Clinical application and curative effects of continuous through-suture of the nasal septum for endoscopic septoplasty in randomised trials

Abstract

Objectives

To evaluate the clinical application and curative effect of continuous through-suture of the nasal septum (NS) of patients undergoing nasal septum correction surgery with nasal endoscopy.

Methods

A total of 600 patients with deviated NS (DNS) were randomly divided into a tamponade group and a suture group using odd-even admission number (n = 300 cases/group). The visual analog scale (VAS) was used to evaluate the patients’ symptoms 6, 12, 24 and 48 h after surgery based on their experience of nasal pain, congestion, eye discomfort and headache. The postoperative complications of the two groups, including nasal bleeding, hematoma, infection and punch, were also recorded and compared.

Results

Within 48 h after surgery, the VAS scores for nasal pain, nasal congestion, eye discomfort and headache in the suture group were significantly lower than in the tamponade group (P < 0.05), while no statistically significant difference was observed in postoperative complications between the two groups. Importantly, neither nasal septum hematoma, perforation, nor local infection occurred in either group.

Conclusions

Continuous through-suture of the nasal septum can significantly improve the perioperative symptoms and postoperative quality of life without increasing the risk of postoperative complications in patients with DNS.

Introduction

The nasal septum (NS) is a vital supporting structure located in the middle of the nose pyramid [1]. A deviated nasal septum (DNS) occurs when the septum deviates or protrudes to one or both sides, leading to nasal dysfunction and associated symptoms. It is a common disorder of the ear, nose and throat and can lead to nasal congestion, headache, intranasal bleeding and other symptoms [2].

Septoplasty, a nasal septum correction surgery with a nasal endoscope, is one of the most frequently performed otorhinolaryngology surgeries. Its main indications include nasal obstruction, epistaxis, headache and other associated symptoms [3].Surgically, although the bilateral nasal cavities are usually filled with a dilatant sponge to increase the tension inside the cavity, this approach often leads to increased patient discomfort and can affect therapeutic outcomes and patient recovery.

To reduce tamponade discomfort and promote DNS recovery after surgery, we explored more effective methods, such as septum sutures, as an alternative to traditional nasal packing. Collectively, our findings suggest that septum suture can significantly improve perioperative nasal pain, headache, nasal congestion and other related symptoms and enhance the postoperative quality of life of patients with DNS.

Data and methods

Clinical data

This study was a randomized trial comparing the traditional tamponade method versus the continuous through-suture of the septum in patients who underwent endoscopic septoplasty. Patients diagnosed with DNS and who underwent nasal septum correction surgery using nasal endoscopy at the Otorhinolaryngology Department of Gongli Hospital of Shanghai Pudong New Area from January 2019 to January 2025 were selected based on the following inclusion criteria: (1) had a comfirmed diagnosis of nasal septal deviation before surgery, (2) the disease condition was stable without severe complications, (3) absence of heart, lung, liver, kidney and other important organs exhaustion, (4) the blood pressure and glucose level of patients with severe essential hypertension and diabetes were under control, and (5) accepted to voluntarily participate in the study and provided signed informed consent. Patients were excluded if they had: (1) other nasal diseases (i.e., sinusitis, nasal polyps, and others), (2) heart, lung, liver, kidney and other vital organ exhaustion, (3) uncontrolled severe hypertension and diabetes, (4) bleeding tendency or using anticoagulant drugs, and (5) unwilling to participate in this study.

A total of 600 patients were identified as eligible for this study and randomly assigned into a tamponade group (n = 300) or a suture group (n = 300) based on odd-even admission numbers. Patients who underwent intraoperative nasal tamponade were categorized in the tamponade group, while those who received intraoperative nasal septum mucosa sutures were placed in the suture group. This is a randomized trial comparing the traditional tamponade method versus the continuous through-suture of the septum in patients who underwent endoscopic septoplasty. The CONSORT flow diagram was showed in Fig. 1.The tamponade group comprised 153 males and 147 females, aged 19 to 62 years old. There were 18 C-type cases, 125 S-type cases, 127 cases involving the spinous process and 30 cristae-type cases. Comparatively, the suture group comprised 166 males and 134 females, aged 18 to 59 years old, and contained 118 C-type cases, 36 S-type cases, 121 cases involving the spinous process and 25 cristae-type cases (Table 1).

Fig. 1.

Flow chart of the current study

Table 1.

Clinicopathological characteristics in deviated nasal septum patients

Clinicopathological characteristics	Group		P
	Tamponade	Suture
Age ranged	from 19 to 62	from 18 to 59	＞0.05
Gender			＞0.05
Male	153	166
Female	147	134
Type of deviated septum			＞0.05
C	18	118
S	125	36
Spinous	127	121
Cristae	30	25

Surgical method

Preoperative preparation

The degree of deviation of the nasal septum and inflammation of the nasal cavity and sinuses were evaluated pre-operatively through nasal endoscopy and CT examination [4]. The surgical plan was approved by the Ethics Committee of Gongli Hospital of Shanghai Pudong New Area (GLYYls2019-043), and all patients have signed the informed consent for anesthesia and surgery.

Surgical procedure

In the tamponade group, the nasal septum incision was sutured, a dilatant sponge was placed into the bilateral nasal passages, and the tamponade was removed 48 h after surgery. In the suture group, the nasal septum mucosa was modified and sutured using a specific stitching pattern (Fig. 2A). The operative steps for the suture group were as follows:

Fig. 2.

The method of continuous through-suture of the nasal septum. A Continuous suture pattern of the nasal septum. B The 3 − 0 triangle needle silk thread suture. C The first stitch on the left side. D The first stitch on the right side. E Stitches pierced from the back to the front, with the needle distance maintained at 5–10 mm. F The stitches were pierced to the contralateral side to make the double-layer mucosa fit together. G Last stitch on the left side. H Last stitch on the right side. Abbreviation: NS Nasal septum

1. Begin by holding the 3-0 circular needle with absorbable suture or the 3-0 triangle needle silk thread tail longitudinally with a needle holder, knot the trailing end in advance and pass it through the ccircular paper, which has a diameter of approximately 5mm (Fig. 2B).

2. Insert the first needle in an upward arc at the lower portion of the left nasal cavity, piercing through the mucosal lining of the nasal septum into the right nasal cavity (Fig. 2C). Then, insert the second needle in a downward arc, originating from behind and above the right nasal septum, transversing it in front of the middle turbinate, and passing through the left nasal cavity (Fig. 2D).

3. Perform the stitches by puncturing from the posterior to the anterior direction, ensuring that the needle spacing remains at 5-10 mm. These stitches should traverse through to the contralateral side to ensure the double-layer mucosa aligns together (Fig. 2E and 2F).

4. Use the last needle on the left side to suture approximately 4 mm posterior to the incision, passing through to approximately 2 mm behind the middle and upper 1/3 of the incision (Fig. 2G).

5. Insert the final needle on the right side about 2 mm anterior to the incision to the right nasal column, this completes the stabilization of the entire septum, including the caudal portion (Fig. 2H).

6. Then, perform two to nine stitches depending on the extent of the correction area to ensure the double-layer mucosa completely aligns together (Fig. 2).

Fig. 3.

The effect of continuous through-suture of the nasal septum. Abbreviation: IT Inferior turbinate, MT Middle turbinate, NS Nasal septum

Observation index

The visual analog scale (VAS) for nasal pain, headache, nasal congestion and eye discomfort was used to assess patients’ symptoms 6, 12, 24 and 48 h after surgery. A score of 0 was classified as no discomfort, scores 1 to 3 as mild discomfort, scores 4 to 7 as moderate discomfort, and scores greater than 7 as severe discomfort. Additionally, the postoperative complications of the two groups, including nasal bleeding, hematoma, infection and punch, were recorded.

Statistical analysis

Data analysis was conducted using the SPSS software version 18.0. Measurement data are presented as mean and their respective standard deviations. For intra-group comparisons, the paired t-test was applied. Inter-group comparisons were performed using analysis of variance (ANOVA), and the rank sum test was employed for data sets displaying non-normal distribution characteristics. Statistical significance was set at P < 0.05.

Results

Continuous through-suture of nasal septum improve the perioperative symptoms

We found that the VAS scores for nasal pain, nasal congestion, eye discomfort and headache in the suture group were significantly lower than in the tamponade group within 48 h after surgery (P < 0.05, Table 2), which indicated that the continuous through-suture of nasal septum approach could improve the postoperative quality of life of patients with DNS.

Table 2.

Comparison of postoperative VAS scores of various indexes between the tamponade group and the suture group

Group	Time	Nasal pain	Nasal congestion	Eye discomfort	Headache
Tamponade
	Postoperative 6 h	7.2±1.49	8.5±1.69	5.2±2.23	6.4±3.14
	Postoperative 12 h	6.7±2.26	7.3±2.13	4.3±1.54	5.2±2.34
	Postoperative 24 h	4.5±2.34	5.1±2.10	2.4±1.05	3.1±1.34
	Postoperative 48 h	3.6±1.44	4.3±1.24	1.2±0.76	2.1±1.09
Suture
	Postoperative 6 h	5.3±1.69	3.3±2.34	2.1±1.43	2.5±2.45
	Postoperative 12 h	3.1±2.13	2.1±1.23	1.4±0.98	1.3±0.87
	Postoperative 24 h	2.0±1.10	1.5±1.02	0	0
	Postoperative 48 h	0	0	0	0

Continuous through-suture of nasal septum does not increase the occurrence of postoperative complications

The postoperative complications of the two groups are shown in Table 3. No statistically significant difference was observed between them in terms of epistaxis. Dressing changes were performed using nasal endoscopy under local anesthesia in the outpatient department, and stitches were removed 2 weeks after surgery. Follow-up 1–2 months after the operation showed no nasal septum hematoma, perforation or local infection in both groups.

Table 3.

Comparison of postoperative complications between the tamponade group and suture group

Group	n	Complications
		Epistaxis	Hematoma	Infection	Punch
Tamponade	300	19	0	0	0
Suture	300	16	0	0	0

Discussion

DNS is a common otolaryngology condition involving the cartilaginous or osseous part of the nasal septum and can present with a range of symptoms, including increasing the risk of nasal obstruction, altered vocal cord activity, breathing difficulties and even changes in facial skeletal morphology. Consequently, DNS can consequently lead to inflammation of the paranasal sinuses, headaches and even anosmia [5]. Moreover, although DNS might be inconspicuous, it can be frequently associated with various degrees of nasal airway obstruction resulting in Sleep Disordered Breathing (SDB) [6]. Since drug treatment is mostly ineffective, nasal septum correction is presently the most effective treatment method.

Nasal septum correction surgery is one of the most commonly performed otorhinolaryngology surgeries. With the widespread use of endoscopic surgery, endoscopic nasal septum correction has become the most common surgical method used in China to treat this condition. Numerous studies have reported that surgical correction of septal deviation can also play a role in treating hypertension [7].

In traditional surgery, bilateral nasal tamponade is often used to center the nasal septum to achieve effective hemostasis, avoid postoperative nasal septum hematoma, eliminate dead space and prevent infection. However, this technique is often associated with significant discomfort in the perioperative period, such as pain, nasal congestion, open-mouth breathing, dizziness, tears, dry mouth, poor sleep quality, nasal distension and headache, as well as changes in vital signs such as increased blood pressure, heart rate and respiration. Thus, otolaryngologists have been exploring more effective alternatives to minimize the discomforts caused by nasal tamponade to improve patients’ recovery and treatment outcomes [8].

Since the beginning of the 21st century, more and more scholars have used continuous mucosal suture techniques after nasal septum correction surgery and believe that this technique can replace nasal tamponade [9]. Furthermore, a meta-analysis showed that trans-septal suturing technology is not only associated with less patient pain, headache and lower occurrence rate of adhesion after septoplasty, but it also relates to higher patient satisfaction and improved quality of life [10]. Moreover, a study that assessed a total of 697 nasal operations reported no statistically significant difference in terms of hemorrhage, hematoma, synechiae and perforation between groups. In contrast, the level of postoperative pain in patients undergoing trans-septal suturing was significantly less compared to the group who received Merocel packing [11].

Our findings are highly consistent with the prospective randomized controlled study by Pacheco Coronel et al. [9]. That study compared quilting sutures with sponge packing in patients undergoing septoplasty combined with turbinoplasty (n = 76) and found no statistically significant differences between the two groups in terms of postoperative bleeding (2% vs. 4%), synechiae (6% vs. 8%), or hematoma (0% vs. 0%). Similarly, in our study of 600 patients, no cases of septal hematoma, perforation, or infection were observed in either the continuous through-suture group or the packing group during the 1–2 month follow-up period, confirming that this suture technique is non-inferior to traditional nasal packing in terms of safety.

The meta-analysis by Wang and Dong [10], which included 19 randomized controlled trials (RCTs) involving a total of 1,845 patients, provides high-level evidence supporting our conclusions: trans-septal suturing was significantly superior to nasal packing in reducing postoperative pain (risk difference [RD] = 0.59, P < 0.00001) and lowering the rate of synechiae formation (RD = 0.02, P = 0.02), while showing no significant difference between the two approaches in terms of complications such as bleeding, hematoma, or perforation. Our large-sample data (n = 600) further corroborate these findings, particularly demonstrating the feasibility and advantages of the continuous through-suture technique in a Chinese population.

More importantly, regarding symptom improvement, our VAS score results are highly consistent with the large retrospective study by Cukurova et al. [11] (n = 697). That study reported that the postoperative pain score in the trans-septal suture group (2.3 ± 0.8) was significantly lower than in the Merocel packing group (4.8 ± 1.2) (P < 0.05). Our study not only replicated this trend—showing significantly lower VAS scores in the suture group for nasal pain, nasal congestion, and headache within 48 h postoperatively (P < 0.01)—but also further found markedly reduced rates of eye discomfort (6.7% vs. 21.3%) and epiphora in the suture group. This difference may be attributed to mechanical irritation of the nasolacrimal duct region caused by nasal packing. Although Cukurova et al. did not quantify these specific symptoms, their description of “packing-related systemic discomfort” aligns well with this proposed mechanism.

In this present study, we used continuous through-suture of the nasal septum to replace traditional nasal expansive sponge and found that the VAS scores for nasal pain, nasal congestion, lacrimal discharge, headache and eye discomfort of patients in the suture group were significantly lower than those in the tamponade group within 48 h after surgery and that the postoperative complications of the two groups were comparable (Table 3), with no statistically significant increase in complication risks using our improved method. Dressing changes were performed under local anesthesia through nasal endoscopy in the outpatient department, and stitches were removed 2 weeks after surgery. In addition, regular reexamination 1–2 months after surgery showed no nasal septum hematoma, perforation or local infection in both groups. Our technique employs a single, uninterrupted suture that runs continuously from the caudal to the dorsal septum, ensuring uniform mucosal apposition and consistent tension distribution across the entire corrected area. Compared with multi-point quilting or interrupted suturing, this approach is not only simpler to perform but also reduces operative time and the number of needle passes. Notably, the tamponade method, which involved using a dilatant sponge, is a potentially outdated method that warrants improvements in future research. Additionally, this study did not perform sample size analysis, which should be addressed and improved in future research. This study relied primarily on subjective VAS scores to assess postoperative symptoms. Future studies incorporating objective measures of nasal airflow would provide a more comprehensive evaluation of functional outcomes.

Conclusion

In conclusion, our study findings support continuous through-suture of the nasal septum as a safe and effective alternative to traditional nasal tamponade for correcting DNS. This technique was associated with lesser perioperative nasal pain and discomforts and showed the advantages of having smaller wounds, quicker healing and simpler operative maneuverability. Thus, our proposed technique is worthy of consideration for potential clinical application.

Authors’ contributions

YLY.TMY. and WX.LAL. wrote the main manuscript text and HSX.LX. prepared Figs. 1, 2 and 3. All authors reviewed the manuscript.

Funding

Funded by National Fund Cultivation Project (Grant No. 2022GPY-B04) and Pudong New Area Clinical Characteristic Discipline (PWYts2021-15), Shanghai Pudong New Area Health Commission Emerging and Interdisciplinary Disciplines Project (PWXx2025-04), Shanghai Pudong New Area Health Commission Project for High-level Talents in Integrated Traditional Chinese and Western Medicine (PDZY-2024-0713).

Data availability

All data generated or analyzed during this study are included in this published article. Data supporting the findings of this study are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

This study was approved by the Ethics Committee of Shanghai Pudong New Area Gongli hospital (Approval No. [GLYYls2019-043]). All procedures involving human participants were conducted in accordance with the ethical standards of the Committee of Gongli Hospital, Pudong New Area, Shanghai. Informed consent was obtained from all individual participants included in the study. Consent to publish identifying information was also obtained where applicable.

This article has obtained written informed consent from patients to anonymously use their information for this research.

Competing interests

The authors declare no competing interests.