Portuguese Version

Year:  2001  Vol. 67   Ed. 2 - (6º)

Artigos Originais

Pages: 180 to 182

Nasal Surgery Without Use of Packing: Results and Techniques.

Author(s): Márcia B. Deppermann*,
Paulo A. M. Manzano*,
Floriano P. Rocha Júnior*;
Elza M. Lemos**,
Antônio C. Cedin***.

Keywords: nasal packing, turbinoplasty, nasal splint

Abstract:
Study design: Clinical prospective. Material and method: One hundred ten patients underwent surgery, using endoscopic techniques and conservative strategies of septal surgery without the use of nasal packing. Aim: The objetives being to evaluate the necessity of post operative packing. We used either nasal splints or septal sutures, video-endoscopic turbinoplasty and minimal invasive techniques for the sinus surgeries. The criteria used for evaluation were the following: breathing comfort has the immediate pos operative, bleeding complications (epistaxis and septal hematoma), the final results of the surgeries and compliance to re-operations.

INTRODUCTION

Nasosinusal surgical procedures are frequently employed in patients who have inflammatory and/or obstructive chronic pathologies non-responsive to clinical therapy. The main surgical indications are anatomical alterations of ostium-meatal complex in rhinosinusopathy, nasal polyposis, septum deviation, hyperplasia of inferior turbinates associated with chronic rhinitis, and compensatory hypertrophy of contralateral turbinate to septal deviation.

Surgical correction of inferior turbinates may be conducted by different techniques, such as total turbinectomy8, partial turbinectomy11, cryosurgery of inferior turbinates4, submucosa cauterization7, laser turbinectomy5 and videoendoscopic turbinoplasty6, which suggest the lack of consensus concerning procedures.

Regardless of the nasosinusal surgical procedure employed, most authors recommend the use of packing for periods that vary from 24 to 72 hours, using different materials, such as furacinate Rayon, glove finger, gauze or Merocel11,9,10.

We presented 110 cases of patients submitted to different surgical nasosinusal procedures, such as septoplasty, inferior and middle endoscopic turbinoplasty, minimally invasive endoscopic surgery of paranasal sinuses, associated or not, between January and August 1999. For turbinate surgery, we used the videoendoscopic turbinoplasty technique, use of splint or sutures for septum and conservative endonasal technique for paranasal sinuses. The purpose was to study post-operative respiratory comfort, bleeding complications (epistaxis and septal hematoma), surgical outcome and acceptance of review surgery, without using any type of post-operative nasal packing.

MATERIAL AND METHOD

We studied 110 patients submitted to nasosinusal surgical procedures between January and August 1999. The mean age was 46 years (23 to 76 years), and there were 69 men and 41 women.

All patients were pre-operatively evaluated with anterior rhinoscopy, nasal endoscopy and paranasal sinuses CT scan.

Out of 110 surgeries, 14 were septoplasties; 53 were septoplasties associated with inferior turbinoplasty; 39 were septoplasties associated with turbinoplasty and endoscopic sinus surgery, and 4 were isolated inferior turbinoplasties.

Surgical procedures were conducted under general anesthesia, controlled hypotension and orotracheal intubation. We used rigid endoscope of Storz 0.30 and 70 degrees - 4mm.

Vasoconstriction to reduce size of nasal turbinates was performed with cotton tips soaked in oxymetazolin chlorydrate 0.5%, followed by infiltration of xylocaine and adrenaline diluted at 1:80,000 with spinal anesthesia needle number 6.

Septoplasty was conducted with economical surgical tactics, based on the techniques described by the literature (Metzenbaum, Killian, Cottle and others)

We performed suture with separated transfixed stitches with chromed catgut 3.0 in order to reposition septal mucous leaflets in cases in which septal surgical reconstruction did not require further stabilization. On the other hand, silicone splint was used when there was the need for further fixation of septal fragments.

In sinusal videoendoscopic surgeries, we considered minimally invasive criteria to air the sinusal cavities affected by inflammatory processes (maxillary, frontal, sphenoid osteoplasty ethmoidectomy with preservation of recovering mucosa of the limits of resection, and polypectomy). It was essential in these procedures to use cutting forceps, because it guaranteed precision of resections and prevented unnecessary traumas.

The surgical technique for correction of turbinates was videoendoscopic turbinoplasty for middle and inferior turbinates. In the technique, we tried to avoid exposure of osteoimucous bloody areas. For inferior turbinates, we conducted a vertical incision on the head and anteriorposterior subperiosteal detachment. Next, we made a mucous flap with superior pedicle and resected the lateral osteomucous portion, using a turbinectomy pair of scissors. The remaining bloody area of the turbinate was protected with the rest of the medial mucous leaflet, inserting it in the recess formed between the maxillary medial wall and the neoturbinate 6. The stabilization of the flap was a result of the repositioning and of the scarring over the turbinate bone tissue. In middle turbinate surgeries, we adopted the same procedure of protecting bloody areas, be it hypertrophied or pneumatized.

Post-operatively, patients were instructed about frequent nasal hygiene with isotonic saline solution and topic vasoconstrictor solution with corticoids for a 7-day period. At the end of the first week, we removed the nasal splint, if used, performed nasal cleaning with aspiration of secretions, removal of crusts and interrupted the use of vasoconstrictor, but maintained saline solution.

RESULTS

Ninety-nine patients (91.9%) submitted to nasosinusal procedures did not receive nasal packing. These patients progressed without hemorrhages, excess of crusts or any other event.

In nine patients (8.1%) that required nasal packing we used for approximately 8 hours half a lamina of Merocel® in each nostril, because of persistent intra-operative bleeding, and one patient required surgical review because of persistent bleeding of posterior lateral nasal artery. One patient (0.9%) presented septal hematoma because of lack of inferior safe incision and he received nasal packing for 24 hours with Merocel®, after post-operative drainage.

The patients that did not require nasal packing reported nasal respiratory comfort on the first post-op days, although they needed to frequently use saline solution to clean the nasal fossa. Five patients (4.5%) of review surgery reported that post-op with nasal packing was better, which motivated their agreement to a second surgical procedure. There was no synechia, septal perforation or epiphora in any of our cases.

DISCUSSION

The use of nasal packing for 1 to 3 days is advocated by most authors in order to avoid post-op nasal bleeding, enable better septal stabilization and prevent post-operative synechia and edema of turbinates11,9,10,2.

In our sample, we managed to obtained satisfactory results without nasal packing (90%), using less aggressive surgical techniques and avoiding exposure of bloody areas. In all patients submitted to septoplasty we used septal suture or splint in order to prevent formation of hematoma and to have better stabilization of cartilaginous fragments. The splint was removed 7 days later.

The technique used to create a neoturbinate at videoendoscopic turbinoplasty has a number of advantages over conventional technique1. For example it does not expose bloody areas, leading to later formation of granulation tissue or synechia. The areas that go through tissue repair by second intention cicatricial process retain a large amount of secretions and provide formation of crusts by the reduction of mucociliar clearance. We observed in the technique used for videoendoscopic turbinoplasty that the thin residual scar left on the lateral side of the turbinate provided less accumulation of secretion and enabled early recovery of nasal function. Other advantages are less Postoperative pain sensitivity6,10, possibility of using it also in mucous tissue hypertrophy, lower risk of hemorrhage, and better control of final structural volume of neoturbinate.

In sinusal surgery, thanks to the use of less aggressive techniques and the knowledge about vascularization, we not only prevented undesired arterial lesions, but also, in some situations, conducted preventive ligatures.

Although the data collected are not part of a prospective study, the analysis of the results motivates the discussion of avoiding routine use of post-op nasal packing in nasosinusal surgeries listed here, using the surgical techniques described by us.

REFERENCES

1. BERENHOLZ, L.; KESSLER, A.; SARFATI, S.; EVIATAR, E.; SEGAL, S. - Chronic Sinusitis: A sequela of inferior turbinectomy Am. J. Rhinol., 12 (4): 257-261, 1998.
2. FLYNN, E E.; MILFORD, C. A.; MACKEY, 1. S. - Multiple submucosal out-fractures of inferior turbinates. J Laryngol. Otol., 104: 239-240, 1990.
3. GRYMER, L. F. - Bilateral inferior turbinoplasty in chronic nasal obstruction. Rhinology, 34: 50-53, 1996.
4. HARTLEY, C.; WILLATT, D. J. - Cryotherapy in the treatment of nasal obstruction: Indications in adults. J. Laryngol. Otol., 109: 729-732, 1995.
5. LIPPERT, B. M.; WERNER, J. A. - CO2 laser surgery of hypertrophied inferior turbinates. Rhinology, 35(1): 33-36, 1997.
6. MABRY, R. L. - Inferior turbinoplasty. Laryngoscope, 92: 459-460, 1982.
7. McCOMBE, A. W; COOK, J.; JONES, A. S. -A comparison of laser cautery and sub-mucosal diathermy for rhinitis. Clin. Otolaryngol, 17: 297-299, 1992.
8. OPHIR, D.; SHAPIRA, A.; MARSHAK, G. - Total inferior turbinectomy for nasal obstruction. Arch. Otolaryngol, 111: 93-95, 1985.
9. RAKOVER, Y; ROSEN, G. -A comparison of partial inferior turbinectomy and cryosurgery for hypertrophic inferior turbinates. J. Laryngol. Otol, 110: 732-735, 1996.
10. SALAM, M. A.; WENGRAF, C. - Choncho-Antropexy or total inferior turbinectomy for hypertrophy of the inferior turbinates? A prospective randomized study J. Laryngol. Otol., 107; 1125-1128, 1993.
11. SERRANO, E.; PERCODANI, J.; WOISARD, V; BRAUN, F.; CLEMENT, O.; FLORES, E; PESSEY, J. J. - Efficacite de la turbinectomie inferieure partielle dans le traitement de Pobstruction nasale. Ann. Otolaryngol. Chin Cervicofac., 113: 379-383, 1996.

* Resident Physician of Otorhinolaryngology - Hospital Beneficência Portuguesa de São Paulo, Clínica Ivan F. Barbosa.
** Assistant Physician of Otorhinolaryngology - Hospital Beneficência Portuguesa de São Paulo, Clínica Ivan F. Barbosa.
*** Coordinator Physician of the Service of Otorhinolaryngology - Hospital Beneficência Portuguesa de São Paulo, Clínica Ivan E Barbosa.

Hospital Beneficencia Portuguesa de São Paulo /SP Clínica de Otorrinolaringologia Ivan F. Barbosa.
Address for correspondence: Antônio Carlos Cedin - Rua Maestro Cardim, 770 - Bela Vista - 01323-001 - São Paulo/SP
Tel: (55 11) 288-0899 - Fax.: (55 11) 253-0705 - e-mail: cedin@clinivan.com.br
Article submitted on July 21, 2000. Article accepted on November 23, 2000.

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