|Year : 2018 | Volume
| Issue : 4 | Page : 333-342
Immediate and short-term outcome of septoplasty with nasal packing with reference to the effect of arterial blood gases’ concentrations
Mohamed A Fatahalla1, Ashraf A Wahba1, Mahmoud M Elsayed2
1 Department of Otorhinolaryngology, Faculty of Medicine, Al-Azhar University, Demiatte, Egypt
2 Department of Anaesethiology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
|Date of Submission||11-Apr-2018|
|Date of Acceptance||03-Mar-2019|
|Date of Web Publication||23-Apr-2019|
Mohamed A Fatahalla
Faculty of Medicine Al-Azhar University Demiatte, Department of Otorhinolaryngology, Faculty of Medicine, Al-Azhar University, Demiatte
Source of Support: None, Conflict of Interest: None
Objectives To evaluate the outcome of septoplasty and the effect of bilateral anterior nasal packing (NP) on surgical outcome and postoperative (PO) arterial blood gas levels.
Patients and methods A total of 90 patients underwent septoplasty: group I included patients who received PO bilateral anterior NP at the end of surgery for 48 h and group II included patients free of NP. Patients were evaluated clinically using the Nasal Obstruction and Septoplasty Effectiveness scale and underwent septoplasty using Cottle’s technique. Arterial blood samples were obtained preoperatively and before NP removal for estimation of arterial blood pH, bicarbonate (HCO3−), partial pressure of O2 (PaO2) and CO2 (PaCO2), and O2 saturation (SaO2) levels. Pain severity was assessed using numeric rating scale at 6 h, D-1, and D-2 PO, and during the first 48 h PO, nasal bleeding in group II was estimated. After NP removal, pack removal-associated pain and amount of bleeding were determined.
Results Operations were conducted uneventfully with nonsignificant difference between groups. At 48 h PO, mean PaO2, PaCO2, and SaO2 levels were significantly lower in all patients than preoperative levels, with significantly lower SaO2 and PaCO2 levels in patients of group I than group II. Numeric rating scale pain scores in both groups showed progressive significant decrease till 48 h PO, with significantly lower scores in group II. Removal of NP resulted in pain scored by more than or equal to 4 in 30 patients and induced minimal bleeding, which was significantly lower than bleeding occurred in patients of group II throughout the 48 h PO. All patients enjoyed significant reduction of Nasal Obstruction and Septoplasty Effectiveness score, with nonsignificant difference between both groups.
Conclusion NP after septoplasty reduced amount of PO bleeding, but pain associated with NP presence and removal-induced deleterious effect on patients’ satisfaction with deleterious effect on arterial blood O2 and CO2 levels but with nonsignificant effect on arterial blood pH or HCO3 concentration.
Keywords: arterial blood gases, nasal packing, nasal septoplasty
|How to cite this article:|
Fatahalla MA, Wahba AA, Elsayed MM. Immediate and short-term outcome of septoplasty with nasal packing with reference to the effect of arterial blood gases’ concentrations. Al-Azhar Assiut Med J 2018;16:333-42
|How to cite this URL:|
Fatahalla MA, Wahba AA, Elsayed MM. Immediate and short-term outcome of septoplasty with nasal packing with reference to the effect of arterial blood gases’ concentrations. Al-Azhar Assiut Med J [serial online] 2018 [cited 2019 Aug 20];16:333-42. Available from: http://www.azmj.eg.net/text.asp?2018/16/4/333/256755
| Introduction|| |
Severe nasoseptal deviation is one of the most common causes of nasal obstruction and deformity, which is consider one of the challenges for plastic surgeons. Septal surgery plays a central role in the management of complex cosmetic and functional problems and should be considered as a basic procedure in nasal surgery .
Septorhinoplasty is one of the most common nasal surgeries performed by otorhinolaryngologists , aiming to create an esthetically elegant nose and harmony in the face by preserving nasal function as well as maintaining or restoring adequate airway .
Bilateral anterior nasal packing (NP) is used after septoplasty with the goals of decreasing the risk of postoperative (PO) bleeding and adhesions . However, nasal obstruction secondary to PO NP may influence respiration during sleep and cause nocturnal oxygen desaturation and obstructive sleep apnea .
Moreover, a significant increase in the number of nocturnal episodes of hypoxia and a significant prolongation of the mean duration of the individual hypoxic periods were demonstrated during the first and the second PO nights with bilateral anterior NP .
Furthermore, multiple studies caution against the use of NP because of the risk of cardiopulmonary complications . Moreover, patients who received NP experienced epiphora, tinnitus, ear fullness, sleep disturbance, and nasal congestion than those who had nasal suturing .
The current study aimed to evaluate outcome of septoplasty and the effect of bilateral anterior NP on surgical outcome and PO arterial blood gas (ABG) levels.
| Patients and methods|| |
The current prospective comparative study was conducted at Otorhinolaryngology and Anesthesiology Departments, JCK Hospital, KSA, since January 2015, so as to include all patients assigned for nasal septal surgeries. Patients were randomly allocated, using sealed envelopes, into two groups: group I included patients who received PO bilateral anterior NP at end of surgery and group II included patients free of PO NP.
Exclusion criteria included presence of nasal polyps, indicated additional surgical procedures, systemic diseases altering blood coagulation cascade, history of bleeding diathesis, or maintenance on anticoagulant therapy. For comparative purpose, the study also included a control group of age-, sex-, and BMI-matched patients assigned for general surgical procedures requiring short operative time and received general anesthesia. Blood samples were obtained from controls after induction of anesthesia for estimation of ABG as control levels.
All patients underwent clinical evaluation for assurance of absence of exclusion criteria and determination of demographic and constitutional data especially body weight and height for calculation of BMI as the ratio of body weight in kilograms divided by the square of height in meters .
Then, patients underwent full otorhinolaryngological examination for ensuring inclusion criteria. The effect of nasal septal disease on patients was evaluated using the Nasal Obstruction and Septoplasty Effectiveness (NOSE) scale, which consists of five inquires about nasal congestion or stuffiness, nasal obstruction, breathing difficulty, sleeping disturbances, and inadequate nasal air flow during exercise. Each point was graduated on five-point scale, with 0 = not a problem, 1 = very mild, 2 = moderate, 3 = fairly bad, and 4 = severe problem, for a total score range of 0–25 .
All patients underwent preanesthetic assessment, and only patients of grades I and II according American Society of Anesthesiologists (ASA) grading system were included in the study. For both groups, general anesthesia was induced with midazolam (0.05 mg/kg) as a preanesthetic medication, propofol (1–2 mg/kg), fentanyl (2 µg/kg), and atracurium (0.5 mg/kg). After tracheal intubation using transoral endotracheal cuffed tube, the lungs were ventilated with 100% O2 using a semiclosed circle system. Ventilation was controlled with a tidal volume of 6–8 ml/kg, and the ventilatory rate was adjusted to maintain end tidal CO2 between 35 and 40 mmHg. Anesthesia was maintained by sevoflurane 2%, and atracurium injection was adapted to the patient’s physiological reaction to surgical stimuli. Heart rate; systolic, diastolic, and mean arterial blood pressures; and oxygen saturation were noninvasively monitored throughout the surgery. Bradycardia and hypotension were defined as heart rate less than 50 beat/min, and mean arterial blood pressure less than 60 mmHg and treated with atropine 0.01–0.02 or ephedrine 5 mg intravenously, respectively.
Preoperatively, patients received intravenous broad-spectrum antibiotic. Surgical procedure for septoplasty was carried out using Cottle’s technique. At the end of surgery, NP covered with fucidin antibiotic cream was bilaterally inserted into nasal cavity of patients of group I.
For patients of group II, nasal lavage was performed 4 h PO, and patients were instructed to use daily nasal irrigation using a mixture of 0.9% normal saline and Sinoclear nasal spray. Nasal irrigation was conducted four hourly for 2 weeks. For patients of group I, NP was removed 48 h PO. Following pack removal, nasal lavage was performed, and daily nasal irrigation was conducted four hourly for 2 weeks after pack removal.
Oral broad-spectrum antibiotic and paracetamol analgesia were given to all patients. No NSAIDs were given to guard against bleeding. Antihistamines, nasal steroids, and topical or oral decongestant drugs were allowed according to need.
Determination of arterial blood gases
- Sampling and measurements: a small arterial blood sample was obtained and sent for immediate determination of arterial blood pH (pH), bicarbonate (HCO3−), partial pressure of oxygen (PaO2) and carbon dioxide (PaCO2), and oxygen saturation (SaO2) levels.
- Timing: two samples were obtained: the first sample was obtained from all patients and controls immediately after induction of anesthesia (baseline levels) and the second sample was obtained under local infiltration anesthesia at 48 h PO in all patients but before removal of NP in group I.
- Pain severity was assessed using an 11-point numeric rating scale (NRS), with 0 indicates no pain and 10 indicates worst pain imaginable. NRS was chosen for being more practical than the graphic visual analog scale, easier to understand for most people, and does not need clear vision, paper, and pen ,. NRS scores of patients of both groups were determined at 6-h, D-1, and D-2 PO.
- During first 48 h PO, nasal bleeding in group II was estimated using a piece of gauze of approximately 1.5×1.5 cm, inserted in each nostril, and each gauze-piece soaked with blood was considered as 1-ml blood loss.
- After removal of NP, pack removal-associated pain was evaluated using NRS score, and the amount of bleeding was estimated as for group II.
- For both groups, the frequency of development of crusts, adhesions, and/or synechiae was recorded on follow-up visits at 1 and 3 months.
| Results|| |
The study included 90 patients who underwent nasal septal surgery, comprising 42 (46.7%) males and 48 (53.3%) females, with mean age of 32.4±8 years (range: 18–46 years). Mean BMI of studied patients was 29.1±4.8 kg/m2, with range of 22.1–37.7 kg/m2. Seventy-eight patients were of ASA grade I, and 12 patients were of ASA grade II. Details of enrollment data of patients and controls are shown in [Table 1].
|Table 1 Patients data of both groups who underwent septoplasty compared with control patients|
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All operations were conducted uneventfully within a mean operative time of 51.2±10 min (range: 30–70 min), and mean intraoperative blood loss of 35.4±11.9 ml (range: 15–60 ml), with nonsignificant (P>0.05) difference between both groups. All patients enjoyed hemodynamic stability throughout the operation, with nonsignificant (P>0.05) difference between both groups. Details of operative and hemodynamic data are shown in [Table 2].
|Table 2 Operative and hemodynamic data of patients of both groups who underwent septoplasty|
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Mean preoperative ABG levels showed nonsignificant (P>0.05) difference between patient group and the control group. However, mean PaO2 levels estimated 48 h PO were significantly lower in patients of group I (P=0.024) and group II (P=0.026) compared with their respective preoperative levels, with nonsignificantly (P>0.05) lower PaO2 levels in group I than group II ([Table 3], [Figure 1]).
|Table 3 Mean levels of arterial blood gases estimated at 48-h postoperatively compared with preoperative and control levels|
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|Figure 1 Mean PaO2 levels estimated in the studied patients throughout the study period. PaO2, partial pressure of O2.|
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Mean SaO2 levels at 48 h PO were significantly (P=0.001) lower in patients compared with their preoperative levels, with significantly (P=0.005) lower SaO2 level in patients of group I than those of group II ([Table 3], [Figure 2]).
|Figure 2 Mean SaO2 levels estimated 48 h PO in patients who had nasal septal surgery compared with preoperative and control levels. PO, postoperative; SaO2, O2 saturation.|
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Mean PaCO2 levels at 48 h PO were significantly lower in patients of group I (P=0.002) and group II (P=0.001) compared with their respective preoperative levels, with significantly (P=0.023) lower PaCO2 levels in group I than group II ([Table 3], [Figure 3]).
|Figure 3 Mean PaCO2 levels estimated 48 h PO in patients who had nasal septal surgery compared with preoperative and control levels. PaCO2, partial pressure of CO2; PO, postoperative.|
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Mean HCO3− levels estimated at 48 h PO were nonsignificantly (P>0.05) lower than their respective preoperative levels and compared with the control levels, with nonsignificant (P>0.05) intergroup difference. Moreover, PO mean arterial pH levels were nonsignificantly (P>0.05) higher in patients of both groups compared with their respective preoperative levels and compared with control levels, with nonsignificant (P>0.05) intergroup difference ([Table 3]).
Throughout the first 48 h PO, NRS pain scores in both groups showed progressive decrease till 48 h PO, with significantly (P<0.05) lower NRS scores at 48 h PO compared with 6 h and D-1 PO and significantly (P<0.05) lower NRS scores at D-1 compared with the scores at 6 h. However, NRS pain scores of patients of group II were significantly lower compared with scores of patients of group I at both 6 h, D-1, and D-2 ([Table 4], [Figure 4]).
|Figure 4 Mean NRS score determined at 6 h, D-1, and D-2 PO determined in both groups. NRS, numeric rating scale.|
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Throughout the first 48 h PO, all patients of group II had minimal nasal bleeding, but despite being in acceptable amount, 20 patients had amount of bleeding of more than or equal to 8 ml for a mean amount of 5.9±2.3 ml (range: 3–9 ml) ([Table 4]).
Among patients of group I, removal of NP resulted in pain scored by more than or equal to 4 in 30 (66.7%) patients, with a mean score of 5.2±0.66, and by less than 4 in 15 patients, with a mean score of 3.1±0.77, for a total pain score of 4.5±1.22. Pack removal-induced minimal bleeding, but 30 patients had bleeding of more than 4 ml with a mean amount of 2.7±1.2 ml (range: 1–6 ml). Despite pack-related pain and pack removal-induced bleeding, packing for 48 h was advantageous, where the amount of removal-associated bleeding was significantly (P=0.001) lower compared with bleeding that occurred in patients of group II throughout the first 48 h PO ([Figure 5]).
|Figure 5 Mean±SD amount of bleeding associated with pack removal in group I and that occurred in patients of group II during first 48 h PO. PO, postoperative.|
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Throughout the follow-up, 24 patients developed PO complications; 19 patients developed nasal crusts and five patients developed nasal adhesions, with nonsignificant difference between both groups. Details of PO outcome of patients of both groups are shown in [Table 4].
All patients enjoyed favorable PO manifested as significant (P<0.05) reduction of NOSE score determined at 1 and 3 m PO compared with preoperative scores with significantly (P<0.05) lower scores at 3 m compared with at 1 m. However, the difference between NOSE scores of both groups was nonsignificant (P>0.05), as shown in [Figure 6].
|Figure 6 Mean NOSE score determined at 1 and 3 m compared with preoperative score in both groups. NOSE, Nasal Obstruction and Septoplasty Effectiveness.|
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| Discussion|| |
The current study reported significant improvement of nasal breathing after septoplasty as judged by significantly lower NOSE scores at 3 m compared with preoperative and 1 m scores, with significantly lower scores at 1 m compared with preoperative scores. Fortunately, NP showed no effect on functional outcome as evidenced by the nonsignificant difference between patients who had NP and those who did not regarding the NOSE score at 1 and 3 m.
In line with the effectiveness of septoplasty and the efficacy of outcome evaluation using NOSE score, Dinesh Kumar and Rajashekar  reported that using NOSE score, PO improvement following both septoplasty with partial inferior turbinectomy and septoplasty alone was highly significant at PO 1, 3, and 6 months compared with preoperative scores. Moreover, Younes and Elzayat  compared closed reduction and septoplasty for management of fracture nose surgery and reported significant improvement in nasal breathing quality of life as judged by significantly lower NOSE scores with septoplasty. Moreover, Hsu et al.  documented that subjective and objective symptoms of nasal obstruction had improved one year after septoplasty.
Unfortunately, NP showed deleterious effect on immediate outcome of septoplasty manifested as pain secondary to presence of the packing and during its removal, and bleeding during pack removal. On the contrary, NP prevented immediate bleeding reported by patients without packing, and the amount of blood loss in these patients was significantly higher than that reported on pack removal.
These findings point to the inefficacy of NP, irrespective of bleeding control, and indicated a fact that its routine use is meaningless, which goes in hand with Bernardo et al.  who documented that septoplasty improves the quality of life of patients with septal deviation and nasal obstruction, but routine use of anterior NP should be challenged for not presenting proven benefit, and Mane et al.  also documented that sutures are useful for closing any inadvertent tears of the septal mucosa and providing additional support for cartilage pieces retained in septoplasty, and NP should be reserved only for patients with increased risk of bleeding. Moreover, Quinn et al.  in their meta-analysis detected eight studies that provided data on PO pain associated with different techniques commonly used to manage the nasal septum after septoplasty and found quilting sutures were significantly less painful than both NP and septal splints.
In support of the inefficacy of NP, multiple studies tried various modifications to improve the outcome of NP, where Eşki et al.  reported that NP use does not affect surgical success and complication rates in septoplasty with no significant difference than pack-free septoplasty apart from pain scores that were significantly higher with NP. Sahin and Aras  found that infiltration of lidocaine into NP significantly reduced patient pain, but patients developed mild to moderate anxiety before NP removal, so the use of techniques without NP can be recommended after septoplasty to ease patient PO discomfort. Moreover, Shakeel et al.  found synthetic polyurethane foam NP was a useful NP option after septoplasty and inferior turbinate surgery, which enabled the surgeons to carry out this surgery safely as a day-case procedure.
Recently, in 2016, Lu et al. , out of their review for management after septoplasty, concluded that despite theoretic advantages, evidence to support the use of PO packing is lacking. Additionally, the use of NP actually causes complications such as PO pain, mucosal injury, bleeding, worsening of breathing owing to sleep disorders, and PO infections, so routine use of anterior NP after septoplasty should be challenged for not presenting proven benefit.
Moreover, bilateral NP induced significantly lower arterial oxygenation estimates (PaO2 and SaO2) with significantly higher PaCO2 despite the nonsignificant effect on arterial blood pH and HCO3 concentration. In line with these findings, Ogretmenoglu et al.  found that NP caused a significant decrease in SaO2, a borderline decrease in PaO2 with insignificant changes in PaCO2, pH, and HCO3, and Yiğit et al.  documented that to prevent decreases in the PaO2 levels, the use of NP with an airway seems to be more appropriate in patients susceptible to hypoxia. Moreover, Yildirim et al.  reported a significant reduction of PO PaO2 and increase of PaCO2 with NP.
Thereafter, Armengot et al.  showed that poorer oxygen saturation after nasal occlusion was detected in 92.5 and in 47.5% reached pathological desaturation and concluded that total NP causes significant nocturnal oxygen desaturation especially in patients with respiratory failure, obesity, or sleep disordered breathing. Moreover, Zayyan et al.  reported that packing with totally occluding NP caused a significant decrease in HCO3 and PaCO2 levels but induced insignificant changes in PaO2, SO2, and pH. However, Banglawala et al.  reported no major cardiopulmonary complications after NP with nonsignificant effect on arterial pH, PaCO2, and PaO2.
Recently, in the study by Çayönü et al. , patients who underwent nasal surgery with totally occlusive NP had a 6.25 times higher risk of immediate respiratory distress than patients who underwent nonrespiratory tract surgery during recovery from general anesthesia.
| Conclusion|| |
The outcome of NP after nasal septoplasty was variable where it is advantageous in reduction of amount of bleeding during the immediate PO period, but pain associated with the presence and removal of NP induced deleterious effect on patients’ satisfaction. Moreover, bilateral NP induced deleterious effect on arterial blood oxygenation and CO2 levels but with nonsignificant effect on arterial blood pH or HCO3 concentration.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2], [Table 3], [Table 4]