Braz. j. . vol.82 número3

BrazJOtorhinolaryngol.2016;82(3):310---313

www.bjorl.org

Brazilian

Journal

of

OTORHINOLARYNGOLOGY

ORIGINAL

ARTICLE

Transeptal

suturing

---

a

cost-efficient

alternative

for

nasal

packing

in

septal

surgery

夽

Daniel

Pérez

Plasencia

_,

_Juan

_Carlos

_Falcón

_,

_Silvia

_Borkoski

_Barreiro

,

María

Sacramento

Bocanegra-Pérez

_,

_Mario

_Vicente

_Barrero

_,

_Ángel

_Ramos

_Macías

a_{HeadNeckSurgDepartment,ComplejoHospitalarioUniversitarioInsular-MaternoInfantil,GranCanaria,Spain} b_{StomatologyDepartment,ComplejoHospitalarioUniversitarioInsular-MaternoInfantil,GranCanaria,Spain}

Received7February2015;accepted12May2015 Availableonline6November2015

KEYWORDS

Septalsurgery; Nasalpacking; Transeptalsuture; Efficiency

Abstract

Introduction:Nasal packing is routinely used in septal surgery to prevent postoperative bleeding.

Objective:Todemonstratethepossibilityoftranseptalsutureasasafeandeffectivewayto avoidnasalpackingandtoimproveefficiency.

Methods:Thisisaprospective,descriptive,inferentialcoststudycomprising92patients.Two randomized groups of patients were analyzed, one with nasal packing and the other with transeptalsuture.

Results:Inthegroupoftranseptalsuturenopatientexperiencedpostoperativebleeding,and astatisticallysignificantreductionofpainandheadachewasdemonstrated.Atthesametime, weimprovedefficiencybysavingonmaterialcosts.

Conclusions:Transeptalsutureisaneffectiveandsafealternativetoclassicnasalpackingin septalsurgery.Moreover,itimprovestheefficiencyoftheinterventionbysavingcosts. © 2015Associac¸˜ao Brasileira de Otorrinolaringologiae CirurgiaC´ervico-Facial. Publishedby ElsevierEditoraLtda.Allrightsreserved.

PALAVRAS-CHAVE

Cirurgiaseptal; Tamponamentonasal; Suturatranseptal; Eficiência

Suturatranseptal---umaalternativacusto-benefícioparatamponamentonasal emcirurgiadosepto

Resumo

Introduc¸ão:Otamponamentonasaléusadorotineiramentenacirurgiaseptalparaevitar san-gramentosnopós-operatório.

夽

Pleasecitethisarticleas:PlasenciaDP,FalcónJC,BarreiroSB,Bocanegra-PérezMS,BarreroMV,MacíasAR.Transeptalsuturing---a

cost-efficientalternativefornasalpackinginseptalsurgery.BrazJOtorhinolaryngol.2016;82:310---3.

∗_{Correspondingauthor.}

E-mail:silviaborkoski@hotmail.com(S.B.Barreiro).

http://dx.doi.org/10.1016/j.bjorl.2015.05.016

Transeptalsuturingisacost-efficientalternativeinseptalsurgery 311

Objetivo: Demonstrarapossibilidadede serealizarumasuturatranseptalcomo alternativa eficazeseguraaotamponamentonasal,commelhoranaeficiênciadaintervenc¸ão.

Método: Esteéumestudoprospectivo,descritivoedecustoinferencial,compreendendo92 pacientes.Doisgruposaleatóriosforamestudados:umcomtamponamentonasaleooutrocom suturatranseptal.

Resultado: Nogrupodesuturatranseptal,nenhumpacienteexperimentousangramentono pós-operatório,tendosidoestatisticamentedemonstradaumasignificantereduc¸ãodecefaléiae dor.Aomesmotempo,houvemelhoranaeficiênciadaintervenc¸ão,comeconomianocustode material.

Conclusões: Asuturatranseptaléumaalternativaeficazeseguraaotamponamentonasal clás-sico.Alémdomais,melhoraaeficiênciadaintervenc¸ão,economizandonocustodematerial. ©2015Associac¸˜ao BrasileiradeOtorrinolaringologiaeCirurgiaC´ervico-Facial.Publicado por ElsevierEditoraLtda.Todososdireitosreservados.

Introduction

Septalsurgeryisoneofthemostfrequentlyperformed pro-ceduresinrhinology.Postoperativenasalpackinghasbeen thefinalstepinthisproceduresinceitsearlydescriptions.1 Thepurposeofnasalpackingistoavoidbleedingorseptal hematoma,reduceedema,optimizethepositionofthe sep-talflaps,closethedeadspace,provideinternalsupportand preventdisplacementofthecartilage.2_{However,these} con-siderationsarenotsupportedinstudieswithlargenumbers ofcases.3

Ontheotherhand,thereisnoconsensusonitsduration, rangingfromlessthan24htomorethanaweek.Moreover, performinganasalpackinginvolvesacertainrisk,andithas beenassociatedwithcardiovascularchanges,nasaldamage, hypoxemia,apnea,ototubaritis,otitismediaand hemotym-panum, foreign-body reactions, infections and even toxic shocksyndrome(amongothers).Themostcommonpatient complaintsarediscomfort,painandnasovagalreflexes at themomentofwithdrawalofthepacking.

Lemmenswrotethatthesearchforalternativesstarted withLee,whodescribescontinuousseptalsutureasan alter-nativeoptiontonasalpacking.4

Methods

We studied a group of 92 patients whounderwent septal surgerybetweenJanuary2008andJanuary2013(5years).

Themainandcompulsoryinclusioncriterionforthestudy waspatients with respiratory unilateral or bilateral nasal distressthatwerefoundwithseptaldysmorphia.Allpatients signedaninformedconsentpriortosurgery.

Exclusioncriteriawerepatientswithchronic rhinosinusi-tis with nasal polyposis, patients with HIV infection and immunosuppressed patients, in orderto avoid bias in the study.

Allprocedureswereperformedundergeneralanesthesia with laryngeal mask. The nose was systematically anes-thetizedwithtopicaltetracaine(10mg/mLwithadrenaline 1%)instilledwithcotton wicks,andlocalanesthetic (0.5% bupivacainewithepinephrine1:200,000)wasinfiltratedin

theseptalmucosasubperichondriallyonboth sidesofthe septum.

The incision was always hemitransfixional, the mucoperiosteal---mucoperichondrium was elevated bilat-erally and the deviated bone and cartilaginous part of theseptum weretakenoff. Aftercorrectingthe deviated structures,theincisionwasclosedwithVicrylTM_3/0.

Thedistributionofpatientsinthetwostudygroupswas randomized(bysealedenvelope).Theyweregivenanasal packing withpolyvinyl alcohol sponge(MerocelTM_{) or 2---3}

transfixingsuturestitcheswithVicrylTM_{3/0usingacurved}

needlewithat least oneor twoverticalstitches andone horizontalstitch,therebyapproximatingtheflapofmucous membraneandavoidingdeadspaces(Fig.1).

All procedures were performed in the afternoon, and patients were hospitalized until the next morning. This periodlastedabout16honaverage(range14---19).

Theywere subsequently checkedthreeandseven days aftersurgery. Duringthefirstvisit,wewithdrewthenasal

Transeptal suture

312 PlasenciaDPetal.

polyvinylalcoholspongesinthegroupofpatientswithnasal packing.All patients wererequired torank postoperative painexperiencedusingavisualscaleofpainintensity clas-sifiedinarangefrom1to5.Thisscaleisbasedonthefacial affective scale.5 _{Then, the patients were checked every} monthfor threemonthstoassess progressin themedium term.

Univariate comparisons of outcome between the two groups were made with 2 analysis, Fisher’s exact test, and t-tests. We used IBM SPSS Statistics Desktop v. 21.0 SoftwareTM_.

Surgical procedures were done in two private medi-cal centers without scientific ethic medical committee. Informedconsentwassignedforeverypatient.

Results

Ninety-twoseptoplastiesdonefromJanuary2008toJanuary 2013wereincludedinthisstudy.Thepatientsweredivided intwogroups(packingortrans-septalsuture)of46patients each.

The sex distribution of patients was 53 men and 39 women,andthemeanagewas32.12yearswithamedian of47years(range18---76).Therewerenosignificant differ-encesbetweenthetwopatientgroups.

All patients had preoperative nasal symptoms such as respiratoryfailure(100%).Otherassociatedsymptomswere rhinorrhea(52.85%),sneezing(45.71%),hyposmia(35.71%) and self-limited epistaxis (17.14%). In rhinoscopy septal deviation was observed in 100% of cases, and inferior turbinate hypertrophy in 71.42% of cases. There were no significantdifferencesinthesepreoperativesymptomsand signsbetweenthetwopatientgroupsstudied.

Mean surgery time was 32min (range14---50), with no significantstatisticaldifferencesbetweengroups.

We studied postoperativepainduring the firstweek in both groups. We have obtained significant differences in favor of thegroup undergoing trans-septal suture.In this grouponlyonepatienthadseverepaincomparedto11in thenasalpackinggroup(p<0.01)(Fig.2).

Wheninterrogatedregardingtheexistenceofheadaches after surgery we observed again significant differences. Thegroupofpatientsundergoingnasalpackinghadhigher headacheincidence(p<0.01)(Fig.3).

In the group of patients with trans-septal suture, the main complications were septal abscess and septal hematoma. In the group of patients with classic packing nonereportedsuchcomplications.Wefound nosignificant differencesbetweenthetwogroups.

Inthelastvisits(3months),thepercentageofpatients withnasalrespiratorydistresswas6.5%inthetrans-septal suturegroupand23.9%inthegroupwithpacking,withno significantdifferences.

Inthetrans-septalsuturegroupweobservedno signifi-cantepistaxis.Inthegroupofnasalpacking4patientsdid reportepistaxisjustafterremoval(8.69%),butnonehadto usethemagain.Thedifferencewassignificantinthiscase (p<0.05)(Fig.4).

One month after surgery 91.31% of patients were sat-isfiedwiththeoutcome ofthesurgery, withnosignificant differencesbetweenthetwosurgicalprocedures.

0 10 20 30 40 50

Count

No pain Very little pain

Little pain

First week postoperative pain

Severe pain Unbearable pain Moderate

pain

Transeptal suture Nasal packing

Figure2 Firstweekpostoperativepain.

Inthecoststudy,weemphasizethesavingsderivedfrom avoiding bilateral nasal packing.The costof each unit of nasalpackinginourcenteriscurrently19.5euros, exclud-ingtaxes.Inusingthisalternativeprocedure,wehavesaved 1794 euros excluding taxes, thereby increasing the effi-ciencyoftheprocess,sinceothercostsaresimilarforboth techniques.

10 20 30 40 50

Count

No pain Very little pain

Little pain

First week postoperative headache

Severe pain Unbearable pain Moderate

pain

Transeptal suture Nasal packing

0

Transeptalsuturingisacost-efficientalternativeinseptalsurgery 313

30

20

10

0

No

Postoperative epistaxis

Group_age

18-28 years old 29-38 years old 39-76 years old

Count

Yes

Figure4 Postoperativeepistaxis.

Discussion

Thisstudyaimstoverifytheusefulnessofnasaltrans-septal suturetoavoidnasalpackingandtoimprovecostefficiency ofthesurgicalprocedure.

Tothisend,wecollecteddatafromeachpatient’s medi-calhistory.Inaddition,wecollectedtheresultsbypatients inthefirstcheck,wheretheywereaskedtochooseavalue from a visual pain scale rating based on facial affective scale.5

Themaincomplaintofpatientsisthepainanddiscomfort relatedtotheremovalofnasalpacking.6

The objectiveofnasalpackingistodiminishthe likeli-hoodof postoperativebleedingbut,asseen inourseries, none of the nasal packing patients had 0% postoperative bleeding,andinfact,4patientsreportedsignificant bleed-ingafterremovalofthepacking,althoughnonehadtouse themagain.Thisagreeswiththedataobtainedinthe meta-analysisbyCertaletal.,7_{whichconcludesthatpatientswith} nasalpackinghaveareducedriskofpostoperative hemor-rhageof1%,whichisnotsignificantfromastatisticalpoint ofview.Norshouldoneforgetthatafterthewithdrawalof classicpacking,thereexiststhepossibilityofhavingtodo thepackingagain,asbleedingmayoccur.4_{Anotherobjective} of the packing is to stabilize parts of the septum carti-lageandbone.Thisstabilizationcanalsobeachievedwith the trans-septal suture structures,which can also remain stablefora muchlongertime,depending onthe material used.2

All studies reviewed conclude that patients suffer less painanddiscomfortifnonasalpacking(1---4,6---7)isused. Thedifferenceisstatisticallysignificantandismostevident inthecaseofheadaches,whicharereducedby57%if trans-septalsutureisperformed.7_{Thesedataareconsistentwith} thoseobtainedinthisstudy.

Withregardtoseptalhematoma,studiesthatcollectthis datadonotshow significantdifferences betweenthe two techniques.7 _{We have seen 2 cases, one of which was a} complicatedonewithseptalabscess.Again,nosignificant differenceswerefoundbetweenthetwogroups.Inorderto avoidtheseproblems,werecommendmakingsomeincisions inseptalmucosaasdrainage.

To all the advantages listed above, we shouldadd the reduction in costs derived from the use of packing. The trans-septal suture is made with the same material used inthehemitransfixionincisionsutureanddoes notinvolve increasingthecostofconsumables,nordoesitincreasethe durationoftheprocedure.

Conclusions

Most surgeons still use nasal packing following septal surgery. This work aims only to draw attention to the possibility of avoiding nasal packing, thereby improving postoperativepatientsandprocessefficiency.

Funding

Thisworkhasnotbeenfundedbyanypublicorprivate com-pany.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

References

1.DubinMR,PletcherSD.Postoperativepackingafterseptoplasty: isitnecessary?OtolaryngolClinNorthAm.2009;42:279---85.

2.Reiter D, Alford E, Jabourian Z. Alternatives to pack-ing in septorhinoplasty. Arch Otolaryngol Head Neck Surg. 1989;115:1203---5.

3.JosephT,MarksNJ.Submucousresectionasanoutpatient pro-cedure.JLaryngolOtol.1991;105:877.

4.Lemmens W, Lemkens P. Septal suturing following nasal septoplasty,avalidalternativefor nasalpacking?Acta Otorhi-nolaryngolBelg.2001;55:215---21.

5.Astudillo W, Mendinueta C, AstudilloE, Gabilondo S. Princip-iosbásicos paraelcontrol deldolortotal.RevSoc EspDolor. 1999;6:29---40.

6.Yilmazer C,Sener M, Yilmaz I,Erkan AN, Cagici CA, Donmez A, et al. Pre-emptiveanalgesia for removal ofnasal packing: a double-blind placebo controlled study. Auris Nasus Larynx. 2007;34:471---5.