Quest for the Ideal Nasal Pack in Post Operative Cases of Septo-Turbinoplasty: Study in a Tertiary Care Hospital

Abstract

To compare the efficacies and post operative outcomes of patients with nasal packing with merocel, intranasal splints and merocel along with intra-nasal infant feeding tubes following septo-turbinoplasty, in patients with nasal obstruction secondary to septal deviation and inferior turbinate hypertrophy. A prospective study was done in 60 patients of symptomatic deviated nasal septum with inferior turbinate hypertrophy. Septoturbinoplasty was performed. Patients’ nasal cavity was packed for 48 h after being randomly divided into 3 groups: (1) packing using merocel, (2) intra-intra nasal septal silicone splint, (3) packing using truncated merocel along with infant feeding tube. Patients were given a questionnaire 24 h post operatively and their reponse was analysed to compare nasal blockage, epistaxis, epiphora and headache. Pain on pack removal was recorded after 48 h. We found that merocel with infant feeding tube had better tolerance than plain merocel in almost all cases, with symptoms of nasal blockage, epiphora, headache and pain on pack removal being lesser than with plain merocel, and comparable to the results produced by nasal splints. Also the epistaxis control in merocel with infant feeding tube was better than with nasal splints. Truncated merocel with infant feeding tubes provides a suitable and cheap replacement for nasal splints which may not be affordable to a lot of patients, or may not in available in many settings. The results are superior to plain merocel and the control of post operative bleeding is better than with intra nasal splints.

Introduction

Septoplasty with turbinoplasty is one of the most common surgeries performed by an otorhinolaryngologist for symptoms of nasal septal deviation and hypertrophied inferior turbinate causing nasal obstruction. The postoperative period is marked by complications such as bleeding from the surgical site, hematoma, abscess formation, septal perforation and synechiae formation [1]. Various methods are used to decrease symptoms such as bleeding by nasal packing [2] with various materials such as BIPP, merocel packs, nasal splints. The choice of selecting these and the amount of time they are kept intranasal does not have a fixed guideline [3] and the selection is based on the operating surgeon’s preference. Depending on the operating surgeon, they may be removed on the first post operative day or on day 5.

These methods not only help in decreasing the post op complications, also help in stabilizing the septal framework and keeping the flap in situ [1].

One of the disadvantages of using nasal packs postoperatively is the discomfort faced by the patient, including nasal stuffiness, difficulty in breathing, hypoxia [4], headache, and watering of eyes. Patients have difficulty falling asleep and have to regularly breathe through the mouth.

Although there are nasal splints with vent available, they increase the financial burden especially for patients from mid and low economic status [5], while not being readily available in many places.

This study aims to find a cost effective, readily available cost effective method to decrease post-op symptoms due to nasal packing. Infant feeding tubes, readily present inside the operating theatre, provide one such easily available method, and when used along with merocel nasal pack. It combines the advantages of both merocel and splints, providing a passage for the movement of air, thereby decreasing the symptoms of nasal blockage, headache, and nasal blockage.

Materials and Methods

A prospective study was done in 60 patients of symptomatic deviated nasal septum with inferior turbinate hypertrophy with symptoms of long standing nasal obstruction. Deviated nasal septum with bilateral inferior turbinate hypertrophy was confirmed on nasal endoscopy and CT scan. Patients between the ages of 20 and 50 who did not have any other significant co-morbidities were selected from June 2018 to January 2019 at our tertiary care hospital.

All patients underwent routine clinical, blood and radiological evaluation and informed consent was taken from all the patients. The patients were then randomly grouped into 3 groups.

All the patients underwent septoplasty under general anesthesia, with Killian’s incision being given 2–3 mm above the caudal end, mucoperiosteal and mucoperichondreal flaps raised, and deviated part of septum removed. The flaps were then placed back. Following this, the patients underwent bilateral turbinoplasty using medial flap raising technique in the same sitting.

In patients from group 1 merocel packs were bilaterally inserted into the floor of the nasal cavity (size 10 in males and size 8 in females).

In patients from group 2, intra nasal septal silicone splints were placed bilaterally in the nasal cavity and fixed by one 3-0 Nylon suture that crossed both septal flaps and splints.

In patients from group 3, the following was done: Infant feeding tube of size 6-8 FG was first cut to remove both the ends of the tube. The remaining tube was cut to 10.5 cm in males and 8.5 cm in females. Both the ends of the tube were blunted slightly so as not to have any sharp ends. The truncated tubes were introduced into bilateral nasal cavity along the medial aspect along the floor. Merocel size 10 in males and size 8 in females was used. The merocel packs were first cut longitudinally into half and then the size was reduced to approximately 6 cm in males and 5 cm in females after taking measurements endoscopically from the external nasal valve to the posterior end of the inferior turbinate. The pack was then introduced into bilateral nasal cavity along the floor on the lateral aspect of the tubes. The tubes were then suctioned to make sure there was a clear air passage and any blood clot that may have collected were removed and the posterior end of the tubes were not hitting the pharyngeal wall. The anterior ends of the tubes were sutured to each other to prevent any slippage of the tube posteriorly into the nasopharynx (Fig. 1).

Fig. 1.

A patient from group 3, with merocel and infant feeding tube in situ post operatively

In all three groups, the packs and splints were placed intra nasally for a period of 48 h, after which it was removed.

Patients were given a questionnaire with visual analogue score on the first post operative day, and their symptoms were recorded. Pain on pack removal was recorded 48 h after surgery, on removal of packs.

Patients were discharged on the second post operative day, and asked to follow up at week 1, week 3, month 2 and month 4. Diagnostic nasal endoscopy was done on all visits to check for post op complications. Any patients who did not come for all 4 follow ups were not included in the study.

Results

Post Op Nasal Blockage

The most common scores were 5–6 in group 2 and 3 (75% and 60%) and 9–10 in group 1 (85%). There was significance difference between post op nasal blockage between the groups, with blockage being least in group 2 (mean 5.5) and maximum for group 1 (mean 9.7) (p < 0.05).

Headache

The most common scores were 3–4 in group 2 (50%) and 3 (55%) compared to 5–6 in group 1 (60%). There was a statistical difference between head ache for the 3 groups, with group 1 having a mean of 6 and groups 2 and 3 having means of 3 and 3.5 respectively.

Epiphora

The most common scores were 5–6 in group 2 (70%) and 3 (85%), compared to 7–8 in group 1 (80%). Epiphora was least in group 2 with a mean of 5.3, followed by group 3 with 6.1 and group 1 with 7.5. The findings were statistically significant.

Epistaxis

The most common scores in group 1 and 3 were 3–4 (55% each), compared to 7–8 in group 2 (50%). Epistaxis was most in group 2 with a statistically significant mean of 8.2, followed by group 3 with 5 and group 1 with 5.1.

Pain on Pack Removal

The most common scores in group 2 and 3 were 3–4 (60% each), compared to 7–8 in group 1 (75%). Maximum pain on pack removal was seen in group 1 with a mean of 7.3 followed by group 3 with 5 and group 2 with 4.8, which showed statistical significance.

All the statistics were calculated using one way ANOVA with p < 0.05.

The results are displayed in a tabular format in Table 1.

Table 1.

Shows a comparison of post operative symptoms in groups 1, 2 and 3 as determined by their visual analogue score

	1–2	3–4	5–6	7–8	9–10
Post op nasal blockage
Group 1				3	17
Group 2		5	15
Group 3			12	8
Headache
Group 1		4	12	4
Group 2	10	10
Group 3	7	11	2
Epiphora
Group 1		1	3	16
Group 2	1	5	14
Group 3		1	17	2
Epistaxis
Group 1		11	7	2
Group 2			4	10	6
Group 3		11	8	1
Pain on pack removal
Group 1		2	3	15
Group 2		12	8
Group 3		12	6	2

The average of the post op symptoms in all 3 groups are shown in Fig. 2.

Fig. 2.

Average scores for post op symptom in patients of all 3 groups

Overall post op nasal blockage was comparable in groups 2 and 3, with maximum being in group 1. Headache and epiphora was comparable in both groups 2 and 3, with maximum in group 1, while epistaxis was maximum in group 2, and almost similar in groups 1 and 3. Pain on pack removal was seen maximum in group 1 with almost similar results in 2 and 3.

All patients were followed up for a period of 4 months at week 1, week 3, month 2 and month 4 postoperatively. There was no significant difference between symptoms for any of the patients on follow up.

Discussion

The postoperative period of septoturbinoplasy is marked by complications such as bleed from the surgical site, hematoma, abscess formation, septal perforation and synechiae formation [1]. These symptoms are commonly alleviated by nasal packing after surgery.

Nasal packing was first described in the otorhinolaryngologic literature in 1951 [6], and since then it has been designed to repress mucosal bleeding and improve wound healing postoperatively, while also helping in flap positioning after surgery [7].

Unfortunately, pain upon its removal has been described by patients as the most unpleasant aspect of the surgical experience [8, 9] and it can increase postoperative morbidity including infections [10], sleep-disordered breathing [11] and so on. Some researchers have even reported that nasal packing did not have a definite advantage in improving nasal airways after nasal surgery and have advocated no packing of the middle meatus thereby preventing packing complications and reducing economic burden [12–14]. However, many others believe that it is still necessary.

Submucosal electrocautery was not done since medial flap inferior turbinoplasty is shown to have better long term outcomes for nasal obstruction when compared to electrocautery [15]. However, the association of inferior turbinoplasty, with septoplasty increases intra-op and post operative bleed [16, 17]. The risk of adhesions also increases in patients undergoing turbinoplasty postoperatively [18].

Hence the requirement of a nasal packing material which, while being easily affordable and available, does not cause the symptoms associated with nasal packing such as nasal obstruction and discomfort, while at the same time effectively reduces post operative epistaxis and posterior pharyngeal wall staining.

Merocel is a compressed, dehydrated sponge composed of hydroxylated polyvinyl acetate that can increase in size within the nasal cavity and compress a bleeding vessel through rehydration with normal saline, is one of the most popular nasal dressings and possesses many advantages, such as low price, ease of manipulation, excellent wet-state elasticity and sufficient support. But the severe pain and bleeding upon removal that patients experience is its major drawback [8, 9] In addition, removable nasal packs generate other complications such as nasal fullness and obstructive sleep apnea secondary to nasal obstruction [19, 20].

Although there are nasal splints with vent available, they increase the financial burden especially for patient from mid and low economic status [5], while not being readily available in many places.

Inserting infant feeding tubes alleviates many of the side effects of merocel, while maintaining the functional capacity of the material. Moreover, it gives better results than if done with plain nasal splints.

Case reports of toxicity have resulted in reduced usage of BIPP are well documented and have the potential risk of bismuth absorption resulting in a toxic confusional state, acute encephalopathy and coma [21, 22] and hence was not used.

Our study shows that merocel that has been truncated in both length and width, inserted with infant feeding tubes into the nasal cavity gives an alternative method to alleviate post operative symptoms. It does not have the nasal fullness, watering of eye, headache or breathing difficulty that is present with inserting only merocel in the nasal cavity, and gives relief in symptoms similar to nasal splint, while not being as expensive and is readily available, with infant feeding tubes, that are present inside the operating theatre. It also does not have pain on removal due to being cut during insertion.

Conclusion

Merocel with infant feeding tubes can be used as a substitute for nasal splints as they help in respiration via the nose post operatively, while decreasing epistaxis and headache and neasal fullness. Moreover, in centres where nasal splints are not available or not affordable for the patients, this can be used as a suitable replacement, with no separate complications, while giving similar results.

Funding

All the authors declare they have not received any funding.

Compliance with Ethical Standards

Conflict of interest

All the authors declare they have no conflicts of interest.

Informed Consent

Written informed consent was obtained from all the individual participants in the study.

Ethical Approval

All procedures performed in the study were in accordance with the ethical standards of the institute.