The Efficacy of Septal Quilting Sutures Versus Nasal Packing in Septoplasty

Abstract

Nasal packing is the classic method adopted by many otolaryngologists to stabilize the nasal septum and decrease the occurrence of postoperative bleeding and septal hematoma after septoplasty. However, because of its associated postoperative morbidity, many surgeons started to adopt alternative methods. This study aimed to assess the outcome and benefits of septal quilting sutures in comparison to nasal packing after septoplasty. A prospective non-randomized comparative interventional study was carried out at two teaching hospitals in Mosul city from January 2020 to January 2021. A total of 60 patients who were candidates for septoplasty, were included in the study. According to the surgeon's preference; 30 patients had placement of septal quilting sutures (group A), and in the other 30 patients nasal packing was performed (group B). Patients were assessed for postoperative morbidity and early outcome in the first 24 h, 1 week and 1 month postoperatively. In the first 24 h after septoplasty, patients in group B had significantly higher levels of nasal/facial pain, headache, sleep disturbance, breathing difficulties and swallowing difficulties compared to group A (p < 0.001). Over the follow up period of 1 month, no significant differences were recorded regarding postoperative bleeding, hematoma, infection, adhesions formation and septal perforation between the two groups (p > 0.05). Septal quilting sutures technique is more favorable in the early period in terms of patient discomfort after septoplasty, better nasal block and nasal/facial pain, the absence of misery on pack removal, with minimal bleeding after surgery.

Introduction

Nasal obstruction is a common complaint presented to otorhinolaryngologists and general practitioners. In fact, one of the most frequent causes of nasal obstruction is a deviated nasal septum [1]. Septoplasty is a common procedure carried out in the daily practice of otorhinolaryngology, in which manipulation of the nasal septum is performed. It has been proven to be effective in relieving nasal obstruction [2, 3]. At the end of such surgery, intranasal packs are traditionally inserted to provide mechanical pressure to minimize the chances of postoperative bleeding and/or septal hematoma formation by elimination of the dead space [4]. In addition, it supports the repositioning and the alignment of the mucosal flaps [5]. Different types of nasal packs are used (e.g. Vaseline-soaked gauze, absorbable gelatin sponges, bismuth iodoform paraffin paste pack, and Merocel) [6].

However, the totally-occlusive nasal packing has many negative effects on the patients' quality of life, which are well studied in the literature. The main disadvantages include; patient's discomfort and local pain, headache, sleep disturbance, dysphagia, breathing difficulty, anxiety and more severe pain on pack removal [7]. Bilateral nasal packing may affect the respiratory function due to inadequate oral breathing causing nocturnal hypoxia, which may become more apparent in patients with obstructive sleep apnea or chronic lung diseases [8]. Eustachian tube dysfunction, intranasal infections, toxic shock syndrome, laryngeal or bronchial spasm, myocardial infarction, cerebrovascular accidents and even sudden death have been reported [4, 8]. In addition, the mucosal damage caused by nasal packing may lead to loss of cilia and affects the mucociliary clearance during the healing period [5, 9]. These difficulties had led many surgeons to adopt the use of septal quilting sutures as a safe and valid alternative to nasal packing. This study was conducted to assess the outcome and the benefits of septal quilting sutures in comparison to nasal packing after septoplasty.

Materials and methods

A prospective, non-randomized comparative interventional study was performed in two hospitals in Mosul city; Al-Jumhori teaching hospital and Al-Salam teaching hospital for the period from January/2020 up to January/2021. The study included 60 patients for whom septoplasty was indicated. The inclusion criteria were patients of both genders who are 17 years of age or older, with symptomatic deviated nasal septum who agree to participate in this study. The exclusion criteria were: patients with systemic diseases (e.g. uncontrolled hypertension), patients on current medical therapy affecting the platelets' function or the coagulation process, previous nasal surgery (e.g. septal surgery), patients with clinical and radiological findings suggestive of chronic rhinosinusitis, not relieved with medical therapy, and patients who needed concomitant nasal surgery (e.g. turbinoplasty, septorhinoplasty or endoscopic sinus surgery).

Informed consent was taken from the patients participating in the study. Preoperative assessment was done including detailed history and a clinical systemic and ENT examination by anterior rhinoscopy and endoscopy. Routine preoperative workup was done and consent form obtained. The preoperative questionnaire was taken.

Patients underwent conventional septoplasty under general anesthesia. They were positioned supine in anti-Trendelenburg position with a head ring for support. Both sides of the septum were infiltrated with 4 ml a solution of 2% lidocaine with 1:100,000 diluted adrenaline. A caudal septal (hemitransfixion) incision was made, the mucoperichondrial flaps on both sides were elevated, the deviated parts of the septal cartilage and bone were resected as well, preserving cartilage as much as possible, and reinsertion of resected cartilaginous septum was done. Then relocating the flaps and the incision was closed by two stitches of 3/0 vicryl sutures.

At the end of surgery, the decision was taken according to the surgeon preference to have either a septal quilting sutures technique or insertion of nasal packs. So, patients were distributed between two groups: Group A for quilting suture technique and Group B for nasal packing.

In group A; 4 stitches of 3/0 round-body needle vicryl were placed in different planes through the septal cartilage, depending on the deviated part of the septum. A suitable small needle holder was used. The first stitch was placed near the caudal end of the septum and inserted from the left side to the right side, then returning back to the left at a distance of about 2 cm away from the first stitch. Then, the same suture was done at a new plane. The final pass of the suture was placed close to the first suture applied on the septum, and stitched with a knot. The nose was left open without packing. In group B; after repositioning the septal flaps, Vaseline-impregnated nasal packs were inserted. After 24 h, the packs were removed.

All patients received analgesia in the form of intravenous paracetamol 500 mg as single dose. Patients were discharged home at the same day of surgery. Local vasoconstrictor nasal spray and local ointment were prescribed. Normal saline 0.9% nasal wash was started in the 1st postoperative day, 6 times daily for 1 week. Patients who were not packed were instructed to start nasal wash and vasoconstrictor nasal spray soon after they were discharged home.

Three follow up visits were arranged: the 1st visit was at the first postoperative day. Patients were checked for bleeding and septal hematoma, presence and severity of local facial pain, headache, sleep disturbance and swallowing difficulty. The 2nd visit was arranged after 1 week, patients were examined for signs of infection, presence of hematoma, crusts, and adhesions. The last visit was after 1 month; patients were re-assessed for possible later complications including adhesions and perforation of the septum.

Postoperative bleeding was defined as ooze of blood that necessitates medical or surgical intervention. Postoperative nasal secretions mixed with traces of blood were not considered as bleeding. It was classified either as 0: no bleeding, (1) minor bleeding that is controlled with 0.1% adrenaline soaked cotton swabs for 5 min, (2) major bleeding that necessitated the application of the nasal packs [10]. The "subjective" symptoms (nasal/facial pain, pain on pack removal, headache, sleep disturbance and swallowing difficulty) were assessed using a visual analogue scale (VAS) following the National Initiative on Pain Control ™ (NIPC); a scale between 0 and 10 (0, no complaint; 10, most severe).

Statistical analysis

Data were analyzed using the statistical package for social sciences (SPSS) software, version 25 (IBM SPSS Inc., Chicago, IL, USA). Quantitative continuous variables were represented by central indices (mean ± standard deviation), which were then compared with those of the other group by the independent sample Student's t-test. Quantitative discrete variables and categorical variables were represented by frequency tables as number of cases, and were analyzed using the Fisher's exact test. P-value of less than 0.05 was considered statistically significant.

Results

Over a one year period, from January 2020 to January 2021, a total of sixty patients who met the study criteria were included. The age range was from 17 to 51 years with a mean age of 27.5 ± 9.29. There were 33 males (55%) and 27 females (45%) with a male to female ratio of 1.2:1. They were divided into two groups: Group A (septal quilting sutures) and Group B (nasal packing). Regarding the age and sex distribution of each group, statistical analysis shows no significant differences between the two groups, as shown in Table 1.

Table 1.

Age and gender distribution of the patients

	Group A n = 30	Group B n = 30	p-Value
Age (years)
Range	17–51	17–51	0.967
Mean ± SD	27.4 ± 9.34	27.5 ± 9.41
Gender
Male	16 (53.3%)	17 (56.7%)	1.0
Female	14 (46.7%)	13 (43.3%)

The mean operative time was 39.27 ± 3.39 min for group A and 37.33 ± 3.63 min for group B. The difference was statistically significant (p = 0.037).

The mean visual analogue scores of postoperative nasal/facial pain, headache and sleep disturbance were higher in group B as shown in Table 2. Statistical analysis revealed that these differences were significant, i.e. patients with nasal packing had significant higher levels of nasal/facial pain and more severe headache in the first 24 h after septoplasty, more sleep disturbance at the first night after surgery and more intense feeling of nasal block than patients with trans septal quilting sutures.

Table 2.

Comparison of the mean VAS scores between the two groups

Trial variables	Group A Mean ± SD	Group B Mean ± SD	p-value
Nasal/facial pain	3.87 ± 2.18	7.13 ± 2.16	< 0.001
Pain on pack removal	0	8.9 ± 1.37	< 0.001
Headache	3.33 ± 1.97	6.83 ± 2.12	< 0.001
Sleep disturbance	3.53 ± 2.3	7.63 ± 1.9	< 0.001
Feeling of nasal block	4.57 ± 1.91	10.0 ± 0	< 0.001

Twenty-six patients (86.7%) in group B had experienced difficult swallowing and poor oral intake in the first 24 postoperative hours, compared to 14 patients (46.7%) in group A. This difference was statistically significant (p = 0.002).

Regarding the early postoperative complications, no major bleeding was recorded among the patients of both groups. In group A, three patients (10%) in the surgical ward had minor bleeding versus none (0%) in group B (p value = 0.237). There was no need for admission and they were discharged on the same day.

At the end of the first week, no patients had septal hematoma or intranasal infection in both groups. Seven patients (23%) in group B and five patients (16.7%) in group A had developed intranasal crusts; this difference was not statistically significant (p = 0.748). With further follow up (after 1 month); no patient in either group had postoperative adhesions. Septal perforation was noticed in one patient in group A and none in group B. The difference was statistically not significant (p = 1.0).

Discussion

Septoplasty is one of the commonest surgeries in otorhinolaryngology, either alone or combined with other procedures. In the literature, some controversies exist regarding post-septoplasty nasal packing, as there was no scientific evidence of benefit to support their routine use [11]. For this reason, this study was conducted in the aim of demonstrating the use of septal quilting sutures versus nasal packing. Patients with nasal packs were found to be 3.6 times more liable for respiratory distress than patients without packs [12]. The most important advantages of the suture technique include: the non-obliteration of the nasal cavities and the absence of agony associated with pack removal, so it highly decreases patient's discomfort and anxiety related to breathing and pack removal [13].

In our study, the sample consisted of 60 patients. This was an approximate number to other papers that have dealt with the same subject [8, 14]. There were 33 males and 27 females, this male preponderance is consistent with the majority of papers which studied septal surgery; that may be explained by the fact that males are more liable to trauma than females [14].

In our study, the mean duration of operation was statistically longer duration in group A, p = 0.037). A similar study done by Korkut et al. [8] was in agreement with our result, although they developed a novel device for inserting the septal quilting sutures; yet, the difference in operation time was still significant (p = 0.026). Ozkiris et al. [15] also agree with our result (p < 0.001).

Regarding the postoperative nasal/facial pain, it is believed that nasal packing leads to more intranasal edema, which further increases the secretion of pain-producing substance, and together with poor drainage, it leads to stimulation of the nerve endings to aggravate nasal/facial pain [5]. In our study, significant higher levels of pain were recorded from the patients of group B compared with the patients in group A. This is in agreement with the findings of Ozkiris et al. [15] and Cukorova et al. [7] where comparable results (p < 0.05) were found.

Probably the most unpleasant aspect of septoplasty is the painful removal of nasal packs [4, 15]. The cause of such pain may be the dislodgement of the blood clot with the adherent tissues after adherence of the nasal pack at the sites of bleeding [16]. All our patients with nasal packs experienced pain on pack removal, with a mean visual analogue score of 8.9 out of 10. This is in agreement with Awan et al. [17], who recorded an approximate score of 8.1.

Regarding postoperative headache, patients in group B experienced much more headache than patients in group A. This is in accordance with Korkut et al. [8] (p < 0.001) and Awan et al. [17] (p < 0.05). Two mechanisms are suggested to explain such headache; first, the obstruction of the sinus ostia by nasal packing leads to impaired ventilation and stasis of mucous secretions causing retention sinusitis [14, 18]. Second, nasal packing causes stretching of the nasal walls and the resultant pain will be perceived as headache [17].

Regarding sleep disturbance, patients with nasal packing had more disturbance of sleep during the first night after surgery in comparison to the septal quilting group. This is probably due to airway obstruction and higher levels of pain in the NP group [14]. Our results go with the study of Ramalingam et al. [18] (p = 0.05) and Korkut et al. [8] (p < 0.001). Killera et al. [16] disagree with our results and found the difference was statistically not significant (p = 0.07).

Regarding swallowing difficulties, as in most nasal surgeries, the patient may complain of throat discomfort and swallowing difficulty in the first 24 h after surgery. This may be due to the insertion of throat pack and the endotracheal intubation itself. Furthermore, nasal obstruction by the packs impairs the closure reflexes of the nasopharynx and oropharynx. Swallowing in the presence of nasal packs (Toynbee maneuver) prevents the air from escaping through the nose. Instead, it blows into the middle ear giving an unpleasant feeling which makes the patients avoid eating and swallowing [14, 17]. Our results are in agreement with Awan et al. [17] (p < 0.001). while Killera et al. (2018) [16] disagree with this result and found the difference between the two groups was not significant (p = 0.183).

Regarding postoperative complications, three patients in group A had minor bleeding in comparison to none in group B. The difference was statistically not significant (p = 0.237). Our results are in agreement with Awan et al. [17], Cukurova et al. [7] and Said et al. [14]. No case of septal hematoma had been recorded in both groups. This is in agreement with Cukurova et al. [7].

The next complication dealt with was infection of the nasal cavity (cellulitis, nasal vestibulitis, and septal abscess). No patient in both groups had this complication. This is in concordance with Ozkiris et al. [15] and Gunaydin et al. [10]. In our study, some patients in both groups had excessive intranasal crusting mainly because of the non-compliance with the instructions of nasal hygiene (nasal wash and application of emollient ointment or cream), which is a common problem seen after nasal surgeries [10]. No significant difference exists between the two groups regarding intranasal crusting. This is in agreement with Said et al. [14] (p = 0.38). However, Ramalingam et al. [18] disagree with our results and found the crusting was much more with nasal packing (p < 0.001), they attributed the reason to the mucosal trauma occurred by packing the nose, which may further lead to synechiae formation.

At 1 month period, no case of mucosal adhesion was seen in both groups. This is in agreement with Korkut et al. [8] and Said et al. [14]; they found no statistical difference regarding adhesion formation between the two groups. Killera et al. [16] disagree with the previous results and recorded significant higher rate of adhesions with nasal packs (p = 0.042). In our study, only one patient in group A developed septal perforation compared to none in group B, and the difference was not statistically significant, which is consistent with many recent studies [8, 10, 15].

Because our study was followed over 1 month period, further longer follow up (3–6 months) was lacking, so long term complications including adhesions, septal perforation, or recurrence of septal deviation were not revealed. We cannot afford databases at 6 months later; this is one of the drawbacks of this study.

Conclusion

The septal quilting sutures procedure can be used as a safe, valid and better substitute to the classical nasal packing after septoplasty. It confers much more benefits in minimizing patients' morbidities and increasing their compliance in the early 24 h after surgery. It is more favorable in terms of patient discomfort after septoplasty, better in terms of nasal block and nasal/facial pain, the absence of misery on pack removal, with similar risks of bleeding and other complications after septoplasty. We suggest limiting the use of nasal packs for certain situations, as in excessive intraoperative bleeding, or for patients in whom septoplasty is combined with other surgeries, e.g. turbinoplasty. Further well-designed randomized controlled trials and meta-analyses are necessary regarding this topic, with larger patient samples and longer duration of follow up.

Funding

No funding was received for conducting this study.

Declaration

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Approval

Before starting the study ethical approval was taken from local institutional committee (medical research ethics committee) with reference: UOM/COM/MREC/20–21(49).