INTRODUCTION

Septoplasty is a surgical procedure directed to the correction of nasal septum deviation. It became a systematized surgery after the description by Killian (1905). Since then, famous Otorhinolaryngologists have developed their surgical techniques, each of them with advantages and disadvantages, indicated individually for each septum deviation4, 7, 8. All of them, however, share the need for septal mucoperichondral detachment. This detachment results in rupture of microcapillaries that can originate postoperative bleeding, presented as epistaxis or septal hematoma. In the literature, among the complications of this type of surgery, synechia, epistaxis, hematoma and septal perforation are the most frequent ones1, 2, 3. These two last reactions can be prevented by taking intra-operative care, but despite that, postoperative bleeding is a frequent finding. Owing to this risk, the use of nasal packing or splints is a common practice, applied at the end of the surgery, and then removed in the early postoperative period1, 2, 4, 5, 6, within 24 to 48 hours after the surgery. Nasal splints and packing normally represent a major postoperative burden to patients, in addition to disturbing the recovery of nasal mucosa ciliary mobility. Such a disturbance is sometimes the reason why patients resist the surgery.

Fibrin glue has been used in different nasal procedures with no reports of complications related to it3, 9-12. Hayward and Mackay2 used this resource in 30 cases of septoplasty and noticed in the early postoperative analysis mild edema and mucosa hyperemia that were supposed to be resultant from allergic reaction to the glue. Volkov and Radev5 used fibrin glue in 40 septoplasties, with no complications resultant from it and with good results concerning prevention of bleedings (similar impression of Wüllstein6).

In order to find a way to keep septal flaps closed after the surgery, without requiring packing or splint, we used the biological glue in patients undergoing septoplasty and assessed the early postoperative evolution of these patients concerning occurrence of complications.

MATERIAL AND METHOD

Twenty patients consecutively submitted to septoplasty (associated or not with other intranasal procedures) were assessed between January and May 2002. The age of patients ranged from 5 to 62 years, being that only one was a child (5 years) and only two had over 40 years (one was 50 years old and the other was 62 years old). The remaining patients ranged from 16 to 37 years of age. Twelve patients were male and 8 were female subjects. The surgery was performed under general anesthesia and using the submucous resection technique of the osteocartilaginous deviation, in order to perform:

1. Mucous retraction with cotton balls soaked in vasoconstrictor;
2. Infiltration of both aspects of the nasal septum with xylocaine at 2% with adrenaline at 1:100,000;
3. Hemitransfixing incision in one of the septal aspects, at about 0.5 to 1 cm from the caudal margin of the septum, according to the requirements of the deviation;
4. Detachment of the bilateral subperichondrium.
5. Removal of the deviated portion of the septum using the Ballenger's knife and Takahashi and Jannsen clasps;
6. Filling of the intra-septal space with fibrin glue Beriplast® P, Aventis, with immediate compression of the flaps during some seconds;
7. Coverage of the septum incision area with fibrin glue. In some cases, we also sutured the incision;
8. Monopolar electrical cauterization of the bleeding points of the nasal and/or sinusal mucosa.

Other surgical procedures were performed according to the need of each case. Table 1 shows the associated procedures performed in 20 patients of the study. These other procedures were performed following the methods that are well standardized for endonasal surgery, using videoendoscopy and/or microscopy.

RESULTS

Of the 20 operated patients, none presented signs of postoperative septum hematoma or severe bleeding and, therefore, no cases required postoperative nasal packing. In the first assessment visit, 1 to 3 days after the procedure, we noticed that the flaps had adapted well to the nasal septum.

As to the functional result, all cases presented significant improvement in nasal respiratory function from the intervention day. The function worsened after the first 14 hours owing to nasal concha edema, as well as accumulation of secretion, fibrin and crusts, but this condition had been reverted in the first reviews.

No case presented any other type of complications, such as formation of synechia, septal perforation, abscess and others.





DISCUSSION

We know that nasal obstruction surgery, when correctly performed, succeeds in 100% of the cases. However, two factors contribute for many patients to refuse this type of treatment. One of them is the fact that nasal obstruction, particularly in adults, does not represent a significant health risk. At variable degrees, it may affect quality of life, but in fact the patient has the option of living with the problem and using clinical control measures, according to his or her will. Another factor is the perspective of an extremely unpleasant postoperative period, when there is the expectation of using nasal packing and splint.

The packing is used to compress not only the septum, but also lower nasal conchae, in order to prevent postoperative bleeding. Nasal splints work exclusively to compress the nasal septum flaps, with no compression on the conchae. These measures have been used since the beginning of the nasal surgery, and normally are very unpleasant (especially nasal packing) to the patient, in addition to delaying the recovery of the mucociliary function and, thus, to increase the number of infectious complications.12 However, we have noticed over the years a progressive reduction in packing time and various groups in the world have already abandoned the use of these resources, with postoperative bleeding rates similar to those detected in practices that use them. Probably, the mastery of microendoscopic endonasal surgical technique, as well as the more efficient use of microcautery, have contributed to reduce the fear that nasal surgeons have concerning these complications.

However, when these measures are not used, there may be septal hematoma between the flaps, caused by bleeding, even if small. Generally speaking, these hematomas affect the patients very little and are fully absorbed within few days. Up to the moment they resolve, however, they hinder the postoperative progression, impair the recovery of nasal mucociliary function, and result in respiratory disturbance. In addition, in some few cases, they may get infected and generate septal abscesses and a cascade of very dangerous complications.

The fibrin glue used in this study consisted of fibrinogen, thrombin and human Factor XIII, bovine antifibrinolytic agent and calcium chloride13. It has hemostasis and adhesive action, reproducing the final steps of the physiological coagulation cascade, forming a clot of stable fibrin. The clot is degraded naturally at the end of some days or weeks, by action of the fibrinolytic enzymes. Few studies have reported allergic reactions to this substance and there is only one case suspected of viral transmission through the glue.

In all cases presented here, we used biological glue to attach the septum flaps at the end of the septoplasty. The glue was used only for this end, and not to perform hemostasis of turbinate or sinusal cavity in cases of other associated procedures. The hemostasis was carried out with careful cauterization, under microscopic or endoscopic visualization, from the mucosa bleeding points. The use of glue in the intra-septal space was easy and quick, requiring only some seconds of compression of the septum for the gluing to be adequate. It rarely took more than 1ml of product to glue the whole detached portion of the septum.

We tried to have a first postoperative review 24 to 72 hours after the procedures so that we could detect any signs of septal hematoma even before its own absorption. We did not detect formation of abscess or postoperative septal bleeding, which made us believe that the biological glue was an excellent substitute for nasal packing or splint to prevent these complications, in addition to ensuring a much more pleasant postoperative period for the patients.

We also observed that in 2 cases (cases 4 and 12), in which there was no septal incision, there was small retraction and thickening of the internal borders of the lesion, which resulted in mild thinning of the corresponding nasal fossa. It did not lead to breathing discomfort to the patients, but we were under the impression that the biological glue was not a good replacement for septum suture, and it may occasionally result in functional failures in too narrow nasal fossae. In another case (case 5), the septal deviation was extremely severe and sinuous, and there was significant laceration of the bilateral mucoperichondrium, but there was no postoperative bleeding nor septum perforation; even though it was an isolated case, we wondered if the glue could also prevent perforation.

In case 11, aged 5 years, the glue was particularly important, since it prevented an unpleasant postoperative period for the child, because it discarded the use of nasal packing or splint, which is even more difficult in pediatric patients.

CONCLUSIONS

The use of biological glue in the intra-septal space of septoplasty surgeries proved to be very effective to prevent septum hematoma and postoperative epistaxis and enabled an uneventful and comfortable recovery for patients in the study, especially in children.
There were no intra or postoperative complications resultant from the use of the biological glue in the studied patients.

REFERENCES

1. Eckel W. Tratamiento quirúrgico de las inflamaciones de las fossas nasales y de los senos paransales. In: Tratado de Otorrinolaringologia, Tomo I, Barcelona: Editora Cientifico-Medica; 1969. p.307-63.
2. Hayward PJ, Mackay IS. Fibrin glue in nasal septal surgery. J Laryngol Otol 1987;101(2):133-8.
3. Skevas A, Gosepath. [Contribution to the closure of septal perforations (author's transl)] Laryngol Rhinol Otol (Stuttg) 1975;54(6):466-9.
4. Killian G. The submucous window resection of the nasal septum. Ann Otol 1905;14:363.
5. Volkov A, Radev I. [The use of autologous fibrin adhesive in septoplasty]. Vestn Otorinolaringol Jan-Feb 1996;(1):45-7.
6. Wüllstein SR. [Septoplasty without postoperative nasal packing. Mucosal repair of the upper airway with human biologica glue (author's transl)]. HNO 1979;27(9):322-4.
7. Cottle M. Concepts of nasal physiology as related to nasal surgery. Arch Otolaryngol 1960;72:11.
8. Metzenbaum M. Replacement of the lower end of the dislocated septal cartilage versus submucous resection of the dislocated end of the septal cartilage. Arch Otolaryngol 1929;9:282.
9. Bertrand B, Doyen A, Eloy P. Triosite implants and fibrin glue in the treatment of atrophic rhinitis: technique and results. Laryngoscope 1996 May;106(5 Pt 1):652-7.
10. Cappabianca P, Cavallo LM, Mariniello G, de Divitiis O, Romero AD, de Dovitiis E. Easy sellar reconstruction in endoscopic endonasal transsphenoidal surgery with polyester-silicone dural substitute and fibrin glue: technical note. Neurosurgery 2001;49(2):473-5.
11. Wax MK, Ramadan HH, Ortiz O, Wetmore SJ. Contemporary management of cerebrospinal fluid rhinorrhea. Otolaryngol Head Neck Surg 1997;116(4):442-9.
12. Weber R, Keerl R, Draf W, Schick B, Mosler P, Saha A. Management of dural lesions occurring during endonasal sinus surgery. Arch Otolaryngol Head Neck Surg 1996;122(7):732-6.

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1 Ph.D. in Medicine, University of São Paulo.
2 Specialist in Otorhinolaryngology.
3 Faculty Professor of Otorhinolaryngology, Federal University of Pernambuco.
Affiliation: Real Instituto de Otorrino e Fono

Address correspondence to: Silvio Caldas Neto - Rua Poeta Zezito Neves, 38, ap. 1801
Recipe - PE - 51020-200 - Tel. (55 81) 3241-0830 - Tel/Fax (55 81) 3427-4610 - E-mail: caldas@hotlink.com.br

Article submitted on July 22, 2002. Article accepted on August 8, 2002