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Outcomes following nasal surgery with and without postoperative nasal dressings.

INTRODUCTION: Surgery to the sinuses has undergone a dramatic change with a paradigm shift from traditional external approaches to endoscopic techniques in the last three decades. Endoscopic Sinus Surgery (ESS) is now considered as the treatment of choice for Chronic Rhinosinusitis which is refractory to maximal medical therapy. (1) Advances in the technology and Instrumentation and availability of high definition Cameras and Endoscopes have led for this consideration. But one notable cause of surgical failure of ESS is adhesion formation postoperatively. Adhesion formation is the most frequent complication of ESS. (2, 3) It has been estimated that up to 25% of patients with adhesion will require revision surgery. (4) Perioperative bleeding has also been considered as main concern in ESS. (5) To prevent postoperative bleeding and to prevent adhesion formation between the raw mucosal surfaces postoperatively, to prevent lateralization of Middle turbinate and thereby obstructing the sinus drainage pathways, Nasal dressings are used postoperatively. Mucosal sparing techniques are being given considerable importance recently. Experience with nasal dressings in Otolaryngologist literature spans more than half a century. (6) Despite of this vast experience, there is still little agreement between surgeons for the need of nasal dressings postoperatively and if required, on the choice of nasal dressings. The area of postoperative management of ESS cavity remains an area of active research and ongoing debate in Otolaryngologist literature. The purpose of this study was to prospectively compare the patients with nasal surgery with and without postoperative nasal dressings and to determine their outcome 6 months postoperatively.

MATERIALS AND METHODS: A prospective evaluation of patients who underwent Nasal surgery (Septoplasty with or without Inferior Turbinoplasty, Endoscopic Sinus Surgery) at tertiary teaching hospital setting between February 2013 to June 2014 was performed. All patients were seen in the outpatient department for an opinion regarding nasal surgery for symptoms of Nasal obstruction, Refractory chronic rhinosinusitis that had been treated for at least 6 months. Medical treatment for chronic rhinosinusitis cases included Antibiotics, Topical steroids, Oral and topical decongestants, systemic steroids for necessary case and Allergy management. We included 160 patients in the study who underwent Septoplasty, Septoplasty with Turbinoplasty, Anterior Endoscopic sinus surgery, Anterior and posterior Endoscopic sinus surgery at medical college hospital between February 2013 and June 2014. The following had been laid as the inclusion criteria for this surgery:

1) Patients with obstructive and impacted deviated nasal septum presenting with nasal obstructive symptoms who underwent Septoplasty with or without Turbinoplasty.

2) Patients with refractory chronic rhinosinusitis with no response to maximal medical therapy and who underwent Endoscopic Sinus surgery (Anterior/Posterior).

3) CT scan documentation of Rhinosinusitis at the end of maximal medical therapy and who underwent Endoscopic sinus surgery.

Postoperatively, we used nasal dressings to pack the nose in some cases. For nasal dressing we used Antibiotic soaked guaze, Merocoel, Cuticel, Gelfoam. We compared the results in the patients with postoperative nasal dressings with patients without nasal dressings. We estimated the results in terms of Postoperative bleeding, Healing, Adhesion (Synechiae) formation and Lateralization of Middle turbinate.

RESULTS: One hundred and sixty patients satisfied the inclusion criteria and had been followed for 6 months postoperatively. Out of 160 patients in the study 98(61.25%) were males and 62(38.75%) were females. 86 patients (53.75%) underwent Septoplasty with or without Turbinoplasty (32 patients underwent Septoplasty and 54 patients underwent Septoplasty with turbinoplasty). 74 patients (46.25%) underwent Endoscopic Sinus surgery (21 patients underwent Anterior ESS and 53 patients underwent Anterior and Posterior ESS).

Nasal dressing following nasal surgery was done in 92 cases (57.5%). No nasal dressing was done in 68 patients (42.5%). In 92 patients with postoperative nasal dressings, 50(51.02%) were males and 42 (67.74%) were females.

Nasal dressings were done following Septoplasty surgery was done in 20 cases (62.5% of total 32 cases), Septoplasty with turbinoplasty in 32 cases (59.26% of total 54 cases), Anterior ESS in 10 cases (47.62% of total 21 cases) and Anterior and Posterior ESS in 30 cases (56.6% of total 53 cases).

For nasal dressings, Antibiotic soaked guaze was used in 21 cases (22.83% of total 92 cases with nasal dressings), Cuticel was used in 22 cases (23.91% of total 92 cases with nasal dressings), Merocoel was used in 39 cases (42.39% of total 92 cases with nasal dressings), Gelfoam was used in 10 cases (10.87% of total 92 cases with nasal dressings).

We noticed Postoperative bleeding in 5 cases (5.43%) in patients with nasal dressing postoperatively of total 92 cases, in 4 cases (5.88%) in patients without nasal dressing postoperatively of total 68 cases. We noticed Adhesion formation in 8 cases (8.7%) in patients with nasal dressing postoperatively of total 92 cases, in 2 cases (2.94%) in patients without nasal dressing postoperatively of total 68 cases. Middle turbinate lateralization is found in 7 cases (17.5%) in patients who underwent ESS with postoperative nasal dressing (total of 40 cases) and in 3 cases (8.82%) in patients who underwent ESS without postoperative nasal dressing (Total of 34 cases).

DISCUSSION: There seems to be a consensus favoring nasal dressing following nasal surgery. However, there is still disagreement about which type of material should be used for nasal dressing. There is wide array of nasal dressings that are available and are been used for nasal dressings for the postoperative nasal cavity, broadly divided into Absorbable and Removable nasal packing materials. Nasal packing materials are used in order to tamponade bleeding surfaces, activate coagulation cascades and also to act as barriers for the formation of adhesion between two denuded mucosal surfaces. The ideal nasal dressing material is one that is absorbable, haemostatic and improves healing. (1)

Currently available dressings that achieve haemostasis worsen wound healing outcomes. The removable nasal packing materials available are Ribbon guaze soaked in antibiotic/Vaseline, Balloon tamponade devices, Polyvinyl acetate sponge (Merocel), Cuticel. The authors experience with balloon tamponade devices is very limited. Removable nasal packing may cause significant bleeding upon removal (7,8,9) and has been shown to cause significant trauma to the nasal mucosa upon removal. (10) Other complications that have been attributed to nasal packing's include Septal perforation, Turbinate necrosis, Toxic shock syndrome, Obstructive sleep apnoea, foreign body reactions. (11, 12) As a result of these adverse effects, removable nasal dressings are uncommonly used and made the authors to avoid their usage in postoperative cases.

The absorbable dressings may be derived from number of materials and include Blood products (Fibrin glue, Floseal), Animal based (Hyaluronic acid based products like Sepragel, Merogel, Gelfilm, Surgiflo), Plant based (Surgicel, carboxy methyl cellulose), Synthetic (Nasopore). As these products are quite expensive and sparsely available at the authors place.

The decision to pack the nose following nasal surgery has undergone much debate with some surgeons advising against it (13, 14) and others advocating it. (15) In reviewing the literature in regard to no packing at all after nasal surgery particularly after ESS, Athanasiadis et al (16) found no incidence of postoperative bleeding in 30 patients who underwent ESS. James et al (17) also found similar results in a slightly bigger group. In fact, when considering the large volume of literature investigating nasal dressings following nasal surgery has any advantage, there is only one RCT that showed the use of nasal dressing on postoperative bleeding when compared to no packing at all (Sindwani R).

In our study, we found that there is no significant difference in Postoperative bleeding in patients with nasal packing (5.43%) and in patients without nasal packing (5.88%). In fact, we found that Adhesion formation rate is quite less in patients without nasal packing (2.94%) when compared to patients with nasal packing (8.7%). Also in issues related to Middle Turbinate lateralization, patients without nasal packing (8.82%) outstand the patients with nasal packing (17.5%). The rate of formation of adhesions and middle turbinate lateralization were found high in cases with nasal packing after Anterior and Posterior ESS when compared to Anterior ESS alone.

CONCLUSION: The decision as to whether to pack the nose after nasal surgery remains controversial. There has been an increasing tendency to move away from removable nasal dressings (Antibiotic guaze, Merocel, Cuticel) due to discomfort and bleeding seen upon removal and also postoperative adhesions. Despite large amount of literature on absorbable biomaterials there has been no conclusive evidence that absorbable nasal dressings show any advantage over no dressing at all in regard to postoperative bleeding, wound healing, Adhesion formation, Middle turbinate lateralization. This study showcases that there is no considerable difference in postoperative bleeding in patients with or without nasal dressings postoperatively. It also shows that wound healing is better and middle turbinate lateralization is less significant in cases without nasal packing's than in cases with post-operative nasal dressings.

DOI: 10.14260/jemds/2015/317

REFERENCES:

(1.) Rowan Valentine and Peter-John wormald: Nasal dressing after endoscopic sinus surgery, 2010.

(2.) Anand VK, Tabaee A, Kacker A, et al. The role of mitomycin C in preventing synechia and stenosis after endoscopic sinus surgery. Am J Rhinol 2004; 18: 311-314.

(3.) Catalano PJ, Roffman EJ. Evaluation of middle meatal stenting after minimally invasive sinus techniques (MIST). Otolaryngol Head Neck Surg 2003; 128: 875-881.

(4.) Shrime MG, Tabaee A, Hsu AK, et al. Synechia formation after endoscopic sinus surgery and middle turbinate medialization with and without Floseal. Am J Rhinol 2007; 21: 174-179.

(5.) Hopkins C, Browne JP, Slack R et al. Complications of surgery for nasal polyposis and chronic rhinosinusitis: the results of national audit in England and Wales. Laryngoscope 2006; 116: 1494-1499.

(6.) Stevens RW. Nasal packing; the rubber pneumatic pack. AMA Arch Otolaryngol 1951; 54: 191194.

(7.) Pomerantz J, Dutton JM. Platelet gel for endoscopic sinus surgery. Ann Otol Rhino Laryngol 2005; 114: 699-704.

(8.) Vaiman M, Eviatar E, Segal S. The use of fibrin glue as hemostatic in ESS:a prospective, randomized study. Rhinology 2002; 40: 185-188.

(9.) Vaiman M, Eviatar E, Segal S. The effect of second generation fibrin glue in in endonasal operations. Otolaryngol Head Neck Surg 2002; 126: 388-391.

(10.) Shaw CL, Dymock RB, Cowin A, Wormald PJ. Effect of packing on nasal mucosa of sheep. J Laryngol Otol 2000; 114: 506-509.

(11.) Weber R, Hochapfel F, Draf W. Packing and stents in endonasal surgery. Rhinology 2000; 38: 49-62.

(12.) Weber R, Keerl R, Hochapfel F, et al. Packing in endonasal surgery. Am J Otolaryngol 2001; 22: 306-320.

(13.) Orlandi RR, Lanza DC. Is nasal packing necessary following endoscopic sinus surgery? Laryngoscope 2004; 114: 1541-1544.

(14.) Eliashar R, Gross M, Wohlgelernter J. Packing in endoscopic sinus surgery: is it really required? Otolaryngol Head Neck Surg 2006; 134: 276-279.

(15.) Franklin JH, Wright ED. RCT of absorbable nasal packing on outcomes of surgical treatment of rhinosinusitis with polyposis. Am J Rhinol 2007; 21: 214-217.

(16.) Athanasiadis T, Beule AG, Robinson Bh, et al. Effects of a novel chitosan gel on mucosal wound healing following ESS in sheep model. Laryngoscope 2008; 118: 1088-1094.

(17.) Jameson M, Gross CW, Kountakis SE. Floseal use in ESS: effect on postoperative bleeding and synechiae formation. Am J Otolaryngol 2006; 27: 86-90.

TABLES AND CHARTS

Chart I: Number of surgical cases.

Chart II: Surgical cases with and without packing.

CHART III: Male and Female distribution of Cases with and without packing

CHART IV: Nasal Packing done cases

CHART V: POST OPERATIVE FOLLOW UP

S. Surya Prakasa Rao [1], Pradeep Vundavalli [2]

AUTHORS:

[1.] S. Surya Prakasa Rao

[2.] Pradeep Vundavalli

PARTICULARS OF CONTRIBUTORS:

[1.] Associate Professor, Department of ENT, AMC.

[2.] Assistant Professor, Department of ENT, NRIIMS.

FINANCIAL OR OTHER COMPETING INTERESTS: None

NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:

Dr. S. Surya Prakasa Rao, Associate Professor in ENT, #50-27-15/1, Seethammadhara NE, Visakhapatnam-530013.

E-mail: pradeepvundavalli@gmail.com drsspao@gmail.com

Date of Submission: 02/02/2015.

Date of Peer Review: 03/02/2015.

Date of Acceptance: 06/02/2015.

Date of Publishing: 11/02/2015.
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Title Annotation:ORIGINAL ARTICLE
Author:Rao, S. Surya Prakasa; Vundavalli, Pradeep
Publication:Journal of Evolution of Medical and Dental Sciences
Article Type:Report
Date:Feb 12, 2015
Words:1997
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