COMPARATIVE STUDY OF DIFFERENT TYPES OF NASAL PACKING IN SEPTOPLASTY

COMPARATIVE STUDY OF DIFFERENT TYPES OF NASAL PACKING IN SEPTOPLASTY

By

Mahmoud Mohamed Abd Al-Azim Soliman, Wael Hassan Abu Al-Wafa and Mohammad Amin Al-Morsy

Department of Otorhinolaryngology, Faculty of Medicine, Al-Azhar University

Corresponding author: Mahmoud Mohamed Abd Al-Azim Soliman,

E-mail: mahmoud-mohamedsoliman80@gmail.com

ABSTRACT

Background: Septoplasty or septal reconstruction is a corrective surgical procedure performed to straighten nasal septum. It may be associated with numerous complications. To minimize these complications, both nasal cavities are frequently packed with different types of nasal packing. The solid and porous characteristics of Merocel not only help in better hemostasis, but also cause more pain during insertion of nasal pack, pain while pack is inside the nasal cavity, and pain during removal of the pack.

Objective: To investigate the effect of using Merocel in glove finger over plain Merocel as a nasal packing after septoplasty.

Patients and methods: Data for this study was collected from patients attending in Al-Sahel teaching hospital during period from March 2019 to December 2020. In this study, the total number of patients is 60, the age ranged from 18 to 45 (38 males, 22 females). All patients presented with symptomatic deviated nasal septum. All cases are diagnosed after taking a detailed history regarding nasal obstruction and associated symptoms like nasal discharge and headache and by endoscopic examination to detect the site of deviation and other nasal abnormalities.

Results: In this study the range of pain scoring in group A was (1-6) and the mean ±SD was 3.300 ± 1.291 while the range in group B was (3-9) and the mean ± SD was 6700 ± 1.489. In this study, moderate bleeding was observed in one patient (3.33%) during pack removal in Group A. In Group B, 18 patients (60%) had moderate bleeding on pack removal, suggesting that glove finger‑coated Merocel plays a role in avoiding friction between Merocel and surgical wound on pack removal, which reduces mucosal damage or bleeding amount. In this study, mild postoperative crustation was observed in 10 patients (33.33%) after pack removal n group A, while in group B there were 14 patients (46.67%). There were no patients with moderate postoperative crustation n group A, while in group B there were 10 patients (33.33%).

Conclusion: Gloved Merocel produces less pain and bleeding during its removal and less postoperative crustation, adhesion and inflammation. Gloved Merocel is preferred over ungloved Merocel as nasal packing following septoplasty. Thus, glove finger Merocel can be used as an excellent packing material.

Keywords: Nasal packing, Septoplasty, Gloved Merocel.

INTRODUCTION

     Nasal packs are widely used in the otorhinolaryngology practice, especially following nasal surgery and epistaxis. In addition to preventing nasal bleeding after nasal surgery, these packs have the potential to support the mucoperichondrial flaps and to minimize the risk of formation of septal hematoma and adhesions (Ozcan et al., 2011).

     A number of different nasal packing materials are available for these purposes such as ribbon gauze with or without medications, absorbable biomaterials, merocel and nasal splints. The type of the nasal packing material used will depend on the performance and experience of the surgeon, the ease of insertion and removal and patient discomfort or pain, especially during removal (Bresnihan et al., 2010).

     Postoperative pain is considered to be the most common morbidity associated with packs used in septoplasty In addition; nasal pack may result in significant mucosal injury and loss of ciliary function. Many attempts, such as shortening the duration of packing and developing new packing material, have been made to minimize the morbidity associated with packing materials (Dag et al., 2014).

     Merocel is the most popular commercial product and has a widespread use around the world. It is a kind of foam pack made of polyvinyl acetate and is packaged in a compressed, dehydrated state to allow ease of insertion. It requires rehydration with saline to activate it. Merocel has both solid and porous characteristics (Deniz et al., 2014).

     The pore gets swollen, causes hemostasis, exerts equal pressure on both sides of septum, and keeps the septum straight following the surgery. However, the most important disadvantage of plain Merocel is the pain. This occurs during insertion of pack, while nasal pack is inside the nasal cavity, and during removal of the nasal pack. It adheres to the bleeding site, incision site, and other raw areas over the septum (Akbari et al., 2012).

     These disadvantages may be overcome by using finger gloved Merocel instead of simple Merocel. The number of studies on the efficacy of Merocel in glove finger during septoplasty is limited. This clinical trial was undertaken to compare the patients’ tolerance and complications of the gloved and ungloved Merocel packs after septoplasty (Çelik et al., 2013).

     The aim of this study was to investigate the effect of using Merocel in glove finger over plain Merocel as a nasal packing after septoplasty.

PATIENTS AND METHODS

     Data for this study was collected from patients attending in Al-Sahel teaching hospital during period from March 2019 to December 2020.

     In this study, the total number of patients is 60, the age ranged from 18 to 45 (38 males, 22 females). All patients presented with symptomatic deviated nasal septum. All cases are diagnosed after taking a detailed history regarding nasal obstruction and associated symptoms like nasal discharge and headache and by endoscopic examination to detect the site of deviation and other nasal abnormalities.

     Also all cases are investigated by C.T scan on the nose and paranasal sinuses by coronal and axial cuts bone window.

     This study was approved by ethical committee of Ear, Nose and Throat department, Faculty of Medicine, Al Azhar Univerity.

Inclusion criteria:

•   Patients undergoing septoplasty for symptomatic deviated nasal septum in the age range of 18–60 years

•   Patients’ willingness to participate in the study

•   Patients without any previous history of nasal surgery

•   Patients without any rhinosinusitis or systemic disorders.

Exclusion criteria:

•   Patients below age of 18

•   Patients with fungal sinusitis, sinonasal polyposis, granuloma and neoplasm of nose and paranasal sinuses.

•   Patients did a previous septoplasty.

•   Patients refuse or unfit for surgery.

Method of data collection:

     All patients are divided into two groups. In patients belonging to Group A, nasal packing was done with gloved Merocel (Merocel 10 cm) after septoplasty and, while in Group B, packing was done with ungloved Merocel.

     Surgery was performed under general anesthesia. Nasal cavity was infiltrated by 2% xylocaine with adrenaline (1 in 1,000,000), a slightly curvilinear incision was made 2 mm–3 mm above the caudal end of septal cartilage on the convex side. In case of caudal dislocation, a transfixion or hemi transfixion incision was made.

     Mucoperichondrial/ mucoperiosteal flaps were raised. The septal cartilage was separated from the vomer and ethmoid plates and the mucoperiosteal flap was raised on the opposite side. Maxillary crest was removed to realign the septal cartilage.

     To correct the bony septum, the deformed parts were removed. Gloved or ungloved Merocel packs were inserted. The gloved Merocel pack was prepared by inserting Merocel into a powder free glove finger and then packing the nasal cavity. Absorption of blood and secretions by Merocel was promoted by incising four or five regions of the glove fingers with a scalpel.

     The free end of the glove finger was sutured together with silk of 2.0 to prevent the escape of the tampon from the nasal passages. Ungloved Merocel is a plain Merocel packing. The pack was removed on the 3^rd postoperative day. All patients received antibiotics, analgesics, and antihistamines for one week postoperatively.

     Pain while removal of pack were assessed by Visual Analog Scale (VAS) numbered from 0 to 10 (0 represents the least pain and discomfort, whereas 10 means the maximum pain and discomfort).

Bleeding during pack removal was graded as follows: 0, no bleeding; 1, mild bleeding (controlled spontaneously without any intervention); 2, moderate bleeding (controlled by the insertion of ephedrine soaked cottonoids); and 3, severe bleeding (controlled by repacking). The patients were followed up weekly for 4 weeks after surgery. At each follow up visit, nasal endoscopy was performed to look for inflammation, crusting, adhesion, and septal perforation.

Crusting was graded as follows: 0, no crusting; 1, minimal crusting; and 2, gross crusting. Adhesions were graded as follows: 0, no adhesion, 1, mild (easy to detach); 2, moderate (hard to detach); and 3, severe (need synechiolysis). Inflammation was graded as 0, no congestion; 1, congestion; 2, ulceration; and 3, granulations.

Statistical analysis:

     The collected data were coded, processed and analyzed using the SPSS (Statistical Package for Social Sciences) version 22 for Windows^® (IBM SPSS Inc, Chicago, IL, USA). Data were tested for normal distribution using the Shapiro Walk test. Qualitative data were represented as frequencies and relative percentages. Chi square test (χ2) to calculate difference between two or more groups of qualitative variables. Quantitative data were expressed as mean ± SD (Standard deviation). Independent samples t-test was used to compare between two independent groups of normally distributed variables (parametric data). P value < 0.05 was considered significant.

RESULTS

     In present study, the age of the patients was in the range of 18–60 years in both groups. Majority of the patients were in the age group of 18–45 years in both groups. The mean age of the gloved Merocel group was 27.733 ± 5.601 years and that of the ungloved Merocel group was 28.100± 7.685.

     In present study there are 60 patients divided into two groups. Group A include 18 males (60%) and 12 females (40%). Group B include 22males (73.33%) and 8 females (33.33%) (Table 1).

Table (1):   Age and sex groups

     The mean score for pain during pack removal for gloved Merocel was 3.300 ± 1.291 and that for ungloved Merocel was 6.700 ± 1.489. There was a statistically significant difference between both the packs (P < 0.001) (Table 2).

Table (2):   Pain during removal of nasal packing

     In present study group A includes 11 patients without bleeding during removal of gloved merocel (36.67%) ,18 patients with mild bleeding (60%), one patient with moderate bleeding (3.33%) and no patients with severe bleeding (00,00%). Group B includes no patients without bleeding (00.00%), 6 patients with mild bleeding (20%), 18 patients with moderate bleeding (60%) and 6 patients with severe bleeding (20.00%) (Table 3).

Table (3):   Bleeding during removal of nasal packing

     In present study group A includes 20 patients without Crusting after removal of gloved merocel (66.67%) ,10 patients with mild Crusting (33.33%), no patients with moderate Crusting (00.00%) and no patients with severe crusting (00.0%). Group B includes 6 patients without Crusting (20%), 14 patients with mild Crusting (46.67%), 10 patients with moderate Crusting (33.33%) and no patients with severe Crusting (00.00%).

     In present study group A includes 19 patients without adhesions after removal of gloved merocel (63.33%) ,11 patients with mild adhesions (36.67%), no patients with moderate adhesions (0%) and no patients with severe adhesions (00,00%). Group B includes 9 patients without adhesions (30.00%), 12 patients with mild adhesions (40.00%), 6 patients with moderate adhesions (20.00%) and no patients with severe adhesions (00.00%).

     In present study group A includes 9 patients without Inflammations after removal of gloved merocel (30.00%), 11 patients with mild Inflammations (36.67%), 10 patients with moderate Inflammations (33.33%) and no patients with severe Inflammations (00.00%). Group B includes 3 patients without Inflammations (10.00%), 12 patients with mild Inflammations (40.00%), 11 patients with moderate Inflammations (36.37%) and no patients with severe Inflammations (00.00%) (Table 4).

Table (4):   Crusting, adhesions and inflammations after removal of nasal packing

DISCUSSION

     In this study results indicate that the use of a glove finger for application of Merocel packing significantly reduces pain and bleeding during pack removal and postoperative crustations, adhesions and infection. We attribute this to less adherence of the glove finger to the structures inside the nose.

     The mean VAS score was higher for ungloved Merocel during removal of pack. These findings support the fact that use of Merocel, due to its potential to adhere to mucosal surfaces, leads to pain during its removal. Study results indicate that the use of a glove finger for application of Merocel packing significantly reduces pain during pack removal. We attribute this to less adherence of the glove finger to the structures inside the nose.

     A study by Celebi et al. (2013) examining the effect of duration of Merocel in glove finger on postoperative morbidity concluded that keeping Merocel inside a glove finger in place for 48 h notably reduces pain occurring during removal and prevents synechiae, bleeding, and septal hematoma without compromising patient comfort. The study conducted by Kim et al. (2012) also showed significant difference in mean VAS scores in terms of pack removal between the two groups (Garth and Brightwell, 2010).

     In this study the range of pain scoring in group A was (1-6) and the mean ±SD was 3.300 ± 1.291 while the range in group B was (3-9) and the mean ± SD was 6700 ± 1.489.

     In this study, moderate bleeding was observed in one patient (3.33%) during pack removal in Group A. In Group B, 18 patients (60%) had moderate bleeding on pack removal, suggesting that glove finger‑coated Merocel plays a role in avoiding friction between Merocel and surgical wound on pack removal, which reduces mucosal damage or bleeding amount.

     In this study, mild postoperative crustation was observed in 10 patients (33.33%) after pack removal n group A, while in group B there were 14 patients (46.67%). There were no patients with moderate postoperative crustation n group A, while in group B there were 10 patients (33.33%).

     In this study, mild postoperative adhesions was observed in 11 patients (36.67%) after pack removal n group A, while in group B there were 12 patients (40.00%). There were no patients with moderate postoperative adhesions n group A, while in group B there were 6 patients (20.00%).

     In this study, mild postoperative inflamation was observed in 11 patients (36.67%) after pack removal n group A, while in group B there were 12 patients (40.00%). There were 10 patients with moderate postoperative inflammation (33.33%) in group A, while in group B there were 11 patients (36.67%).

CONCLUSION

     In this study we compared the use of merocel and gloved merocel as anasal pack after septoplasty in patients to show which of them is more hemostatic, less painful and fewer incidences of postoperative crustation, adhesion and inflammation.

     Gloved Merocel produces less pain and bleeding during its removal and less postoperative crustation, adhesion and inflammation.

     Gloved Merocel is preferred over ungloved Merocel as nasal packing following septoplasty. Thus, glove finger Merocel can be used as an excellent packing material.

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