[Review: pathophysiology and methodology of nasal packing]

[Fundamentals and practice of the application of nasal packing in sinonasal surgery]

BACKGROUND AND OBJECTIVES

This paper presents an overview on nasal packing materials which are available in Germany. The current literature is analyzed whether there are robust criteria regarding use nasal packing after sinonasal surgery, whether there are fundamental and proven advantages or disadvantages of products, and what this means in clinical practice.

MATERIALS AND METHODS

Selective literature analysis using the PubMed database (key words "nasal packing", "nasal tamponade", "nasal surgery", "sinonasal surgery", or "sinus surgery"), corresponding text books and resulting secondary literature.

RESULTS AND CONCLUSIONS

Because of systematic methodological shortcomings, the literature does not help in the decision-making about which nasal packing should be used after which kind of sinonasal surgery. In fact, individual approaches for the many different clinical scenarios are recommended. In principle, nasal packing aims in hemostasis, should promote wound healing, and should not result in secondary morbidity. Nasal packing materials should be smooth (non-absorbable materials), inert (absorbable materials), and should not exert excessive pressure. Using non-absorbable packing entails the risk of potentially lethal aspiration and ingestion. For safety reasons inpatient control is recommended as long as this packing is in situ. With other, uncritical packing materials and in patients with special conditions, outpatient control could be justified.

Nasal Packing in Septal Surgery: A Narrative Review

Recently, alternatives to intranasal packing following septoplasty and rhinoseptoplasty have been widely used and promoted. Here, we aimed to systemically review and compare the different types of nasal packing used in these two surgeries. To assess patient comfort and surgical outcomes, we conducted a comprehensive search of multiple databases such as PubMed, MEDLINE, Web of Science, and Google Scholar to identify and evaluate relevant articles. A detailed and extensive search was performed with the help of the keywords "nasal packing," "septoplasty," "rhinoseptoplasty," "nasal splints," and "intranasal packing." Overall, our review findings indicate that alternative methods (e.g., trans-septal suturing and insertion of intranasal splints) are better options than intranasal packing.

[Postoperative treatment following paranasal sinus surgery]

Postoperative care is a crucial aspect for the success of paranasal sinus interventions. Basic procedures include saline nasal wash, which should be started on the first postoperative day, topical steroids, and antibiotics in cases of infection. Medical treatment involves aspiration of secretion in the inferior meatus during the first week. Removal of scabs in the surgical field should be carried out under endoscopic control beginning at the second week. Intervals are scheduled individually. Occlusion of the nose for the time of epithelium regeneration provides a moist space in the ethmoid, which improves wound healing.

[Complications and side effects of conservative treatment of rhinological diseases]

BACKGROUND

The spectrum of rhinological diseases is wide, as is that of their drug-based treatment. Only 1272 compounds coded R01 (nasal preparations) are listed in the ATC group (Anatomical Therapeutic Chemical Classification). Conservative therapy of rhinological diseases additionally includes systemic (often oral) application of corticosteroids, antibiotics and immunomodulators.

OBJECTIVE

The aim of this paper is to outline possible complications of medication (subdivided into classes of ingredients) commonly used to treat rhinological diseases in hospitals. Useful therapeutic and preventive measures will be presented.

MATERIALS AND METHODS

Based on the expert information in the current pharmacological drug index (ATC) for the R01 group as well as literature research in the PubMed, Cochrane Library and MEDLINE databases, medication used for the treatment of rhinological diseases was analysed in terms of side effects and their frequency.

RESULTS

Common side effects of intranasally applied medication are local irritations, burning, dryness and epistaxis. Orally or intravenously applied rhinological medication can affect the organs and lead to side effects such as cardiac dysrhythmia or alterations of the blood count. It is recommended that the therapeutic be selected on an individual basis and that the patient be thoroughly informed about possible side effects.

CONCLUSION

Particularly when treating children or pregnant or breastfeeding women, the indications of all nasal preparations should be checked carefully. The huge variety of rhinologicals enables an optimal individual selection on the basis of consideration of known side effects.

Current Approaches to Epistaxis Treatment in Primary and Secondary Care

BACKGROUND

The lifetime prevalence of epistaxis is approximately 60%, and 6-10% of the affected persons need medical care. In rare cases, severe bleeding calls for the rapid initiation of effective treatment.

METHODS

This review is based on pertinent articles that were retrieved by a selective search PubMed, and on the authors' clinical experience.

RESULTS

There are no German guidelines for the management of epistaxis. The available evidence consists mainly of retro spective analyses and expert opinions. 65-75% of the patients who require treatment can be adequately cared for by their primary care physician or by an emergency physician with baseline measures. If there is persistent anterior epistaxis, an otorhinolaryngologist can control the bleeding sastisfactorily in 78-88% of cases with chemical or electrical cauterization. Nasal packing is used if this treatment fails, or for posterior epistaxis. In a retrospective study, surgical treatment was found to be more effective than nasal packing in the treatment of posterior epistaxis (97% versus 62% treatment success). Percutaneous embolization is an alternative treatment for patients whom general anesthesia would put at high risk.

CONCLUSION

The treatment of severe or recurrent epistaxis requires the interdisciplinary collaboration of the primary care physician, the emergency physician, the practice-based otolaryngologist, and the hospital otolaryngology service. Uniform guidelines and epidemiological studies on this topic would be desirable.

Comprehensive review on endonasal endoscopic sinus surgery

Endonasal endoscopic sinus surgery is the standard procedure for surgery of most paranasal sinus diseases. Appropriate frame conditions provided, the respective procedures are safe and successful. These prerequisites encompass appropriate technical equipment, anatomical oriented surgical technique, proper patient selection, and individually adapted extent of surgery. The range of endonasal sinus operations has dramatically increased during the last 20 years and reaches from partial uncinectomy to pansinus surgery with extended surgery of the frontal (Draf type III), maxillary (grade 3-4, medial maxillectomy, prelacrimal approach) and sphenoid sinus. In addition there are operations outside and beyond the paranasal sinuses. The development of surgical technique is still constantly evolving. This article gives a comprehensive review on the most recent state of the art in endoscopic sinus surgery according to the literature with the following aspects: principles and fundamentals, surgical techniques, indications, outcome, postoperative care, nasal packing and stents, technical equipment.

Comparative analysis of Cutanplast and Spongostan nasal packing after endoscopic sinus surgery: a prospective, randomized, multicenter study

Commercial gelatin-based packing materials are available under different names and compositions to be used after endoscopic sinus surgery (ESS). The purpose of this study was to investigate the efficacy of Spongostan and Cutanplast nasal packing on patients' subjective symptoms, hemostasis, and wound healing following ESS. One hundred adult patients with chronic sinusitis requiring the same extent of ESS were included. Following surgery, one nasal cavity was packed with Cutanplast and the other one with Spongostan. Patients' subjective symptoms while the packing was in situ, hemostatic properties, degree of remaining amount of packing materials, postoperative wound healing, and the cost of the pack were evaluated. Cutanplast and Spongostan are equally effective in the control of postoperative bleeding following ESS. However, Cutanplast packing was significantly more comfortable than Spongostan for nasal obstruction, postnasal drip, rhinorrhea, and headache. Furthermore, the Cutanplast packing was significantly less painful at all time points. The remaining amount of the pack was significantly lower in the Cutanplast than Spongostan packing. Spongostan packing appears to impair wound healing within the sinus cavities up to 3 months postoperatively. Cutanplast was less expensive than Spongostan as used in this study. Cutanplast may be more useful gelatin-based packing material than Spongostan in terms of efficacy and cost-benefit after ESS.

Nasal packing and stenting

Nasal packs are indispensable in ENT practice. This study reviews current indications, effectiveness and risks of nasal packs and stents. In endoscopic surgery, nasal packs should always have smooth surfaces to minimize mucosal damage, improve wound healing and increase patient comfort. Functional endoscopic endonasal sinus surgery allows the use of modern nasal packs, since pressure is no longer required. So called hemostatic/resorbable materials are a first step in this direction. However, they may lead to adhesions and foreign body reactions in mucosal membranes. Simple occlusion is an effective method for creating a moist milieu for improved wound healing and avoiding dryness. Stenting of the frontal sinus is recommended if surgery fails to produce a wide, physiologically shaped drainage path that is sufficiently covered by intact tissue.

[Wound healing after endoscopic sinus surgery and postoperative management]

Understanding the physiological concepts of wound healing after rhinologic procedures facilitates detection and management of more or less obvious problems of wound healing. In this review, the physiologic processes involved in wound healing are explained, and typical clinical constellations are presented. Based on challenges of anatomy and physiology, recent findings are summarized, and possible conclusions for managing the postoperative mucosa are drawn.

Effect of carboxymethylcellulose nasal packing on wound healing after functional endoscopic sinus surgery

BACKGROUND

Functional endoscopic sinus surgery (FESS) has become the treatment of choice for patients with medically resistant chronic rhinosinusitis. Nasal packing is usually placed after the surgery to support wound healing and prevent adhesions. The purpose of this study was to investigate the effect of carboxy-methylated cellulose (CMC) nasal packing on wound healing after FESS compared with no nasal packing.

METHODS

Twenty-six patients underwent bilateral FESS. The patients were randomized to receive CMC mesh or gel packing on one side and no packing on the opposite side. The patients were followed at 2, 4, and 12 weeks after surgery. Endoscopically visible CMC, crusting, mucosal integrity, synechia formation, granulation tissue formation, and adverse side effects were assessed and documented.

RESULTS

No adverse side effects were observed. No significant differences were found between the CMC-packed side and the unpacked side with respect to the outcome measure of wound healing. No difference was found between two different forms of CMC in terms of wound healing. Two weeks after surgery, endoscopically visible CMC was detected in four patients of the CMC mesh group, whereas none of the patients in the CMC gel group had endoscopically visible CMC (p = 0.040).

CONCLUSION

As we were unable to establish an effect, we must question the efficacy of this packing material and the necessity of its use after FESS based on the technique of the Graz University Medical School. The mesh form of CMC could be potentially useful as a vehicle for extended drug delivery owing to its longer retention time in the nose.

[Current aspects in epistaxis]

A survey of current literature on the topic of epistaxis revealed only a circumscript number of publications with a high methodologic value. The analysis of these publications showed that there is a controversy on the necessity of routine coagulation tests in epistaxis patients. These tests should only be performed in cases with clinical evidence of a coagulation disorder. Also, there is an ongoing controversy on the value of local cooling with ice or cold packs. Nasal creams and decongestive nose drops have been found to be effective in uncomplicated epistaxis. Rhinoscopically and endoscopically targeted coagulation of bleeding vessels and nasal packing are recommended treatment options. There is a debate on discontinuation of anticoagulant therapy, if INR is within normal limits in Cumadin patients. Intractable epistaxis requires a broad armamentarium of different diagnostic and therapeutic options. Recurrent epistaxis in hereditary syndromes remains to be a challenge, although some advances have been made in diagnosis and symptomatic treatment. Some new medical drugs, as Viagra or Cialis may have nosebleeds as side-effects.