THE IMPACT OF USING INTRANASAL SPLINTS ON MORBIDITY AND PREVALENCE OF ADHESIONS

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1 THE IMPACT OF USING INTRANASAL SPLINTS ON MORBIDITY AND PREVALENCE OF ADHESIONS Munassar S. Al-Muflehi Faculty of Medicine, Hadhramout University of Science and Technology, Yemen. By KEY WORDS: Intranasal, Splints, Adhesions. ABSTRACT This study investigates the influence of using intranasal splints (INS) for prevention of adhesions and to assess the morbidity associated with their use. The retrospective study was carried out during the period from March 1997 to April 2004, at Al-thorah Hospital in Sanaa, Ibin Sina Hospital and Al-Amal private clinic in Al-mukulla (Yemen). 210patients were divided into two groups. Group one with splints and group two without. Score of adhesions, bleeding, pain, crusting, and septum position ܽa <l^é ÛÂ< ØnÚ< íé }] Ö]< ÌÞù]< l^é ÛÂ<»< xñ] Ö]< Ù^ÛÃj ]< m_< î Â< ðç Ö]< í ] Ö]< å â< êï i <ÔÖ Òæ< Hl^Î^ jö ]<àú<íè^îçö]<øq_<àú<íé ËŠÖ]<l^éÞ ÏÖ]<^ ç }æ<l^éþ ÏÖ]<l^é ÛÂæ<êËÞù]<ˆq^ ] <Œ ^Ú<àÚ<ìËÖ]<»<í ] Ö]<å â<kè q_<jì çò ¹]<l^é ÛÃÖ]<»<xñ] Ö]<Ù^ÛÃj <ífu^ ¹]<ØÒ^¹]< è <êûé ÃjÖ]< ð^ßé < àe]< îëjšúæ< ð^ãß e< êqƒçûßö]< Ý^ÃÖ]< ì çnö]< îëjšú<»< 2004< Øè ec< îju< 1997 <ğ^ è Ú< ì Â< æ< jòéú< î Â< íé ÛÂ< D210E< ì Â< æ< á^jòéú< kè q_< JDàÛéÖ]E< øó¹^e< ØÚù]< Ì çjšúæ <ğ^ è Ú<D50E< Š <±æù]<íâçû]<kßû i<h jâçû <±c<üãûéšïi<<hdì_ Ú]<80æ<Øq 130E<D210E <Ù^ÛÃj ]<áæ e<ğ^ è Ú<D160E< j <æ<íñ^ú<íéþ^nö]<íâçû]<æ<l^é ÛÃÖ]<ð] qc< ßÂ<xñ] Ö]<^ãéÊ<k ÛÃj ] <Ý Â< íö^u<»< A12.5< Hxñ] Ö]< Ù^ÛÃj ]< íö^u<»< A10< l^î^ jö ]< VêÖ^jÖ^Ò< sñ^jßö]< kþ^òæ< Hxñ] Ö] <»<A42<Ü{{Öù]<Jxñ] Ö]<Ù^ÛÃj ]<Ý Â<íÖ^u<»<A2<Hxñ] Ö]<Ù^ÛÃj ]<íö^u<»<a2j5<ìèˆßö]<jxñ] Ö]<Ù^ÛÃj ] <Ù^ÛÃj ]<íö^u<»<<a4<ê{ëþù]<ˆq^{ ]<gïm<jxñ] Ö]<Ù^ÛÃj ]<Ý Â<íÖ^u<»<A6J25<Hxñ] Ö]<Ù^ÛÃj ]<íö^u <»<A10<Hxñ] Ö]<Ù^ÛÃj ]<íö^u<»<a16< Ï{jÖ]æ<Í^{Ë ]<Jxñ] Ö]<Ù^ÛÃj ]<Ý Â<íÖ^u<»<A6J25<Hxñ] Ö] 1

2 <Ý Â<íÖ^u<»<<A90<Hxñ] Ö]< Ù^ÛÃj ]<íö^u<»<a93<êëþù]<ˆq^ ]<íú^ïj ]<Jxñ] Ö]< Ù^ÛÃj ]<Ý Â<íÖ^u <ÄÎçjÞ<ì <l ^u<»<øe<l ^ ]<ØÒ<»<xñ] Ö]<Ý] ~j ^e<x ßÞ< <í ] Ö]<Ùø}<àÚ<Jxñ] Ö]<Ù^ÛÃj ] < <Jáçòé æ<ð^ãß <ØnÚ<íÊ^ ]<Ð^ß¹]<»< è < æ<l^î^ jöøö<í Â<áçÓi<á_ INTRODUCTION The use of intranasal splints (INS) in nasal surgery specialy following septal and turbinate operations. Salinger and Cohen were the first to use intranasal splints for surgery of a difficult septum [ 1]. Several types of materials have been used in the past such as strips of x-ray film, and the polyethylene tops of coffee cans. Recently, several types of preformed splints are available for example silicon or soft splints. The most important and frequent use of splints is to prevent adhesions between the septum and the lateral wall of the nose, other reasons suggested for the use of intranasal splints are to prevent formation of septal hematoma, to provide septal stability, to hold the septal graft used to close septal perforation [ 2 ], and to support packing in epistaxis [ 3].The prevalence of adhesions which most Ear, Nose, Throat (ENT) surgeons would like to avoid was reported to be 6-11% [ 4,5]. It is even higher (36%) following turbinate resection alone, 31% of turbinate resection in combination with the septal surgery and only 7% of other procedures [ 6]. Cambell et. al., showed that the incidence of adhesions following high risk surgery was reduced from 26% to 0% by inserting silastic splints at the end of operation and leaving them in place for 7days [ 7 ]. Eliopoulos and Philippakis reported the use of wax paper enveloping fucidin gauze to pack the nose postoperatively and stated that it was very effective in prevention of formation of nasal adhesions [ 8]. Most papers published stressed on adhesions and their prevention by using intranasal splints, but few concentrate on the morbidity such as pain and crust formation. This study was carried out to examine the role of using intranasal splints in preventing adhesions and the morbidity associated with their use. MATERIALS AND METHODS This is a retrospective study, which carried out during the period from March 1997 to April 2004 at Al-thorah hospital in Sana a and Ibin-Sina Teaching hospital and Al-Amal private clinic in Al-mukulla city (Yemen). The charts of 2

3 210 patients who underwent septal surgery alone and the lateral wall of the nose (polypectomy, turbinectomy) with or without correction were reviewed. We have no function endoscopic sinus surgery (FESS). Splints were used in 50patients, and in 160patients, no splints were inserted. Following surgery the noses were packed with Vaseline-fucidin ribbon gauze pack in almost all cases the pack was left for 48hours, then removed. The splints remained 10days postoperatively. The patients were given normal saline to wash at home. The patients were followed up one month and 3months after surgery. The prevalence of adhesions, pain, bleeding, perforation, crust formation and septal medialization have been recorded in each group. RESULTS Of the 210 patients included in this study, 130 males and 80 females. The overall mean age was 28years. The patients were divided into two groups, group one comprised of 50patients where splints were used, and group two comprised of 160patients without splints. Seventy five patients had septopl-asty alone, and the remaining 135patients had a combination of septoplasty (turbinectomy, polypectomy and others). The adhesions scores in both groups were not significant 2(10%) in the splint group and 8(21.5%) in the non splint group. Bleeding scores was slightly significant, 4(2.5%) in the non splint group, while 1(2%) in the splint group. The pain scores were highly significant in the splint group with 21patients out of 50(42%) compared to 10patients out of 160(6.25%) in the non splint group. The maximum pain during removal of the splints. 3cases had vasovagal attacks. Perforation scores were with 2(4%) patients in the splint group, while with 10(6.25%) patients in the non splint group. Crust formation scores were highly significant in the splint group with 8(16%) compared to the non splint group with 16(10%). The septum medialization scores 93% in the splint group, while 90% in the non splint group. Other complication like anosmia, acute sinusitis, nasal tip deformity and toxic shock syndrome have been recorded. DISCUSSION Since its introduction 45years ago intranasal splints has become, after pressure equilization tubes, the most frequently used prostheses in otolaryngology (18). The use of intranasal splints was advocated in the early 1970s after 3

4 Foxen and Gilchrist used them to prevent nasal adhesions (10,11). Many ENT specialists still use intranasal splints in nasal surgery, although their practice was not based on any scientific evidence of their effectiveness (12). Despite this the available literature does not give a clear definition of its role in intranasal surgery. Campbell et al., advised using intranasal splints in patients undergoing multiple nasal procedures because of increased risk of adhesions [ 8], while [13] Cook et. al., did not think it effective in preventing adhesions. Von Schoenberg et. al., found a low risk of adhesion in patients when intranasal splints was used 4%. However 3months postoperatively the splinted and non [14.18] splinted group had the same low rate of adhesion 2%. Pingle et. al., carried out a survey of 440consultants and found that 33% of them never or rarely used intranasal splints, and reported an adhesion rate 5%. They finalized by asking can we justify the routine use of nasal splints or is there a better method of postoperative care with a view to avoidance of adhesion [ 15]. The incidence of adhesions in this study was not significant. The patients with adhesions were treated in the outpatient clinic under local anesthesia. Watson et. al., reported recurrent adhesions despite adequate splinting in Wagener's granulomatosis [16] patient. It is difficult to predict which will develop adhesions. The score of [8,14,18] pain in this study was 41% which is in agreement with others. Shone et. al., found crusting rate 21%, where intranasal splints was not used [ 5], while in this study was 10%. However crusting was highly significant with the use of intranasal splints in patients who were resident in Sana a and Syuon, where the humidity reach as low as 10%. The presence of intranasal splints may affect the ciliary function resulting in an increased prevalence of crusting. Nasal toilet is important in reducing the rate of crust formation. Perforation of septum is a well known complication of nasal septum surgery. The incidence of perforation [17,18] has been reported to be The use of intranasal splints did not [13] increase the risk of perforation as shown by Cook et. al.,, and Al-Mazrou and Zakzouk [ 18], as well as this study. Bleeding after nasal surgery is mostly from turbinates. White et. al., reported an incidence 7%. The patients who developed post operative bleeding, 2patients of splinted group, and 3patients of non splinted group. This study as well as other study it have proved that intranasal splints were not of significant value in proventing nasal adhesions 4

5 [ ] but it increases morbidity (pain, discomfort). The use of INS should be restricted to patients predisposed to the formation of adhesions. In conclusion the use of intranasal splints in septal surgery has to be individualized. Nasal irrigation using saline is of importance to prevent crusting and minimize occurrence of adhesions. REFERENCES 1- Salinger S, Cohen D. (1955). Surgery of the difficult septum. Arch. Oto. laryngol. Vol. 61: [ ]. 2- Johnson N. (1964). Septal surgery and rhinoplasty. Transaction of the Ameri-can Academy of ophthalmology and otolaryngology. Vol. 68: [ ]. 3- Goode R. (1982). Magnetic intranasal splints. Arch. Oto. laryngol. Vol. 108: [319]. 4- Fischer ND, Biggars WP, MacDonald HJ. (1981). The bookend nasal septal splint. Oto. laryngol. Head Neck Surg. Vol. 89: [ ]. 5- Shone GR, Clegg RT. (1987). Nasal adhesions. J. Laryngol. Otol. Vol. 101: [ ]. 6- Talaat M, El-Sabawy E, Baky F, Raheem A. (1987). Submucous diathermy of the inferior turbinates in chronic hyperthophic rhinitis. J. Laryngol. Otol. Vol. 101: [ ]. 7- White A, Murray JA. (1988). intranasal adhesion formation following surgery for chronic nasal obstruction. Clin. Oto. laryngol. Vol. 13: [ ]. 8- Campbell JB, Watson MG, Shenoi PM. (1987). The role of intranasal splints in the prevention of post-operative nasal adhesions. J. Laryngol. Otol. Vol. 101: [ ]. 9- Eliopoulos PN, Philippakis C. (1989). Prevention of postoperative intra-nasal adhesions (a new material). J. Laryngol. Otol. Vol. 103: [ ]. 10- Foxen EHM. In: Balantyne J, Groves J, editors. (1971). Scott-Browns diseases of the Ear, Nose, Throat. 3 rd ed. London: Butterworths. [ ]. 11- Glichrist AG. (1974). Surgery of the nasal septum and pyramid. J. Laryngol. Otol. Vol. 88: [ ]. 12- Malki D, Quine SM, Pfleiderer AG. (1999). Nasal splints revisited. J. Laryngol. Otol. Vol. 113: [ ]. 13- Cook JA, Murrant NJ, Evans KL, Lavelle RJ. (1992). Intanasal splints and their effects on intranasal adhesions and septal stability. Clin. Oto. laryngol. Vol. 17: [24-27]. 5

6 14- Von Schoenberg M, Robinson P. (1992). The morbidity from nasal splints in 105 patients. Clin. Oto. Laryngol. Vol. 17: [ ]. 15- Pringle MB. (1992). The use of intranasal splints:a consultant survey. Clin. Oto. laryngol. Vol. 17: [ ]. 16- Watson MG, Marchall HF. (1990). Intranasal adhesions which recur despite splinting: an ominous sign? J. Laryngol. Otol. Vol. 104: [ ]. 17- Von Schoenber M, Robinson P, Ryan R. (1993). Nasal packing after routine nasal surgery-is it justified? J. Laryngol. Otol. Vol. 107: [ ]. 18- Al-Mazrou KA., and Zakzouk SM. (2001). Saudi. Med. J. Vol. 22(7): [ ]. 6