The Post-Operative Phase of Septal Surgery
Manish Munjal*, Pankaj Arora, Shubham Munjal and Tulika Saggar
Division of Rhinology, Department of ENTHNS, Dayanand Medical College, India
Submission:June 04, 2020;Published:July 02, 2020
*Corresponding author:Manish Munjal, Division of Rhinology, Department of ENTHNS, Dayanand Medical College, Ludhiana, India
How to cite this article:Manish M, Pankaj A, Shubham M, Tulika S. The Post-Operative Phase of Septal Surgery. Glob J Oto, 2020; 22(4): 556095.DOI: 10.19080/GJO.2020.22.556095
Abstract
Septal surgery necessitates s a tamponade to achieve hemostasis at the cost of the available rigid nasal airway. The unexpected sequele in the post-operative phase of septal surgery need to be kept in mind.
Keywords:Postoperative; Septal surgery; Toxic shock
Review of Literature
Nasal packs achieve hemostasis, stabilize the unstable nasal architecture, prevent septal swelling and hematoma formation. The roller gauze cotton pack has an untoward sequel of severe nasal pain, watering eyes, dryness of mouth, mouth breathing, annoying Toynbee man oeuvre associated with swallowing, foul odour and profuse rhinorrhea [1]. Wallace [2] advocated combining in -dwelling nasal catheters with packing to facilitate normal nasal respiration. This technique was first described by Paulus Arginela in the 7th century. Babington and Donelly [3] inserted a nasopharyngeal airway which to have a smooth recovery after nasal surgery. It maintains nasal respiration, the patient recovers consciousness quietly and there is usually minimal bleed. On the contrary [4] observed no definite advantage from the patient’s point of view, by utilizing tubes and nasal packing.
Eustachian tube dysfunction too manifests as a troublesome entity following nasal packing [5]. There is inflammation or stasis of peri tubal lymphatics. Mechanical interference thus is the cause of tubal dysfunction, Tos and Bonding, and if severe may lead go middle ear effusion [7,8]. Tubal dysfunction is due to combination of surgical oedema and a direct effect of nasal packing [9].
Unno et al. [10] and Cassisi et al. [11] demonstrated that besides the local effect of nasal packing there was also a systemic effect. Packing stimulates nose pulmonary reflex which results in reduced pulmonary compliance and increase in pulmonary resistance. These changes in pulmonary mechanics were also postulated by Sessions [12,13]. Jacobs et al. [14] in their study suggested that aspiration, sedation, and degradation of pulmonary function with age are the primary causes of hypoxemia associated with nasal packing. Cook [15] and Mohammed Rashed et al. [16] in their study found that there is a significant increase in the mean values of PCO2 and HCO3 and significant decrease in PO2 after packing the nose.
Nocturnal O2 desaturation
nasal packing should be removed as early as possible and O2 therapy provided routinely especially in old and in patients with inadequate pulmonary reserve or with cardiac disease [17]. It increases the frequency and duration of apneic episodes during sleep [18]. when the nose is occluded. O2 desaturation may be so significant in the aetiology if postoperative cardiac arrhythmias and M.I [19]. Buckley et al. [20] found that post-operative nasal packing produced a statistically significant change in O2 saturation dieting sleep. The change was, however of such a small magnitude that is unlikely to be clinically significant.
Toxic shock syndrome
There have been numerous references in literature of this very serious and sometimes fatal conditions complicating surgeries where intranasal splints and/or packs have been used [21-30]. TSS is a multisystem disorder first reported by Todd et.al in [31]. According to the Centres for Disease Control (1980 & 1981), definition of TSS requires the presence of 6 major criteria. These are
a. Fever >38.9 C with chills
b. Diffuse macular erythroderma and desquamation of palms and soles 1-2 weeks after the onset of illness
c. Hypotension systolic B.P <90mmHg in adults or below fifth percentile by age in children younger than 16 years old, Ortho’s ratio drops in diastolic B.P.>15 mmHg from lying to sitting or orthostatic syncope)
d. Mucous membranes involvement (vaginal, oropharyngeal, or conjunctival hyperemia)
e. Involvement of 3 or more of the following organ systems
i. GIT (vomiting and diarrhoea at the onset of illness)
ii. Muscular (severe myalgia or creatinine kinase level at least twice the upper limit of normal.
iii. Renal (serum urea N2 or creatinine levels at least twice the upper limit of normal or urinary sediment with pyuria (>5 WBC per high power field even in the absence of U.T.I).
iv. Hepatic (total bilirubin, SGOT and/or SGPT levels at least twice the upper limit of normal).
v. Haematologic (leukocytosis with high proportion of immature neutrophils, platelet count <10/cu mm, hyponatremia, hypocalcemia).
vi. CNS (disorientation, paraesthesias of hands and feet, alterations in consciousness without focal neurological signs when fever and hypotension are absent.
vii. Blood, urine, throat, CSF, vaginal vault cultures show negative results as the infection is almost always localized.
Absence of other causes such as streptococcal scarlet fever, drug reactions, rash associated with viral infections, Rocky Mountain spotted fever, leptospirosis, Kawasaki disease and expanded version of scalded skin syndrome.
TSS is caused by exotoxin producing staphylococcus aureus infections 40-44% of healthy persons carry staphylococcus aureus in their nose. Any foreign material may be pack or splint, along with blood, moist nasal environment and layered nasal mechanics can lead to conditions which are favorable for bacterial growth. Bacteria produce toxins. Trauma to the mucous membranes, which occurs following surgery, facilitated entry of toxins into the body leading to TSS. This syndrome is fatal in approximately 10% with most patients succumbing to irreversible respiratory failure, hypoperfusion and disseminated intravascular coagulation. It is, therefore, advised to swab the internal nose with povidoneiodine or similar antibacterial cleansing agent at the beginning of the procedure and coverage with broad- spectrum anti staphylococcal antibiotic 24 hours prior to surgery and for 48 hours postoperatively. Cotton gauze pack is not biocompatible and may lead to foreign body reaction.
Crusting
This is another frequent complication found after nasal packing [32-34] it was found in 10% cases of nasal packing in a study conducted by Fjermedal et al. [35].
Paraffinoma
Paraffinoma as a complication of nasal packing was described by Becker [36].
Synechia Formation
Nasal packs become adherent to the surrounding mucosa and when removed leaves some shreds and raw areas which later result in synechia formation.
Chances of Aspiration of Pack
The most common reasons cutes for post septoplasty nasal packing are bleeding, internal support, increased tissue apposition, decreased Edema, and closure of dead space [1]. Each of these indications for nasal packing can be easily managed in ways that are much less uncomfortable to the patient with pleasing results.
Conclusion
Vis a vis septal surgery, the surgical outcome and satisfaction of the patient depends on three step care, the pre-operative, perioperative and the post-operative. A long time follow up takes care of other associated factors like allergy to environmental allergens.
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