15.2.1 Internal Dressing

Packs

The function of intranasal packs is to provide appropriate tissue compression to approximate the wound surfaces and prevent swelling, bleeding, and hematoma formation. The physiological wound healing should be supported by establishing a moisty milieu that can help to accelerate epithelialization and to reduce granulation and scar formations. ⁵ These goals are particularly important when there are large, open wounds in the mucosa, like those resulting from endoscopic sinus surgery or a strip turbinectomy. Basically, a pack after sinus surgery can be avoided by minimal mucosa traumatization and meticulous bleeding control. ⁶ – ¹⁰ Because there is only a limited evidence of beneficial effect by packs, many nasal surgeons never use nasal packing after septorhinoplasty. ¹ , ¹¹

Packing materials for sinus or turbinate wound surfaces are placed temporarily and some kind of them are generally removed after a period of 1 to 3 days. ¹² These include Silastic-coated foam packs (Rhinotamp; Fig. 15.1 ), selfexpanding polyvinyl acetate packs (Merocel; Fig. 15.2 ), and hydrogel-coated packs (Rapid Rhino; Fig. 15.3 ).

One of the main selection criteria should be minimal adhesion to the mucosa with a good hemostatic action. Pack removal should be painless and should not damage the mucosa. Packs with slick or gel-like surface provide a measurably better comfort to patients and less pain and bleeding during removal. ¹³ – ¹⁷ Another option is to use hemostyptic packing materials as biodegradable materials that liquefy as wound healing progresses. ¹⁸ Remnants can be removed by means of suction during postoperative care. This eliminates the pack-removal procedure that patients dread. These materials include gelatin sponge (Gelfoam, Gelaspon; Fig. 15.4 ), hyaluronic acid (Merogel), carboxymethylcellulose (Tabotamp), and chitosan-dextran gel (PosiSep; Fig. 15.5 ). Side effects like increased rates of granulations, scar formations, and new bone formations had been shown after the use of these materials. ¹⁰ , ¹⁹ – ²¹ An advantage was reported that after the use of carboxymethylcellulos, ²² hyaluronic acid, ²³ and chitosan-dextran gel, ²⁴ a lower rate of synechias had been demonstrated, but no advantages in terms of wound healing parameters or postoperative bleeding rates. ²⁵ – ²⁷

Splints

Internal splints are designed to keep reconstructed portions of the septum from dislodging and prevent hematoma formation about the septum. They are also used to prevent synechia formation between wound surfaces. ²⁸ , ²⁹ The most commonly used splints are Doyle nasal airway splints ( Fig. 15.6 ) and Reuter Silastic ( Fig. 15.7 ) or Teflon splints. Specially molded stents can be used to maintain the patency of enlarged passages in functional endoscopic sinus surgery ( Fig. 15.8a, b ).

It is wrong to expect internal packing to salvage a poor postoperative result in the septum, sinus ostia, or external nasal shape. Also, a pack that fits too tightly or is too long will interrupt venous and lymphatic drainage, resulting in unnecessary swelling.

The duration of septal splinting and the danger of submucous hematoma formation can be reduced by placing multiple transseptal mattress sutures ( Fig. 15.9 ). Good results can be achieved with double-armed 4–0 Vicryl sutures (Johnson & Johnson Medical GmbH) on a straight needle. ³⁰ , ³¹

15.2.2 External Dressing

The function of the external dressing is to secure the mobilized skin on the cartilaginous and bony nasal framework. It should reduce potential spaces that may fill with blood or serum, leading to hematomas and swelling. The external dressing should also protect the mobilized nasal segments from displacement due to external trauma or intranasal swelling.

Like the internal dressing, the external dressing cannot salvage a technically poor result due, for example, to inadequate osteotomies or resections. Before the external dressing is applied, postoperative edema and blood residues should be massaged from the nasal dorsum so that the result can be assessed. The principle of “what you see is what you get” applies. ³² , ³³

The external dressing should consist of at least two layers: a skin-friendly adhesive dressing and a firm nasal splint.

The adhesive dressing for the skin consists of several, slightly overlapping adhesive strips that are placed across the nasal dorsum from the root of the nose to the supratip area. ² , ³² – ³⁶ They are applied over a Gelfoam strip about 0.5 cm wide that is first placed along the full length of the nasal dorsum. This will facilitate dressing changes. One or two longer adhesive strips are slung over the nasal tip without obstructing the nares ( Fig. 15.10 ).

Various materials can be used for the nasal splint. Plaster cast materials are widely used and are easily shaped to fit the individual nose. One disadvantage of casts is that they adhere poorly to the adhesive dressing, and the dressing will tend to loosen as swelling subsides, often requiring additional fixation. Malleable aluminum splints are also available. The Denver splint (Summit Medical, Inc.) ( Fig. 15.11 ) is supplied in three pieces—an adhesive tape to which an aluminum splint is attached with Velcro, padded by a foam strip. Thermoplastics ³⁷ can be trimmed to match the nasal size and can be accurately molded to the postoperative shape. Preshaped thermoplastic splints are supplied with an adhesive surface and adhere well to the adhesive dressing. Special preshaped thermoplastics (bess|rhino Thermo-Splint) consisting of malleable small plate for the front and a small bridge to cover the nasion had shown good results in reduction of postop swellings especially after bony reduction in the nasofrontal angle. An adherent foil with markings helps to shape the optimal size of the external splint ( Fig. 15.12a, b ). The splint covers the nasal dorsum, the nasal tip, and two-thirds of the caudal margin of the alar cartilage ( Fig. 15.12c ). A splint that fits too tightly can cause ischemia in the dorsal nasal skin. If pain is reported, therefore, the splint should be changed without delay. Normally the external dressings are removed at 1 week. The dressing may be extended an additional week, depending on the degree of swelling and the extent of the corrections.

15.3.1 First Postoperative Day

All solid packings should be removed from the nasal cavity and, if placed, also from the ethmoid after sinus surgery or from the inferior turbinate after a turbinectomy on the first postoperative day. Pack removal must be done carefully, and spraying pantocaine and naphazoline into the nose will facilitate the procedure. ³⁸ , ³⁹

Slight postoperative bleeding causes blood to collect in the nasal cavity. This blood coagulates and dries, forming blackish crusts. Sinus operations are followed by mucous drainage from the opened sinus, which also dries to form crusts ( Fig. 15.13 ). Serous and mucous wound secretions collect on the floor of the nasal cavity and in the sinuses. Patchy fibrin deposits form on surgical mucosal defects, especially on the turbinates, and dry to form crusts ( Figs. 15.14 and 15.15 ).