Use of Nonabsorbable Sponge Alone vs Nonabsorbable Sponge along with Wax Plate as Intranasal Splints in Nasal Surgeries: A Comparative Study

INTRODUCTION

Nasal packing is an important step for any nasal procedure in order to prevent bleeding and mucosal edema, to obtain proper flap apposition, and to assist in better healing. Packing materials act by applying pressure on damaged vessels and help in thrombus formation and organization. Nasal adhesions or synechiae is one of the few complications encountered in nasal surgeries.^1,2 The intranasal splints (INSs) play a major role in preventing the contact with the raw surfaces, thereby preventing synechiae formation. In 1955, for the first time, nasal splints were used in intranasal surgery by Salinger and Cohen³ Recently, INSs made of silicon are also used as an alternative to nasal packing. Several types of materials have been used in the past, such as strips of X-ray film and the polyethylene tops of coffee cans, drug and intravenous fluid containers, silicon or soft splints, magnet-containing silicone rubber INSs, Guastella/Mantovani septo-valvular splint, etc.⁴ In the last 20 years, six randomized controlled trials (RCTs) compared the outcomes of septal surgery with and without the use of INSs.⁵ Silicon is the most widely used INS.⁶ But in this study we used wax plates as splint material because it is soft and economical.

AIMS AND OBJECTIVES

To study the efficacy of the use of wax plate as an INS in nasal surgeries in reducing the incidence of synechiae formation in the postoperative period and thereby advocate its use along with anterior nasal packing (ANP).

MATERIALS AND METHODS

This is a prospective observational study done between August 2015 and March 2017 in the Department of ENT and HNS at Sriram Chandra Bhanj Medical College, Cuttack, India. Sixty patients were selected from those who were admitted for surgeries involving the septum such as conventional and endoseptoplasty, septorhinoplasty, functional endoscopic sinus surgery (FESS) with septoplasty, and posttraumatic nasal bone fracture correction and were randomly placed into two groups: group I and group II with the following inclusion and exclusion criteria.

RESULTS

In our study 28.33% (n = 17) of the patients were in the age-group 15–30 years, 41.66% (n = 25) were in the age of 31–45 years, and 30% (n = 18) were in the age of 46–60 years (Table 1). Besides 60% (n = 36) of the patients were males and 40% (n = 24) were females (Table 2). In group I, 23.33% (n = 7) underwent septoplasty, 20% (n = 6) underwent nasal fracture reduction, 26.66% underwent endoseptoplasty, 23.33% (n = 7) underwent FESS + septoplasty, and 6.66% (n = 2) underwent rhinoplasty. In group II 30% (n = 9) of the patients underwent septoplasty, 36.66% (n = 11) underwent nasal fracture reduction, 16.66% (n = 5) endoseptoplasty, 13.33% (n = 4) FESS + septoplasty, and 3.33% (n = 1) underwent rhinoplasty (Table 3). Postoperative discomfort was measured in all the patients in the study using the 10-point visual analog scale (VAS) in the 3rd postoperative week.

Both groups were observed for various complications such as bleeding, infection, discomfort, synechiae formation, and epiphora in the follow-up period, and the results were tabulated (Table 4) and compared using SPSS software. In both groups, no case of postoperative bleeding was encountered, but one case of infection and epiphora were seen in group I, which was not seen in group II (statistically insignificant, value p = 0.5). Discomfort was reported in seven cases in group I and four cases in group II but found to be statistically insignificant. (p = 0.253). However the number of synechiae cases noticed in group II (n = 9) was found to be statistically significant when compared to group I (n = 1), p value = 0.006 (<0.05).

DISCUSSIONS

Investigations by Pirsig on more than 2,000 patients show that the use of nasal splinting for 4–7 days could avoid intranasal adhesions in almost all cases.⁷ Roberto et al. had found out its efficiency to prevent post-surgical adhesion once any of the patients who underwent septoplasty with turbinectomy (0% in splinted vs 10.6% in non-splinted group).⁸ Nabil-ur Rahman concluded that complications are related to the type of procedure performed, and adhesions are common complication if INS is not provided.⁹ White and Murray concluded that adhesion may be prevented by insertion of nasal splint.¹⁰ Schoenberg et al. found a low risk of adhesion early in the first week postoperatively when INSs were used, and the highest incidence of intranasal adhesions occurred in nonsplinted patients who had surgery to both walls of their nasal cavity (3.6% in splinted vs 31.6% in nonsplinted).¹¹ Campbell et al. inserted a nasal splint into one side of the nose of¹⁰⁶ patients undergoing a variety of intranasal procedures, and all adhesions occurred on the nonsplinted side and more commonly when the bilateral wall procedures had been performed (8% in splinted vs 26% in nonsplinted), and they concluded that splints were justified for bilateral wall procedures but that their increased morbidity did not justify their use in single wall procedures. In the present study, we used a unique material, namely, wax plate as INS, which is economical, soft, tolerable discomfort, easily malleable, and more importantly can be tailored made to size that fits the nostril (Figs 1 and 2). In the present study also, the wax splinted group showed significantly (p < 0.05) lower synechia, i.e., only 3% incidence vs 30% in nonsplinted group (Table 4). These results are comparable with that of Campbell et al and Schoenberg et al.¹² It can also be removed very easily with minimal discomfort and so can be used in all septal surgeries to reduce the overall complication especially prevention of synechiae formation.¹³

CONCLUSION

Although in the present study the results were comparatively insignificant, the low cost, easier availability, and lower synechiae rates associated with wax plates make this an ideal material to be used as INSs in nasal surgeries.

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