In the Recovery Room

A thoughtful routine of patient management after surgery is essential to protect and sometimes enhance the results of surgery. The patient and surgeon have worked together to carefully prepare for the operation, and the surgeon has presumably done his very best in the operating room. Now is not the time to drop the ball. As soon as the patient enters the recovery room, postoperative care begins.

If the patient is conscious, let him know where he is and that he is safe and that the surgery went well. Patients want to hear that the nose is improved and that they will be pleased with the result. Tell them.

The head of the bed or gurney should be elevated to assist drainage and resist undue immediate swelling in virtually every case. A “moustache” dressing should be placed at the base of the nose only if there is blood draining from the nose. If this is the case, bleeding should be monitored and should stop or decrease to an occasional small trickle before the patient is allowed to leave the surgical center or hospital. Persistent steady bleeding must be investigated and stopped. In the absence of bleeding, the mustache dressing is actually detrimental. It blocks airflow into the nose and promotes clot formation in the nasal airways or splints, which can prevent the patient from breathing well at home.

It is helpful for the postanesthesia care unit (PACU) personnel to show the patient how to use nasal saline. Very often the remainder of the single-use saline bottle can be given to the patient as a sample if surgical center policy permits this. Early and frequent use of nasal saline will keep the nasal airways moist, cut down on clot and crust formation, and make the patient more comfortable after surgery.

If members of the patient’s family or friends who will serve as caregivers are present, take the time to speak with them after surgery. They want to know that the surgery went well and that their loved one is in good condition. They should already have been given written instructions for postoperative care issued by your office, but now is a good time to emphasize key instructions that you want them to follow. Table III.1 lists important directions that may be reviewed with the family or friends.

The First Few Days

It is helpful for the patient to continue to sleep and rest with the head elevated to assist drainage of secretions and limit nasal and facial swelling. The patient’s activity level should gradually increase, but there can be no heavy lifting or exertion that raises the heart rate.

Continued use of nasal saline is recommended and is especially important if splints are in place. Many surgeons place splints in surgery, and some of these have an attached tube that facilitates nasal airflow even in the presence of significant intranasal edema. Saline will help keep the tubes patent and allow the patient to breathe and be more comfortable. The patient may sniff the saline through the nose, but is cautioned to avoid blowing the nose forcefully for 6 weeks from the date of surgery for the reasons given in Table III.1.

If a cast has been applied to the nose, it should be kept dry, which means the patient must be careful when washing the face and taking showers. Many patients take baths instead to avoid getting the cast wet.

The patient should gently clean the visible sutures in the columella (if present) and nasal vestibule to prevent crusting. This may be done by gently applying a solution of half-strength hydrogen peroxide (the patient may mix equal amounts of water and hydrogen peroxide) to the sutures with a cotton-tipped applicator. Instruct patients before surgery that doing this consistently will make suture removal faster and less painful, and they will almost always comply. After cleaning the sutures, a thin coating of antibacterial ointment can be applied to the sutures. Cleaning in this way two to three times per day will prevent crust accumulation in most cases.

The First Office Visit

The first postoperative office visit usually occurs on the fifth to seventh day after surgery. Patients should know that they can come in sooner if there is excessive discomfort, crusting, bleeding, or any other concern.

If crusts are present over the sutures or splints, the first item of business is to remove them. This will make suture and splint removal faster for the surgeon and much easier on the patient. Depending on the quality of healing, remove all or some of columellar and alar base sutures. If the wound edges are more swollen or erythematous than normal, or if there is a tendency for them to separate slightly when the first sutures are removed, consider removing every other stitch. If the patient was a smoker prior to surgery, these findings should raise a suspicion that he is smoking postoperatively against your advice. To prevent widening of the scars after suture removal, it is helpful to place a flexible, quick-acting glue (Flexible Collodion, Mallinckrodt Baker, Inc., Phillipsburg, NJ) and tape over the incisions, and ask the patient to return in a few days, at which time the tape can be removed or replaced and any remaining sutures taken out.

Next, the nasal splints, if present, are carefully removed. The patient will experience some discomfort, so this must be done as gently as possible and the patient reassured while it is happening. Patients usually experience significant relief and sometimes disbelief at the newfound ability to breathe through the nose. They should be reminded that the splints were occupying space and may have prevented more intra-nasal swelling, so that there may be an interval in which swelling does increase and the nasal airways close down a bit. Once this swelling is resolved, the airway should open back up to a functional level. If patients know to expect this phenomenon, they will not be concerned by it.

Now that the splints are out, take time to examine the inside of the nose and gently clean any residual clots, crusts, or accumulations of mucus. You should be able to see the entire nasal airway on both sides. Remind the patient that it is important to continue to use nasal saline to prevent crusting in the nose.

If during surgery the nasal septum was found to be very disrupted or crooked, then leaving the nasal splints in longer is an option. The presence of perfectly straight supports on either side of the healing septum may exert a beneficial effect. Patients can generally tolerate an extra week of splinting if they understand your reasons for keeping the splints in. If there was disruption of the septal mucosa and the adjacent turbinate during surgery, extended splinting could also be helpful in preventing synechiae from forming. It is the author’s preference to maintain patients on oral antibiotics while the splints are present, recognizing that old blood and secretions can become trapped beneath the splints.

Remove the cast last. This is the moment where the new nasal shape is revealed. The patient and family will be most interested in how the nose looks immediately after the cast comes off. The patient may have perspired during suture and splint removal which can actually facilitate removal of the cast. The cast and underlying tape can be quite adherent to the skin, so proceed gently. A forceps and an elevator or the stick end of a cotton-tipped applicator may be used to gently pry the tape off the skin in a side-to-side fashion. Adhesive removers such as Detachol (Ferndale Laboratories, Inc. Fern-dale, MI) can be used to speed cast and tape removal. In rare cases the patient’s skin can be unusually sensitive to adhesive removers, so use them carefully, if at all.

When the cast comes off the patient’s reaction is usually positive. The nose is straighter; the hump is gone or reduced. On the other hand, the nose may be swollen, sometimes unevenly, and the patient and family may express disappointment. In the former case make sure the patient sees the improvements. In the latter, reassure him that it will take some time for the true result to become visible. In either case take photographs when the cast has been removed. Patients may inadvertently injure their noses soon after cast removal, so it is reassuring to have photographs showing the improvements you achieved before the injury.