Braz. j. . vol.82 número6

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www.bjorl.org

Brazilian

Journal

of

OTORHINOLARYNGOLOGY

ORIGINAL

ARTICLE

The

effects

of

the

time

of

intranasal

splinting

on

bacterial

colonization,

postoperative

complications,

and

patient

discomfort

after

septoplasty

operations

夽

Abdullah

Karatas

a,∗

,

Filiz

Pehlivanoglu

b

,

Mehti

Salviz

a

,

Nuray

Kuvat

b

,

Isil

Taylan

Cebi

a

_,

_Burak

_Dikmen

a

_,

_Gonul

_Sengoz

b

a_Haseki_Training_and_Research_Hospital,_Ear_Nose_and_Throat_Clinic,_Istanbul,_Aksaray,_Turkey

b_Haseki_Training_and_Research_Hospital,_Infectious_Diseases_and_Clinical_{Microbiology,}_Istanbul,_Aksaray,_Turkey

Received1June2015;accepted15November2015 Availableonline6February2016

KEYWORDS

Nasalsplint; Patientcomfort; Septoplasty

Abstract

Introduction:Themainreasonfornasaltamponplacementafterseptoplastyistoprevent post-operativehemorrhage,whilethesecondarypurposeisinternalstabilizationafteroperations involvingthecartilaginous-bonyskeletonofthenose.Siliconeintranasalsplintsareas success-fulasothermaterialsincontrollingpostoperativehemorrhagesofseptalorigin.Thepossibility ofleavingthesplintsintranasallyforextendedperiodshelpsstabilizetheseptuminthe mid-line.However,thereisnothingintheliteratureabouthowlongthesesplintscanberetained insidethenasalcavitywithoutincreasingtheriskofinfection,postoperativecomplications, andpatientdiscomfort.

Objective:The current study aimed to evaluate the association between the duration of intranasalsplinting andbacterialcolonization,postoperativecomplications,andpatient dis-comfort.

Methods:Patientswhohadundergoneseptoplastyweredividedintothreegroupsaccordingto thedayofremovalofthesiliconesplints.Thesplintswereremovedonthefifth,seventh,and tenthpostoperativedays.Theremovedsplintsweremicrobiologicallycultured.Earlyandlate complicationswereassessed,includinglocalandsystemicinfections,tissuenecrosis,granuloma formation,mucosalcrusting,synechia,andseptalperforation.Postoperativepatientdiscomfort wasevaluatedbyscoringthelevelsofpainandnasalobstruction.

Results:Nosignificantdifferencewasfound intherateofbacterialcolonization amongthe

differentgroups.Decreasedmucosalcrustingandsynechiaweredetectedwithlongerusage

intervals ofintranasal silicone splints. Postoperative pain and nasal obstruction were also diminishedbythethirdpostoperativeday.

夽 _Please_cite_this_article_as:_Karatas_A,_Pehlivanoglu_F,_Salviz_M,_Kuvat_N,_Cebi_IT,_Dikmen_B,_et_al._The_effects_of_the_time_of_intranasal splint-ingonbacterialcolonization,postoperativecomplications,andpatientdiscomfortafterseptoplastyoperations.BrazJOtorhinolaryngol. 2016;82:654---61.

∗_{Corresponding}_author.

E-mail:akrts2000@yahoo.ca(A.Karatas). http://dx.doi.org/10.1016/j.bjorl.2015.11.008

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Conclusions: Siliconesplintswerewelltoleratedbythepatientsandanynegativeeffectson postoperativepatientcomfortwerelimited.Infact,prolongedsplintusageintervalsreduced latecomplications.Long-termsiliconenasalsplintusageisareliable,effective,and

comfort-ablemethodinpatientswithexcessivemucosaldamageandinwhomlong-termstabilization

ofthebonyandcartilaginousseptumisessential.

creativecommons.org/licenses/by-nc-nd/4.0/).

PALAVRAS-CHAVE

Splintnasal;

Confortodopaciente; Septoplastia

Efeitosdotempodepermanênciadesplintsintranasaissobreacolonizac¸ão bacteriana,complicac¸õesnopós-operatórioedesconfortodopacienteapós septoplastia

Resumo

Introdução: A principal razão para a colocação de tampões nasais em septoplastias é a prevenção dehemorragia pós-operatória, enquanto oobjetivo secundário é aestabilização internaapóscirurgiasqueenvolvamoesqueletocartilaginosodonariz.Ossplintsintranasais desiliconesãotãoeficazescomooutrosmateriaisparaocontroledehemorragiasdoseptono pós-operatório.Apossibilidadedemanterossplintsintranasaisporlongosperíodosajudaa esta-bilizaroseptonalinhamédia.Noentanto,nãohánadanaliteraturasobrequantotempoesses

splintspodemsermantidosnacavidadenasalsemaumentaroriscodeinfecc¸ão,complicac¸ões nopós-operatórioecausardesconfortoaopaciente.

Objetivos: Opresenteestudotevecomoobjetivoavaliaraassociaçãoentreotempode tam-ponamentocomsplintsintranasaisecolonizaçãobacteriana,complicaçõesnopós-operatório edesconfortodopaciente.

Método: Ospacientessubmetidos aseptoplastiaforamdivididos em trêsgrupos,de acordo com odia daremoc¸ão dos splintsde silicone.Os splintsforam removidos no5◦_, ₇◦ _e ₁₀◦

diasdepós-operatório,easeguir,cultivadosmicrobiologicamente.Complicaçõesprecocese tardiasforamavaliadas,incluindoinfecçõeslocaisesistêmicas,necrosedotecido,formação degranulomas,crostasnamucosa,sinéquiaseperfuraçãodosepto.Odesconfortodopaciente nopós-operatóriofoiavaliadocomousodepontuaçãodosníveisdedoredeobstruçãonasal.

Resultados: Nenhumadiferençasignificantefoiencontradanataxadecolonizaçãobacteriana entreosdiferentesgrupos.Diminuiçõesdaformaçãodecrostasnamucosaedesinéquiasforam detectadascomtemposmaislongosdeusodesplintsdesilicone.A doreaobstruçãonasal

tambémdiminuíramnoterceirodiadepós-operatório.

Conclusões: Ousodesplintsdesiliconefoibemtoleradopelospacientes,eseusefeitos

neg-ativos sobre o conforto do paciente no pós-operatório foram limitados. De fato, o tempo

prolongado deusoteve um efeitoredutorsobreascomplicac¸ões tardias.Ousoprolongado

desplintnasaldesiliconeéummétodoconfiável,eficazepoucodesconfortávelempacientes comlesãoexcessivadamucosaenaquelescujaestabilizac¸ãoósseaecartilaginosadoseptoa longoprazoéessencial.

creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

Surgicalinterventionsdirectedatthenasalseptumare fre-quently applied in the daily practices of Ear, Nose, and Throat(ENT) specialists.Septalsurgeryforfunctional and esthetic purposes is commonly performed. The methods andmaterials used innasal packingare numerous in sep-toplasty. Various materials including cotton tape, gauze, paraffingauze,Tefla,Merocel,sponges,andsiliconenasal splintshavebeenrecommendedforthispurpose.1

Althoughthesematerialshavebeenemployedprimarily topreventpossiblehemorrhagefollowingseveral interven-tions,theyarealsoexpectedtocontributetothe stabiliza-tionofthenasalcartilaginousbonyskeletonatthemidline andpromotemucosalhealing.2,3_{Additionally,}_nasal_packing

isusedtopreventsynechiaeorrestenosis,particularlyafter surgery.2,3 _Recently, _silicone _nasal _splints _have _been _used

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siliconesplintsaidhemostasisasmuchasothermaterials.1,2

However,thesupporttheyprovidetoassistinmaintaining theseptum in themidline andtheir facilitating effecton mucosalhealingincasesofpossiblemucosalinjuryarethe mainreasonsfortheselectionofsiliconenasalsplints.2---4

Recently,siliconesplintshavebecome morepreferable inseptumsurgerycomparedtotheothermaterials.Silicone splints have the advantage of being safely and comfort-ablyretainedintranasallylongerthanothermaterials.This intervalcan be lengthenedup to 10 days in some cases. However,somelocalandraresystemiccomplications(e.g., tissuenecrosis,infections,etc.)mayariseduringintranasal tamponapplications.5---11

Unfortunately, there is no information in the litera-ture concerning how long these splints can be retained intranasally without increasing the risk of complications. Also,studies are limited concerning the effects of splint usage intervals on patient discomfort and complications, such as mucosal crusting and synechia. The current study aimed to evaluate the association of intranasal splinting intervals with bacterial colonization, early and latecomplications (tissue necrosis, mucosal crusting,and synechia), and patient discomfort. Another goal was to determinetheoptimalintranasalretentiontimeforsilicone splintsaftersurgery.

Methods

Subjects

This was a prospective randomizedclinical trial. Patients whohadundergoneseptoplastyandfunctional septorhino-plastybetweenFebruary 2014andSeptember2014 atthe HasekiTrainingandResearchHospitalwereincludedinthe study.Thepatientswerechosenbysealedenvelopeand ran-domlyassignedintooneof threegroups (Groups1---3).All patientsunderwentadetailedexaminationincludingnasal endoscopy,anteriorrhinoscopy,andcomputedtomography (CT)scan,ifnecessary,inordertoexcludeothersinonasal pathologies.The patients receiving operationsother than septoplasty, such as turbinate surgery, sinus surgery, and revisioncases,wereexcludedfromthisstudy.Patientswho requiredarhinoplastyandosteotomywerealsoexcluded. However,patients whohad a high dorsal septaldeviation andrequiredopenseptoplastywereadmittedtothestudy. Thesepatients were preoperatively equallydistributed to allgroups. Patientswithsystemicdiseases or immunosup-pressionwerealsoexcluded.Patientswhofailedtofollow postoperative instructions and take medications properly wereexcludedintheevaluationphase.

Three patient groups were created according to the removal time of the silicone splints. The splints were removedonthefifth,seventh,andtenthpostoperativedays inGroups1,2,and3,respectively.Thenumberofpatients in Groups 1, 2, and 3 were 32, 33, and 30, respectively. Group 1 consisted of 24 male and eight female patients withameanageof 30.0±8.1years(range:19---47 years); Group2consistedof25maleandeightfemalepatientswith amean ageof 29.7±8.1 years(range:19---47 years);and Group3consistedof20maleandtenfemalepatientswith ameanageof29.0±7.14years(range:18---42years).The

meanagesofthethreegroupswerenotdifferentfromeach other(p=0.890).Allsubjectswerevolunteersandwritten informedconsentwasobtainedoncethepatientswerefully apprisedofthedesign,aim,andclinicalimplicationsofthe study.

Surgicalprocedures

All procedures were performed under general anesthesia bythe samesurgeon.Eitheran open approachor Killian’s methodwaschosen for theseptoplastytechnique accord-ing tothe septalpathology. Polyglactin910 suture (Vicryl RapideTM_;_Ethicon_---_CA,_United_States)_was_used_in_Killian’s

methodandpolypropylenesuture(Prolene®_;_Ethicon_---_CA,

UnitedStates)wasusedintheopenapproach.Thesesuture materials wereonly usedfor closing atthe initialincision lines. Transseptal sutures were not used in any patients. Silicone splints withairway tubes (DoyleTM _Intranasal

Air-waySplint; Medtronic--- MN,United States)wereinserted in each nasalcavity afterthe surgery. Preoperative intra-venousantibioticprophylaxiswithsulbactam---ampicillinwas administered toall patients. Postoperative oral antibiotic treatmentswereadministereduntiltheremovalofthe sil-icone splints, in accordance with the routine practice in this clinic. In the current study, cefdinir tablets (300mg) wereadministeredpostoperativelytwotimesperday. Cef-dinirwaspreferredforitsGram-positiveandGram-negative efficacy.12---14_{Additionally,} _nasal_lavage_with_saline_solution

wasprescribedfourtimesperday.

Patientdiscomfort

Postoperative patient discomfort wasevaluated by visual analogscale(VAS)scoringofnasalobstructionandpain.VAS scores for postoperative pain measurements(0---10; 0: no pain, 10: unacceptable pain) were noted by the patients everymorningbeforetakinganalgesicsfromthefirst post-operativedayuntilthesplintswereremoved.Postoperative nasalobstructionwasalsoevaluatedbyVASscoring(0to10; 0:noobstruction,10:fullobstruction)everymorningafter nasallavage.

Complications

Complications were evaluated in two categories, which included bacterial colonization/infection related to early complicationsandlatecomplications(mucosalcrustingand synechia).

Atthecontrolexamination, allpatients wereobserved and evaluated for pressure tissue necrosis and local and systemicinfectionsigns(e.g.,nasal vestibularhyperemia, tenderness, purulent discharge, septal hematoma, septal abscess,fever,andgeneralpoorhealthinthepostoperative period).

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Table1 Cultureresultsaccordingtothegroups.

5th(n=32) 7th(n=33) 10th(n=30) p

n % n % n %

Gram-positive 15 46.9 10 30.3 15 50.0 0.229

Gram-negative 16 50.0 18 54.5 17 56.7 0.864

Fungus 0 0.0 0 0.0 1 3.3 0.484

Nogrowth 1 3.1 5 15.2 2 6.7 0.106

Total 32 100.0 33 100.0 30a ₁₀₀

a _Two_different_bacterial_colonization_occurred_together_in_five_patients_in_Group_3.

performedbythesameperson.Thesurgeonwhoperformed theoperationsdidnotparticipateinthisevaluation.

Microbiologicalprocedures

Materialremovedfromtherightnasalcavitywasincludedin thestudyinallpatients.Trypticsoybroth(2mL)waspoured onthe splints, which were then sent to themicrobiology laboratorytobeincubatedfor2hat37◦_C._A_0.01_mL_sample

fromthefluidsamplescontainingthesplintswasobtained andcultivatedinchocolateagarandMcConkeyagar.Plaques keptintheincubatorwereevaluatedafter24and48hand colonycountswereperformed.Bacterialidentificationwas performedforeachcolonyusingconventionalmethods.

Statisticalanalysis

Rate and frequency values were used in the descriptive statistics.Thechi-squaredtestandFischer’stest(when chi-squared test conditions were not met) were used in the analysisofcategoricaldata.SPSS22.0software(SPSSInc. ---Chicago,IL,UnitedStates)wasusedforstatisticalanalysis. Ethical approval for the study was obtained from the HasekiTrainingandResearchHospitalEthicsCommitteeon February5,2014(ProtocolNo.38).

Results

Bacterialcolonizationandinfection-relatedearly complications

No significant differences between the three groups regardingbacterialcolonizationratesofGram-positiveand Gram-negative bacteria (p=0.229), fungi (p=0.864), or

othermicroorganisms(p=0.484),andnogrowth(p=0.106) werefound(Table1).

When Gram-negative bacterial colonization was evalu-atedaccording to theintranasal splint retention interval, thegrowthrateofthemainpathogenicspecies( Enterobac-ter spp., Escherichia coli, and Klebsiella spp.) and other specieswerenotsignificantlydifferentamongGroups1---3 (p=0.616, p=0.322,p=0.582,andp=0.962,respectively;

Table2).

When Gram-positive bacterial colonization was evalu-atedaccording to theintranasal splint retention interval, the growth rate of methicillin-resistant Staphylococcus epidermidis (MRSE), methicillin sensitive S. epidermidis

(MSSE),methicillin-resistantStaphylococcusaureus(MRSA), methicillin-sensitiveS. aureus (MSSA), and other types of specieswerenotsignificantlydifferentamongGroups1---3 (p=0.317,p=0.132,p=1,p=0.601,andp=0.108, respec-tively;Table3).

When the staphylococci with and without methicillin-resistance were analyzed together, the growth rate of MRSE/MRSA (major pathogenic species), MSSE/MSSA (can befound in nasal flora), andother species inGroups 1---3 were not significantly different (p=0.239, p=0.134, and

p=0.108,respectively;Table4).

Allpatients wereobserved andevaluatedfor infection relatedtoearlylocalandsystemiccomplications(e.g., pres-suretissuenecrosis,nasalvestibularhyperemia,tenderness, purulent discharge,septalhematoma, abscess,fever, and generalpoorhealth).Nolocalorsystemiccomplicationsin thepostoperativeperiodweredetected.

Patientdiscomfort

Inallgroups,themeanpainVASscoreswerehigherinthe first three days than in the other days. The mean pain

Table2 DistributionofthemainGram-negativepathogenbacteriaamongthegroups.

5th(n=32) 7th(n=33) 10th(n=30) p

n % n % n %

Enterobacterspp. 4 12.5 4 12.1 6 20.0 0.616

E.coli 3 9.4 6 18.2 2 6.7 0.322

Klebsiellaspp. 4 12.5 2 6.1 4 13.3 0.582

Others 5 15.6 6 18.2 5 16.7 0.962

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Table3 DistributionofGram-positivebacteriaamongthegroups.

5th(n=32) 7th(n=33) 10th(n=30) p

n % n % n %

MRSE 1 3.1 4 12.1 4 13.3 0.317

MSSE 8 25 3 9.1 3 10.0 0.132

MRSA 0 0 1 3.0 0 0 1

MSSA 2 6.3 1 3.0 2 6.7 0.601

Others 4 12.5 1 3.0 6 20.0 0.108

Total 15 46.9 10 30.3 15 50.0 0.229

MRSE,methicillinresistantStaphylococcusepidermidis;MSSE,methicillinsensitiveStaphylococcusepidermidis;MRSA,methicillin resis-tantStaphylococcusaureus;MSSA,methicillinsensitiveStaphylococcusaureus.

Table4 DistributionofGram-positivebacteriaamongthegroupsaccordingtothemethicillinresistance.

5th(n=32) 7th(n=33) 10th(n=30) p

n % n % n %

MRSE/MRSA 1 3.1 5 15.2 4 13.3 0.239

MSSE/MSSA 10 31.3 4 12.1 5 16.7 0.134

Others 4 12.5 1 3.0 6 20.0 0.108

Total 15 46.9 10 30.3 15 50.0 0.229

MRSE,methicillinresistantStaphylococcusepidermidis,MSSE,methicillinsensitiveStaphylococcusepidermidis;MRSA,methicillin resis-tantStaphylococcusaureus;MSSA,methicillinsensitiveStaphylococcusaureus.

VASscoresdecreasedsignificantlyafterthethirddayinall groups(p<0.05)(Fig.1).

Inallgroups,themeannasalobstructionVASscoreswere loworsimilarwithpreoperativevaluesforalldays. There-fore,itcouldbesuggestedthattherewasatolerablelevel ofnasalobstructionforthepatients(Fig.2).

Latecomplications

Mucosalcrusting:prolongedmucosalcrustingwasdetected in 12 patients in Group 1, six patients in Group 2, and

two patients in Group 3. The rate of mucosal crusting wasdecreasedwithprolongedintranasalsplintingintervals (p=0.0105;Table5).

Synechiae

SynechiaewerefoundinsixpatientsinGroup1,twopatients in Group 2, and no synechiae were found in Group 3. Therateofsynechiaformationwassignificantlydecreased with prolonged intranasal splinting intervals (p=0.0244;

Table5).

1st day

2nd day

3rd day

4th day

5th day

6th day

7th day

8th day

9th day

10th day

Group 1 8 8 7 5 4

Group 2 8 7 7 4 4 2 2

Group 3 8 8 7 4 4 3 2 2 1 1

0 1 2 3 4 5 6 7 8 9

Group 1 Group 2 Group 3

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Preop 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th

Group 1 8 8 8 6 6 5

Group 2 7 8 7 6 4 4 4 4

Group 3 8 8 8 7 5 5 5 4 5 4 4

0 1 2 3 4 5 6 7 8 9

Days Group 1 Group 2 Group 3

Figure2 Nasalobstructionscoresinthegroups.

Table5 Latecomplicationsinthegroups.

5th(n=32) 7th(n=33) 10th(n=30) p

n % n % n %

Mucosalcrusting 12 37.5 6 18.2 2 6.6 0.0105

Synechia 6 18.8 2 6.0 0 0.0 0.0244

Discussion

Nasal packing methods andapplication intervals are vari-ableafterseptoplastyoperations. Severalsurgeonsdonot use any nasal packing materials, preferring transseptal sutures only. Patient discomfort and local or systemic adversereactionsduetonasalpackingresultedindifferent applicationsconcerningtheselectionofpackingmaterials, postoperative antibiotic therapies, and the duration of nasalpacking.Theuseofantibioticsinpatientswithnasal packing is controversial. Nasal packing applications have beenacceptedasatechniquethatmightpossiblyresultin localandevensystemicinfectionsincludingStaphylococcal Toxic Shock Syndrome (STSS).5---11 _Therefore, _as _a _routine

application in manyclinics, oral antibiotics arecontinued untilthetamponsareremoved.Recommendationsfor post-operative antibiotherapy are commonly found in classical textbooks.15,16 _However, _a _number _of _reports _have _been

published recently in the medical literature suggesting that postoperative antibiotherapy is unnecessary after septoplastyorrhinoplasty.Georgiouetal.,intheirreview of antibiotic prophylaxis in rhinoplasty and septoplasty, evaluated the outcomes of 11 different studies.17 _These

studies confirmed that the risk of infection is very low in elective nasal operations and thus, routine antibiotic prophylaxis is unnecessary. Antibiotic prophylaxis has been recommended in cases of complicated revisions, in patients with a tendency to develop infection, and in patientsinwhomlong-termnasaltamponapplicationsare planned.17,18_However,_although_there_are_published_reports

not recommending postoperative antibiotic prophylaxis, manyENTspecialistscontinue toprescribeoralantibiotics untiltheremovalofthetampons.

InastudyperformedbytheAmericanRhinology Associa-tion,therateofantibioticprescriptionofthesurgeonsafter septoplastywasreportedas70%. Therationale for antibi-oticusewasreportedasinfectioncontrolin60%ofcases, preventionof toxic shock in 31.5% of cases,medico-legal purposesin4.9%ofcases,andpreventingfoulodorsin3.1% of cases.19 _In _the _current _study,_cefdinir _tablets ₍₃₀₀_mg)

were administered postoperatively two times a day. We foundthattherewerenochangesinbacterialcolonization propertiesduetosplintingintervalsandnoinfectionswere relatedtoearlycomplications.However,severalpathogenic agentsalongwithnormalflorabacteriawereisolatedinthe cultures(Tables1---4).Therefore,werecommendthat post-operativeantibioticprophylaxisshouldbeprescribeduntil theremovalofthenasalsplints.

Intheirliteraturereview,Weber etal.evaluatednasal packing materials (other than silicone splints) according toretention timesand side effects.In their study, reten-tionintervalsformaterialssuchasMerocel,paraffingauze, gauze,fingerstalls, and silastic splints ranged from24 to 72h.20 _However,_there_has_been_no_consensus_in_retention

intervalsofsiliconenasalsplints.Inourstudy,wefoundthat siliconenasalsplints might be retainedintranasally up to 10dayswithout increasinginfection-relatedearly compli-cationrates.

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present study. In the literature, facial pain, headaches, nasalobstruction,xerostomia,anddysphagiadue tonasal obstructionaremajorparametersintheassessmentof post-operativepatientdiscomfort.21,22

In our study, postoperative pain scores were higher in the first three days and decreased significantly after the fourthday.Splintusageintervalsdidnothaveanyincreasing effectonthepainscores.Withtheuseofanalgesics,pain complaintsweresustainedatareasonablelevel.

Preoperativeandpostoperativenasalobstructionscores werecomparableandVASscoresmeasuredduringtheuseof siliconesplintsweresimilartopreoperativevaluesorlower. Therefore, nasal obstruction due to silicone nasal splints wasconsideredacceptable.Whentheeffectofsplintusage intervals onpain and nasal obstruction scores was evalu-ated,long-termuseofnasalsplintswaseasilytoleratedby thepatients anddidnothaveaseriousnegativeeffecton patientcomfort.

Prolonged mucosal crusting and synechia are two late complicationsafterseptoplastythatcanobstructnasal air-flow.Wefoundthatthelongersplintusageintervalresulted in decreased mucosal crusting and synechia rates. These findings correlate well with other studies suggesting that siliconesplintshaveapositiveeffectonhealingand epithe-lizationbyprovidingthedurabilityofnasalmucosa.2,3

Limitations

No significant changes in bacterial colonization proper-ties due to splint usage intervals were detected and no infection-related early complications were observed in this study. However, toxic shock syndrome (TSS) is a rarebutveryimportantsystemicinfectionthatcan result fromnasal packingapplications(siliconesplintsandother materials).3---11_The_sample_size_of_this_study_was_very_small

fortheassessmentofararecomplicationsuchasTSS; there-fore,studieswithlargersamplesizesareneededtoobtain aconclusivedecisionconcerningSTSSrisk.

Conclusion

Theuse ofsiliconesplintswaswelltolerated bypatients; negativeeffectsonthepostoperativepatientcomfortwere limited.Infact,aprolongedsplintusagetimeintervalhad a reducing effecton later complications such asmucosal crustingandsynechia.Long-termsiliconenasalsplintusage isareliable,effective,andcomfortablemethodforpatients withexcessivemucosaldamageandinwhomlong-term sta-bilizationofthebonyandcartilaginousseptumisessential.

Financial

support

Financialsupportwasprovidedbythemanagementofthe HasekiTrainingandResearchHospital.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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