Nasal Packing Research Articles

The Packed Epistaxis Patient: Risks of Rebleeding? A Pilot Study to Inform Outpatient Management of Packed Patients.

Current common practice for patients with idiopathic epistaxis which requires nasal packing is to admit as an in-patient for overnight observation. Anecdotally, many patients do not re-bleed, so admissions may be unnecessary. Several factors have been suggested to be associated with an increased risk of re-bleeding, such as hypertension, anticoagulant use, and male gender. We set out to investigate these factors, to create a local guideline to identify patients who may be safe to discharge with a pack in situ. We collected the data on the most recent admissions in our department, who each received a non-absorbable nasal pack for idiopathic epistaxis (n = 100). Data points included age, gender, anticoagulation status, and comorbidities. Data from 100 patients were audited. Of those, 13 were found to have re-bled through their packing (13%). Statistically significant predictors of re-bleed were as follows: Male sex (OR = 9.81, P = .048, 95% CI 1.02-94.11), aspirin use (OR = 8.11, P = .047, 95% CI = 1.03-63.79), hypertension (OR = 8.14, P = .040, 95% CI = 1.10-60.26), and age (OR = 0.93, P = .018 95% CI = 0.88-0.99). Re-bleed in patients managed with non-absorbable packing for idiopathic epistaxis is uncommon. Risk factors may include male sex, hypertension, and aspirin use. ENT departments nationally may consider discharging patients' home with pack in situ, for removal as an outpatient, in the absence of these risk factors.

Comparing the Effect of Topical Lignocaine and Bupivacaine in Nasal Packs for Pain Relief in Post Operative Nasal Surgery Patients

This randomized controlled trial compared the analgesic efficacy of lignocaine, bupivacaine, and placebo nasal packs in patients undergoing nasal surgeries, including septoplasty and functional endoscopic sinus surgery (FESS). A total of 100 patients, aged 18–60 years, were randomly assigned into three groups: lignocaine (n=34), bupivacaine (n=33), and placebo (n=33). Postoperative pain was assessed using the Visual Analog Scale (VAS) over 24 hours. Additional analgesic requirements, side effects, recovery time, and length of hospital stay were recorded. Bupivacaine provided significantly lower pain scores at all intervals compared to lignocaine and placebo (p < 0.05). The bupivacaine group had a lower need for additional analgesics (39.4%) compared to lignocaine (76.5%) and placebo (81.8%) (p = 0.041). Side effects such as nausea and vomiting were similar across all groups. The bupivacaine group experienced a shorter hospital stay (2.0 days) compared to the lignocaine (2.5 days) and placebo (3.0 days) groups (p = 0.038). In conclusion, bupivacaine-soaked nasal packs offer superior pain relief, reduce the need for additional analgesics, and shorten hospital stays, making it a preferable option for postoperative pain management in nasal surgeries.

Comparing the Efficacy of Fentanyl Nasal Packing on Postoperative Pain in Patients Undergoing Nasal Surgeries Versus Normal Saline Pack—A Randomized Control Trial

Comparing the Efficacy of Fentanyl Nasal Packing on Postoperative Pain in Patients Undergoing Nasal Surgeries Versus Normal Saline Pack—A Randomized Control Trial

Current Practices: Antibiotic Use Following Placement of Nasal Packing.

Current Practices: Antibiotic Use Following Placement of Nasal Packing.

Sinonasal Outcomes after Endoscopic Pituitary Surgery in Patients With Cushing's Disease.

The endoscopic endonasal approach (EEA) has become the preferred treatment for pituitary tumors, with minimal sinonasal morbidity. However, patients with Cushing's disease (CD) may represent a subgroup with prolonged impairment of sinonasal quality of life (QOL). We retrospectively identified patients with CD who underwent EEA at our institution. Control patients with non-functional tumors were matched by age, gender, and extent of EEA. The primary outcome was post-operative 22-item Sino-Nasal Outcome Test (SNOT-22) scores. Ten patients with CD met the selection criteria and 20 controls were selected for comparison. Nine of the CD patients achieved persistent endocrinologic remission post-operatively. Comparing the CD and control groups, there was no difference in post-operative SNOT-22 score at 1 or 3 months. At 6 months, SNOT-22 scores were significantly worse in the CD group (27.4 ± 21.6 vs. 2.8 ± 2.3, P = .039). SNOT-22 scores improved to normal from 1 to 6 months in the control cohort (P = .007), but not in the Cushing's group (P = .726). Morbidity was present across all SNOT-22 domains, but was highest in the sleep domain (P = .023). Only morbidity in the facial domain improved over time (P = .032). Patients with CD have significantly prolonged postoperative sinonasal QOL impairment following EEA compared to patients with non-functioning tumors, who normalize within 6 months. In CD patients, only morbidity in the facial domain, likely related to post-operative pain and nasal packing, improved over time, while the sleep domain was the most affected.

Incidence and Risk Factors for Toxic Shock Syndrome After Endoscopic Sinus Surgery: A Systematic Review.

Toxic shock syndrome (TSS) is a rare but serious complication after sinonasal surgery and a commonly cited consideration for prescribing antibiotics when nasal packing or stents are placed. Most reports are limited to case reports or small series. The aim of this systematic review was to describe the incidence, risk factors, and clinical course of patients who developed TSS as a complication of endoscopic sinus surgery (ESS) and/or septoplasty. A systematic review was conducted using MEDLINE, EMBASE, CINAHL, Web of Science, and Cochrane Library databases. Eligibility criteria were patients of any age who developed TSS as a complication of ESS and/or septoplasty. Twenty-five studies were included in the final review. Seventy cases were identified over 38 years (1982-2020). The pooled incidence of TSS after sinonasal surgery was 0.0003 (0.0002-0.0004, 95% confidence interval, CI) or 30 per 100,000 persons. Among 33 patients with single-subject data, mean age was 33.8 years (29.73-37.87, 95% CI). Seventeen (51.5%) patients had nasal packing, 3 (9.1%) had stents, 5 (15.2%) had both, 7 (21.2%) had none. Fourteen (42.4%) patients had nonabsorbable packing and 5 (15.2%) had absorbable packing. Sixteen (48%) patients received peri-operative antibiotics. Thirty-two (97%) patients had full recovery. The incidence of TSS after sinonasal surgery is very rare. TSS can occur with and without nasal packing and prophylactic antibiotics were not protective. Outcomes were favorable with appropriate recognition and management. Further study is needed to determine which patients are most at risk for TSS.

Efficacy of a RADA-16 peptide hydrogel versus chitosan-based polymer in improving patient comfort during postoperative debridement: A randomized controlled trial.

Bioresorbable nasal packing is associated with a decreased incidence of adhesions and bleeding postoperatively after endoscopic sinus surgery (ESS). However, discomfort during postoperative debridement is still a major area of concern for patients. Our objective was to compare the efficacy of a peptide hydrogel to that of a chitosan-based polymer in reducing pain during debridement after ESS. A prospective, multicenter, randomized, blinded trial was conducted in adults undergoing bilateral total ethmoidectomy for chronic rhinosinusitis. Participants served as their own controls with each subject receiving the hydrogel in a randomized ethmoid cavity and chitosan-based polymer in the contralateral ethmoid cavity. Participants were evaluated at 1, 4, and 12weeks postoperatively. Pain during debridement as well as endoscopic evaluation of mucosal healing and hemostasis were measured. Thirty patients who underwent ESS were included in this trial. During the week 1 postoperative debridement, patients reported significantly less pain on the hydrogel-treated side compared to the chitosan-based polymer-treated side. There were no significant differences in bleeding severity, Lund-Kennedy scores, debridement time, or need for further intervention between the two groups. This study demonstrated the efficacy of a peptide hydrogel inminimizing pain during postoperative debridement.

Survey on the use of nasal tamponades in sinunasal surgery

Currently, there is an intensive discussion about enhancing and expanding outpatient rhinosurgical procedures. Many questions about how to stratify into out- and inpatient procedures are still not sufficiently clarified. Particularly, the use of nasal packing materials is not adequately discussed. We performed a Germany-wide survey among otorhinolaryngologists regarding the use of nasal packing materials in sinonasal surgery. Additionally, we asked for any complication in relation to nasal packing. In 85,6% nasal packing was used for septal and turbinate surgery at least occasionally, in 44,2% always. In sinus surgery these numbers are 94,1% and 49%, respectively. Non-resorbable nasal packing materials were predominantly used.Most frequent complications were bleeding with nasal packing in situ (> 50% of respondents) and posterior dislocation (24% of respondents), requiring emergency treatment. Death was listed in 5 patients. One patient suffered from permanent brain damage due to hypoxia. Application of non-resorbable nasal packing materials with occlusion of the nasal cavity carry a substantial risk of complications, which necessitate emergency treatment, thus requiring inpatient care.

Sinunasal surgery as outpatient procedure with special consideration of nasal packing - Position paper of the German Society of Otorhinolaryngology, Head and Neck Surgery, the working group Rhinology/Rhinosurgery (ARHIN) of the German Society of Otorhinolaryngology, Head and Neck Surgery and German Professional Association of Otorhinolaryngologists

Currently, there is an intensive discussion on advancing and expanding outpatient rhinosurgical procedures. Many questions about how to stratify into out- and inpatient procedures are still not sufficiently clarified. Particularly, the use of nasal packing materials is not adequately discussed. Development of a checklist to stratify sinunasal procedures into in- or outpatient procedures with consideration of current scientific literature and risk factors. After comprehensive assessment of the literature and analysis of specific risk factors, a list of sinunasal procedures is presented, which should be performed as inpatient procedures. We present a checklist for in- and outpatient sinunasal procedures, which considers social, medical and surgical factors as well as the use of nasal packing materials. Furthermore, a checklist is added to assess, whether patients are ready for discharge after a planned outpatient procedure.

Sewing: A New Quilting Suture Method for Nasal Septum Repair

A deviated nasal septum leads to congestion and headaches. Surgery is the primary treatment, requiring careful postoperative septum positioning to prevent bleeding and hematoma. The study compared this method with nasal packing and traditional nasal septum suturing regarding surgical time, patient pain, nasal obstruction, and bleeding after septoplasty. The surgical time for nasal packing was significantly shorter than that for the other 2 suturing methods (P < 0.0001), but there was no statistically significant difference between the two suture methods (P = 0.1358). The Visual Analog Scale scores showed that the pain in the packing group was significantly higher than that in the other 2 groups within 2 days after surgery (P < 0.0001). The pain during suture removal was significantly higher in the packing group than in the “sewing group” (P < 0.0001). The number of injuries to the outer wall of the nasal cavity by continuous suturing was significantly higher than that by sewing (P < 0.0001). Tearing within 2 days after surgery was significantly higher in the packing group than in the other 2 groups (P < 0.0001). Compared with nasal packing, nasal septum suturing can significantly reduce postoperative pain and tearing, improve comfort, and do not increase bleeding. The newly described nasal septum sewing method in this study has no difference in surgical time compared with the traditional suturing method and can reduce injuries to the outer wall of the nasal cavity. In addition, it is painless and easy to remove during suture removal.

Safety and effectiveness of a drug-loaded haemostatic sponge in chronic rhinosinusitis: a randomized, controlled, double-blind study

Some cases of chronic rhinosinusitis (CRS) require surgical treatment and postoperative nasal packing, but bleeding and adhesion are common complications after nasal surgery. Biodegradable drug-loaded implants hold great therapeutic options for the treatment of CRS, but little data are available regarding the safety and efficacy of a novel drug-loaded haemostatic sponge (DLHS) in the sinus. The aim of this study was to investigate the safety and efficacy of DLHS in the sinus. We conducted a prospective, randomized, controlled, double-blind clinical trial. In this clinical trial, 49 patients were enrolled and randomly divided into 2 groups: group A (n = 25) had the DLHS containing 1 mg budesonide and 0.67 mg sodium hyaluronate placed into the sinus, and group B (n = 24) had the Nasopore placed after ESS. Endoscopic follow-up was performed for 12 weeks, and the findings were classified using the discharge, inflammation, polyps/oedema (DIP) endoscopic appearance scores. All patients completed questionnaires to evaluate their sinonasal symptoms by using the sinonasal outcome test-22 (SNOT-22) Chinese version and visual analogue scale (VAS). Serum cortisol concentration in group A was measured prior to surgery and at days 1, 3, 7, and 14 after nasal surgery. Comparing group A and group B, at 2 weeks, no significant differences were observed in either objective or subjective parameters. The mean value of VAS for rhinorrhoea and DIP for oedema and the mean value of nasal adhesion were significantly lower in Group A than in Group B at 6 and 12 weeks, but a significant difference did not occur in SNOT-22 and VAS for dysosmia between the two groups at 6 and 12 weeks. The mean serum cortisol concentrations in group A at the follow-up were within normal limits without remarkable fluctuations. This study demonstrates the safety and efficacy of a novel biodegradable DLHS with the possibility of being used in CRS patients, and this sponge may reduce inflammation and minimize adhesions via controlled local drug delivery without measurable systemic exposure.

Intraoperative Incidental Internal Carotid Artery Injury in Extended Endoscopic Endonasal Approaches—Causes, Prevention, and Management: A Technical Note

AbstractIn spite of good anatomical awareness, the position of internal carotid artery (ICA) can be tricky in an intraoperative setup with disease causing very significant distortion of anatomy and shift of carotid artery and its branches. A 45-year-old gentleman presented with complaints of left hemicranial headache and painless progressive vision loss in both eyes (left more than right) for 8 months. A probable clinico-radiological diagnosis of meningioma was reached. Intraoperatively, bleeding occurred from left side ICA, control of which was achieved using a long gauze piece used as conventional nasal pack with crushed muscle beneath the gauze piece along with abdominal fat, which was further reinforced with Surgicel. The parasellar ICA is the most common segment injured. Dehiscent or bulging canal of ICA, presence of pseudoaneurysm, attachment of sphenoid septae to the canal, displacement by the lesion, nonenlarged sella because of small size of lesion or vertically oriented lesions, and vessel wall abnormalities increase the risk of injury. It is very essential to have a preoperative discussion involving the skull base surgeons (neurosurgeons and otorhinolaryngologists), neuroradiologists, and neuroanesthetists regarding the complications expected in the case. In case of ICA bleed, the target should be to achieve a temporary hemostasis. In small tears, cottonoids for pressure and bipolar for cauterization will help stop the bleeding, while in larger tears, giving moderate pressure using crushed muscle and cottonoids to achieve intra-operative hemostasis should be tried. After intraoperative hemostasis, the patient needs to be shifted to angiography suite for endovascular stent placement.

Postoperative management following endoscopic skull base surgery.

The purpose of this opinion is to review current evidence regarding postoperative management following endoscopic skull base surgery. Postoperative management encompasses consideration of level of care, laboratory tests, analgetic and antiemetic therapy, antibiotic, antithrombotic and antiepileptic prophylaxis, pharmacological and nonpharmacological cerebrospinal fluid (CSF) pressure reduction measures, including CSF diversion, activity restrictions, nasal packing removal, nasal debridement and toilet, nasal glucocorticoid administration, positive pressure ventilation, imaging, CSF leak diagnosis, and future perspectives. Although significant effort has been put into research of postoperative measures after endoscopic skull-base surgery, there is a heterogeneity of practices and deficit of high-level studies, which would enable highly powered systematic reviews and meta-analyses.

Contemporary Trends in Frontal Sinus Balloon Sinuplasty: A Pilot Study

Introduction Balloon sinuplasty (BSP) is a common treatment modality used in the management of chronic rhinosinusitis (CRS). Although it has gained popularity, minimal self-reported data on its utilization and complications have been reported. The goal of this study was to describe current practices and complications experienced during frontal sinus BSP. Methods An anonymous 20-question online survey was distributed to members of the American Osteopathic Colleges of Ophthalmology and Otolaryngology-Head and Neck Surgery from August 1, 2022, to August 30, 2022. The questions were listed as multiple choice or percentage sliding bars, and data were collected using a commercial online survey service site. Results were reported as frequencies, means, and percentages. Results Forty-two respondents participated in the survey, with the majority practicing in the following hospital settings: community (34, 80.95%), hybrid (5, 11.90%), and academic (3, 7.14%). The southeast had the largest proportion of respondents (13, 30.95%), versus the midwest (12, 28.57%), southwest (10, 23.81%), northeast (5, 11.90%), and northwest (2, 4.76%). On average, 50.52% of cases were performed in the hospital setting, 48.50% in-office, and 42.40% in surgery centers. Respondents who primarily used BSP, reported a yearly average of 35.72 cases, a median of 12 cases, and a range of 0-361 cases. Respondents who used BSP with functional endoscopic sinus surgery (FESS), reported a yearly average of 48.62 cases, a median of 31 cases, and a range of 0-189 cases. Nasal packing was utilized both intraoperatively (11.72%) and postoperatively (3.62%). Early complications included postoperative headaches (9.86%), acute bacterial sinusitis (ABRS) (3.52%), and tooth/facial numbness (0.86%). Reported long-term complications included postoperative synechiae (5.10%), orbital complications (0.14%), and skull base complications (0.10%). A previously unreported complication was identified through this study, accidental sphenopalatine fossa dilation. Conclusions This study contributes to the growing body of literature on frontal sinus BSP by characterizing utilization and complications from a large otolaryngologic academy.

Hereditary Hemorrhagic Telangiectasia (Osler's Disease): Systemic, Interdisciplinary, Relatively Common–and Often Missed.

Hereditary hemorrhagic telangiectasia (HHT, Rendu-Osler-Weber disease, or Osler's disease for short) is a systemic disease that can severely impair the quality of life and that requires interdisciplinary treatment. Among rare diseases, it is relatively common, with a prevalence of approximately 1/5000. This review is based on publications retrieved by a selective literature search, including the two international guidelines on clinically relevant aspects of HHT. On average, about two decades elapse between the initial symptoms and the diagnosis of HHT. 95% of patients have nosebleeds; these usually begin before age 20 but can occur at any time, from infancy to old age. The diagnosis is usually made on clinical grounds on the basis of the characteristic telangiectases, a positive family history, and possible involvement of the gastrointestinal tract, lungs, liver, and brain. Nosebleeds can sometimes be reduced by outpatient measures including counseling on keeping the nose moist (expert consensus), self-application of a nasal packing (which improves the quality of life, according to an online survey), and the prescription of tranexamic acid (reduction of nosebleeds from 17.3% [5.5; 27.6] to 54%). In particular, screening (expert consensus) for pulmonary vascular malformations (frequency 10-50%) can prevent many adverse outcomes. If pulmonary vascular malformations cannot be ruled out, antibiotic prophylaxis is recommended before medical procedures that can cause bacteremia (expert consensus). Broad awareness of the condition, early diagnosis, and interdisciplinary treatment improve the quality of life and ultimate outcome of persons with HHT. Nevertheless, there are few options supported by good evidence for the appropriate treatment of this rare, often serious disease.

Ligation of anterior ethmoidal artery nasal branch: anatomical-based management of recalcitrant epistaxis.

Recurrent epistaxis, despite conservative therapies (i.e. nasal packing or direct vessel coagulation), is generally treated with ligation of the sphenopalatine artery (SPA). Indeed, the rationale behind SPA ligation lies in its ability to disrupt arterial blood supply to the nasal mucosa, thereby reducing the likelihood of recurrent bleeding episodes (1). Nevertheless, in some cases, nosebleeds persist despite appropriate SPA ligation, opening discussion of the anterior ethmoidal artery (AEA) contribution in recalcitrant epistaxis that, for some authors, is up to 28.8% (2). From an anatomical point of view, the AEA leaves the orbital cavity and passes the ethmoidal roof through the ethmoidal canal, before entering inside the anterior cranial fossa via the lateral lamella (3). Endocranially, the AEA gives posterior branches which vascularize the anterior cribriform plate, whereas its many trunk continues anteriorly and divides into two branches: the anterior meningeal branch, and a second vessel that enters inside the nasal fossa through the cribroethmoidal foramen located 2.86 ± 1.93 mm (range, 1-7 mm) (4) anteriorly to the first olfactory phylum, giving rise to the so-called nasal branch (NbAEA) (5).

CPAP-induced sphenoid sinus pressures after endoscopic sinus surgery.

Positive pressure transmitted from continuous positive airway pressure (CPAP) to the sinuses and skull base in the early post-operative period has not been studied in live subjects and controversy exists in when to restart this post-operatively. This study found that approximately 32.76% and 13.52% of the delivered CPAP pressures reached the post-surgical sphenoid sinus and the mid-nasal cavity, respectively, suggesting that surgical factors such as tissue edema, nasal packing, blood, and nasal secretions may provide a protective effect.

Tualang Honey-impregnated Nasal Pack in Endoscopic Sinus Surgery Reduces Post-operative Inflammation and Bacterial Growth

Tualang Honey-impregnated Nasal Pack in Endoscopic Sinus Surgery Reduces Post-operative Inflammation and Bacterial Growth

Evaluation of sodium hyaluronate-based composite hydrogels for prevention of nasal adhesions.

During the healing process after intra-nasal surgery, the growth and repair of damaged tissues can result in the development of postoperative adhesions. Various techniques have been devised to minimize the occurrence of postoperative adhesions which include insertion of stents in the middle meatus, application of removable nasal packing, and utilizing biodegradable materials with antiadhesive properties. This study assesses the efficacy of two sodium hyaluronate (SH)-based freeze-dried hydrogel composites in preventing postoperative nasal adhesions, comparing them with commonly used biodegradable materials in nasal surgery. The freeze-dried hydrogels, sodium hyaluronate and collagen 1(SH-COL1) and sodium hyaluronate, carboxymethyl cellulose, and collagen 1 (SH-CMC-COL1), were evaluated for their ability to reduce bleeding time, promote wound healing, and minimize fibrous tissue formation. Results showed that SH-CMC-COL1 significantly reduced bleeding time compared to both biodegradable polyurethane foam and SH-COL1. Both SH-COL1 and SH-CMC-COL1 exhibited enhanced wound healing effects, as indicated by significantly greater wound size reduction after two weeks compared to the control. Histological analyses revealed significant differences in re-epithelialization and blood vessel count among all tested materials, suggesting variable initial wound tissue response. Although all treatment groups had more epithelial growth, with X-SCC having higher blood vessel count at 7 d post treatment, all treatment groups did not differ in all histomorphometric parameters by day 14. However, the long-term application of SH-COL1 demonstrated a notable advantage in reducing nasal adhesion formation compared to all other tested materials. This indicates the potential of SH-based hydrogels, particularly SH-COL1, in mitigating postoperative complications associated with nasal surgery. These findings underscore the versatility and efficacy of SH-based freeze-dried hydrogel composites for the management of short-term and long-term nasal bleeding with an anti-adhesion effect. Further research is warranted to optimize their clinical use, particularly in understanding the inflammatory factors influencing tissue adhesions and assessing material performance under conditions mimicking clinical settings. Such insights will be crucial for refining therapeutic approaches and optimizing biomaterial design, ultimately improving patient outcomes in nasal surgery.

Merocel versus a new septal clip with splint in post septal surgery cases: a prospective study

Septoplasty is one of the most frequently performed surgical procedures in otorhinolaryngology to overcome nasal obstruction. Following septal surgery, nasal packs are commonly inserted by surgeons to support and appose septal flaps the types of which depend on the preference and experience of the surgeon.Background We conducted a study to compare the Merocel sponge with that of a newly developed septal clip with the splint in patients who underwent septoplasty or submucosal resection to find out which one is better. A total of 50 patients were included in the study over a period of 3 years. Patients were divided into 2 groups of 25 each where group M is for patients receiving Merocel after surgery and group C is for patients receiving septal clips with splints.Aim The aim of this study was to assess and compare the effects of a Merocel pack on nasal functions with that of the septal clip and their eventual complications and outcome in the post-operative period.Results The main observations that were found in both groups in the immediate postoperative period were (1) pain (2) nasal obstruction (3) sleep disturbance (4) headache (5) epiphora (6) dryness of mouth and (7) postnasal drip. Pain was mild to moderate in the case of group M (MPS was 2.4) and moderate to severe degree in the case of group C (MPS was 5.7).Nasal obstruction was more common in Merocel group patients. Sleep disturbance, headache, epiphora, post-nasal drip, and dryness of mouth were also more in the Merocel group. After pack removal in both groups, the nasal examination was done to see crusts, vestibulitis, and septal ulcers. All these findings were more in the septal clip with the splint group.Conclusions It was observed that Merocel nasal packing causes significant morbidity and discomfort in the immediate post-operative period as compared to septal clips. It is also expensive. The new septal clips with splints can be used as an effective alternative to Merocel for approximation of flaps after septal surgery.