The Impact Of Different Nasal Packings On Postoperative Complications Mahmut Deniz M.D, Zafer C ¸ iftc¸i M.D, Aklime Is¸ık M.D, Oral Burak Demirel M.D, Erdo˘gan G¨ultekin M.D PII: DOI: Reference:
S0196-0709(14)00095-7 doi: 10.1016/j.amjoto.2014.04.001 YAJOT 1376
To appear in:
American Journal of Otolaryngology–Head and Neck Medicine and Surgery
Received date: Accepted date:
3 March 2014 22 April 2014
Please cite this article as: Deniz Mahmut, C ¸ ift¸ci Zafer, I¸sık Aklime, Demirel Oral Burak, G¨ ultekin Erdo˘gan, The Impact Of Different Nasal Packings On Postoperative Complications, American Journal of Otolaryngology–Head and Neck Medicine and Surgery (2014), doi: 10.1016/j.amjoto.2014.04.001
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Deniz
1
THE IMPACT OF DIFFERENT NASAL PACKINGS ON POSTOPERATIVE COMPLICATIONS
T
Mahmut Deniz *, Zafer Çiftçi *, Aklime Işık *, Oral Burak Demirel*, Erdoğan Gültekin*
RI P
Institution : * Namık Kemal University Medical Faculty Department of Otorhinolaryngology
MA NU
SC
Mahmut Deniz: Assistant professor, M.D, [email protected] Zafer Çiftçi: Assistant professor, M.D, [email protected] Aklime Işık: Research assistant,M.D, [email protected] Oral Burak Demirel: Research assistant,M.D, [email protected] Erdoğan Gültekin: Associate professor,M.D, [email protected] Each of the authors has contributed to, read and approved this manuscript. None of the authors has any conflict of interest, financial or otherwise. This manuscript is original and it, or any part of it, has not been previously published; nor is under consideration for publication elsewhere.
AC
Abstract
CE
PT
ED
Address for correspondence : Assist. Prof. Mahmut Deniz,M.D Namık Kemal University Medical Faculty Department of Otorhinolaryngology Tekirdağ/TURKEY E mail : [email protected] Telephone number : 0090 282 250 51 88
Objective: The objective of this study was to find out if there is any association between the use of nasal packings and nasal synechia formation, septal perforation, postoperative infection and epistaxis in patients who underwent septoplasty and concha reduction operations.
Methods: This retrospective study was conducted at a tertiary referral center. 130 patients were randomly selected among patients who underwent endonasal surgery in Namık Kemal University Hospital between January 1st 2012 and August 1 st 2013. Retrospective analysis of these patients’ files, including operative reports and follow up
Deniz
ACCEPTED MANUSCRIPT
2
notes, was done. The postoperative findings of patients who had septal splints and
T
merocel nasal packings were compared and analyzed for statistical significance.
RI P
Results: The results of the study showed a statistically significant difference in the frequency of synechia formation between two groups (p0.05).
Conclusion: Our findings suggest that intranasal splints are superior to merocel nasal packings in terms of preventing nasal synechia formation. Insertion of a septal splint
ED
after nasal surgery should be preferred to avoid this complication. On the other hand,
PT
other factors should be sought in the etiology of postoperative infection, septal
CE
perforation, and epistaxis.
AC
Key words: septoplasty, synechia, intranasal splint, perforation, infection, epistaxis
INTRODUCTION Septoplasty and reduction of the inferior turbinates are the most commonly used surgical interventions to enhance nasal airway compromised secondary to septal deviations or spurs and turbinate hypertrophy. Following these operations nasal packing materials are used in an attempt to prevent synechia and haematoma formation, support septal flap apposition and reduce the dead space between the subperichondrial flaps(1,2). However, various complications, such as nasal synechia formation, septal
Deniz
ACCEPTED MANUSCRIPT
3
perforation, postoperative infection and epistaxis were reported associated with the use of nasal packings (3,4).
T
Nasal splints and merocel nasal packings are used following endonasal surgical
RI P
interventions. The literature review showed that use of nasal splints is favoured by some authors (5,6) whereas use of merocel nasal packing is advocated by others (7,8). It was
SC
even suggested by some authors that use of any nasal packing material was associated
suturing techniques (9,10,11,12).
MA NU
with the above mentioned complications and they should be replaced by trans-septal
The main objective of our study was to find out if there is any association between the use of nasal packings and nasal synechia formation, septal perforation, postoperative infection and epistaxis. This topic is quite interesting for otolaryngologists because
ED
septoplasty and concha reduction are day in day out procedures in ENT surgery. A
PT
careful reflection of the use of well known medical products is just as important as the investigation of new material. For this purpose, we retrospectively investigated the
CE
complication rates associated with the use of septal splints and merocel nasal packings
AC
in our patients and discussed our findings under the scope of literature.
MATERIALS AND METHODS This investigation was done with the permission of Namık Kemal University Ethics committee. Following endonasal surgery, septal splints or merocel nasal packings are routinely used in our department. 130 patients, randomly selected among patients who underwent septoplasty and inferior turbinate reduction with radiofrequency in Namık Kemal University Hospital between January 1st 2012 and August 1st 2013, were enrolled in this study. Operative reports and follow up notes of patients were inspected and the association between the use of different nasal packings and frequencies of nasal
ACCEPTED MANUSCRIPT
Deniz
4
synechia formation, septal perforation, postoperative infection and epistaxis were investigated. According to operative reports and follow up notes all operations were
T
performed by the same surgeon, with a classical killian incision for septoplasty and
RI P
radiofrequency for concha reduction. Bilateral anterior merocel nasal packs were removed on the second day after the surgery and nasal splints were removed on the
SC
seventh day. All patients who had surgery used antibiotics (sulbactam-ampicilin), 750 mg PO BID for 7 days and nasal shower with 0.9% saline solution for 3 weeks. The
MA NU
patients were evaluated on a weekly basis following removal of the packings. All patients were examined, crusts were removed and retained secretions were aspirated in the first, second and fourth postoperative weeks. A last control was performed at the end of second month. In every control visit, the patients were examined with 0 (zero)
ED
degree rod telescope in our clinic and follow up notes were recorded.
PT
The statistical analysis of data was performed by SPSS for Windows, version 13 (SPSS Inc., Chicago, IL, USA), computer software. While comparing the groups
CE
Kruskal Wallis test (KW), for comparing the double groups Mann–Whitney-U test
AC
(MWU) and for comparing the qualitative data Chi square tests (x2) were used. Results are assessed at the level where p < 0.05. RESULTS
The review of patient files showed that of 130 patients, 61 were female and 69 were male. The number of patients who received septal splint was found to be 59 (%45.38). The number of patients who received merocel nasal packing was found to be 71 (%54.61). The mean ages for septal splint group and merocel packing group were 36.61±11.2, and 37.1±10.3, respectively, ranging from 18 to 61. The two groups were similar in demographic parameters.
ACCEPTED MANUSCRIPT
Deniz
5
Postoperative nasal synechia was found to occur in 14 of 71 patients (%19.71) in merocel packing group, whereas no synechia was found in patients in intranasal splint
T
group (%0) (Figure 1). This difference was found to be statistically significant with a p
20% 18% 16% 14% 12% 10%
MA NU
SC
synechia
RI P
value of 0.05).
Deniz
ACCEPTED MANUSCRIPT
7
Postoperative infection (periorbital cellulites and rhinosinusitis) was found to be seen in 2 of 59(%3.38) patients in splint group and in 3 of 71 (%4.22) of patients in merocel
RI P
groups in terms of frequency of infection (p=0.874) (p>0.05).
T
group (Figure 3). No statistically significant difference was observed between the
SC
4.50% 4.00%
3.00%
3.38%
2.50%
4.22%
2.00%
MA NU
3.50%
2.81%
Splint group merocel group
1.69%
1.50%
0.50% 0.00%
PT
infection
ED
1.00%
epistaxis
CE
Figure 3: Postoperative infection and epistaxis frequencies in both groups Epistaxis after removal of nasal packings in postoperative period (4 weeks) were
AC
found to be seen in 1 of 59 (%1.69) patients in septal splint group and 2 of 71 (%2.81) patients in merocel packing group (Figure 3). Among the groups, no significant statistical difference in terms of postoperative epistaxis frequencies was observed (p=0.549) (p>0.05). The result of our study showed that the intranasal splint presented higher efficacy on prevention of post-surgical synechias than merocel nasal packing because none of the patients who were treated with intranasal splint showed post-surgical synechia (P0.05).
ACCEPTED MANUSCRIPT
Deniz
8
DISCUSSION Following endonasal surgery various nasal packing materials are used to control
T
bleeding, prevent hematoma formation and support septal flap apposition (3). Despite
RI P
their advantages, nasal packings have certain drawbacks including obligatory mouth breathing, headache, dysphagia, risk of aspiration, airway obstruction, eustachian tube
SC
blockage, a considerable degree of pain during pack removal and foreign body reaction. In addition, complications including infection, synechia, septal perforation and epistaxis
MA NU
following removal of packs were also reported (9,13). Merocel packings and intranasal splints are the most commonly used materials following endonasal surgeries and literature review revealed that there are several studies favoring or disfavoring use of these packing materials.
ED
Merocel packing was reported to have a high effectiveness in controlling epistaxis
PT
originating from especially the anterior region of the nose (7, 8). Despite this, Garth et al. proposed that Merocel packing had a tendency to adhere to the mucosa and caused
CE
more bleeding and discomfort during removal (13). In a previous study by Acioglu et
AC
al., merocel nasal packing was found to have the highest rate of pain and bleeding following removal (14). It was also shown that this type of nasal packing could cause significant mucosal injury and ciliary dysfunction (15). A higher rate of complications (including hemorrhage, vestibulitis and septal perforation) were found in the packed group in a study by Schoenberg et al. who also reported that the removal of packing proved to be most painful event in the postoperative period (16). Use of intranasal splints has been increasing in the last years due to their ability to keep the operated septum in its position, preventing the occurrence of epistaxis and nasal synechia (4). Asaka et al. proposed that nasal splinting could be an alternative to nasal gauze packing. They also reported that nasal splinting was easy to use and not
Deniz
ACCEPTED MANUSCRIPT
9
time consuming, but trans-septal suturing was found to be technically difficult and time consuming (17). Yong et al. stated that the mucosal status was better on the splint side
T
than the control side. They also concluded that insertion of a silastic septal splint after
RI P
septal surgery should be accepted as a routine procedure (18). On the other hand, some studies demonstrated that paired silicon splints may not prevent adhesions and can add
SC
to postoperative discomfort (19). An increase in morbidity has also been observed associated to the procedure such as anxiety of splint removal, pain, discomfort and some
MA NU
cases involving the toxic shock syndrome (20,21).
In the literature, as an alternative application to nasal packing, different forms of haemostatic suturing techniques of the nasal septum have been described (9,10,11,12). These studies concluded that although these techniques increase the mean duration of
ED
the surgical procedure, they are efficient in preventing synechia formation. However, in
PT
terms of infection, haematoma and perforation no differences were found between use of these techniques and nasal packings. There is yet no consensus in the literature about
CE
which technique or material should be used.
AC
In our study, the incidence of epistaxis in the merocel group, although statistically insignificant, was higher than the splint group (p>0.05). This finding was in consistent with the previously reported studies (7,8,13). The rates of infection and septal perforation were also found to be higher in the merocel group in our study but statistically insignificant (p>0.05). We assume that in larger series, these differences may gain statistical significance. Further studies should be performed to find out methods to decrease the incidence of infection on both the splints and merocel packings. However, our results showed that there is a statistically significant difference between the two groups in terms of synechia formation. In the merocel group, almost 1 in 5 patients was found to develop synechia whereas no patient in the splint group presented
ACCEPTED MANUSCRIPT
Deniz
10
with synechia at the end of the follow up period. This result was found to be consistent with the literature (13,16). Despite the ongoing debate, the results of our study proved
T
strong evidence that use of silicone nasal splint was superior to merocel packing in
RI P
preventtion of synechia formation (p
S0196-0709(14)00095-7 doi: 10.1016/j.amjoto.2014.04.001 YAJOT 1376
To appear in:
American Journal of Otolaryngology–Head and Neck Medicine and Surgery
Received date: Accepted date:
3 March 2014 22 April 2014
Please cite this article as: Deniz Mahmut, C ¸ ift¸ci Zafer, I¸sık Aklime, Demirel Oral Burak, G¨ ultekin Erdo˘gan, The Impact Of Different Nasal Packings On Postoperative Complications, American Journal of Otolaryngology–Head and Neck Medicine and Surgery (2014), doi: 10.1016/j.amjoto.2014.04.001
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Deniz
1
THE IMPACT OF DIFFERENT NASAL PACKINGS ON POSTOPERATIVE COMPLICATIONS
T
Mahmut Deniz *, Zafer Çiftçi *, Aklime Işık *, Oral Burak Demirel*, Erdoğan Gültekin*
RI P
Institution : * Namık Kemal University Medical Faculty Department of Otorhinolaryngology
MA NU
SC
Mahmut Deniz: Assistant professor, M.D, [email protected] Zafer Çiftçi: Assistant professor, M.D, [email protected] Aklime Işık: Research assistant,M.D, [email protected] Oral Burak Demirel: Research assistant,M.D, [email protected] Erdoğan Gültekin: Associate professor,M.D, [email protected] Each of the authors has contributed to, read and approved this manuscript. None of the authors has any conflict of interest, financial or otherwise. This manuscript is original and it, or any part of it, has not been previously published; nor is under consideration for publication elsewhere.
AC
Abstract
CE
PT
ED
Address for correspondence : Assist. Prof. Mahmut Deniz,M.D Namık Kemal University Medical Faculty Department of Otorhinolaryngology Tekirdağ/TURKEY E mail : [email protected] Telephone number : 0090 282 250 51 88
Objective: The objective of this study was to find out if there is any association between the use of nasal packings and nasal synechia formation, septal perforation, postoperative infection and epistaxis in patients who underwent septoplasty and concha reduction operations.
Methods: This retrospective study was conducted at a tertiary referral center. 130 patients were randomly selected among patients who underwent endonasal surgery in Namık Kemal University Hospital between January 1st 2012 and August 1 st 2013. Retrospective analysis of these patients’ files, including operative reports and follow up
Deniz
ACCEPTED MANUSCRIPT
2
notes, was done. The postoperative findings of patients who had septal splints and
T
merocel nasal packings were compared and analyzed for statistical significance.
RI P
Results: The results of the study showed a statistically significant difference in the frequency of synechia formation between two groups (p0.05).
Conclusion: Our findings suggest that intranasal splints are superior to merocel nasal packings in terms of preventing nasal synechia formation. Insertion of a septal splint
ED
after nasal surgery should be preferred to avoid this complication. On the other hand,
PT
other factors should be sought in the etiology of postoperative infection, septal
CE
perforation, and epistaxis.
AC
Key words: septoplasty, synechia, intranasal splint, perforation, infection, epistaxis
INTRODUCTION Septoplasty and reduction of the inferior turbinates are the most commonly used surgical interventions to enhance nasal airway compromised secondary to septal deviations or spurs and turbinate hypertrophy. Following these operations nasal packing materials are used in an attempt to prevent synechia and haematoma formation, support septal flap apposition and reduce the dead space between the subperichondrial flaps(1,2). However, various complications, such as nasal synechia formation, septal
Deniz
ACCEPTED MANUSCRIPT
3
perforation, postoperative infection and epistaxis were reported associated with the use of nasal packings (3,4).
T
Nasal splints and merocel nasal packings are used following endonasal surgical
RI P
interventions. The literature review showed that use of nasal splints is favoured by some authors (5,6) whereas use of merocel nasal packing is advocated by others (7,8). It was
SC
even suggested by some authors that use of any nasal packing material was associated
suturing techniques (9,10,11,12).
MA NU
with the above mentioned complications and they should be replaced by trans-septal
The main objective of our study was to find out if there is any association between the use of nasal packings and nasal synechia formation, septal perforation, postoperative infection and epistaxis. This topic is quite interesting for otolaryngologists because
ED
septoplasty and concha reduction are day in day out procedures in ENT surgery. A
PT
careful reflection of the use of well known medical products is just as important as the investigation of new material. For this purpose, we retrospectively investigated the
CE
complication rates associated with the use of septal splints and merocel nasal packings
AC
in our patients and discussed our findings under the scope of literature.
MATERIALS AND METHODS This investigation was done with the permission of Namık Kemal University Ethics committee. Following endonasal surgery, septal splints or merocel nasal packings are routinely used in our department. 130 patients, randomly selected among patients who underwent septoplasty and inferior turbinate reduction with radiofrequency in Namık Kemal University Hospital between January 1st 2012 and August 1st 2013, were enrolled in this study. Operative reports and follow up notes of patients were inspected and the association between the use of different nasal packings and frequencies of nasal
ACCEPTED MANUSCRIPT
Deniz
4
synechia formation, septal perforation, postoperative infection and epistaxis were investigated. According to operative reports and follow up notes all operations were
T
performed by the same surgeon, with a classical killian incision for septoplasty and
RI P
radiofrequency for concha reduction. Bilateral anterior merocel nasal packs were removed on the second day after the surgery and nasal splints were removed on the
SC
seventh day. All patients who had surgery used antibiotics (sulbactam-ampicilin), 750 mg PO BID for 7 days and nasal shower with 0.9% saline solution for 3 weeks. The
MA NU
patients were evaluated on a weekly basis following removal of the packings. All patients were examined, crusts were removed and retained secretions were aspirated in the first, second and fourth postoperative weeks. A last control was performed at the end of second month. In every control visit, the patients were examined with 0 (zero)
ED
degree rod telescope in our clinic and follow up notes were recorded.
PT
The statistical analysis of data was performed by SPSS for Windows, version 13 (SPSS Inc., Chicago, IL, USA), computer software. While comparing the groups
CE
Kruskal Wallis test (KW), for comparing the double groups Mann–Whitney-U test
AC
(MWU) and for comparing the qualitative data Chi square tests (x2) were used. Results are assessed at the level where p < 0.05. RESULTS
The review of patient files showed that of 130 patients, 61 were female and 69 were male. The number of patients who received septal splint was found to be 59 (%45.38). The number of patients who received merocel nasal packing was found to be 71 (%54.61). The mean ages for septal splint group and merocel packing group were 36.61±11.2, and 37.1±10.3, respectively, ranging from 18 to 61. The two groups were similar in demographic parameters.
ACCEPTED MANUSCRIPT
Deniz
5
Postoperative nasal synechia was found to occur in 14 of 71 patients (%19.71) in merocel packing group, whereas no synechia was found in patients in intranasal splint
T
group (%0) (Figure 1). This difference was found to be statistically significant with a p
20% 18% 16% 14% 12% 10%
MA NU
SC
synechia
RI P
value of 0.05).
Deniz
ACCEPTED MANUSCRIPT
7
Postoperative infection (periorbital cellulites and rhinosinusitis) was found to be seen in 2 of 59(%3.38) patients in splint group and in 3 of 71 (%4.22) of patients in merocel
RI P
groups in terms of frequency of infection (p=0.874) (p>0.05).
T
group (Figure 3). No statistically significant difference was observed between the
SC
4.50% 4.00%
3.00%
3.38%
2.50%
4.22%
2.00%
MA NU
3.50%
2.81%
Splint group merocel group
1.69%
1.50%
0.50% 0.00%
PT
infection
ED
1.00%
epistaxis
CE
Figure 3: Postoperative infection and epistaxis frequencies in both groups Epistaxis after removal of nasal packings in postoperative period (4 weeks) were
AC
found to be seen in 1 of 59 (%1.69) patients in septal splint group and 2 of 71 (%2.81) patients in merocel packing group (Figure 3). Among the groups, no significant statistical difference in terms of postoperative epistaxis frequencies was observed (p=0.549) (p>0.05). The result of our study showed that the intranasal splint presented higher efficacy on prevention of post-surgical synechias than merocel nasal packing because none of the patients who were treated with intranasal splint showed post-surgical synechia (P0.05).
ACCEPTED MANUSCRIPT
Deniz
8
DISCUSSION Following endonasal surgery various nasal packing materials are used to control
T
bleeding, prevent hematoma formation and support septal flap apposition (3). Despite
RI P
their advantages, nasal packings have certain drawbacks including obligatory mouth breathing, headache, dysphagia, risk of aspiration, airway obstruction, eustachian tube
SC
blockage, a considerable degree of pain during pack removal and foreign body reaction. In addition, complications including infection, synechia, septal perforation and epistaxis
MA NU
following removal of packs were also reported (9,13). Merocel packings and intranasal splints are the most commonly used materials following endonasal surgeries and literature review revealed that there are several studies favoring or disfavoring use of these packing materials.
ED
Merocel packing was reported to have a high effectiveness in controlling epistaxis
PT
originating from especially the anterior region of the nose (7, 8). Despite this, Garth et al. proposed that Merocel packing had a tendency to adhere to the mucosa and caused
CE
more bleeding and discomfort during removal (13). In a previous study by Acioglu et
AC
al., merocel nasal packing was found to have the highest rate of pain and bleeding following removal (14). It was also shown that this type of nasal packing could cause significant mucosal injury and ciliary dysfunction (15). A higher rate of complications (including hemorrhage, vestibulitis and septal perforation) were found in the packed group in a study by Schoenberg et al. who also reported that the removal of packing proved to be most painful event in the postoperative period (16). Use of intranasal splints has been increasing in the last years due to their ability to keep the operated septum in its position, preventing the occurrence of epistaxis and nasal synechia (4). Asaka et al. proposed that nasal splinting could be an alternative to nasal gauze packing. They also reported that nasal splinting was easy to use and not
Deniz
ACCEPTED MANUSCRIPT
9
time consuming, but trans-septal suturing was found to be technically difficult and time consuming (17). Yong et al. stated that the mucosal status was better on the splint side
T
than the control side. They also concluded that insertion of a silastic septal splint after
RI P
septal surgery should be accepted as a routine procedure (18). On the other hand, some studies demonstrated that paired silicon splints may not prevent adhesions and can add
SC
to postoperative discomfort (19). An increase in morbidity has also been observed associated to the procedure such as anxiety of splint removal, pain, discomfort and some
MA NU
cases involving the toxic shock syndrome (20,21).
In the literature, as an alternative application to nasal packing, different forms of haemostatic suturing techniques of the nasal septum have been described (9,10,11,12). These studies concluded that although these techniques increase the mean duration of
ED
the surgical procedure, they are efficient in preventing synechia formation. However, in
PT
terms of infection, haematoma and perforation no differences were found between use of these techniques and nasal packings. There is yet no consensus in the literature about
CE
which technique or material should be used.
AC
In our study, the incidence of epistaxis in the merocel group, although statistically insignificant, was higher than the splint group (p>0.05). This finding was in consistent with the previously reported studies (7,8,13). The rates of infection and septal perforation were also found to be higher in the merocel group in our study but statistically insignificant (p>0.05). We assume that in larger series, these differences may gain statistical significance. Further studies should be performed to find out methods to decrease the incidence of infection on both the splints and merocel packings. However, our results showed that there is a statistically significant difference between the two groups in terms of synechia formation. In the merocel group, almost 1 in 5 patients was found to develop synechia whereas no patient in the splint group presented
ACCEPTED MANUSCRIPT
Deniz
10
with synechia at the end of the follow up period. This result was found to be consistent with the literature (13,16). Despite the ongoing debate, the results of our study proved
T
strong evidence that use of silicone nasal splint was superior to merocel packing in
RI P
preventtion of synechia formation (p
