Nasal septal packing: which one?

Eur Arch Otorhinolaryngol (2012) 269:1777–1781 DOI 10.1007/s00405-011-1842-1 RHINOLOGY Nasal septal packing: which one? Engin Acıoğlu • Deniz Tuna Edizer • Özgür Yiğit • Fırat Onur • Zeynep Alkan Received: 5 July 2011 / Accepted: 9 November 2011 / Published online: 9 December 2011 Ó Springer-Verlag 2011 Abstract The aim of this study was to investigate the effects of four different types of nasal packs on pain, nasal fullness and postoperative bleeding following septoplasty. Prospective randomised double blind study was conducted. The study group included 119 patients who underwent endonasal septoplasty under general anaesthesia. Four types of nasal packing materials were utilized: (1) Merocel standard 8-cm nasal dressing without airway, (2) Doyle Combo splint (DCS), (3) Merocel in a glove finger and (4) Vaseline gauze. All packs were removed at the 48th hour (±3 h) after the surgery. Three different variables were investigated following the surgical procedure: (1) pain, (2) nasal fullness and (3) bleeding after removal of the nasal packing material. DCS produced the greatest pain at the first and sixth postoperative hours. At the first postoperative day, the greatest pain score was reported for Merocel in the glove finger and the least for Merocel. The pain scores during the removal of the nasal packings were highest for Merocel and lowest for Merocel in the glove finger. DCS had the lowest nasal fullness score. Bleeding ratio was highest for Merocel, followed by Vaseline gauze, DCS and Merocel in the glove finger. Many different commercially available packing materials are presently used, each with inherent advantages and disadvantages. We evaluated the pain, nasal fullness and bleeding potential of four nasal packing materials and determined that Merocel had the highest pain potential during removal and the highest rate of bleeding following removal. E. Acıoğlu (&)
D. T. Edizer
Ö. Yiğit
F. Onur
Z. Alkan Department of Otorhinolaryngology, İstanbul Training and Research Hospital, Örnek mah. Libadiye Cad. Tahralı sitesi, B1 blok kat:6 d:27 Ataşehir, Istanbul, Turkey e-mail: drengin@hotmail.com Keywords Nasal packing
Merocel
Septoplasty
Nasal pain Introduction Nasal packs are widely used in the practice of otorhinolaryngology, especially following nasal surgery and epistaxis. In addition to preventing nasal bleeding after nasal surgery, these packs have the potential to support the septal mucoperichondrial flaps and to minimize the risk of formation of septal hematomas and adhesions [1]. A number of different nasal packing materials are available for these purposes. 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. Ideally, nasal packs should be easy to insert and remove, with minimal discomfort, and they should also effectively prevent postoperative bleeding [2, 3]. Removal of the nasal packs is considered by patients to be one of the most stressful and painful parts of these types of surgery [2]. The pain perceived during removal of the nasal pack has been previously investigated and some authors advocate not using any nasal packing following septoplasty because of this pain [4]. Apart from the patient discomfort, nasal packing also necessitates a hospital stay and administration of antibiotics, and it interferes with nasal physiology [5]. A nasal pack may result in significant mucosal injury and loss of ciliary function [6]. Use of nasal packs carries the risk of pain but also imparts an uncomfortable sense of nasal fullness as nasal secretions accumulate. In this study, we investigated the effects of four different types of nasal packs with respect to pain, nasal fullness and postoperative bleeding following septoplasty. 123 1778 Materials and methods The study group included 119 patients (82 males, 37 females) who underwent endonasal septoplasty under general anaesthesia. Patients were recruited between the years 2009 and 2010. Nasal packing was performed for all of the participants. Four types of nasal packing materials were utilized: (1) a Merocel standard 8-cm nasal dressing without airway (Medtronic Xomed Inc., FL, USA); (2) a Doyle Combo splint (Boston medical products, MA, USA); (3) a Merocel standard 8-cm nasal dressing in a glove finger; and (4) Vaseline gauze to form four patient treatments, A, B, C and D, respectively. Merocel is composed of expandable hydroxylated polyvinyl acetate. The DCS is composed of a nasal airway splint on the septal side with expandable sponge on the lateral side. The patients were randomly assigned, in a 1:1 ratio using a computer-generated list of random numbers, to one of the treatment groups with the different types of nasal packing materials. The same nasal packing materials were used for both sides of the nose for each particular patient. All packs were removed on the 48th hour (±3 h) after the surgery. Exclusion criteria were a history of nasal surgery, allergy, bleeding disorders and any chronic co-morbidity. All patients received the same medications in the form of a prophylactic oral antibiotic (amoxicillin and clavulanic acid, 1,000 mg twice daily) and analgesic (flurbiprofen, 100 mg twice daily). The study was approved by the local ethics committee. Three different variables were investigated following the surgical procedure: (1) pain; (2) nasal fullness; and (3) bleeding after removal of the nasal packing material. The pain intensity and nasal fullness were graded by the patients according to the visual analogue scale (VAS), a 10-cm scale where 0 indicates no pain or fullness and 10 indicates the most severe pain and fullness. The pain scores were recorded at 1, 6 and 24 h postoperatively and during nasal pack removal at 48 h postoperatively. The nasal fullness scores were recorded at 1, 6 and 24 h postoperatively and just before the removal of the nasal packs. Reactionary bleeding was also recorded after nasal pack removal according to the following scale: 0 = no bleeding; 1 = blood seeping from the nose; and 2 = continuous bleeding from the nose. Neither local nor systemic medications were used before the removal of the nasal packings. The patients were asked to mark the visual analogue scales simultaneously at the appropriate times while supervised by the physician. One week after removal of the nasal packing, during routine postoperative care, all patients were asked to classify their nasal packing material as comfortable, moderate and uncomfortable. The surgical procedures were performed by two of the authors, while the removal of the packs and data collection 123 Eur Arch Otorhinolaryngol (2012) 269:1777–1781 was carried out by another author. Analyses were performed by another author who was blinded to the patients and interventions. The VAS scores for pain and nasal fullness were compared both between and within the groups. Statistical analyses Statistical analyses were performed using SPSS for Windows (version 16.0; SPSS Inc., Chicago, IL, USA). Categorical variables were analyzed by a Chi-square test. Differences between the groups were analysed by One-way ANOVA with a post hoc Bonferroni correction test, whereas the difference within the groups was analysed by a general linear model and repeated measures of ANOVA, with a post hoc Bonferroni correction test. A p value\0.05 was considered statistically significant. Results Group A (Merocel) consisted of 30 patients, Group B (DCS) 30 patients, Group C (Merocel in the glove finger) 30 patients, and group D (Vaseline gauze) 29 patients. One patient from group D was excluded due to packing removal outside of our clinic. The mean age of the patients was 31.29 ± 11.0 (range 17–62 years). No nasal packs were dislodged unintentionally or removed earlier than the estimated time (48 h following surgery). Repacking was not required and septal hematomas were not seen in any of the patients. No patient was lost during the course of pain and/or nasal fullness chart filling. No significant bleeding was encountered at the time of pack removal. All of the participants successfully completed the survey. No statistically significant difference was found between the groups in terms of age, gender and weight (p = 0.927, p = 0.154, p = 0.358, respectively). No postoperative infections and/or any other complications were seen. The mean pain scores of the four nasal packing materials are given in Fig. 1. The DCS produced the greatest pain at the first and sixth postoperative hours compared to others, but these differences showed no statistical significance (p [ 0.05). At the first postoperative day, the greatest pain score was reported for Merocel in the glove finger and the least for Merocel; the difference between these reached statistical significance (p = 0.019). The difference between the pain scores for the other nasal packing materials did not show statistical significance at the first postoperative day. The pain scores reported by the patients during removal of the nasal packings were highest for Merocel and lowest for Merocel in the glove finger. DCS, Merocel in the glove finger, and Vaseline gauze all showed statistically lower VAS scores than Merocel during Eur Arch Otorhinolaryngol (2012) 269:1777–1781 1779 Table 1 Comparison of pain scores at different postoperative hours among groups Time Merocel DCS Merocel in glove finger Vaseline Mean difference (time a - b) a b 1st hour 6th hour 1.150 24th hour 1.637* 1st hour 1st hour 1st hour Sig.p 0.082 0.036 48th hour 6th hour -0.733 0.883 1.000 1.000 24th hour 1.683 0.107 48th hour 1.867* 0.032 6th hour 0.360 1.000 24th hour -0.480 1.000 48th hour 0.937 0.443 6th hour 1.497 0.059 24th hour 1.652* 0.011 48th hour 1.879* 0.019 Bold values are statistically significant * p: Bonferroni correction Fig. 1 The mean pain scores for four nasal packing materials removal of the nasal packing. (p = 0.033, p = 0.003, p = 0.014, respectively). The difference between the pain scores of other nasal packing materials did not show statistical significance at the removal of the nasal packing. Comparison of the pain scores for the nasal packing materials at each chart filling time (1st, 6th, 24th and 48th hours postoperatively) is given in Table 1. Pain scores reported by patients with Merocel in the glove finger were not significantly different among chart filling times (p [ 0.05). Merocel alone produced the greatest pain during removal, which was statistically similar with the postoperative first hour scores. This pain was significantly higher than that experienced at the sixth hour and the first day, with p values of 0.012 and 0.000, respectively. The pain scores of the DCS and Vaseline gauze were highest at the first postoperative hour followed by the sixth hour, first day and during removal. The difference in pain scores between the first postoperative hour and during withdrawal reached statistical significance for both DCS and Vaseline gauze. (p = 0.032 and p = 0.019, respectively). The mean nasal fullness scores of the four nasal packing materials are shown in Fig. 2. Nasal fullness scores reported by the patients were not significantly different at the first postoperative hour (p [ 0.05). At the sixth hour and first day postoperatively reported nasal fullness was greatest for Merocel in the glove finger, followed by Merocel, Vaseline gauze and DCS. The difference in nasal fullness scores between Merocel in the glove finger and DCS reached statistical significance at the sixth hour and first day postoperatively, with p values of 0.017 and 0.000, respectively. Nasal fullness scores for DCS also reached Fig. 2 The mean nasal fullness scores for four nasal packing materials significantly lower levels than Merocel and non-significantly lower levels than Vaseline gauze at the first day, postoperatively. (p = 0.034 and p = 0.076, respectively). Nasal fullness scores recorded just before withdrawal of the nasal packings were not significantly different for any packings (p [ 0.05). Bleeding at the time of pack removal (48 h postoperatively) did not necessitate any further treatment other than conservational measures, such as application of a decongestant containing cottonoids. Continuous bleeding was 123 1780 Fig. 3 The classification of nasal packing materials by the patients at a first week control experiment encountered only in one patient (in the Merocel group) but this ceased within 30 min. The bleeding ratio was highest for Merocel (10/30), followed by Vaseline gauze (5/29), DCS (3/30) and Merocel in the glove finger (1/30). Post removal bleeding ratio for Merocel was significantly higher than that for DCS or Merocel in the glove finger (p = 0.028 and p = 0.003), and was non-significantly higher than for Vaseline gauze (p = 0.156). Following routine postoperative control in the first postoperative week, all patients also classified the nasal packing materials used as shown in Fig. 3. Although Vaseline gauze seemed to be more comfortable, the Merocel in the glove finger in general was more advantageous. Discussion Nasal surgery, especially septoplasty, is one of the most common surgical interventions in the practice of otorhinolaryngology. Nasal packs are used for these interventions not only to reduce bleeding but also to prevent complications such as septal hematoma [1, 7]. Many types of nasal packs are commercially available. The advantages and disadvantages of the nasal packs vary depending on the type. One of the major concerns of patients is the pain associated with packing material, especially during its removal [8]. Nasal fullness is another discomfort caused by the nasal packs. Accumulation of nasal secretions further contributes to the symptom of nasal fullness. The nasal packing materials should ideally induce hemostasis, produce no discomfort while in the nasal cavity and permit removal with minimal pain. They should also not produce tissue damage or be dislodged. The measurement of pain presents some problems, but visual analogue scales can be used to quantify pain with high sensitivity and reproducibility [3]. Simplicity and accuracy lead to the common utilization of the VAS scores [3, 9]. 123 Eur Arch Otorhinolaryngol (2012) 269:1777–1781 To avoid bleeding and complications, more comfortable nasal packing materials are being developed. On the other hand, some authors do not advocate the use of nasal packing materials following nasal surgeries [4]. In addition, in some studies comparing nasal packing with no packing, higher pain scores and higher rate of complications were reported in the nasal packing group [1, 10, 11]. Merocel is one of the most common packing materials used after septoplasty. It has been widely studied and compared with other packing materials and almost all investigations point to the fact that Merocel has a tendency to adhere to mucosa. Most importantly, Merocel causes more bleeding and discomfort during removal [2, 3, 12, 13]. In our study, Merocel caused the highest pain scores during removal, whereas Merocel in the glove finger caused the least pain on removal, with the difference between these two treatments reaching statistical significance (p = 0.03). Merocel also caused more bleeding than the other packings tested, with one bleed classified as continuous. These findings support the fact that use of Merocel, due to its potential to adhere mucosal surfaces, leads to pain and bleeding during its removal. The DCS, which consists of a nasal splint at the septal side and an inflatable part on the turbinate side, caused less pain during removal compared to Merocel alone. From this point of view, we might speculate that septal adhesion by Merocel is the major reason for the pain and bleeding during its removal. However, since the difference between the pain scores for Merocel and DCS was not statistically significant (p [ 0.05), it is premature to draw this conclusion. Merocel in the glove finger had the least bleeding ratio following removal (1 of 30 patients), despite the fact that it had caused significantly more pain than the Merocel alone at the first postoperative day (p = 0.019). On the other hand, the pain scores were significantly lower for removal of the Merocel in the glove finger than for Merocel alone (p = 0.03). However, the use of Merocel in the glove finger has an important disadvantage: it has the potential to dislodge unintentionally, especially during sneezing, although we did not encounter any such case in the present study. If we examine the changes in pain scores for each individual packing material, all but Merocel showed the lowest pain scores during removal. Merocel, on the other hand, was reported to be most painful during its removal at the second postoperative day. The differences between the pain scores of the first day and the removal, and the sixth hour and the removal were statistically significant (p = 0.000 and p = 0.012, respectively). Interestingly, the pain scores for removal of the packing materials other than Merocel were lower than the scores recorded for the first hour, the sixth hour and first day postoperatively. These findings point to the pain potential of Merocel during its removal. Eur Arch Otorhinolaryngol (2012) 269:1777–1781 The discomfort associated with nasal fullness was highest for Merocel in the glove finger at the sixth hour and first day postoperatively. At the second postoperative day, just before removal of the packings, the nasal fullness scores of the packing materials were not significantly different from each other, a finding that leads us to consider that regardless of the type of the packing material, patients complain of an approximately equal degree of discomfort due to sensation of nasal fullness after the first postoperative day. The lower pain scores associated with Vaseline gauze compared to Merocel is an interesting finding, since the use of Vaseline gauzes has largely been abandoned due to its reputation to cause pain and discomfort, especially during removal. The pain reported during removal of Merocel was significantly higher than that reported for Vaseline gauze (p = 0.014). The most conspicuous problem with the use of Vaseline gauze was that the removal is rather more time consuming and stressful for the patients. The ease of removal of the Vaseline gauze seems inferior to that of the other packings. Postoperative pain is considered to be the most common morbidity associated with packings used in septoplasty. Postoperative infections and worsening of breathing disorders during sleep are among other morbidities [1, 14]. Many attempts have been made to minimize the morbidity of packing materials, such as shortening the duration of packing and developing new packing materials [15]. In the present survey, we did not encounter any postoperative infections or any other complication associated with the packings. Although the necessity for the use of nasal packings following nasal surgeries is still a matter of debate, many surgeons prefer to use packings. Many different commercially available packing materials are being used and each has inherent advantages and disadvantages. 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