The use of nasal packing following septoplasty has been proposed to serve multiple purposes. One of the most common reasons for use of packing is to prevent postoperative complications such as bleeding and formation of either synechiae or a septal hematoma. Stabilization of the remaining cartilage to prevent postoperative deviation is another reason that packing may be used. Although it appears intuitive that packing may prevent or decrease the incidence of these complications, evidence supporting this assertion is limited at best. Furthermore, certain types of nasal packing have been demonstrated to increase postoperative pain and have been implicated as a causative factor of catastrophic complications, such as toxic shock. With limited evidence to suggest a beneficial effect and a potential for deleterious side-effects, the routine use of postoperative packing following septoplasty should be questioned.
There is a lack of consensus regarding the need for nasal packing following septoplasty. The use of postoperative packing has been proposed to minimize postoperative complications such as hemorrhage, formation of synechiae, and septal hematoma. Additionally, postoperative packing is thought to stabilize the remaining cartilaginous septum and minimize persistence or recurrence of septal deviation. Despite these theoretic advantages, evidence to support the use of postoperative packing is lacking. Additionally, nasal packing is not an innocuous procedure. The use of nasal packing carries several risks which, given the lack of firm evidence to support its efficacy, should call into question its routine application.
Morbidity of nasal packing
While life-threatening risks associated with nasal packing have been documented, these complications occurred primarily in the setting of posterior packing placed for the treatment of epistaxis. The presumed etiology of death in these cases, the naso-pulmonary reflex, has not been noted in the modern literature of postseptoplasty packing. The most common morbidity associated with packing in postseptoplasty patients is postoperative pain. Additional potential complications include worsening of sleep disordered breathing and postoperative infection, including reports of toxic shock syndrome due to postseptoplasty packing.
Attempts have been made to limit the morbidity of nasal packing through limiting the duration of packing and altering packing materials. Overall, the wide variety of packing materials and techniques complicates a clear assessment of the risks associated with postoperative septoplasty packing. Illum and colleagues found decreased pain with removal when using fingerstall packs compared with Merocel or hydrocortisone-terramycine gauze packs with ventilation tubes. Some authors have found rehydration of foam packs with topical anesthetic to lessen discomfort upon pack removal. Silastic nasal splints are frequently used in place of packing and may be associated with less morbidity.
Efficacy of nasal packing
While the morbidity and risks associated with postoperative nasal packing may be tolerated or minimized, the existence of such complications requires an evaluation of the importance of postseptoplasty nasal packing. In 1989, Guyuron published one of the few studies describing the efficacy of nasal packing in maintaining an adequate postoperative airway. In this study, 50 subjects undergoing septorhinoplasty were randomized to receive packing with polysporin-impregnated gauze or placement of a quilting suture without nasal packing. Twenty-three subjects in the packed group and 22 subjects in the suture group were available for follow-up at up to 16 and 26 months, respectively. Subjective breathing improvement was found to be significantly more prevalent among the packed group. Additionally, a significantly higher percentage of persistent septal deviation was found among the unpacked group.
These findings, however, were called into question by Oneal who noted that subjects’ awareness of packing as a point of study may have introduced bias into the patients’ subjective assessment of breathing improvement. He additionally noted that this finding, and the finding of persistent deviation as more common among the unpacked group, is weakened by the lack of preoperative assessment of degree of septal deviation. It is also important to note that this study was performed in the context of septorhinoplasty, not septoplasty alone.
Subsequent studies have failed to demonstrate a clear advantage to nasal packing while noting an increased morbidity with the use of packing. Nunez and colleagues prospectively studied 59 subjects undergoing septal surgery and randomized them to packing with Vaseline gauze or no packing and placement of a septal quilting suture. Pain was recorded by a visual analog scale on postoperative day one and was found to be significantly higher in the packed group. The authors found no difference in the prevalence of adhesions, crusting/mucosal atrophy or granuloma formation between the two groups during follow-up at 6 weeks. The presence of persistent septal deviation and the extent of airway improvement were not evaluated in this study.
Von Schoenberg and colleagues studied 95 subjects undergoing routine nasal surgery and randomized them to receive packing (either bismuth iodoform paraffin paste (BIPP) or Telfa) or no packing. Subjects undergoing septoplasty were further randomized to receive splints or no splints. Packs were removed at 24 hours postoperatively. Pain was recorded by visual analog scale during the first 24 hours, during pack removal, over the first week, and at the time of splint removal. Pain was significantly higher in the packed group at all points of measurement, and removal of packing proved to be the most painful event during the postoperative period, irrespective of whether splints were present. The authors found a higher rate of complications (including hemorrhage, vestibulitis and septal perforation) in the packed group, though it is not clear if this reached statistical significance. The incidence of intranasal adhesions was similar for the packed and unpacked groups, though the duration of follow-up with regard to this finding is unclear.
Additional series have demonstrated septal surgery without the use of postoperative packing to be safe. Reiter and colleagues retrospectively studied 75 patients who underwent septorhinoplasty with placement of a quilting suture and no packing and identified only two cases of bleeding, both attributed to bleeding from lateral osteotomy sites. More recently, Bajaj and colleagues reported a series of 78 subjects who underwent septoplasty without postoperative packing, with quilting suture used in just over a quarter of cases. They identified a 7.7% rate of postoperative hemorrhage with only half of these patients (3.8%) requiring packing to control bleeding.
Overall, the literature suggests that the use of nasal packing following septoplasty does not provide a clear advantage in improving nasal airway, nor does it appear to prevent postoperative complications. Furthermore, there is a clear increase in postoperative morbidity, specifically pain, with the use of both nasal packing following septoplasty. See Table 1 for a summary.
| Author(s) | n | Procedure | Packing | Outcome |
|---|---|---|---|---|
| Guyuron | 50 | Septorhinoplasty | Packing with polysporin-impregnated gauze vs quilting suture only |
|
| Nunez et al | 59 | Septal surgery | Packing with Vaseline gauze vs quilting suture only |
|
| Von Schoenberg et al | 95 | Routine nasal surgery | Packing with BIPP or Telfa vs no packing |
|
a Indicates no statistical analysis was performed or results did not reach statistical significance.
Efficacy of nasal packing
While the morbidity and risks associated with postoperative nasal packing may be tolerated or minimized, the existence of such complications requires an evaluation of the importance of postseptoplasty nasal packing. In 1989, Guyuron published one of the few studies describing the efficacy of nasal packing in maintaining an adequate postoperative airway. In this study, 50 subjects undergoing septorhinoplasty were randomized to receive packing with polysporin-impregnated gauze or placement of a quilting suture without nasal packing. Twenty-three subjects in the packed group and 22 subjects in the suture group were available for follow-up at up to 16 and 26 months, respectively. Subjective breathing improvement was found to be significantly more prevalent among the packed group. Additionally, a significantly higher percentage of persistent septal deviation was found among the unpacked group.
These findings, however, were called into question by Oneal who noted that subjects’ awareness of packing as a point of study may have introduced bias into the patients’ subjective assessment of breathing improvement. He additionally noted that this finding, and the finding of persistent deviation as more common among the unpacked group, is weakened by the lack of preoperative assessment of degree of septal deviation. It is also important to note that this study was performed in the context of septorhinoplasty, not septoplasty alone.
Subsequent studies have failed to demonstrate a clear advantage to nasal packing while noting an increased morbidity with the use of packing. Nunez and colleagues prospectively studied 59 subjects undergoing septal surgery and randomized them to packing with Vaseline gauze or no packing and placement of a septal quilting suture. Pain was recorded by a visual analog scale on postoperative day one and was found to be significantly higher in the packed group. The authors found no difference in the prevalence of adhesions, crusting/mucosal atrophy or granuloma formation between the two groups during follow-up at 6 weeks. The presence of persistent septal deviation and the extent of airway improvement were not evaluated in this study.
Von Schoenberg and colleagues studied 95 subjects undergoing routine nasal surgery and randomized them to receive packing (either bismuth iodoform paraffin paste (BIPP) or Telfa) or no packing. Subjects undergoing septoplasty were further randomized to receive splints or no splints. Packs were removed at 24 hours postoperatively. Pain was recorded by visual analog scale during the first 24 hours, during pack removal, over the first week, and at the time of splint removal. Pain was significantly higher in the packed group at all points of measurement, and removal of packing proved to be the most painful event during the postoperative period, irrespective of whether splints were present. The authors found a higher rate of complications (including hemorrhage, vestibulitis and septal perforation) in the packed group, though it is not clear if this reached statistical significance. The incidence of intranasal adhesions was similar for the packed and unpacked groups, though the duration of follow-up with regard to this finding is unclear.
Additional series have demonstrated septal surgery without the use of postoperative packing to be safe. Reiter and colleagues retrospectively studied 75 patients who underwent septorhinoplasty with placement of a quilting suture and no packing and identified only two cases of bleeding, both attributed to bleeding from lateral osteotomy sites. More recently, Bajaj and colleagues reported a series of 78 subjects who underwent septoplasty without postoperative packing, with quilting suture used in just over a quarter of cases. They identified a 7.7% rate of postoperative hemorrhage with only half of these patients (3.8%) requiring packing to control bleeding.
Overall, the literature suggests that the use of nasal packing following septoplasty does not provide a clear advantage in improving nasal airway, nor does it appear to prevent postoperative complications. Furthermore, there is a clear increase in postoperative morbidity, specifically pain, with the use of both nasal packing following septoplasty. See Table 1 for a summary.
