoperatively was 1.4, compared with a mean score of 5.7 during packing removal at 24 hours (p < 0.001). The authors commented that packing removal was the most painful postoperative event. Similarly, Eliopoulos and Philippakis used septal splints made of wax paper and an antibiotic gauze and removed them after 12 days. (12) They concluded that this splint did not induce trauma, and its removal was painless.

In our study, there was no significant difference in mean pain scores at 1 week. This can be attributed to the use of analgesics during that time. The opposite was found in the study by von Schoenberg et al, who found that the packing group had a significantly higher mean pain score after 1 week than did the Silastic splint group (p < 0.001). (11) Their explanation for this phenomenon was that the nasal packing was associated with a degree of trauma that persisted after it was removed. On the other hand, the study by Malki et al found that patients with splints experienced significantly more pain and discomfort at 1 week than did those who did not receive a splint (mean scores: 2.2 and 0.5, respectively; p < 0.0001). (9) Similar findings were reported by Campbell et al, (2) Cook et al, (3) and Al-Mazrou and Zakzouk. (4)

At the 1-week follow-up in our study, there were no significant differences between the two groups in the incidence of nasal bleeding, nasal discharge, vestibulitis, and crust formation. In another study by von Schoenberg et al, 3 patients (2.9%) developed vestibulitis while their splints were still in place. (13) All of these patients had been packed with bismuth iodine paraffin paste (BIPP) packing in addition to a splint, and the BIPP packing might have been a contributing factor. Nunez and Martin observed crust formation in 22.7% of their patients who received packing, but this was not significantly different from the rate in those who did not receive packing. (8)

Our finding that residual deformity was significantly more common in the packing group at 6 weeks is in accordance with the study by Malki et al, who concluded that septal splints enhance the stability of the septum following septoplasty. (9)

Jung et al recruited 40 patients who had undergone septoplasty only, without sinus surgery or turbinoplasty. (14) A Silastic septal splint was inserted into one side of the nasal cavity at the end of each septoplasty; the other side served as a control. The splinted side and control side were randomly selected. On the postoperative day 7, there was no significant difference in nasal discomfort between the splinted and control sides, but the mucosal status was better on the splinted side. At 14 days postoperatively, the symptom score (2.7 vs. 3.8; p < 0.001) and mucosal status (1.5 vs. 1.9;p = 0.013) were significantly better on the splinted side. They concluded that insertion of a Silastic septal splint after septal surgery should be accepted as a routine procedure.

At 6 weeks in our study, the incidence of intranasal adhesions on endoscopic examination was significantly higher in the packing group. Synechiae formation was as a result of a chronic inflammatory process following injury to the lateral nasal wall during surgery, as well as to the septal mucosa by the nasal packs. The intranasal splints, which remained in place for 7 days postoperatively, prevented contact between the lateral nasal wall and the raw mucosal surfaces of the septum. This finding was in agreement with that of Campbell et al, who found that adhesions occurred in 17% of patients, all of which were in unsplinted nasal cavities (p < 0.001). (2)

Deniz et al retrospectively compared postoperative findings in 130 patients who had received septal splints and Merocel nasal packings. (15) Their study found that the Merocel packing group had a significantly greater incidence of synechiae formation (p < 0.05).

Our finding that the incidence of nasal obstruction at 6 weeks was not significantly different between the two groups was similar to the findings of Cook et al, who found similar improvements in airway patency at 6 weeks in both splinted and nonsplinted patients. (3)

It has been postulated that the use of nasal splints during septal surgery leads to a higher incidence of septal perforation. (16) In our study, no case of septal perforation occurred in either group. Likewise, Deniz et al found no statistically significant difference in postoperative septal perforation between their splint and packing groups. (15)

In conclusion, our study found that intranasal septal splint application after septoplasty was associated with less postoperative pain and fewer complications than was anterior nasal packing. We believe that these factors--in addition to the ease, effectiveness, and safety of splinting--make it a superior alternative to nasal packing after septal surgeries.

References

(1.) Mladina R, Cujic E, Subaric M, Vukovic K. Nasal septal deformities in ear, nose, and throat patients: An international study. Am J Otolaryngol 2008;29(2):75-82.

(2.) Campbell JB, Watson MG, Shenoi PM. The role of intranasal splints in the prevention of post-operative nasal adhesions. J Laryngol Otol 1987; 101 (11): 1140-3.

(3.) Cook JA, Murrant NJ, Evans KL. Lavelle RJ. Intranasal splints and their effects on intranasal adhesions and septal stability. Clin Otolaryngol Allied Sci 1992;17(1):24-7.

(4.) Al-Mazrou KA, Zakzouk SM. The impact of using intranasal splints on morbidity and prevalence of adhesions. Saudi Med J 2001;22(7): 616-18.

(5.) Grymer LF, Melsen B. The morphology of the nasal septum in identical twins. Laryngoscope 1989;99(6 Pt l):642-6.

(6.) Yavuzer R, Jackson IT. Nasal packing in rhinoplasty and septorhinoplasty: It is wiser to avoid [letter], Plast Reconstr Surg 1999; 103 (3):1081-2.

(7.) Pringle MB. The use of intra-nasal splints: A consultant survey. Clin Otolaryngol Allied Sci 1992;17(6):535-9.

(8.) Nunez DA, Martin FW. An evaluation of post-operative packing in nasal septal surgery. Clin Otolaryngol Allied Sci 1991;16(6):549-50.

(9.) Malki D, Quine SM, Pfleiderer AG. Nasal splints, revisited. J Laryngol Otol 1999;113(8):725-7.

(10.) Nayak DR, Murty KD, Balakrishna R. Septal splint with wax plates. J Postgrad Med 1995;41(3):70-1.

(11.) von Schoenberg M, Robinson P, Ryan R. Nasal packing after routine nasal surgery--is it justified? J Laryngol Otol 1993;107(10):902-5.

(12.) Eliopoulos PN, Philippakis C. Prevention of post-operative intranasal adhesions (a new material). J Laryngol Otol 1989; 103(7) :664-6.

(13.) von Schoenberg M, Robinson P, Ryan R. The morbidity from nasal splints in 105 patients. Clin Otolaryngol Allied Sci 1992;17(6): 528-30.

(14.) Jung YG, Hong JW, Eun YG, Kim MG. Objective usefulness of thin Silastic septal splints after septal surgery. Am J Rhinol Allergy 2011;25(3):182-5.

(15.) Deniz M, Ciftci Z, Isik A, et al. The impact of different nasal packings on postoperative complications. Am J Otolaryngol 2014 Apr. 27 [Epub ahead of print],

(16.) East C, Paun S. Nasal septal perforations. In: Gleeson M, ed. Scott-Brown's Otorhinolaryngology, Head and Neck Surgery. 7th ed. Vol.

Raman Wadhera, MS; Naushad Zafar, MS; Sat Paul Gulati, MS; Vijay Kalra, MS; Anju Ghai, MD

From the Department of Otorhinolaryngology (Dr. Wadhera, Dr. Zafar, Dr. Gulati, and Dr. Kalra) and the Department of Anaesthesiology (Dr. Ghai), Pt. Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences Rohtak, Haryana, India.

Corresponding author: Dr. Raman Wadhera, 6/8FM, Medical Enclave, Rohtak-124001, Haryana, India. Email: dr.wadhera@yahoo.com
Table 1. Postoperative findings after 48 hours in the two groups

                                    n (%)

Finding                  Splint group   Packing group   p Value

Nasal bleeding             3 (10.0)       20 (66.7)     <0.01 *

Swelling over the face     3 (10.0)       24 (80.0)     <0.01 *
and nose

Watering of the eyes          0           20 (66.7)     <0.01 *

Nasal discharge            2 (6.7)        13 (43.3)      0.028 *

Nasal obstruction          7 (23.3)       30 (100)      <0.001 *

Feeding difficulty         2 (6.7)        13 (43.3)      0.028 *

Tip cellulitis            10 (33.3)       17 (56.7)      0.069

Septal hematoma               0               0           N/A

* Statistically significant difference.

Table 2. Distribution of postoperative comparison at 6 weeks in the
two groups

                              n (%)

                        Splint    Packing
Finding                 group      group     p Value

Residual deformity     2 (6.7)    8 (26.7)    0.038 *
Intranasal adhesions      0       4 (13.3)   <0.05 *
Nasal discharge        4 (13.3)   5 (16.7)    0.718
Nasal obstruction         0       2 (6.7)     0.15
Nasal crusting            0          0         N/A
Septal perforation        0          0         N/A

* Statistically significant difference.
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Title Annotation:ORIGINAL ARTICLE
Author:Wadhera, Raman; Zafar, Naushad; Gulati, Sat Paul; Kalra, Vijay; Ghai, Anju
Publication:Ear, Nose and Throat Journal
Article Type:Report
Date:Sep 1, 2014
Words:3234
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