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Postoperative Packing After Septoplasty: Is It Necessary?
Postop erative Packing Af ter Septoplast y : Is It Ne cess ar y? Marika R. Dubin, MD*, Steven D. Pletcher, MD KEYWORDS Septoplasty Packing Nasal splints Morbidity Complications
There is a lack of consensus regarding the need for nasal packing following septoplasty. The use of postoperative packing has been proposed to minimize postoperative complications such as hemorrhage, formation of synechiae, and septal hematoma. Additionally, postoperative packing is thought to stabilize the remaining cartilaginous septum and minimize persistence or recurrence of septal deviation. Despite these theoretic advantages, evidence to support the use of postoperative packing is lacking. Additionally, nasal packing is not an innocuous procedure. The use of nasal packing carries several risks which, given the lack of firm evidence to support its efficacy, should call into question its routine application. MORBIDITY OF NASAL PACKING
While life-threatening risks associated with nasal packing have been documented, these complications occurred primarily in the setting of posterior packing placed for the treatment of epistaxis.1 The presumed etiology of death in these cases, the naso-pulmonary reflex,2–5 has not been noted in the modern literature of postseptoplasty packing. The most common morbidity associated with packing in postseptoplasty patients is postoperative pain.6–8 Additional potential complications include worsening of sleep disordered breathing9 and postoperative infection, including reports of toxic shock syndrome due to postseptoplasty packing.10 Attempts have been made to limit the morbidity of nasal packing through limiting the duration of packing and altering packing materials.11–13 Overall, the wide variety of packing materials and techniques complicates a clear assessment of the risks associated with postoperative septoplasty packing. Illum and colleagues13 found decreased pain with removal when using fingerstall packs compared with Merocel or hydrocortisone-terramycine gauze packs with ventilation tubes. Some authors have found rehydration of foam packs with topical anesthetic to lessen discomfort
Department of Otolaryngology, Head and Neck Surgery, University of California, 400 Parnassus Avenue, Box 0342, San Francisco, CA 94143, USA * Corresponding author. E-mail address: [email protected] (M.R. Dubin). Otolaryngol Clin N Am 42 (2009) 279–285 doi:10.1016/j.otc.2009.01.015 0030-6665/09/$ – see front matter ª 2009 Published by Elsevier Inc.
oto.theclinics.com
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Dubin & Pletcher
upon pack removal.14,15 Silastic nasal splints are frequently used in place of packing and may be associated with less morbidity. EFFICACY OF NASAL PACKING
While the morbidity and risks associated with postoperative nasal packing may be tolerated or minimized, the existence of such complications requires an evaluation of the importance of postseptoplasty nasal packing. In 1989, Guyuron published one of the few studies describing the efficacy of nasal packing in maintaining an adequate postoperative airway.16 In this study, 50 subjects undergoing septorhinoplasty were randomized to receive packing with polysporin-impregnated gauze or placement of a quilting suture without nasal packing. Twenty-three subjects in the packed group and 22 subjects in the suture group were available for follow-up at up to 16 and 26 months, respectively. Subjective breathing improvement was found to be significantly more prevalent among the packed group. Additionally, a significantly higher percentage of persistent septal deviation was found among the unpacked group. These findings, however, were called into question by Oneal who noted that subjects’ awareness of packing as a point of study may have introduced bias into the patients’ subjective assessment of breathing improvement.17 He additionally noted that this finding, and the finding of persistent deviation as more common among the unpacked group, is weakened by the lack of preoperative assessment of degree of septal deviation. It is also important to note that this study was performed in the context of septorhinoplasty, not septoplasty alone. Subsequent studies have failed to demonstrate a clear advantage to nasal packing while noting an increased morbidity with the use of packing. Nunez and colleagues7 prospectively studied 59 subjects undergoing septal surgery and randomized them to packing with Vaseline gauze or no packing and placement of a septal quilting suture. Pain was recorded by a visual analog scale on postoperative day one and was found to be significantly higher in the packed group. The authors found no difference in the prevalence of adhesions, crusting/mucosal atrophy or granuloma formation between the two groups during follow-up at 6 weeks. The presence of persistent septal deviation and the extent of airway improvement were not evaluated in this study. Von Schoenberg and colleagues6 studied 95 subjects undergoing routine nasal surgery and randomized them to receive packing (either bismuth iodoform paraffin paste (BIPP) or Telfa) or no packing. Subjects undergoing septoplasty were further randomized to receive splints or no splints. Packs were removed at 24 hours postoperatively. Pain was recorded by visual analog scale during the first 24 hours, during pack removal, over the first week, and at the time of splint removal. Pain was significantly higher in the packed group at all points of measurement, and removal of packing proved to be the most painful event during the postoperative period, irrespective of whether splints were present. The authors found a higher rate of complications (including hemorrhage, vestibulitis and septal perforation) in the packed group, though it is not clear if this reached statistical significance. The incidence of intranasal adhesions was similar for the packed and unpacked groups, though the duration of followup with regard to this finding is unclear. Additional series have demonstrated septal surgery without the use of postoperative packing to be safe. Reiter and colleagues18 retrospectively studied 75 patients who underwent septorhinoplasty with placement of a quilting suture and no packing and identified only two cases of bleeding, both attributed to bleeding from lateral osteotomy sites. More recently, Bajaj and colleagues19 reported a series of 78 subjects who underwent septoplasty without postoperative packing, with quilting suture used
Postoperative Packing After Septoplasty
in just over a quarter of cases. They identified a 7.7% rate of postoperative hemorrhage with only half of these patients (3.8%) requiring packing to control bleeding. Overall, the literature suggests that the use of nasal packing following septoplasty does not provide a clear advantage in improving nasal airway, nor does it appear to prevent postoperative complications. Furthermore, there is a clear increase in postoperative morbidity, specifically pain, with the use of both nasal packing following septoplasty. See Table 1 for a summary. EFFICACY AND MORBIDITY OF INTRANASAL SPLINTS
Intranasal (septal) splints have been used as an alternative to nasal packing to prevent intranasal adhesions and maintain septal stability. The incidence of intranasal adhesions following septoplasty is not clear, though has been reported to be as high as 31% when septal surgery is combined with inferior turbinate surgery.20 Similar to nasal Table 1 Efficacy of nasal packing
a
Author(s)
n
Procedure
Packing
Outcome
Guyuron16
50
Septorhinoplasty
Packing with polysporinimpregnated gauze vs quilting suture only
Subjective breathing improvement more prevalent in packed group (95.6% vs 64%, P<.01). Higher percentage of persistent septal deviation in unpacked group (41% vs 13%, P<.05).
Nunez et al7
59
Septal surgery
Packing with Vaseline gauze vs quilting suture only
Higher pain in packed group on postoperative day one (P<.05). No significant difference in prevalence of adhesions, crusting/mucosal atrophy, or granuloma formation between two groups
Von Schoenberg et al6
95
Routine nasal surgery
Packing with BIPP or Telfa vs no packing
Higher pain in packed group at 24 h, during pack removal, and over first week (P<.001 for each) Higher rate of complications in packed groupa
Indicates no statistical analysis was performed or results did not reach statistical significance.
281
282
Dubin & Pletcher
packing, septal splints have demonstrated morbidity that calls into question their routine use. Campbell and colleagues21 prospectively studied 106 subjects undergoing routine nasal surgery who received splint placement in one nasal cavity at the conclusion of surgery. Pain was found to be significantly worse on the splinted side at 7 days postoperatively. The authors reported a higher incidence of adhesions among the unsplinted side, but it is not clear if this reached statistical significance, and the period of follow-up is limited at 6 weeks. Von Schoenberg and colleagues22 prospectively studied 105 subjects undergoing septal and other routine nasal surgery who were randomized to receive or not receive nasal splints. Pain was found to be significantly higher at 7 days postoperatively among the splinted group. Three subjects developed vestibulitis and two subjects developed late septal perforations, all within the splinted group; however, these subjects were also packed with BIPP for the first 24 hours. Intranasal adhesions were assessed at 1 week and 3 months. The incidence of early intranasal adhesions (at 1 week) was higher in subjects without splints; however, there was no difference in adhesions at 3 months. The authors attribute this latter finding to the administration of nasal toilet during the first postoperative visit and conclude that the routine use of splints is not justified in light of their attendant morbidity. Malki and colleagues23 in a similar study of 110 subjects undergoing combined septal and inferior turbinate surgery, randomized to splints or no splints, found increased pain at 1 week postoperatively in the splinted group and no difference in adhesions at 6 weeks. The authors similarly concluded that simple nasal toilet is sufficient for the prevention of postoperative intranasal adhesions and that routine use of nasal splints is not justified. Along with prevention of synechiae, septal splints have been postulated to improve postoperative septal stability. Cook and colleagues24 studied 100 subjects undergoing septal surgery or septal plus inferior turbinate surgery, randomized to receive splints or no splints. Septal positioning was assessed postoperatively, characterized as straight, mild/moderate deviation, or surgically unacceptable deviation. No difference was found between the splinted or unsplinted groups with regard to this outcome. See Table 2 for a summary of outcomes with nasal splinting. On balance, the literature on the use of septal splints fails to demonstrate either a significant decrease in postoperative complications or a significant improvement in postoperative airway. Furthermore the use of septal splints is associated with increased postoperative pain. Overall discretion is advised in the use of surgical splints. Patients who are anticipated to be an increased risk of synechiae due to abutting mucosal injury of the septum and inferior turbinate, or those who are unlikely to perform routine post-operative nasal toilet may be appropriate candidates for postoperative splints. ALTERNATIVES TO PACKING AND SPLINTS
Given the limited evidence to support postoperative packing and splints and the significant associated morbidity, many have come to favor alternative methods of preventing complications of septoplasty. A septal quilting suture appears be an effective means of preventing postoperative bleeding and hematoma while avoiding the morbidity of packing or splints. Lemmens and colleagues25 evaluated the postoperative septal stability using this technique. Out of 226 subjects, only a single persistent septal deviation was noted. Alternatively, some authors have had success with intraseptal application of fibrin glue.26–28 Daneshrad and colleagues,28 in their review of 100 cases of septoplasty
Postoperative Packing After Septoplasty
Table 2 Efficacy of intranasal splints
a
Author(s)
n
Procedure
Splinting
Outcome
Campbell et al21
106
Routine nasal surgery
One nasal cavity splinted
Pain worse on splinted side at 7 days postoperatively (P<.05) Higher incidence of adhesions among unsplinted side at 6 weeks (17% vs 0%)a
Von Schoenberg 105 et al22
Routine nasal surgery
Splints vs no splints
Pain higher in splinted group at 7 days postoperatively (P<.001) Higher incidence of early nasal adhesions in unsplinted groupa but no difference at 3 months
Malki et al23
110
Septal surgery 1 inferior turbinate surgery
Splints vs no splints
Increased pain at one week postoperatively in splinted group (P<.0001) No difference in adhesions at 6 weeks
Cook et al24
100
Septal surgery inferior turbinate surgery
Splints vs no splints
No difference in postoperative septal positioning
Indicates no statistical analysis was performed or results did not reach statistical significance.
in which fibrin glue was used to approximate the septal flaps, experienced no cases of hematoma, infection, or perforation. The authors concluded that the use of fibrin glue is a rapid and reliable means to prevent complications associated with septoplasty. The cost of materials for performing this technique should be weighed against its potential advantages. SUMMARY
The use of nasal packing following septoplasty is thought to stabilize the remaining septum and prevent complications such as bleeding, septal hematoma, and formation of synechiae. While these assertions appear intuitive, there is little evidence to support either a decrease in postoperative complications or improved surgical outcomes with the routine use of postoperative packing. Evaluation of the efficacy and rate of complications in the literature is complicated by the existence of multiple packing materials and techniques. Increased morbidity in the form of postoperative pain, however, is consistently noted with the use of nasal packing. The use of septal splints in lieu of packing is also associated with increased postoperative pain. The routine use of splints does not appear to decrease postoperative complications or improve surgical outcomes when compared with less morbid techniques, such as septal quilting sutures and postoperative nasal douching. Therefore,
283
284
Dubin & Pletcher
placement of nasal packing or septal splints following septoplasty should be reserved for patients with increased risk of postsurgical complications.
REFERENCES
1. Fairbanks DNF. Complications of nasal packing. Otolaryngol Head Neck Surg 1986;94:412–5. 2. Angell James JE. Nasal reflexes. Proc R Soc Med 1969;62:1287–93. 3. Ogura JH, Harvey JE. Nasopulmonary mechanics – experimental evidence of the influence of the upper airway upon the lower. Acta Otolaryngol 1971;71:123–32. 4. Ogura JH, Togawa K, Dammkochler R. Nasal obstruction and the mechanics of breathing. Physiologic relationships and effects of nasal surgery. Arch Otolaryngol 1966;83:135–50. 5. Cassisi NJ, Biller HF, Ogura JH. Changes in arterial oxygen tension and pulmonary mechanics with use of posterior packing in epistaxis. Laryngoscope 1971; 81:1261–6. 6. Von Schoenberg M, Robinson P, Ryan R. Nasal packing after routine nasal surgery – is it justified? J Laryngol Otol 1993;107:902–5. 7. Nunez DA, Martin FW. An evaluation of post-operative packing in nasal septal surgery. Clin Otolaryngol 1991;16:549–50. 8. Samad I, Stevens HE, Maloney A. The efficacy of nasal septal surgery. J Otolaryngol 1992;21:88–91. 9. Taasan V, Wynne JW, Cassisi N, et al. The effect of nasal packing on sleep-disordered breathing and nocturnal oxygen desaturation. Laryngoscope 1981;91: 1163–72. 10. Toback J, Fayerman JW. Toxic shock syndrome following septorhinoplasty. Arch Otolaryngol 1983;109:627–9. 11. Lubianca-Neto JF, Sant’anna GD, Mauri M, et al. Evaluation of time of nasal packing after nasal surgery: a randomized trial. Otolaryngol Head Neck Surg 2000;122:899–901. 12. Hajiioannou JK, Bizaki A, Fragiadakis G, et al. Optimal time for nasal packing removal after septoplasty. A comparative study. Rhinology 2007;45:68–71. 13. Illum P, Grymer L, Hilberg O. Nasal packing after septoplasty. Clin Otolaryngol 1992;17:158–62. 14. Lachanas VA, Karatzias GT, Pinakas VG, et al. The use of tetracaine 0.25% solution in nasal packing removal. Am J Rhinol 2006;20:483–4. 15. Lavy JA, Small GV, Jay N, et al. A prospective randomized controlled study of 4% lignocaine solution in Merocel nasal pack removal. Rhinology 1996;34:219–21. 16. Guyuron B. Is packing after septorhinoplasty necessary? A randomized study. Plast Reconstr Surg 1989;84:41–4. 17. Oneal RM. Is packing after septorhinoplasty necessary? A randomized study. Plast Reconstr Surg 1989;84:45–6. 18. Reiter D, Alford E, Jabourian Z. Alternatives to packing in septorhinoplasty. Arch Otolaryngol Head Neck Surg 1989;115:1203–5. 19. Bajaj Y, Kanatas S, Carr N, et al. Is nasal packing really required after septoplasty? Int J Clin Pract July 2008, in press. 20. White A, Murray JAM. Intranasal adhesion formation following surgery for chronic nasal obstruction. Clin Otolaryngol 1988;13:139–43. 21. Campbell JB, Watson MG, Shenoi PM. The role of intranasal splints in the prevention of post-operative nasal adhesions. J Laryngol Otol 1987;101:1140–3.
Postoperative Packing After Septoplasty
22. Von Schoenberg M, Robinson P, Ryan R. The morbidity from nasal splints in 105 patients. Clin Otolaryngol 1992;17:528–30. 23. Malki D, Quine SM, Pfleiderer AG. Nasal splints, revisited. J Laryngol Otol 1999; 113:725–7. 24. Cook JA, Murrant NJ, Evans KL, et al. Intranasal splints and their effects on intranasal adhesions and septal stability. Clin Otolaryngol 1992;17:24–7. 25. Lemmens W, Lemkens P. Septal suturing following nasal septoplasty, a valid alternative for nasal packing? Acta Otorhinolaryngol Belg 2001;55:215–21. 26. Hayward PJ, Mackay IS. Fibrin glue in nasal septal surgery. J Laryngol Otol 1987; 101:133–8. 27. Vaiman M, Eviatar E, Segal S. The use of fibrin glue as hemostatic in endonasal operations: a prospective randomized study. Rhinology 2002;40:185–8. 28. Daneshrad P, Chin GY, Rice DH. Fibrin glue prevents complications of septal surgery: findings in a series of 100 patients. Ear Nose Throat J 2003;82:196–7.
285
There is a lack of consensus regarding the need for nasal packing following septoplasty. The use of postoperative packing has been proposed to minimize postoperative complications such as hemorrhage, formation of synechiae, and septal hematoma. Additionally, postoperative packing is thought to stabilize the remaining cartilaginous septum and minimize persistence or recurrence of septal deviation. Despite these theoretic advantages, evidence to support the use of postoperative packing is lacking. Additionally, nasal packing is not an innocuous procedure. The use of nasal packing carries several risks which, given the lack of firm evidence to support its efficacy, should call into question its routine application. MORBIDITY OF NASAL PACKING
While life-threatening risks associated with nasal packing have been documented, these complications occurred primarily in the setting of posterior packing placed for the treatment of epistaxis.1 The presumed etiology of death in these cases, the naso-pulmonary reflex,2–5 has not been noted in the modern literature of postseptoplasty packing. The most common morbidity associated with packing in postseptoplasty patients is postoperative pain.6–8 Additional potential complications include worsening of sleep disordered breathing9 and postoperative infection, including reports of toxic shock syndrome due to postseptoplasty packing.10 Attempts have been made to limit the morbidity of nasal packing through limiting the duration of packing and altering packing materials.11–13 Overall, the wide variety of packing materials and techniques complicates a clear assessment of the risks associated with postoperative septoplasty packing. Illum and colleagues13 found decreased pain with removal when using fingerstall packs compared with Merocel or hydrocortisone-terramycine gauze packs with ventilation tubes. Some authors have found rehydration of foam packs with topical anesthetic to lessen discomfort
Department of Otolaryngology, Head and Neck Surgery, University of California, 400 Parnassus Avenue, Box 0342, San Francisco, CA 94143, USA * Corresponding author. E-mail address: [email protected] (M.R. Dubin). Otolaryngol Clin N Am 42 (2009) 279–285 doi:10.1016/j.otc.2009.01.015 0030-6665/09/$ – see front matter ª 2009 Published by Elsevier Inc.
oto.theclinics.com
280
Dubin & Pletcher
upon pack removal.14,15 Silastic nasal splints are frequently used in place of packing and may be associated with less morbidity. EFFICACY OF NASAL PACKING
While the morbidity and risks associated with postoperative nasal packing may be tolerated or minimized, the existence of such complications requires an evaluation of the importance of postseptoplasty nasal packing. In 1989, Guyuron published one of the few studies describing the efficacy of nasal packing in maintaining an adequate postoperative airway.16 In this study, 50 subjects undergoing septorhinoplasty were randomized to receive packing with polysporin-impregnated gauze or placement of a quilting suture without nasal packing. Twenty-three subjects in the packed group and 22 subjects in the suture group were available for follow-up at up to 16 and 26 months, respectively. Subjective breathing improvement was found to be significantly more prevalent among the packed group. Additionally, a significantly higher percentage of persistent septal deviation was found among the unpacked group. These findings, however, were called into question by Oneal who noted that subjects’ awareness of packing as a point of study may have introduced bias into the patients’ subjective assessment of breathing improvement.17 He additionally noted that this finding, and the finding of persistent deviation as more common among the unpacked group, is weakened by the lack of preoperative assessment of degree of septal deviation. It is also important to note that this study was performed in the context of septorhinoplasty, not septoplasty alone. Subsequent studies have failed to demonstrate a clear advantage to nasal packing while noting an increased morbidity with the use of packing. Nunez and colleagues7 prospectively studied 59 subjects undergoing septal surgery and randomized them to packing with Vaseline gauze or no packing and placement of a septal quilting suture. Pain was recorded by a visual analog scale on postoperative day one and was found to be significantly higher in the packed group. The authors found no difference in the prevalence of adhesions, crusting/mucosal atrophy or granuloma formation between the two groups during follow-up at 6 weeks. The presence of persistent septal deviation and the extent of airway improvement were not evaluated in this study. Von Schoenberg and colleagues6 studied 95 subjects undergoing routine nasal surgery and randomized them to receive packing (either bismuth iodoform paraffin paste (BIPP) or Telfa) or no packing. Subjects undergoing septoplasty were further randomized to receive splints or no splints. Packs were removed at 24 hours postoperatively. Pain was recorded by visual analog scale during the first 24 hours, during pack removal, over the first week, and at the time of splint removal. Pain was significantly higher in the packed group at all points of measurement, and removal of packing proved to be the most painful event during the postoperative period, irrespective of whether splints were present. The authors found a higher rate of complications (including hemorrhage, vestibulitis and septal perforation) in the packed group, though it is not clear if this reached statistical significance. The incidence of intranasal adhesions was similar for the packed and unpacked groups, though the duration of followup with regard to this finding is unclear. Additional series have demonstrated septal surgery without the use of postoperative packing to be safe. Reiter and colleagues18 retrospectively studied 75 patients who underwent septorhinoplasty with placement of a quilting suture and no packing and identified only two cases of bleeding, both attributed to bleeding from lateral osteotomy sites. More recently, Bajaj and colleagues19 reported a series of 78 subjects who underwent septoplasty without postoperative packing, with quilting suture used
Postoperative Packing After Septoplasty
in just over a quarter of cases. They identified a 7.7% rate of postoperative hemorrhage with only half of these patients (3.8%) requiring packing to control bleeding. Overall, the literature suggests that the use of nasal packing following septoplasty does not provide a clear advantage in improving nasal airway, nor does it appear to prevent postoperative complications. Furthermore, there is a clear increase in postoperative morbidity, specifically pain, with the use of both nasal packing following septoplasty. See Table 1 for a summary. EFFICACY AND MORBIDITY OF INTRANASAL SPLINTS
Intranasal (septal) splints have been used as an alternative to nasal packing to prevent intranasal adhesions and maintain septal stability. The incidence of intranasal adhesions following septoplasty is not clear, though has been reported to be as high as 31% when septal surgery is combined with inferior turbinate surgery.20 Similar to nasal Table 1 Efficacy of nasal packing
a
Author(s)
n
Procedure
Packing
Outcome
Guyuron16
50
Septorhinoplasty
Packing with polysporinimpregnated gauze vs quilting suture only
Subjective breathing improvement more prevalent in packed group (95.6% vs 64%, P<.01). Higher percentage of persistent septal deviation in unpacked group (41% vs 13%, P<.05).
Nunez et al7
59
Septal surgery
Packing with Vaseline gauze vs quilting suture only
Higher pain in packed group on postoperative day one (P<.05). No significant difference in prevalence of adhesions, crusting/mucosal atrophy, or granuloma formation between two groups
Von Schoenberg et al6
95
Routine nasal surgery
Packing with BIPP or Telfa vs no packing
Higher pain in packed group at 24 h, during pack removal, and over first week (P<.001 for each) Higher rate of complications in packed groupa
Indicates no statistical analysis was performed or results did not reach statistical significance.
281
282
Dubin & Pletcher
packing, septal splints have demonstrated morbidity that calls into question their routine use. Campbell and colleagues21 prospectively studied 106 subjects undergoing routine nasal surgery who received splint placement in one nasal cavity at the conclusion of surgery. Pain was found to be significantly worse on the splinted side at 7 days postoperatively. The authors reported a higher incidence of adhesions among the unsplinted side, but it is not clear if this reached statistical significance, and the period of follow-up is limited at 6 weeks. Von Schoenberg and colleagues22 prospectively studied 105 subjects undergoing septal and other routine nasal surgery who were randomized to receive or not receive nasal splints. Pain was found to be significantly higher at 7 days postoperatively among the splinted group. Three subjects developed vestibulitis and two subjects developed late septal perforations, all within the splinted group; however, these subjects were also packed with BIPP for the first 24 hours. Intranasal adhesions were assessed at 1 week and 3 months. The incidence of early intranasal adhesions (at 1 week) was higher in subjects without splints; however, there was no difference in adhesions at 3 months. The authors attribute this latter finding to the administration of nasal toilet during the first postoperative visit and conclude that the routine use of splints is not justified in light of their attendant morbidity. Malki and colleagues23 in a similar study of 110 subjects undergoing combined septal and inferior turbinate surgery, randomized to splints or no splints, found increased pain at 1 week postoperatively in the splinted group and no difference in adhesions at 6 weeks. The authors similarly concluded that simple nasal toilet is sufficient for the prevention of postoperative intranasal adhesions and that routine use of nasal splints is not justified. Along with prevention of synechiae, septal splints have been postulated to improve postoperative septal stability. Cook and colleagues24 studied 100 subjects undergoing septal surgery or septal plus inferior turbinate surgery, randomized to receive splints or no splints. Septal positioning was assessed postoperatively, characterized as straight, mild/moderate deviation, or surgically unacceptable deviation. No difference was found between the splinted or unsplinted groups with regard to this outcome. See Table 2 for a summary of outcomes with nasal splinting. On balance, the literature on the use of septal splints fails to demonstrate either a significant decrease in postoperative complications or a significant improvement in postoperative airway. Furthermore the use of septal splints is associated with increased postoperative pain. Overall discretion is advised in the use of surgical splints. Patients who are anticipated to be an increased risk of synechiae due to abutting mucosal injury of the septum and inferior turbinate, or those who are unlikely to perform routine post-operative nasal toilet may be appropriate candidates for postoperative splints. ALTERNATIVES TO PACKING AND SPLINTS
Given the limited evidence to support postoperative packing and splints and the significant associated morbidity, many have come to favor alternative methods of preventing complications of septoplasty. A septal quilting suture appears be an effective means of preventing postoperative bleeding and hematoma while avoiding the morbidity of packing or splints. Lemmens and colleagues25 evaluated the postoperative septal stability using this technique. Out of 226 subjects, only a single persistent septal deviation was noted. Alternatively, some authors have had success with intraseptal application of fibrin glue.26–28 Daneshrad and colleagues,28 in their review of 100 cases of septoplasty
Postoperative Packing After Septoplasty
Table 2 Efficacy of intranasal splints
a
Author(s)
n
Procedure
Splinting
Outcome
Campbell et al21
106
Routine nasal surgery
One nasal cavity splinted
Pain worse on splinted side at 7 days postoperatively (P<.05) Higher incidence of adhesions among unsplinted side at 6 weeks (17% vs 0%)a
Von Schoenberg 105 et al22
Routine nasal surgery
Splints vs no splints
Pain higher in splinted group at 7 days postoperatively (P<.001) Higher incidence of early nasal adhesions in unsplinted groupa but no difference at 3 months
Malki et al23
110
Septal surgery 1 inferior turbinate surgery
Splints vs no splints
Increased pain at one week postoperatively in splinted group (P<.0001) No difference in adhesions at 6 weeks
Cook et al24
100
Septal surgery inferior turbinate surgery
Splints vs no splints
No difference in postoperative septal positioning
Indicates no statistical analysis was performed or results did not reach statistical significance.
in which fibrin glue was used to approximate the septal flaps, experienced no cases of hematoma, infection, or perforation. The authors concluded that the use of fibrin glue is a rapid and reliable means to prevent complications associated with septoplasty. The cost of materials for performing this technique should be weighed against its potential advantages. SUMMARY
The use of nasal packing following septoplasty is thought to stabilize the remaining septum and prevent complications such as bleeding, septal hematoma, and formation of synechiae. While these assertions appear intuitive, there is little evidence to support either a decrease in postoperative complications or improved surgical outcomes with the routine use of postoperative packing. Evaluation of the efficacy and rate of complications in the literature is complicated by the existence of multiple packing materials and techniques. Increased morbidity in the form of postoperative pain, however, is consistently noted with the use of nasal packing. The use of septal splints in lieu of packing is also associated with increased postoperative pain. The routine use of splints does not appear to decrease postoperative complications or improve surgical outcomes when compared with less morbid techniques, such as septal quilting sutures and postoperative nasal douching. Therefore,
283
284
Dubin & Pletcher
placement of nasal packing or septal splints following septoplasty should be reserved for patients with increased risk of postsurgical complications.
REFERENCES
1. Fairbanks DNF. Complications of nasal packing. Otolaryngol Head Neck Surg 1986;94:412–5. 2. Angell James JE. Nasal reflexes. Proc R Soc Med 1969;62:1287–93. 3. Ogura JH, Harvey JE. Nasopulmonary mechanics – experimental evidence of the influence of the upper airway upon the lower. Acta Otolaryngol 1971;71:123–32. 4. Ogura JH, Togawa K, Dammkochler R. Nasal obstruction and the mechanics of breathing. Physiologic relationships and effects of nasal surgery. Arch Otolaryngol 1966;83:135–50. 5. Cassisi NJ, Biller HF, Ogura JH. Changes in arterial oxygen tension and pulmonary mechanics with use of posterior packing in epistaxis. Laryngoscope 1971; 81:1261–6. 6. Von Schoenberg M, Robinson P, Ryan R. Nasal packing after routine nasal surgery – is it justified? J Laryngol Otol 1993;107:902–5. 7. Nunez DA, Martin FW. An evaluation of post-operative packing in nasal septal surgery. Clin Otolaryngol 1991;16:549–50. 8. Samad I, Stevens HE, Maloney A. The efficacy of nasal septal surgery. J Otolaryngol 1992;21:88–91. 9. Taasan V, Wynne JW, Cassisi N, et al. The effect of nasal packing on sleep-disordered breathing and nocturnal oxygen desaturation. Laryngoscope 1981;91: 1163–72. 10. Toback J, Fayerman JW. Toxic shock syndrome following septorhinoplasty. Arch Otolaryngol 1983;109:627–9. 11. Lubianca-Neto JF, Sant’anna GD, Mauri M, et al. Evaluation of time of nasal packing after nasal surgery: a randomized trial. Otolaryngol Head Neck Surg 2000;122:899–901. 12. Hajiioannou JK, Bizaki A, Fragiadakis G, et al. Optimal time for nasal packing removal after septoplasty. A comparative study. Rhinology 2007;45:68–71. 13. Illum P, Grymer L, Hilberg O. Nasal packing after septoplasty. Clin Otolaryngol 1992;17:158–62. 14. Lachanas VA, Karatzias GT, Pinakas VG, et al. The use of tetracaine 0.25% solution in nasal packing removal. Am J Rhinol 2006;20:483–4. 15. Lavy JA, Small GV, Jay N, et al. A prospective randomized controlled study of 4% lignocaine solution in Merocel nasal pack removal. Rhinology 1996;34:219–21. 16. Guyuron B. Is packing after septorhinoplasty necessary? A randomized study. Plast Reconstr Surg 1989;84:41–4. 17. Oneal RM. Is packing after septorhinoplasty necessary? A randomized study. Plast Reconstr Surg 1989;84:45–6. 18. Reiter D, Alford E, Jabourian Z. Alternatives to packing in septorhinoplasty. Arch Otolaryngol Head Neck Surg 1989;115:1203–5. 19. Bajaj Y, Kanatas S, Carr N, et al. Is nasal packing really required after septoplasty? Int J Clin Pract July 2008, in press. 20. White A, Murray JAM. Intranasal adhesion formation following surgery for chronic nasal obstruction. Clin Otolaryngol 1988;13:139–43. 21. Campbell JB, Watson MG, Shenoi PM. The role of intranasal splints in the prevention of post-operative nasal adhesions. J Laryngol Otol 1987;101:1140–3.
Postoperative Packing After Septoplasty
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