1

Introduction

Nasal septal surgery is one of the most common operations in otorhinolaryngology, alone or in combination with other procedures, such as inferior turbinoplasty, endoscopic sinus surgery and rhinoplasty .

Nasal packing materials are widely used in endonasal surgery, including septoplasty, turbinectomy and paranasal sinus surgery. They are also used to prevent synechiae and haematoma formation, to support septal flap apposition, and to close dead space between cartilage and subperichondrial flaps .

Several types of nasal packs are used post-operatively in nasal and sinus surgery. There are various packing materials described in the literature, such as different types of gauzes with or without medication, Telfa, cellulose and foam, absorbable gelatin sponges, Merocel, internal nasal splint, polyethylene oxide gel and alginate . The type of the nasal packing material used will depend on the preference and experience of the surgeon, the ease of insertion and removal and – more importantly – any patient discomfort or pain, especially during removal .

Post-operative pain, mucosal injury, worsening of breathing due to sleep disorders, displacement and aspiration of the packing material, allergy, toxic shock syndrome and postoperative infections are the complications associated with nasal packing . There have been few studies suggesting that nasal packing should not be used because of the discomfort at the time of removal . As alternatives to nasal packing, internal splints and septal suturing have been used recently .

This study aimed to compare transseptal suturing against two different types of nasal packs with respect to pain, operative time and postoperative complications following nasal septal surgery.

2

Materials and methods

One hundred and fifty patients (82 males, 68 females), who had nasal septal surgery from January 2008 through December 2011, were enrolled into the study. Sample size was calculated by a statistician as 50 patients in each group to achieve a power of 80% and an alpha error of 0.05. The study was approved by the local ethical committee. Informed consent was obtained from all patients. The patients with vasomotor rhinitis, nasal polyposis, allergic rhinitis, immune deficiencies, pulmonary and/or cardiovascular disorders, and those who received long term drug therapy for any condition were excluded from the study. Three types of nasal packing systems were utilized: (1) transseptal suturing; (2) internal nasal splint (Invotec International, FL, USA); (3) Merocel standard 8-cm nasal dressing without airway (Medtronic Xomed Inc., FL, USA) to form three patient treatments, A, B, and C, respectively. Patients were randomly assigned to either group in transseptal suturing, nasal splint and Merocel groups as they appeared on the surgery list. The patients and study nurses recording the outcome were blinded to the patients allocation and the packing technique used.

Patients were enrolled for the intended treatments by M.Ö. All patients were operated by using the classic septoplasty operation technique under general anesthesia. At the end of the surgery, the patients were randomly selected to have either nasal packs or transseptal suturing. The operative time for nasal septal surgery was measured from the hemitransfixation incisions to complete nasal packing or intranasal suturing.

In group A, 4 separate sutures were placed horizontally, vertically or obliquely depending on the elevated part of the septum, using 4/0 Vicryl as the suture material. The places and positions of the sutures were designed according to the elevated parts of the septum. The least number of sutures which was enough to stabilize the septum was applied. In group B, nasal cavity was packed with an internal nasal splint. In group C, nasal cavity was packed with a Merocel. The Merocel pack was inserted along the floor of the two nasal cavities first and then irrigated with 5 ml of saline. The patients were discharged the day after surgery with analgesic (paracetamol tablet) and antibiotic (amoxicillin/clavulanic acid tablet) in weight-related doses. Patients were asked to record their pain levels on a visual analogue score (VAS), during 48 h. The pain score charts (VAS) consisted of a 10 cm linear scale with 10 gradations ranging from 1 (no pain) to 10 (severe pain). Merocel and internal nasal splint tampons were removed on post-operative second day. Patients were also asked to report any bleeding in the following three weeks. A follow-up visit was scheduled after three months to check for septal perforation, synechiae and adhesion formation.

Data analysis was performed by using SPSS for Windows, version 11.5 (SPSS Inc., Chicago, IL, USA). Data were analyzed by Chi-square or Fisher’s exact test, where appropriate. A p value less than 0.05 was considered statistically significant.

2

Materials and methods

One hundred and fifty patients (82 males, 68 females), who had nasal septal surgery from January 2008 through December 2011, were enrolled into the study. Sample size was calculated by a statistician as 50 patients in each group to achieve a power of 80% and an alpha error of 0.05. The study was approved by the local ethical committee. Informed consent was obtained from all patients. The patients with vasomotor rhinitis, nasal polyposis, allergic rhinitis, immune deficiencies, pulmonary and/or cardiovascular disorders, and those who received long term drug therapy for any condition were excluded from the study. Three types of nasal packing systems were utilized: (1) transseptal suturing; (2) internal nasal splint (Invotec International, FL, USA); (3) Merocel standard 8-cm nasal dressing without airway (Medtronic Xomed Inc., FL, USA) to form three patient treatments, A, B, and C, respectively. Patients were randomly assigned to either group in transseptal suturing, nasal splint and Merocel groups as they appeared on the surgery list. The patients and study nurses recording the outcome were blinded to the patients allocation and the packing technique used.

Patients were enrolled for the intended treatments by M.Ö. All patients were operated by using the classic septoplasty operation technique under general anesthesia. At the end of the surgery, the patients were randomly selected to have either nasal packs or transseptal suturing. The operative time for nasal septal surgery was measured from the hemitransfixation incisions to complete nasal packing or intranasal suturing.

In group A, 4 separate sutures were placed horizontally, vertically or obliquely depending on the elevated part of the septum, using 4/0 Vicryl as the suture material. The places and positions of the sutures were designed according to the elevated parts of the septum. The least number of sutures which was enough to stabilize the septum was applied. In group B, nasal cavity was packed with an internal nasal splint. In group C, nasal cavity was packed with a Merocel. The Merocel pack was inserted along the floor of the two nasal cavities first and then irrigated with 5 ml of saline. The patients were discharged the day after surgery with analgesic (paracetamol tablet) and antibiotic (amoxicillin/clavulanic acid tablet) in weight-related doses. Patients were asked to record their pain levels on a visual analogue score (VAS), during 48 h. The pain score charts (VAS) consisted of a 10 cm linear scale with 10 gradations ranging from 1 (no pain) to 10 (severe pain). Merocel and internal nasal splint tampons were removed on post-operative second day. Patients were also asked to report any bleeding in the following three weeks. A follow-up visit was scheduled after three months to check for septal perforation, synechiae and adhesion formation.

Data analysis was performed by using SPSS for Windows, version 11.5 (SPSS Inc., Chicago, IL, USA). Data were analyzed by Chi-square or Fisher’s exact test, where appropriate. A p value less than 0.05 was considered statistically significant.