Braz. j. . vol.81 número2

www.bjorl.org

Brazilian

Journal

of

OTORHINOLARYNGOLOGY

ORIGINAL

ARTICLE

Assessment

of

mucosal

changes

associated

with

nasal

splint

in

a

rabbit

model

夽

,

夽夽

Mehmet

Tan

_,

_M.

_Tayyar

_Kalcioglu

,

Nurhan

Sahin

,

Tuba

Bayindir

,

Emine

Samdanci

_,

_Aliye

_Filiz

a_{DepartmentofOtorhinolaryngology,InonuUniversityMedicalFaculty,Malatya,Turkey}

b_{DepartmentofOtorhinolaryngology,IstanbulMedeniyetUniversitySchoolofMedicine,Istanbul,Turkey} c_{DepartmentofPathology,InonuUniversityMedicalFaculty,Malatya,Turkey}

d_{DepartmentofOtorhinolaryngology,ZekaiTahirBurakHospital,Ankara,Turke}

Received19November2013;accepted28March2014 Availableonline23August2014

KEYWORDS Nasalmucosa; Nasalseptal perforation; Nasalseptum; Tamponssurgical

Abstract

Introduction:Thereisnoconsensusondurationofthenasalsplintafternasalseptum surger-ies.The pressureofnasalsplintonthemucosamay causetissuenecrosisandnasalseptum perforation.

Objectives:Toinvestigatethehistopathologicalchangesofthenasalmucosacausedbynasal splintsinarabbitmodel.

Methods:NosplintwasusedingroupA.Bilateralsiliconenasalsplintswereplacedforfive, ten,and15daysingroupsB,C,andD,respectively.Biopsyofthenasalmucosawasperformed afterremovalofsplint.Histopathologicevaluationswereperformed.Theseverityanddepth oftheinflammationwerescored.

Results:GroupA hadanormalhistologicalappearance.Comparisonoftheresultsofgroups B,C,andDwithgroupAdemonstratedstatisticallysignificantdifferenceswithregardstothe severityofhistopathologicalfindings.Therewasnostatisticallysignificantdifferencebetween groupsBandC.TherewerestatisticallysignificantdifferencesbetweenthegroupsBandD, andalsobetweengroupsCandD.

Conclusions:Longerdurationofnasalsplinthadahigherriskforseptalperforation.Therefore, removalofthesplintassoonaspossiblemaybehelpfulforpreventingpotentialperforations. © 2014Associac¸ãoBrasileira de Otorrinolaringologiae CirurgiaCérvico-Facial. Publishedby ElsevierEditoraLtda.Allrightsreserved.

夽 _{Institution:IstanbulMedeniyetUniversity,SchoolofMedicine,Turkey.} 夽夽

Pleasecitethisarticleas:TanM,KalciogluMT,SahinN,BayindirT,SamdanciE,FilizA.Assessmentofmucosalchangesassociatedwith nasalsplintinarabbitmodel.BrazJOtorhinolaryngol.2015;81:184---9.

∗_{Correspondingauthor.}

E-mail:[email protected](M.T.Kalcioglu).

http://dx.doi.org/10.1016/j.bjorl.2014.08.004

1808-8694/©2014Associac¸ãoBrasileiradeOtorrinolaringologia eCirurgiaCérvico-Facial. PublishedbyElsevierEditoraLtda.All rights

PALAVRAS-CHAVE Mucosanasal; Perfurac¸ãodosepto nasal;

Septonasal; Tampõescirúrgicos

Avaliac¸ãosobrealterac¸õesnamucosa,associadasaousodesplintsnasais,utilizando coelhoscomocobaias

Resumo

Introduc¸ão: Nãoexiste consensoacercadotempodepermanênciadesplintsnasaisno pós-operatóriodecirurgiasnosepto.Apressãocausadapelosmesmosnamucosanasalpodecausar necroseeperfurac¸õesseptais.

Objetivos: Investigarmudanc¸ashistopatológicasdamucosa nasalcausadasporsplintsnasais emcoelhos.

Método: NenhumsplintsfoiutilizadonogrupoA.Splintsdesiliconeforamutilizadospor5, 10 e15 diasnos grupos B, Ce D, respectivamente. Biópsia da mucosa nasal foi realizada apósa remoc¸ãodos mesmos.Avaliac¸ões histopatológicasforamrealizadas, eagravidadee aprofundidadedoprocessoinflamatórioforammedidas.

Resultados: GrupoAapresentouumaaparênciahistológicanormal.Comparac¸õesderesultados entreosgruposB,CeDcomogrupoA demonstraramdiferenc¸asestatísticasrelevantes na gravidadehistopatológica.Nãohouvediferenc¸asestatísticasrelevantesentreosgruposBeD, assimcomoentreosgruposCeD.

Conclusão:Deacordocomosresultados,quantomaioradurac¸ãonousodesplintsnasaismaioro riscodeperfurac¸ãoseptal.Portanto,aremoc¸ãodesplintsnasaisdeveserrealizadaassimque possível,prevenindopotenciaisperfurac¸ões.

©2014Associac¸ãoBrasileiradeOtorrinolaringologiaeCirurgiaCérvico-Facial.Publicado por ElsevierEditoraLtda.Todososdireitosreservados.

Introduction

Various types of packing are placed into the nasal pas-sagesafternasalseptum surgeriesinordertoensure that thebilateralmucoperichondrialflapsaresecuredinplace. Securingthemucoperichondrialflapsisimportanttoprevent complications suchas bleedingor hematoma.1 _Placement

of packingintothe nasalpassages betweenthe nasal lat-eralwallandtheseptumalsopreventspotentialsynechiae. Thereisnoconsensusonhowlongthenasalsplint canbe keptinplacewithoutcausinginjurytothenasalstructures.2

Nasal septum perforation as a post-surgical complica-tionisobservedinapproximately0.7---1.4%ofpatientsafter septoplasty.3_{Nasalseptumperforationoccursdueto}

respec-tivemucosaldamage,particularly.Suchaperforationmay becausedbydisruptedbloodfloworiginatingfromthenasal splintpressureonthemucosaandtissuenecrosis.

Thepresentstudyassessedthehistopathologicalchanges of thenasal mucosacaused bynasal splint andevaluated therelationshipbetweenthedurationofnasalpackingand septalperforationinarabbitmodel.

Methods

TheexperimentalstudywasapprovedbytheExperimental AnimalEthicsCommittee(2011/A39).Atotalof28healthy rabbitswithnormalanteriorrhinoscopicexaminationwere included. Animals were randomly assigned to four equal groups.Inthecontrolgroup(groupA),nonasalsplintwas placed. Nasal packing was placed using bilateral silicone nasal splints sutured with 4-0 silk suture and were held in placefor five,ten,and 15days ingroups B,C, andD, respectively,afteranesthesiausingketaminehydrochloride

80mg/kg IM(Ketalar 10mL flask, E.Warner Lambert)and xylazinehydrochloride2mg/kgIM(Rompun50mL2%flask, Bayer) combination. After the procedure, metamizole 10mg/kgwasadministeredintramuscularlytorelievepain. Thesizeofnasalsplintwasapproximately1.5cm×0.7cm diameter.

According to the clinical observations, septal perfora-tiondue to the nasal splint wasseen onthe end portion (proximal)of the splint. Based onthis observation, biop-sieswere obtained 1cm behindthe columella, measuring approximately0.5cm×0.5cm diameter,under anesthesia in the group A at the beginning of the study and in the other groups, after the nasal splint was removed. The biopsyspecimenwasfixed ina 10%neutralformalin solu-tionandaroutinetissuefollow-up wasperformed.It was then embedded in paraffin and cut into 5␮m thickness. Hematoxylin---eosin(H---E)stained sectionswere evaluated underlight microscopyby twosingle-blindedpathologists; allevaluationsbetweenthetwopathologistswerein agree-ment.

Thesurfaceofnormalseptalmucosawaslinedby respi-ratoryepithelium,withhyalinecartilage,whichconsistsof vessels and connective tissue under the submucosa. The findingswerecompared withnormalmucosal patternand scoredfrom0to3,basedonthepresenceandcharacterof inflammation(acuteorchronicinflammation),mucosal ero-sion,ulceration, andperforation. The acuteinflammation wasshownbyneutrophilprepotencywithrareeosinophils. Also,the severity of the inflammation was scored by the number of inflammatory cells in a 400× magnification area (no inflammatory cells [0]; less than 10 inflamma-torycells,mild1_{;10---30inflammatorycells,moderate}2_;and

over 30 inflammatory cells, severe3_{). Histomorphological}

Table1 The severityandlocalizationofinflammationin groupD.

Groups Inflammationa _Localizationb

0 1 2 3 0 M MS P

A 1 + +

2 + +

3 + +

4 + +

5 + +

6 + +

7 + +

B 1 + +

2 + +

3 + +

4 + +

5 + +

6 + +

7 + +

C 1 + +

2 + +

3 + +

4 + +

5 + +

6 + + +

7 + +

D 1 + +

2 + +

3 + +

4 + +

5 + +

6 + +

7 + +

a_{Inflammation:0,noinflammation;1,mild;2,moderate;3,}

severe.

b _{Localization:0,normal;M,limitedtothemucosa;MS,limited}

tothemucosaandthesubmucosa;P,perforation.

mucosa,involvingthesubmucosa,andmucosalulcerations and/orperforations.

SPSS 17.0 was used for statistical evaluation. The Kruskal---Wallistestwasusedtocompareallgroups,andthe Mann---WhitneyUtestwasusedforcomparingtwogroups.

Results

Inflammatoryandhistopathologicchangesobserved inthe groups areshown in Table1. The controlgroup (groupA) hadanormalhistologicalappearance(Fig.1).Therewasno inflammationinthegroupA.InthegroupB,therewasmild inflammationinvolvingthemucosainfiveanimals,and mod-erateinflammationthatextendedtothesubmucosaintwo animals(Fig.2).Theaverageseverityoftheinflammation was1.28forthegroupB(Fig.3).

IngroupC,mildinflammationinvolvingthemucosawas foundintwoanimals,moderateinflammationextendingto thesubmucosa inthreeanimals, andsevere inflammation

Figure1 Normalhistologicalappearance(hematoxylin---eosin [H---E]100×).

Figure 2 Acuteinflammation confined tothemucosa (H---E 400×).

extendingthesubmucosaintwoanimals(Fig.4).Increased inflammationwasseeninthegroupCcomparedtogroupB. IngroupD,therewassevereinflammationextendingto thesubmucosainfouranimals(Fig.5).Oneanimalwasfound to have moderate inflammation extending to the submu-cosa. Intwoanimals,severe inflammation presentedwith perforations and ulcerations.The average severity of the

Inflammation

Se

ver

ity of inflammation

3

2.5

1.5

0.5

0 1 2

Groups

A B C D

Figure4 Severeacuteinflammationofthesubmucosa(H---E 200×).

Figure5 Ulcerationofthemucosa(H---E100×).

inflammationwas2.85(Fig.3).Therewasincreased inflam-mationcomparedwithgroupC.

Theresultsshowedthattherewasastatistically signifi-cantdifferenceintheseverityofhistomorphologicalfindings betweenthegroupAandtheothergroups(groupsB,C,and D).

There wasno statisticallysignificant differenceon the severityofhistomorphologicalfindingsbetweengroupBand C(p>0.05).However,statisticallysignificantdifferencesin theseverityofhistomorphologicalfindingsbetweengroups BandD,andgroupsCandD(psplint)heldforthelongest timeandmacroscopicperforationswereseenintwoanimals inthisgroup.

Discussion

Septoplasty,septorhinoplasty,andendoscopicsinussurgery are commonly performed surgical methods by ear, nose, and throat, and plastic surgeons. Various types of nasal packing are used both to prevent nasal bleedings and/or septal hematomas, and also to support fenestrated parts untiltheyarehealedwithfibrin,especiallyinseptoplasty

andseptorhinoplasty.1_{Nasalpackingusedinthesesurgeries}

affectsfunctionofthenoseandcomfortofthepatient. How-ever,therehasbeennoconsensusachievedontheduration, indications,andtypeofnasalpacking.2,4

Nasalpackingmaycausevariousproblemssuchasnasal septalperforations,5_{pyogenicgranulomas,}6_{life-threatening}

toxicshocksyndromes,7_{obstructivesleepapneas,}8_reduced

oxygensaturationandincreasedpulserates,9_pains,10,11_and

necrosisoftheinferiorturbinate.5_{Changesintheear}

pres-sureassociatedwithnasalpackingwerealsofound.12_Ithas

beenacceptedthatthedurationofnasalpackingpotentially influencesthedevelopmentofthesecomplications.Theuse ofnasal packing afterseptal surgeryis still under discus-sion.Inordertoavoidthecomplicationsof nasalpacking, trans-septalsuturingtechniqueshavebeenadoptedinstead ofpacking,andvariouscomparativestudieshavebeen con-ductedinthisrespect.Inonesuchstudy,Ardehalietal.11

comparedpatientswhoreceivednasalpackingwithpatients whoreceivedtrans-septalsuturingaftersurgeryandfound nosignificantdifferencesfortherateofhematoma, perfo-rations,andsynechiae.Camirandetal.13_{reportedthatthey}

didnotuseanytypeofnasalpackingafterthesurgeryand documentednocomplications,suchasepistaxis,synechiae, hematoma,orseptalperforations,similartothefindingsof Lemmensetal.14

Genc et al. investigated the effects of nasal packing moistened with vaseline-nitrofurazone against trans-nasal suturingtechniquesontheseptumofrabbitsbyevaluating thehistopathologicalchangesofpackingonnasalmucosa.15

Thepackingwasheldinthenosefor48h.Increasedmucosal inflammationwasobservedinbothtechniques,andno sta-tisticalsignificancewasfoundwhencomparedtothecontrol group.McIntoshetal.16_{causedwoundsonthenasalmucosa}

on an animal model, then applied Merocel® _{as packing} material to the one side and leftthe other side without packing.Thepackingwasremovedonthefifthday,andno histopathologicaldifferenceinthere-epithelizationand cil-iaryfunctionsofthenasalmucosawasfoundbetweenthe twogroups. Thisstudy suggestedthatholdingthepacking inplaceforextendedperiodsfollowedbyendoscopicsinus surgeries has no effects on the recovery of the mucosa. Againstthese studies, the present study found significant increasedinflammationscoresevenifthenasalpackingwas keptinthenoseforfivedays.Itissuggestedthatthis find-ingcouldbeduetonecrosisasaresultofmucosalpressure. Necrosisonthecartilage wasobservedin groupD, where thepackingwasheldfor thelongest timeinourstudy.In addition,perforation wasobserved in two animalsin this group. Nasal septal perforation may be related with the hypoxemic---ischemicnecrosisofthecartilageasaresultof pressure.

Maccabee et al. investigated the histopathological effectsofnasalpackingonparanasalsinusmucosa.17 _They

resultinginloss ofthe entire epitheliallayer is similarto thefindingsofthepresentstudy.However,itisimpossible forthesiliconenasalpackingusedinthepresentstudy to beintroducedintotheregeneratedepithelium.Theuseof nasalpackingisexpectedtodisruptciliaryactivity,which isoneofthemostimportantelementsofnasalepithelium. Shaw,inhisstudyonthenasalmucosaofsheep,showedthat theciliarysurfaceonthenose wasreducedby 50---68%by intranasalpacking.18_{Anotherstudycomparedthe}

mucocil-iaryactivitybyrhinoscintigraphyfollowingseptumsuturing ofnasalpacking,andfoundnomeaningfuldifferences.Also, nopre-andpost-operativedifferenceswerefound.19_Inthe

presentstudy,epithelialinflammationwasobservedatthe lowest level in the group in which the nasal packing was removedatanearlystage.Likewise,itis anticipatedthat earlyremovalofnasalpackingcontributespositivelytothe ciliaryfunction.

The knowledgeof howlong afrequentlyusedmaterial canbeheldinaspecificregionandwhichproblemsmayarise duringthisperiodhaspotentialtocontributetothemore efficientuseof that material.There hasbeen no consen-susonhowlong nasalpackingshouldbeheld inthenose. Toaddressissue,mostoftheear,nose,andthroatsurgeons andsourcebookshaverecommendedtheremovalofpacking at48handbeyond.InacontrolledstudybyJiannisetal., 75patients were treated by septoplasty, and thepacking washeldinplacefor24hinonegroup,and48hinanother group.20 _{Theyscored thepatientcomfortduringthis time}

usingavisualanalogscale.Theyfoundthatthepatient com-fortwaspoorerinthegroupwherethepackingwasheldin placefor48h.Thesamestudyfoundnodifferencesfor post-operativecomplicationsofbleedingandpain,alsoreporting that the group where the packing was held for 48h had higherfever.Theyrecommendedtheremovalofthepacking intheshortesttimepossible.However,theymadeno men-tionofitseffectsonnasalmucosaintheirstudy.Thisfinding isinsupportofthepresentfindingthatthepackingshould beremovedquickly.Inanotherstudy,nostatistically signifi-cantdifferenceswerefoundforhemorrhagiccomplications betweenmaintenanceofthepackingfor24hor48h.4

There hasbeen noconsensusonhow long thepacking usedafter nasal surgery should be held in the nose, and the typeof packing to be used.No studies, except for a study by Lubiancaet al.4 _{regarding the duration of nasal}

packinginthenose,werefoundintheliterature.Thisstudy alsoreportedthattherewerenostatisticaldifferencesfor hemorrhagiccomplicationsbetweentheplacementof24-h packingand48-hpacking.Ensuringthatpatientscanquickly returntotheirworkandresumetheirdailysocialactivities afterthesurgeryisanimportantcriterionusedtoassessthe successof operations. However,despite short hospitaliza-tionafternasaloperations,extendeddurationofthenasal packingseriouslydisruptsthepatient’scomfort.

Conclusion

After nasal splint, the inflammation of the nasal mucosa andthe risk for septal perforation increasedas thenasal splintwaskeptinplacelonger.Conceivably,therecouldbe acorrelationbetweenseptalperforationandtheduration ofnasalsplintafterseptoplasty.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

Acknowledgements

The research wassupported by the Research Fund of the InonuUniversity,Malatya,Turkey.

The authors would like to thank Ms. Nazire Bulam, a biostatistics expert from the Turgut Ozal Medical Center Medical Center,whocontributedtostatistical evaluations ofthisstudy.

Theauthors wouldalsolikethank SeckinUlualp, M.D., from the Department of Otolaryngology-Head and Neck Surgery University of Texas Southwestern Medical Center Dallas, Texas, USA, for his assistance with editing the manuscript.

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