Abstract
Septal correction is the commonest surgery by rhinologists worldwide. We aimed at studying the comfort level of the patient with standard postoperative nasal packing with Merocel and placing quilting sutures in septum leaving the nose unpacked in the postoperative period. We conducted the study in the tertiary care centre enrolling 82 patients in a quasi-randomised method of odd and even numbers placing them in the nasal packing group and the quilting group respectively. We used analogue scoring method for subjective assessment of comfort level in the postoperative period and the surgeon objectively assessed the patient on follow up. The results were tabulated and analysed. Postoperative pain, headache and sleep disturbance was significantly more in the nasal packing group. We found that the crusting is commonly seen in patients in the nasal packing group. Quilting the nasal septum and leaving the nasal cavity unpacked increases the comfort level of the patient in the postoperative period. The resultant pain, headache and sleep disturbance caused by nasal packing can be significantly avoided by using quilting the septum without nasal packing. We also observed that by avoiding nasal packing postoperatively, the patients were more comfortable and compliant with the treatment regimen and follow-up.
Keywords: Septal deviation, Nasal packing, Quilting suture, Postoperative
Introduction
Out of every ten patients, eight patients have some degree of nasal septal deviation in the general population. Septal correction (septoplasty or submucosal resection of septum-SMR) is a routine procedure for surgical correction of this deformity [1]. This is a commonly seen anatomical deformity causing a nasal obstruction in our day to day clinics [2]. The advantages and disadvantages of the methods used for septal correction have been debated over many decades [3] but post procedure packing has been thought to be equally relevant for the outcome of the procedure.
Postoperative packing reduces the chances of haemorrhage, synechiae formation and haematoma of the septum. Packing is thought to keep the septum in the midline by altering the cartilage memory provided scoring was done per-operatively. A variety of packing materials have been used for this purpose namely simple lubricated gauze pack, cot pack, Merocel pack, sponge pack [4]. Merocel packing is popular among these methods [5].
These methods of packing are not foolproof and not without complications. Nasal discomfort, headache, secondary sinusitis, significant bleeding while removal of the pack are some important issues related to nasal packing [6, 7]. Toxic shock syndrome (TSS) is one of the most dreaded complications described because of nasal packing [8].
To alleviate such problems of nasal packing septal flap suturing techniques were identified and followed [9]. Of them, quilting septal sutures of the septal flaps using catgut were first described and often executed method [10]. This method reduces the need for packing the nose postoperatively. This study aims at comparing these two methods of nasal septal alignment and patient comfort level under various categories.
Methodology
This study was conducted at our Institute after obtaining the clearance from the Institutional Human Ethics Committee. This is a prospective quasi-randomised study conducted on 82 adult patients in the Department of Otorhinolaryngology of our institute from June 2016 to January 2018. Patients with significant nasal obstruction with documented nasal septal deviation on clinical examination and diagnostic nasal endoscopy (DNE) above the age of 20 years were included in the study. Patients with a previous history of nasal surgery, documented sinus disease or nasal polyposis, a comorbid illness like diabetes, systemic hypertension, coronary artery disease on aspirin therapy, valvular heart disease on therapy were excluded from the study.
Patients were included in the study after obtaining consent from the patient and the first attendant in the presence of a patient counsellor. After they were enrolled, patients are listed in nasal packing group (odd number) and septal quilting group (even number). Preoperatively, all the patients were evaluated by standard clinical protocol. DNE was done for all the patients. All the patients were investigated for anaesthetic fitness and taken up for the procedure under general anaesthesia.
All the patients underwent septal correction under inhalation general anaesthesia (Sevoflurane). Before the start of the procedure, the nasal vibrissae are prepared and face draped. The entire procedure was done using 0 degrees Hopkin’s telescope and Kar Storz camera console system. All the patients had a caudal septal incision. After elevating the mucoperichondrial and mucoperiosteal flaps on either side deviated septal framework was corrected depending on the need and incision sutured with 4-0 vicryl (Fig. 1).
Fig. 1.
Endoscopic septal correction steps-clockwise
In the nasal packing group, patients nose was packed with standard 8 cm Merocel pack each on both sides of the nasal cavity after approximating the septal flaps. In the quilting sutures group, 3-0 round body vicryl was used to quilt the septal flaps from posterior to anterior spaced by a centimetre and knot fixed on the side opposite of the incision. Their nose was not packed (Fig. 2).
Fig. 2.
The method of quilting the septal framework past septoplasty
All the patients were observed for 24 h (6 h in the post-op ward) before discharging them from the hospital.
In the nasal packing group, both the nasal packs were removed after 24 h in the post-op ward. Occasional decongestant packs were used if there is significant ooze which is removed after ten minutes. In the quilting group, nasal douching is started after 6 h postoperatively.
Nasal douching is explained to all the patient in a stepwise manner. Nasal irrigation is carried out with a saline solution three times a day for the next 15 days.
All the patients were prescribed analgesics, ciprofloxacin 500 mg twice daily. They were given a follow-up schedule on 5th, 14th postoperative days (POD). During the 1st POD and each of the visits, they were assessed subjectively and objectively. The patients were subjectively assessed with an analogue score on their follow up visit (100—severe to 0—none). The patients were also assessed objectively by the attending surgeon and clinical impression was documented. The subjective assessment tools were pain, ooze, headache, sleep disturbance and epiphora (1st and 5th POD results were compared). The objective assessment of the patients included the need for manual suctioning, haematoma, presence or absence of crusts, synechiae (5th and 14th POD observations were compared). All the sutures were removed on the 5th postoperative day for all the patients.
Statistical analysis was done using the SPSS (version 20). Both the T test and Chi square test of association were used for the comparison between the two groups. p value of 0.05 or less was considered statistically significant.
Results
Evaluation of Postoperative Pain
The analogue scoring of the patients were tabulated (Table 1). The mean pain score in the packing group was 42.2 compared to 32.2 in the quilting group. Also, the pain score remained significant in the 5th POD visit in the nasal packing group (21.4). The pain score in the quilting group was almost negligible on the 14th POD. The values were found to be statistically significant both in the 1st POD (0.01) and in the 5th POD (0.03) (Fig. 3).
Table 1.
Subjective analysis of 1st and 5th POD analogue scoring
| 1st POD | 5th POD | 14th POD | |
|---|---|---|---|
| Nasal packing | |||
| Pain | 42.2 (± 5.4) | 21.4 (± 4.6) | 4.4 (± 3.2) |
| Ooze | 31.0 (± 4.5) | 9.2 (± 3.2) | 2.1 (± 2.1) |
| Headache | 46.2 (± 5.6) | 14.3 (± 4.3) | 10.3 (± 3.2) |
| Sleep disturbance | 54.6 (± 6.8) | 11.2 (± 2.1) | 2.1 (± 1.2) |
| Epiphora | 43.7 (± 7.2) | 9.2 (± 3.2) | 1.1 (± 0.4) |
| Quilting | |||
| Palo | 32.2 (± 4.4) | 11.4 (± 2.4) | 2.4 (± 1.2) |
| Ooze | 11.0 (± 3.3) | 2.2 (± 1.6) | 0 |
| Headache | 26.2 (± 4.6) | 4.3 (± 1.2) | 1.3 (± 0.2) |
| Sleep disturbance | 14.6 (± 2.4) | 4.2 (± 1.0) | 2.1 (± 1.2) |
| Epiphora | 13.7 (± 5.l) | 4.2 (± 1.4) | 1.1 (± 0.4) |
| p value | |||
| Pain | 0.01 | 0.03 | |
| Ooze | 0.03 | 0.004 | |
| Headache | 0.05 | 0.02 | |
| Sleep disturbance | 0.02 | 0.21 | |
| Epiphora | 0.05 | 0.30 | |
Fig. 3.
Pain score of the patients in the nasal packing and the quilting group on 1st POD
Evaluation of Postoperative Bleeding/Ooze
The mean score for postoperative ooze was very less in the quilting group (11.0) when compared to the nasal packing group (31.0). It was noted that the ooze was almost not witnessed by any of the patients in the quilting group on the 14th POD. The values were found to be statistically significant on the 1st and 5th POD i.e., p value 0.03 and 0.004 respectively.
Evaluation of Postoperative Headache
The postoperative headache was found to be more in the nasal packing group (46.2) than in the quilting group (26.2). The results were statistically significant both in the 1st and 5th POD i.e., p value 0.05 and 0.02 respectively.
Evaluation of Sleep Disturbance
The 1st POD sleep disturbance was more in the nasal packing group (54.6) than in the quilting group (14.6). The results were statistically significant on the 1st POD (p value = 0.02) but subsequent visits it was statistically insignificant (p value = 0.21) (Fig. 4).
Fig. 4.
Sleep disturbance score in the nasal packing and quilting group on 1st POD
Evaluation of Epiphora
There was more epiphora in the nasal packing group (43.7) compared to the quilting group (13.7). The results were statistically significant only in the 1st POD (p value = 0.05).
Evaluation of the Need for Manual Suctioning
It was documented that all the patients in the nasal packing group needed manual suctioning in the 5th POD and at least 58% of them needed in the 14th POD. Whereas, only 68% of the patients in the quilting group needed manual suctioning in the 5th POD and only 2% needed suctioning in the 14th POD (Fig. 5).
Fig. 5.
Objective differences between the nasal packing and quilting group on 5th POD
Evaluation of Postoperative Haematoma
95% of the patients in the nasal packing develop haematoma on the 5th POD but only 34% of the patients had a haematoma on the 5th POD in the quilting group. This again adds to the stability of the septal framework and prevents the chances of septal deviation recurrence (Fig. 5).
Evaluation of Postoperative Crusting
It was observed that 70–78% of the patients in the nasal packing group developed crusts in 5th and 14th POD. The crusting was less in the quilting group of patients (7%—5th POD: 2%—14th POD).
Evaluation of Postoperative Synechiae
It was documented that none of the patients in the quilting group developed synechiae at the end of 14th POD, whereas 41% of the patients in the nasal packing group developed some amount of synechiae at the end of 14th POD (Fig. 5).
Discussion
The average age group of the study population was 29 years with a male preponderance. The postoperative pain was more in the nasal packing group than in the quilting group, mainly because of the significant mucosal trauma that happens while packing and removal of nasal packing. Although the use of Merocel packs reduces the trauma, still its use can cause significant pain postoperatively. The study conducted by Naghibzadeh et al. [7], Walker et al. [8] and Cukurova et al. [11] showed similar results. It was noted that postoperative ooze which included blood stained discharge was significantly more in the nasal packing group than in the quilting group. The difference was statistically significant. Cukurova et al. [11] had reported more ooze due to nasal packing in their study.
The assessment of sleep disturbance in the study was focused on the 1st POD. There was a significant difference between the nasal packing group and the quilting group. Awan et al. [12] found that 81% of the patients had poor sleep after nasal packing in the 1st POD. Similar results were noted in the study conducted by Jawaid et al. [13] and Turhan et al. [14]. All these studies used merocel for postoperative nasal packing. Our study results corroborated with theirs showing a marked difference the nasal packing group and the quilting group. In a study done by Asaka et al. [15], sponge packing was used and the patients sleep disturbance was found to be less pronounced.
The headache was more in the nasal packing group than in the quilting group. This headache is due to the obstruction of the normal sinus drainage pathway because of nasal packing and patient developing retention sinusitis [12, 16]. Our study showed similar results (p value = 0.05, 1st POD and p value = 0.02, 5th POD). It was found that the epiphora was significantly more in the nasal packing group than in the quilting group (p value = 0.05, 1st POD). This was similar to the studies reviewed in the literature [12, 17].
Septal haematoma is not uncommon post septal correction done for marked septal deviation. This results secondary to poor handling of the mucoperichondrium and mucoperiosteum during the surgery. In the study conducted by Cukurova et al. [11], Ansari et al. [18] and Gunaydin et al. [19] the septal haematoma was considerably less. In our study, quilting significantly reduced the chances of a haematoma. It was also observed that manual suction clearance on the postoperative nasal cavity was frequently needed for patients who have their nasal cavity packed postoperatively. These observations were similar to some of the studies reviewed [13, 17] (Table 2).
Table 2.
Objective assessment of the patients
| 5th POD | 14th POD | |
|---|---|---|
| Nasal packing (41) | ||
| Manual suctioning | ||
| Yes | 41 (100%) | 24 (58%) |
| No | 0 | 17 |
| Haematoma | ||
| Yes | 39 (95%) | 3 (7%) |
| No | 2 | 38 |
| Crusting | ||
| Yes | 29 (70%) | 32 (78%) |
| No | 12 | 9 |
| Synechiae | ||
| Yes | 11 (26%) | 18 (41%) |
| No | 30 | 23 |
| Quilting (41) | ||
| Manual suctioning | ||
| Yes | 28 (68%) | 1 (2%) |
| No | 13 | 40 |
| Haematoma | ||
| Yes | 14 (34%) | 2 (5%) |
| No | 27 | 39 |
| Crusting | ||
| Yes | 3 (7%) | 1 (2%) |
| No | 38 | 40 |
| Synechiae | ||
| Yes | 2 (5%) | 0 (none) |
| No | 39 | 41 |
We observed that crusting was more in the nasal packing group than in the quilting group both in 5th POD and 14th POD follow up schedule. This was similar to the observations of Thapa et al. [20] who found significantly more crusting in the nasal packing. But in their study medicated gauze packing was used instead of Merocel. Nevertheless, nasal packing causes some degree of mucosal trauma that results in crust formation which in turn can leads to synechiae formation.
In the studies reviewed regarding the development of nasal synechiae [11, 21, 22]; all of them observed more synechiae formation in the nasal packing group than in the quilting group. Our study showed similar results, 26% of the patients in the nasal packing group showed synechiae formation.
Conclusion
Sepal correction for nasal septal deviation is a commonly done surgical procedure. We conducted the study to know the improvement in the quality of postoperative comfort level of the patient when the nasal cavity is not packed postoperatively. We found that the level of pain, sleep disturbance in the immediate postoperative period, nasal crusting to be less in the quilting group. By avoiding nasal packing postoperatively the patients were more comfortable and compliant with the treatment. We would recommend a more elaborate study to evaluate the difference between these two groups.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Compliance with Ethical Standards
Conflict of interest
The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: The authors certify that they have no affiliations with or involvement in any organisation or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this manuscript.
Ethical Approval
The author hereby declares that there were no ethical issues involved in the publishing of this article in any journal.
Footnotes
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