RHINOLOGY

Septal stapler use during septum surgery

Guven Yıldırım • Cemal Cingi • Ercan Kaya

Received: 23 February 2012 / Accepted: 14 August 2012 / Published online: 28 August 2012

� Springer-Verlag 2012

Abstract Although discussions regarding nasal packing

are still ongoing, to eliminate any possible complications,

surgeons have used nasal packing for many years. Septo-

plasty is one of the most frequently performed operations by

head and neck surgeons. Any methods to diminish the sur-

gical time or bring comfort to the surgeon will be well

appreciated. In this study, we attempted to demonstrate the

usefulness of the stapler method by comparing preoperative

and postoperative results from the visual analog scale

(VAS), nasal obstruction symptom evaluation (NOSE),

rhinosinusitis quality of life questionnaire (RQLQ), and

acoustic rhinomanometry values. In addition, we evaluated

pain scores, postoperative complications, and breathing

after nasal packing, stapling, and trans-septal suturing

techniques. Patients were divided into three groups. In the

first group, deviated cartilage was removed or repositioned

and mucoperichondrial flaps were closed with a bioresorb-

able stapler after septoplasty. Four or five staples were

placed on the septum. In the second group, the septum was

sutured continuously with 4/0 Pegelak (Dogsan TR). In the

third group, Merocel packs were used without any sutures

and were kept for 48 h. Nasal packing leads to patient dis-

comfort after septal surgery; however, there is no difference

in patient comfort between closing the mucoperichondrial

flaps by suturing the septum or using a stapler. After surgery,

there were no differences between the groups in terms

of successful breathing. This situation was assessed by

endoscopic examination and acoustic rhinomanometry.

Thus, there was no objective or subjective difference. Sta-

pling increases the doctor’s comfort level and surgical time

is optimized. Although experienced surgeons can easily

suture the septum, less experienced ones have some diffi-

culty; therefore, stapling may provide more benefit to the

latter. Further, four staples are sufficient to close the septum.

Keywords Stapler � Septoplasty � Nasal packing �Septal suture

Introduction

Septoplasty is one of the most frequently performed

operations by head and neck surgeons [1, 2], and has been

used since ancient times. Deviated cartilage and bone

removed from the septum leaves a dead space; therefore, to

reduce the risk of septal hematoma, surgeons apply nasal

packs or suture techniques [3].

Complications may occur following septoplasty, such as

perforation, postoperative bleeding, hematoma, infection,

and abscess formation [1]. To eliminate these complica-

tions, nasal packing has been used by surgeons for many

years. The purpose of nasal packing is to prevent the for-

mation of synechiae and the development of hematomas,

ensure the apposition of septal flaps, fill the dead space, and

prevent displacement of the cartilage that has been replaced

[4]. There is currently no consensus in the literature

regarding, which material to use or when to remove it.

Nasal packing is not a completely harmless method; it

can lead to continued bleeding, cardiovascular changes,

nasal injury, hypoxia, foreign body reaction, and infection

[4]. The most important disadvantage is discomfort of the

patient, who usually requires hospitalization and antibiotic

G. YıldırımOkmeydani Education and Research Hospital, Istanbul, Turkey

C. Cingi (&) � E. Kaya

Medical Faculty, Department of Otorhinolaryngology,

Osmangazi University, Eskisehir, Turkey

e-mail: ccingi@ogu.edu.tr

123

Eur Arch Otorhinolaryngol (2013) 270:939–943

DOI 10.1007/s00405-012-2165-6

treatment [4]. These postoperative drawbacks of nasal

packing, including patient discomfort and side effects, have

prompted surgeons to seek alternatives. For example,

methods such as septal splints, quilting sutures, clips, and

clamps have been used [3–10] with differing results. In

addition to these methods, fibrin glue has been used suc-

cessfully for adhering septal mucosal flaps [1, 10]. In

recent years, different bioresorbable staplers have been

used in septoplasty surgery [11, 12].

In this study, we attempted to demonstrate the usefulness

of the stapler method by comparing preoperative and post-

operative results from the visual analog scale (VAS), nasal

obstruction symptom evaluation (NOSE), rhinosinusitis

quality of life questionnaire (RQLQ), and acoustic rhino-

manometry values. In addition, we evaluated pain scores,

postoperative complications, and breathing after nasal

packing, stapling, and trans-septal suturing techniques.

Materials and methods

Sixty adult patients were included in our study group who

had been diagnosed as ‘‘septal deviation’’ and underwent

primary septoplasty surgery. None of the patients had any

systemic disease and/or any paranasal sinus pathology.

Before starting the study, Ethics Committee approval was

obtained.

Nasal septal deviation was classified as right- or left-

sided. All patients were operated on under general anes-

thesia, using the same surgical technique. Lidocaine

(20 mg/ml) and epinephrine HCl (0.0125 mg) were used as

local anesthetics for vasoconstriction. At the end of sur-

gery, all patients were randomly selected for postoperative

nasal packs, staplers, or trans-septal sutures.

Patients were divided into three groups. In the first

group, deviated cartilage was removed or repositioned and

mucoperichondrial flaps were closed with a bioresorbable

stapler after septoplasty. Septal stapler was inserted into the

nasal cavity and absorbable staples were delivered to bring

together the elevated septal mucosal flaps face to face. Four

or five staples were placed on only the elevated area of the

mucosal flaps (Figs. 1, 2).

In the second group, the septum was sutured continu-

ously with 4/0 Pegelak (Dogsan TR). In the third group,

Merocel (Invotec International, Jacksonville, FL, USA)

packs were used without any sutures and were kept for 48 h.

Preoperative patient comfort was evaluated with a VAS

from 0 to 4 (0, poor; and 4, excellent in all groups). The

comfort status of all patients was ascertained with a VAS

on postoperative day 2. Nasal patency was objectively

evaluated with acoustic rhinomanometry preoperatively in

all patients. NOSE and RQLQ scores were also assessed.

At postoperative day 21, nasal patency was evaluated

again with acoustic rhinomanometry. NOSE and RQLQ

assessments were also made to evaluate differences

between the applied methods.

The patients were not hospitalized. Postoperatively, the

patients received amoxicillin/clavulanate (1 g) orally twice

daily for 7 days as an antibiotic prophylaxis. In addition,

patients received an oral analgesic. In the septal suture and

stapler groups, these treatments began on postoperative day

1, and in the packing group, treatment began on day 2.

Sinus rinse nasal lavage was used in the latter group.

IBM SPSS 19.0 and Sigmastat 3.5 were used to analyze

the data. The assumptions of normality were analyzed

using a Shapiro–Wilk’s test. A one-way analysis of vari-

ance (ANOVA) was used for normally distributed data. For

data with a non-normal distribution, a Kruskal–Wallis one-

way analysis of variance by rank test was used. The data

were summarized as the mean ± standard deviation (SD)

and median (Q1, Q3). A p value \ 0.05 was considered

statistically significant.

Fig. 1 Application of septal stapler

Fig. 2 Staples on septum

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Results

All patients in the study were male and between the ages of

19 and 34 years (mean 27 ± 4.3 years). The surgical out-

comes of the three groups were evaluated as clinically

successful, and there were no complications such as infec-

tion, hematoma, perforation, and abscess formation in any

of the patients. There was minimal leakage of blood in

patients with sutures or on whom staplers were used.

Additional packing was not required in any patient.

Preoperative VAS scores did not differ among the three

groups (p = 0.895); however, postoperative VAS scores

were significantly lower in the nasal packing group

(p \ 0.05). Postoperative VAS scores for the stapler and

suture groups did not differ significantly (p = 0.430).

When we evaluated the differences between the VAS

scores before and after treatment, the mean difference (in

the direction of decline) was 4.1 ± 0.97 in the stapler group,

4.15 ± 1.31 in the septum suture group, and 6.40 ± 1.43 in

the packing group.

When we compared the data obtained at first postoper-

ative day there were no significant difference between the

groups. Similarly, the difference of the NOSE scores,

acoustic rhinometry, and RQLQ results obtained at 21st

postoperative day was not significant between groups.

Preoperative NOSE values did not differ among the

three groups (p = 0.753), nor did postoperative NOSE

values obtained at 21st day (p = 0.276). When we exam-

ined the differences between the NOSE values before and

after treatment, the mean difference (in the direction of

decline) was 5.7 ± 0.923 in the stapler group, 5.90 ± 0.641

in the suture group, and 6.20 ± 0.620 in the packing group.

Although the mean difference in the packing group

seemed to be high, it was not statistically significant

(p = 0.130).

Preoperative RQLQ values did not differ among the

three groups (p = 0.646), nor did postoperative RQLQ

values (p = 0.061). When we examined the differences

between the RQLQ values before and after treatment, the

mean difference (in the direction of decline) was 0.80 ±

0.696 in the stapler group, 2.95 ± 0.686 in the septum

group, and 3.30 ± 0.733 in the packing group. Although

the mean difference in the packing group seemed to be

high, it was not statistically significant (p = 0.130).

Differences between postoperative left MCA1 (first

minimal cross sectional area) values, preoperative left

MCA2 values, postoperative left MCA2 (second minimal

cross sectional area) values, preoperative right MCA1

values, postoperative right MCA1 values, preoperative

right MCA2 values, and postoperative right MCA2 values

in the three groups were analyzed using an ANOVA and

there were no significant differences between the groups

(F = 0.284, p = 0.75; F = 0.636, p = 0.53; F = 0.184,

p = 0.83; F = 0.835, p = 0.44; F = 0.082, p = 0.92;

F = 0.068, p = 0.93; F = 0.192, p = 0.83; F = 0.103,

p = 0.90, respectively).

The differences in preoperative and postoperative left

MCA1 values, preoperative and postoperative left MCA2

values, preoperative and postoperative right MCA1 values,

and preoperative and postoperative right MCA2 values in

the three groups were examined using an ANOVA, and

there were no significant differences between the groups

(F = 0.401, p = 0.67; F = 0.504, p = 0.61; F = 0.060,

p = 0.94; F = 0.279, p = 0.76, respectively).

Discussion

Deviated septum is a very common pathology seen by ear,

nose, and throat (ENT) physicians. Physical examinations,

as well as some objective tests, allow us to correctly

diagnose this condition. Rhinomanometry and acoustic

rhinometry are useful to distinguish the spread of septum

deviation and different reasons for nasal obstruction. In

this way, it is possible to monitor the efficacy of surgery

[13]. But it is well known that there is a controversial

issue regarding correlation of subjective and objective

results of nasal surgery. The NOSE scale and RQLQ are

widely used methods for evaluating nasal symptoms. VAS

is also an important measurement to evaluate patient

comfort. But they do not necessarily correlate with phys-

ical findings.

Quality of life is the main concern for doctors treating

their patients. Therefore, the negative effects of nasal

packing on postoperative day 2 should be of concern. In

our study, we attempted to qualify the results of surgery by

nasal patency. For this purpose, we applied preoperative

and postoperative acoustic rhinometry, and were able to

compare surgical results with repeated tests.

Beside the QOL of the patients, many new methods and

materials are launched in order to serve surgeons QOL

parallel to the development of medical industries. Many

techniques were described to decrease surgical time and

reduce complications for septoplasty. Nevertheless, each

technique has its own advantages and disadvantages [4–11,

14–18]. Different techniques and materials have been

proposed over the years and results obtained by comparing

these techniques have been reported. Further, the usage

times of these techniques vary.

Discussions regarding packing are ongoing. For exam-

ple, some surgeons remove the packs on the day of surgery,

whereas, others leave them in place for 7 days postopera-

tively [19]. We removed the packs on the second day after

surgery in the present study. Although some techniques

display disadvantages during removal, there can be diffi-

culties during application.

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In patients with septal suturing, there are no problems

related to removal and postoperative patient comfort levels

are higher; however, the operation time is prolonged [20,

21]. Suturing the septum requires a longer operation time

as compared with stapler use. In addition, although con-

tinuous suturing during septum surgery requires a certain

degree of experience and ability, stapling is an easier

method to perform, especially by inexperienced surgeons.

Ardehali [7] compared trans-septal suturing, nasal

packing, and intranasal splints in classical septoplasty and

did not find any significant differences in the incidence of

mucosal adhesion.

Intranasal splints were introduced in 1955 by Salinger

and Cohen [22]; many splints were adapted from materials

such as X-ray film or polythene, and the tops of coffee

cans. Goode [23] reported a method using magnet mounted

pre-shaped splints that applied pressure. Different types of

splints have been constructed, such as silastic sheets, sili-

con, or dental utility wax plates [24].

A study comparing the complications of septal clips and

nasal packing techniques demonstrated that septal clips

have some beneficial effects on morbidity and discomfort,

are easier to insert, require less effort, and are inexpensive

[25].

Recently, fibrin glue was introduced as a new technique.

This technique is recommended because of its ease of

application, short operation time, short hospital stay, and

patient satisfaction. However, in a study in rabbits, fibrin

glue was shown to cause distinctive inflammation, mucosal

injury and thickening, decreased cartilage thickness, and

segmental cartilage loss [18].

Biochemical data regarding these techniques were

evaluated and the results between the techniques were

aimed to reveal. Free radical damage can play a primary

role in the pathogenesis of many diseases [26, 27]. The

effects of nasal septum suturing or packing application

after septoplasty on oxidative stress have been investigated.

As indicators of oxidative stress in patients, malondialde-

hyde, sulfhydryl (SH) groups, and nitric oxide (NO) levels

were measured at four different times. SH levels in the

suturing group demonstrate that this technique is more

favorable than nasal packing in terms of the oxidant–anti-

oxidant system [28]. Therefore, the antioxidant–oxidant

balance is better protected by suturing than packing [28].

Veluswamy et al. [25] examined the effects of packing

on the middle ear using tympanometry and revealed that

there were no permanent effects on eustachian tube func-

tion. In our study, all three techniques were evaluated by

endoscopic examination and acoustic rhinomanometry. On

postoperative day 21, patients were assessed for bleeding,

adhesion, hematoma, infection, abscess formation, and

perforation risk. No significant differences were found

between the techniques with respect to these complications.

There were no significant differences in pre- and post-

operative VAS scores between the three groups. In addi-

tion, preoperative VAS scores decreased in all three

groups. Although the difference before and after treatment

may have seemed high in the packing group, it was not

statistically significant (p = 0.434).

Quality of life was evaluated preoperatively and on

postoperative day 21 using NOSE and RQLQ assessments.

When differences in NOSE values were examined, the

mean values for all three groups had decreased. Although

the highest average was in the packing group, it was not

statistically significant (p = 0.134). When differences in

RQLQ values were examined, the mean values in all three

groups had decreased. Although the highest average was

in the packing group, it was not statistically significant

(p = 0.080).

The effects of the different techniques on left- and right-

sided septum deviation were investigated using an

ANOVA. There were no significant differences in left- or

right-sided deformity between the three groups (p = 0.94,

0.76).

Conclusion

Nasal packing leads to patient discomfort after septal sur-

gery; however, there is no difference in patient comfort

between closing the mucoperichondrial flaps by suturing the

septum or using a stapler. After surgery, there were no

differences between the groups in terms of successful

breathing. This situation was assessed by endoscopic

examination and acoustic rhinomanometry. Thus, there was

no objective or subjective difference. Stapling increases the

doctor’s comfort level and surgical time is optimized.

Although experienced surgeons can easily suture the sep-

tum, less experienced ones have some difficulty; therefore,

stapling may provide more benefit to the latter. Further, four

staples are sufficient to close the septum.

Conflict of interest None.

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