Nasal splinting using silicone plates without gauze packing following septoplasty combined with inferior turbinate surgery

Factors influencing residual plus moist HS-W calcium alginate packing material after endoscopic sinus surgery

OBJECTIVE

This study aims to evaluate the presence of residual Plus Moist HS-W (PM), a novel calcium alginate packing material, during the initial postoperative visit following endoscopic sinus surgery. The research aims to identify factors that influence the quantity of remaining PM.

METHODS

A retrospective review of medical records was conducted for patients who underwent middle meatus packing with PM.

RESULTS

A total of fifty-two patients (representing 92 sides of paranasal sinuses) were included in the analysis. The remaining PM was classified as follows: absent (0) in 41 out of 92 cases, minimal (1) in 22 out of 92 cases, moderate (2) in 15 out of 92 cases, and substantial (3) in 14 out of 92 cases. Notably, all three patients who underwent Draf III surgery exhibited a significant amount of PM during their initial visit, with two patients classified as grade 2 and one patient as grade 3. Other factors investigated were found to be unrelated to the persistence of PM. Removal of all PM was achieved effortlessly using suction under flexible endoscopy.

CONCLUSION

This study highlights the efficacy of PM in post-endoscopic sinus surgery care. It is important to limit an amount of PM, particularly in Draf III procedures.

The Time to Spontaneous Drop of Polyglactin 910 (Vicryl) in the Nasal Cavity

Sutures play a crucial role in closing mucosal incisions during endoscopic nasal surgery. The duration until the spontaneous drop of polyglactin 910 (Vicryl) sutures in the nasal cavity remains uncertain. To investigate this, we examined the medical records of patients who underwent septoplasty, inferior turbinate reduction, or endoscopic modified medial maxillectomy with polyglactin 910 sutures. The sutures were counted and monitored during follow-up visits, and removal occurred only if patients reported discomfort. In our study of 124 patients, a total of 453 sutures were placed during surgery. Eighteen sutures had to be intentionally removed due to discomfort. Importantly, no surgical site infections were observed during the follow-up period. We found that sutures on the lateral nasal wall persisted longer than those on the nasal septum, with respective half-lives of 70 days and 64 days (p = 0.0071). In conclusion, using polyglactin 910 sutures in nasal surgery and allowing them to dissolve naturally in the submucosa is an effective approach. The sutures exhibit longer persistence on the lateral nasal wall compared to the nasal septum.

Is postoperative nasal packing after septoplasty safe? A systematic review and meta-analysis of randomized controlled studies

OBJECTIVES

To systemically review and compare post-septoplasty complications between total nasal packing and other techniques.

METHODOLOGY

We searched electronic databases (PubMed, Scopus, and Cochrane Library) and additional sources. The most recent search was on November 30th, 2020. Randomized controlled trials (RCTs) comparing adverse events after post-septoplasty nasal packing versus other techniques were included. The outcomes were adverse events, including respiratory distress, oxygen desaturation, pain severity, bleeding, hematoma, sleep disturbance, infection, crusting, epiphora, dysphagia, perforation, adhesion, and residual septal deviation.

RESULTS

There were 47 studies (4,087 participants) in this systematic review. Nasal packing was more likely to cause adverse events than other techniques. There were significant increases in respiratory distress, pain, sleep disturbance, crusting, epiphora, dysphagia, and adhesion. There were no statistically significant differences in oxygen desaturation, bleeding, hematoma, infection, perforation, and residual septal deviation. Subgroup analysis found that trans-septal suture was less likely to cause post-operative complications compared with total nasal packing.

CONCLUSION

Nasal packing after septoplasty was more likely to cause adverse events, including respiratory distress, pain, sleep disturbance, crusting, epiphora, dysphagia, and adhesion. Furthermore, there were no benefits of nasal packing in preventing bleeding, hematoma, and residual septal deviation when compared with other techniques. Routine nasal packing after septoplasty should be avoided. Trans-septal suture should be considered instead.

Efficacy of nasal septal splints for preventing complications after septoplasty: A meta-analysis

BACKGROUND

The efficacy of nasal septal splints, which are used as alternatives to nasal packs for preventing complications such as synechia and maintaining septal stability after septoplasty, remains controversial. The present meta-analysis assessed the efficacy and safety of nasal septal splints used after septoplasty.

METHODS

PubMed and Google Scholar databases were systematically searched until June 20, 2019. Randomized controlled trials or cohort or case-control studies comparing patients who received nasal septal splints with those who did not receive splints after septoplasty were included. Primary outcomes included postoperative pain, infection, bleeding, hematoma formation, synechia, and perforation. Random effects models were used to calculate risk differences and risk ratios with 95% confidence intervals (CIs).

RESULTS

Thirty-three eligible studies were included. The estimated rate of synechia was significantly lower in the splint group (0.037, 95% CI 0.024-0.056) than in the no splint group (0.087, 95% CI 0.055-0.135; P = 0.003), while visual analog scale scores for pain and the estimated rates of infection, bleeding, hematoma, and perforation were comparable between groups.

CONCLUSIONS

These findings suggest that the use of nasal septal splints as alternatives or in addition to nasal packing prevent synechia after septoplasty without increasing other complications, including pain, thus adding to evidence supporting the use of septal splints, particularly in cases where postoperative synechia is expected.

A Comparative Study Between Septal Quilting Sutures Without Nasal Packing and Only Nasal Packing Post-septal Correction

Septal correction is the commonest surgery by rhinologists worldwide. We aimed at studying the comfort level of the patient with standard postoperative nasal packing with Merocel and placing quilting sutures in septum leaving the nose unpacked in the postoperative period. We conducted the study in the tertiary care centre enrolling 82 patients in a quasi-randomised method of odd and even numbers placing them in the nasal packing group and the quilting group respectively. We used analogue scoring method for subjective assessment of comfort level in the postoperative period and the surgeon objectively assessed the patient on follow up. The results were tabulated and analysed. Postoperative pain, headache and sleep disturbance was significantly more in the nasal packing group. We found that the crusting is commonly seen in patients in the nasal packing group. Quilting the nasal septum and leaving the nasal cavity unpacked increases the comfort level of the patient in the postoperative period. The resultant pain, headache and sleep disturbance caused by nasal packing can be significantly avoided by using quilting the septum without nasal packing. We also observed that by avoiding nasal packing postoperatively, the patients were more comfortable and compliant with the treatment regimen and follow-up.

Resection of inverted papilloma in nasal cavity with transseptal access and crossing multiple incisions minimizes bleeding and reveals the tumor pedicle

OBJECTIVE

Sinonasal inverted papilloma can be resected endoscopically, but has a risk of recurrence. This risk can be minimized by identifying the pedicle of the tumor and ensuring complete resection. Intraoperative bleeding, particularly from the tumor, decreases endoscopic visualization and contributes to failure to identify the tumor pedicle, and piecemeal resection with dissection of the non-tumoral mucosa makes it impossible to distinguish the tumor pedicle. Previously reported transseptal access with crossing multiple incisions (TACMI) increases mobility of an inverted papilloma within the otherwise restricted nasal cavity. This technique often allows en bloc resection complete with the pedicle and control of bleeding.

METHODS

We retrospectively reviewed our patients who underwent endoscopic resection of inverted papilloma with or without TACMI and compared the operating times, estimated blood loss, and en bloc resection and recurrence rates between the two groups.

RESULTS

Thirty-five patients underwent endoscopic resection of inverted papilloma (Krouse stage 2-4) with (n = 23) or without (n = 12) TACMI. The operating time was longer in the TACMI group (218±68 min) than in the non-TACMI group (129±33 min). Estimated blood loss was less in the TACMI group (72±103 mL vs. 120±136.5 mL) but this finding was not significant. En bloc resection was achieved in 19 patients (83%) in the TACMI group but not in any patient in the non-TACMI group. There were no recurrences in the TACMI group. Multivariate analysis showed significant relationships between estimated amount of blood loss and operating time according to Krouse stage and whether or not TACMI was performed.

CONCLUSIONS

Endoscopic resection of inverted papilloma with TACMI may achieve better treatment results with less blood loss.

Nasal silicone splints and quilting sutures using a septum stitch device following septoplasty: a prospective comparative study

PURPOSE

Although nasal splints and trans-septal sutures are preferred for septal closure following septoplasty, quilting sutures, also known as continuous mattress sutures, are technically challenging and thus time consuming. Recently, the utility of a novel stitch device was demonstrated for quilting sutures; however, whether it contributes to the technical solution and time management of septal sutures remains unclear. This study aims to quantify the time and cost of septal closure following septoplasty by comparing nasal splints with quilting sutures using the septum stitch device.

METHODS

We prospectively examined 23 patients who underwent septoplasty and assigned them to the following two groups: group 1, underwent the quilting suture for septal closure following septoplasty; group 2 underwent the nasal silicone splint method. We recorded the total operation time and surgical time for septal closure. Furthermore, we evaluated postoperative symptoms with Visual Analogue Scale (VAS) scores and compared the complication rate.

RESULTS

We observed no significant difference in the average of total operating time (P = 0.641) and the surgical time for septal closure (P = 0.886). Among postoperative symptoms, only nasal bleeding was significantly worse in group 1 on postoperative day 1 (P = 0.023). In addition, the occurrence of postoperative complications was insignificant between both groups.

CONCLUSIONS

The septum stitch facilitated safe and easy quilting suturing without significant increase of operation time.

Surgical Outcomes of Bony Batten Grafting to Correct Caudal Septal Deviation in Septoplasty

Improtance

Correction of caudal septal deviation with a batten graft has been popularized recently. However, few reports have documented the surgical outcomes of this technique, especially the use of bony batten grafts in septoplasty.

Objective

To evaluate the surgical outcomes of bony batten grafting for the management of caudal septal deviation in endonasal septoplasty.

Design, Setting, and Participants

This retrospective cohort study evaluates the medical records of 141 patients with caudal septal deviation who underwent septoplasty using bony batten grafts from September 1, 2011, through February 29, 2016, at a tertiary referral hospital. Patients were divided into primary and secondary surgery groups. Patients were also divided into the septoplasty plus turbinate surgery and the septoplasty only group. Endoscopic assessment of deviation correction was performed, and postoperative complications were analyzed.

Main Outcomes and Measures

Patient satisfaction and symptom improvement were evaluated via telephone interviews by using the Nasal Obstruction Symptoms Evaluation (NOSE) scores.

Results

Of the 141 patients (24 women [17%] and 117 men [83%]; mean [SD] age, 32.8 [12.9] years), 86 (61%) rated their symptoms in the postoperative survey as much improved; 50 (35.5%), improved; 4 (2.8%), no change; and 1 (0.7%), worse. All patients had significantly improved mean (SD) postoperative NOSE scores (28.7 [22.0]; 95% CI, 25.0-32.4) compared with preoperative scores (70.5 [26.7]; 95% CI, 66.0-75.0; P < .001). No significant intergroup differences were observed in surgical outcome between the 116 patients undergoing primary surgery (mean [SD] NOSE score, 28.2 [21.9]) and 25 undergoing secondary surgery (mean [SD] NOSE score, 30.8 [24.3]; P = .34). No significant difference in surgical outcome was found between the 102 patients in the turbinate surgery group (mean [SD] NOSE score, 28.1 [20.8]) and 39 in the septoplasty only group (mean [SD] NOSE score, 30.4 [23.7]; P = .65). On endoscopic examination for surgical outcome, 128 patients (90.8%) had a straight septum and 13 (9.2%) had improved but residual caudal deviation. Postoperative complications included septal hematoma in 4 patients, hyposmia in 2, and chondritis in 1; all patients were treated successfully. Four patients required revision surgery because of incomplete functional correction or a desire for rhinoplasty.

Conclusions and Relevance

Septoplasty using bony batten grafts is useful for correcting caudal septal deviation with favorable surgical outcomes and an acceptable complication rate.

Level of Evidence

3.

A new modification of Doyle splint (Hemi-split Doyle) in rhinoplasty with alar base reduction

Patients perceive the pulling of a nasal splints as the most feared and stressful part of nasal surgery. Even the incisions made for alar base surgery can partly or entirely dehisce. So, we have been using modified Doyle silicone splints. We compared the modified Doyle silicone splints with conventional Doyle silicone splint. Included in the study were 64 patients undergoing alar base surgery together with open septorhinoplasty. Group 1 (n = 32) patients received a conventional Doyle intranasal silicone splint and group 2 (n = 32) received modified splint that we call a hemi-split Doyle splint. The pain felt by the patients during the removal of the splints was recorded according to the visual analogue scale (VAS). On days two and four postoperatively, the nasal stuffiness score (NOSE) was recorded. On day four postoperatively an intranasal examination was conducted to establish if dehiscence had occurred on the alar base incision line. In group 2, the pain scores during splints removal were significantly lower than those in group 1. Whereas no dehiscence on the alar base incision line was observed after tampon removal in group 2, the incision dehisced in eight patients in group 1. The NOSE scores on postoperative days two and four showed no difference between the groups. The hemi-split Doyle splint causes less pain during removal and particularly does not lead to dehiscence of incisions made during alar base surgery in rhinoplasty patients.

Transseptal access with crossing multiple incisions for improved pedicle control and septum preservation: "How I do it"

INTRODUCTION

Recently, the surgical management of nasal tumors has been greatly influenced by advanced endoscopic techniques. To achieve complete endoscopic resection of large obstructing nasal tumors, a sufficient corridor for adequate exposure is also required. In the Japanese language, TACMI means "master expert," and herein we describe an endoscopic technique with novel elements that we term transseptal access with crossing multiple incisions (TACMI). This approach enables a direct transseptal approach to the pedicle through tumor transposition while allowing complete septal reconstruction and stability.

METHODS

We prospectively collected data from eight patients who underwent the TACMI approach for sinonasal tumors.

RESULTS

When using TACMI, complete en bloc neoplasm resection was achieved in all but one patient, who underwent piecemeal tumor removal. The follow-up duration ranged from 10 to 28 months (mean, 19 months). None of the patients experienced septal perforation, nasal valve incompetence, or tumor recurrence.

CONCLUSION

We presented evidence that TACMI was a simple, efficient, and effective technique for tumor transposition, and for pedicle visualization and access of challenging unilateral sinonasal lesions. These advantages contributed to limited blood loss, improved pedicle control, and complete nasal valve and septum preservation without functional deficits.

Is nonabsorbable nasal packing after septoplasty essential? A meta-analysis

OBJECTIVES

Septoplasty is one of the most frequently performed rhinologic surgeries. Complications include nasal bleeding, pain, headache, septal hematoma, synechia, infection, residual septal deviation, and septal perforation. In this study, we aimed to compare complication rates among patients according to packing method.

METHODS

We performed a literature search using PubMed, Embase, and the Cochrane Library through August 2016. Our systematic review followed Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Random effect models were used to calculate risk differences and risk ratio with 95% confidence intervals (CIs). Cases referred to the nonpacking group included patients treated with transseptal sutures or septal splints. Cases referred to as the packing group included patients treated with nonabsorbable packing such as Merocel or gauze.

RESULTS

Our search included 20 randomized controlled trials (RCTs) with a total of 1,321 subjects in the nonpacking group and 1,247 subjects in the packing group. There were no significant differences between packing methods regarding bleeding, hematoma, perforation, infection, and residual septal deviation. The risk differences of postoperative pain, headache, and postoperative synechia were -0.50 [95% CI: -0.93 to -0.07, P = .02], -0.42 [95% CI: -0.66 to -0.19, P = .0004], and -0.03 [95% CI: -0.06 to -0.01, P = .01], respectively.

CONCLUSIONS

Nonabsorbable nasal packing is no more effective than treatments without packing after septoplasty. Septal splints and transseptal sutures reduce postoperative pain, headache, and synechia.

LEVEL OF EVIDENCE

1B Laryngoscope, 127:1026-1031, 2017.

Do we really need to coat the novel silicone intranasal splints with antibiotics?

PURPOSE

The novel silicone intranasal splints are suggested to resist biofilm formation due to their surface characteristics. We aimed to ascertain the necessity of coating these splints with antibiotics to prevent splint associated infections, in vitro.

MATERIALS AND METHODS

Pieces of Doyle II airway nasal splints made of medical grade silicone were divided into two test groups, treated with either (i) 0.2% nitrofurazone solution or (ii) 0.2% nitrofurazone containing ointment, and a control group, treated with (iii) 0.9% saline. Splint pieces were then incubated with Staphylococcus aureus solutions at 37°C for 48 and 96h. Following this, the splint pieces were incubated in 20ml Mueller Hinton agar and appearing colonies were counted.

RESULTS

Following 48and 96h of incubation, the colonization rates in the saline group were significantly higher than the nitrofurazone ointment group (p<0.001). The colonization rates in the liquid nitrofurazone group were significantly lower in comparison to the nitrofurazone ointment group (p<0.001 and p=0.019 respectively).

CONCLUSIONS

The method of coating the splints with antibiotic was superior to using uncoated splints in terms of preventing S. aureus colonization. The rather smooth surfaces of the splints were insufficient to block bacterial colonization and coating them with antibiotics seems to be beneficial for the prevention of infections.

The effects of the time of intranasal splinting on bacterial colonization, postoperative complications, and patient discomfort after septoplasty operations

Introduction

The main reason for nasal tampon placement after septoplasty is to prevent postoperative hemorrhage, while the secondary purpose is internal stabilization after operations involving the cartilaginous-bony skeleton of the nose. Silicone intranasal splints are as successful as other materials in controlling postoperative hemorrhages of septal origin. The possibility of leaving the splints intranasally for extended periods helps stabilize the septum in the midline. However, there is nothing in the literature about how long these splints can be retained inside the nasal cavity without increasing the risk of infection, postoperative complications, and patient discomfort.

Objective

The current study aimed to evaluate the association between the duration of intranasal splinting and bacterial colonization, postoperative complications, and patient discomfort.

Methods

Patients who had undergone septoplasty were divided into three groups according to the day of removal of the silicone splints. The splints were removed on the fifth, seventh, and tenth postoperative days. The removed splints were microbiologically cultured. Early and late complications were assessed, including local and systemic infections, tissue necrosis, granuloma formation, mucosal crusting, synechia, and septal perforation. Postoperative patient discomfort was evaluated by scoring the levels of pain and nasal obstruction.

Results

No significant difference was found in the rate of bacterial colonization among the different groups. Decreased mucosal crusting and synechia were detected with longer usage intervals of intranasal silicone splints. Postoperative pain and nasal obstruction were also diminished by the third postoperative day.

Conclusions

Silicone splints were well tolerated by the patients and any negative effects on postoperative patient comfort were limited. In fact, prolonged splint usage intervals reduced late complications. Long-term silicone nasal splint usage is a reliable, effective, and comfortable method in patients with excessive mucosal damage and in whom long-term stabilization of the bony and cartilaginous septum is essential.

The impact of different nasal packings on postoperative complications

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. One hundred thirty patients were randomly selected among patients who underwent endonasal surgery in Namık Kemal University Hospital between January 1st 2012 and August 1st 2013. Retrospective analysis of these patients' files, including operative reports and follow-up notes, was done. The postoperative findings of patients who had septal splints and Merocel nasal packings were compared and analyzed for statistical significance.

RESULTS

The results of the study showed a statistically significant difference in the frequency of synechia formation between two groups (p<0.05). The frequency of synechia formation was found to be higher in the Merocel packing group. However, no statistically significant difference was found between groups in terms of postoperative infection, septal perforation, and epistaxis (p>0.05).

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 after nasal surgery should be preferred to avoid this complication. On the other hand, other factors should be sought in the etiology of postoperative infection, septal perforation, and epistaxis.

Endoscopic single-handed septoplasty with batten graft for caudal septum deviation

OBJECTIVE

Septoplasty is usually performed with a Killian incision in Japan. However, the major drawback of the Killian incision is the inability to correct deviations of the caudal part of the septum. For patients with mild deviation of the caudal part of the septum but with a straight caudal end, we performed a modified Killian incision and used a batten graft to correct the deviated cartilage under endoscopy. The aim of this study was to evaluate the usefulness of our surgical technique for these cases.

METHODS

We prospectively collected data of 17 patients who underwent endoscopic septoplasty with a batten graft. Objective assessment by computed tomography and subjective assessment by questionnaire were performed before and 3 months after the surgery.

RESULTS

On computed tomography, the ratio of the area of the convex side to that of the concave side in the anterior portion of the nasal cavity was significantly improved after surgery (p<0.001). Subjective assessment revealed a significant improvement in nasal obstruction (p=0.002). There were no complications in this study.

CONCLUSION

The herein-described septoplasty with a batten graft is technically easy and considered to be useful for deviation of the caudal part of the septum in selected cases.

Influence of surface properties of Merocel® (polyvinyl acetal) and silicone nasal splints on biofilm formation

The objective of the study was to investigate biofilm formation on Merocel(®) and silicone nasal splint after nasal septal surgery. 50 patients who were scheduled to undergo nasal septal surgery were included in this study. The patients were randomized into receiving an insert of Merocel(®) or silicone splint after septoplasty. In group 1 (8 females, 17 males) and group 2 (10 females, 15 males), Merocel (®) packs or silicone splints were inserted into nasal cavities at the end of the procedures, respectively. All packs were removed 48 h after insertion, and samples were taken from the packs under sterilized conditions. Scanning electron microscopy was performed to observe biofilm formation on the surfaces of Merocel(®) and silicone splints. Biofilm formation was observed in 25 (100%) and 3 (12%) of the Merocel(®) and silicone splint samples, respectively. Our study revealed that biofilm formation on Merocel(®) packs is significantly higher than silicone splints, mainly due to the different texture and surface properties of these materials. Considering the hazardous effects of biofilm formation on humans, our observations in this study may guide surgeons to choose the most appropriate packing material after nasal septal surgery.

Is nasal packing necessary after septoplasty? A meta-analysis

BACKGROUND

Nasal packing is routinely used after septoplasty because it is believed to decrease risk of postoperative bleeding, hematomas, and adhesions. Multiple studies have shown, however, that there are numerous complications associated with nasal packing. The purpose of this work was to perform a meta-analysis on the existing literature to evaluate the role of nasal packing after septoplasty.

METHODS

Two independent reviewers conducted a literature search using EMBASE, OVID, Medline, PubMed, Google scholar, Cochrane Library, and reference list review from 1966 to August 2010 to identify studies assessing nasal packing after septoplasty. All papers were reviewed for study design, results, and were assigned an Oxford level of evidence grade, Detsky score, and Methodological Index for Nonrandomized Studies (MINORS) score.

RESULTS

Sixteen papers were identified that met the inclusion criteria. Eleven papers were randomized control trials, 3 were prospective, and 2 were retrospective studies. Nasal packing did not show benefit in reducing postoperative bleeding, hematomas, septal perforations, adhesions, or residual deviated nasal septum. There was, however, an increase in postoperative infections. Two studies using fibrin products as nasal packing showed a decreased bleeding rate.

CONCLUSION

Nasal packing after septoplasty does not show any postoperative benefits. Fibrin products show a possibility of decreasing postoperative bleeding. Routine use of nasal packing after septoplasty is not warranted. This is the first meta-analysis conducted on this topic.