The LaryngoscopeVC 2013 The American Laryngological,Rhinological and Otological Society, Inc.

Postoperative Management in the Prevention of Complications AfterSeptoplasty: A Systematic Review

Jason G. Quinn, BSc; James P. Bonaparte, MSc, MD, FRCS(C); Shaun J. Kilty, MD, FRCS(C)

Objectives/Hypothesis: The purpose of this article is to assess the relative rates of septal hematomas, synechiae, andseptal perforations associated with methods commonly used to manage the nasal septum after septoplasty. As a secondaryobjective, we assessed the relative contribution of each method of septal management with respect to pain and patientdiscomfort.

Study Design: Systematic review.Methods: A systematic literature search was performed for all relevant English randomized controlled, cohort, or case–

control trials. Inclusion criteria included any study that assessed postoperative septal hematoma, perforation, or synechiaeformation and reported on these outcomes regardless of method of septoplasty. Two authors independently extracted studyinformation and analyzed all included articles for bias.

Results: A total of 279 studies were identified, with 17 meeting the inclusion criteria. The majority of the studies had ahigh risk of bias that prevented the performance of a meta-analysis. Eight studies provided data on postoperative pain associ-ated with different techniques, and quilting sutures were found to be significantly less painful than both nasal packing andseptal splints.

Conclusions: Due to the low level of evidence and the high bias of the studies, the results of this systematic review failto demonstrate a clear benefit among any of the postseptoplasty treatment techniques. However, the results do demonstratethat septal sutures are associated with less postoperative pain versus the other methods of septal management in thisreview.

Key Words: Septoplasty, complications, nasal packing, septal suture, hematoma, perforation, synechiae.Laryngoscope, 123:1328–1333, 2013

INTRODUCTIONA septoplasty is a common surgical procedure per-

formed by otolaryngologists and plastic surgeons.Although uncommon, complications such as septal hema-toma, synechial bands, and septal perforation can causeconsiderable short- and long-term patient morbidity.1

Surgeons have developed a variety of techniques to helpreduce the incidence of these complications. Internal sta-bilization techniques such as nasal packing2 and septalsplinting,3 as well as procedures that remove the deadspace between adjacent mucosal flaps (nasal packing4

and quilting sutures5) are widely utilized. However,there are limited data as to their efficacy. A limitation of

these methods is the potential increase in patient post-operative morbidity, specifically pain6 and patientdiscomfort.7 The use of septal splints and nasal packinghave both been associated with increased postoperativepain.6,8,9 Although rare, toxic shock syndrome has alsobeen associated with the use of both nasal packing10 andseptal splints.11

Given the lack of consensus regarding the optimalmethod of management of the nasal septum after septo-plasty, a clear understanding of the evidence wouldprovide surgeons with a guide to choosing an evidence-based treatment method. Therefore, the purpose of thisarticle is to conduct a systematic review to assess therelative rates of septal hematoma, synechiae, and septalperforation associated with methods commonly used tomanage the nasal septum after septoplasty. As a second-ary objective, we will assess the relative contribution ofeach method of septal management with respect to painand patient discomfort.

MATERIALS AND METHODSA computerized literature search was performed by the

first author (J.G.Q.) as well as by a senior librarian usingExcerpta Medica Database, Cumulative Index to Nursing andAllied Health Literature, Medline, and Cochrane databasesusing the terms ‘‘septoplasty,’’ ‘‘septorhinoplasty,’’ ‘‘nose septumreconstruction,’’ and ‘‘nose reconstruction.’’ The search was lim-ited to articles published in English between 1947 and August18, 2012. The review was limited to English because it was

From the University of Ottawa (J.G.Q.) and Department ofOtolaryngology–Head and Neck Surgery, University of Ottawa (J.P.B.,S.J.K.), Ottawa, Ontario, Canada.

Editor’s Note: This Manuscript was accepted for publicationOctober 4, 2012.

Presented at the 24th Congress of the European Rhinologic Societyand 31st International Symposium on Infection and Allergy of the Nose,Toulouse, France, June 17–21, 2012.

All research was conducted at the Department of Otolaryngology–Head and Neck Surgery, University of Ottawa, Ottawa, Ontario,Canada.

The authors have no funding, financial relationships, or conflictsof interest to disclose.

Send correspondence to Dr. Shaun J. Kilty, Department of Otolar-yngology–Head and Neck Surgery, Ottawa Hospital, Civic Campus,Parkdale Clinic, Room 242, 1053 Carling Ave., Ottawa, ON, Canada.E-mail: shaunkilty@hotmail.com

DOI: 10.1002/lary.23848

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understood by the two article reviewers (J.G.Q., S.J.K.), andaccess to translators was not available.

The retrieved article abstracts were then reviewed by twoauthors (J.G.Q., J.P.B.). Studies were eligible to be included in thesystematic review if they met all of the following criteria: anystudy that assessed for postoperative hematoma, synechiae, orseptal perforation and reported on any of these outcomesregardless of the method of septoplasty. Specifically, the articlehad to contain information on the occurrence of any one of sep-tal perforation, hematoma, or nasal synechiae, and it had to

include the sample size, number of complications, and datarelating to subject attrition.

An article was excluded if (Fig. 1): 1) it did not meet theinclusion criteria; 2) it included a significant number of cases ofother sinonasal surgeries, and extraction of data specific toseptoplasty was not possible; or 3) the article did not includepostoperative follow-up data.

References of the retained articles were reviewed to iden-tify additional relevant articles that were not found with theinitial search strategy. In total, an additional 10 full texts wereobtained as a result of this search strategy.

Relevant data were gathered from the full text of all retainedarticles by two authors (J.G.Q., S.J.K.). The reviewers also independ-ently analyzed the included articles using the Cochrane risk of biasassessment tool for randomized controlled trials12 and the Newcas-tle–Ottawa quality assessment scale for cohort and case–controltrials.13 Information gathered included subjects’ demographicinformation, postoperative care intervention, and patient painor discomfort from the postoperative septal treatment.

All disagreements between reviewers were discussed dur-ing a consensus meeting. Data were entered into an EpiDatadatabase and analyzed using the statistical package ReviewManager (RevMan), version 5.1.14 A descriptive analysis wasperformed on all data. The relative risk (RR) of the postopera-tive septal treatment for each of the complications of interestwas computed based on reported data.

RESULTSA total of 17 studies with 2,079 participants were

included and reviewed in this study. Overall patientcharacteristics could not be calculated due to incompletereporting on patient variables among studies. Theresults of bias assessment and study characteristics aredescribed in Table I.2,3,6,9,15–26 Overall rates of perfora-tion, hematoma, and adhesions were 2.1%, 0.7%, and

Fig. 1. Search strategy.

TABLE I.Study Characteristics and Assessment of Bias.

Study Year Design Comparison Quality

Ardehali and Bastaninejad2 2009 RCT Suture vs. splint High risk of bias*

Cook et al.3 1992 RCT Splint vs. pack High risk of bias*

Awan and Iqbal6 2008 RCT Suture vs. pack High risk of bias*

Gunaydin et al.8 2011 RCT Suture vs. pack High risk of bias*

Malki et al.9 1999 RCT Splint vs. pack High risk of bias*

Al-Raggad et al.15 2007 RCT Suture vs. pack Uncertain risk of bias*

Guyuron16 1989 RCT Suture vs. pack High risk of bias*

Gyawali et al.17 2008 RCT Pack vs. pack High risk of bias*

Habesoglu et al.18 2010 Cohort Glue vs. pack 8/9†

Hajiioannou et al.19 2007 RCT Pack vs. pack High risk of bias*

Illum et al.20 1992 Cohort Pack vs. pack 8/9†

Korkut et al.21 2010 RCT Suture vs. pack High risk of bias*

Kula et al.22 2010 RCT Pack vs. splint vs. suture High risk of bias*

Leighton et al.23 1996 RCT Pack vs. no intervention Uncertain risk of bias*

Lubianca-Neto et al.24 2000 RCT Pack vs. pack High risk of bias*

Nunez and Martin25 1991 RCT Suture vs. pack High risk of bias*

Cukurova et al.26 2012 RCT Suture vs. pack High risk of bias*

*Risk of bias as assessed using Cochrane risk of bias assessment tool for RCTs.†Risk of bias as assessed using the Newcastle–Ottawa quality assessment scale for cohort and case–control trials, with score of 9 indicating highest

level of evidence for methodology.RCT ¼ randomized clinical trial.

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3.8%, respectively. A standard error could not be calcu-lated for complication rates. Due to the low occurrencerates of complications, it is not valid to apply a normaldistribution to the data.

Quilting Versus Nasal PackingFigures 2 to 4 summarize the results of the studies

with respect to complications between the use of quiltingsutures and nasal packing. The results of these studiesfailed to demonstrate a benefit associated with eithertechnique with respect to complications. Three studiesfailed to report on hematomas,16,22,25 and two did notreport on perforations.6,25

Quilting Versus SplintsThe results of two2,22 studies providing a compari-

son between quilting sutures and nasal splints aresummarized in Figures 5 and 6. The results of thesestudies failed to demonstrate a benefit associated witheither technique with respect to complications. No dataare available comparing the occurrence of hematomasdue to lack of reporting in one study22 and nonoccur-rence of the complication in the other.2

Nasal Splints Versus Nasal PackingThree studies,3,9,22 with a total of 244 participants,

provided data on the complication rates of nasal packing

Fig. 2. Quilting sutures versus nasal packing: relative risk of perforation (total ¼ number of participants per group). CI ¼ confidence interval;RCT ¼ randomized clinical trial; M-H ¼ Mantel-Haenszel.

Fig. 3. Quilting sutures versus nasal packing - relative risk of adhesions. CI ¼ confidence interval; RCT ¼ randomized clinical trial.

Fig. 4. Quilting sutures versus nasal packing: relative risk of hematoma. CI ¼ confidence interval; RCT ¼ randomized clinical trial.

Fig. 5. Quilting sutures versus nasal splints: relative risk of adhesions. CI ¼ confidence interval; RCT ¼ randomized clinical trial.

Fig. 6. Quilting sutures versus nasal splints: relative risk of perforation. CI ¼ confidence interval; RCT ¼ randomized clinical trial.

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versus nasal splinting. Only one study provided data on he-matoma rates, and no septal hematomas were reported.3

The RRs of complications when comparing nasal packingand nasal splints are summarized in Figures 7 and 8. Theresults of these studies failed to demonstrate a benefit asso-ciated with either technique with respect to complications.

Fibrin Glue Versus Nasal PackingFibrin glue was compared to nasal packing in one

cohort study with 43 participants.18 No septal hemato-mas occurred in either group. Data on septal perforationwere not reported. There was a trend toward a reductionin adhesion rates when using fibrin glue (RR, 0.18; 95%confidence interval [CI], 0.01-3.61).

No Intervention Versus Nasal PackingOne study with a total of 50 participants provided

data comparing nasal packing to no intervention.23 Thenumbers of septal perforations and adhesions were notreported. Septal hematomas did not occur in eithergroup so the RR of complications could not be calculated.

Postoperative PainData on postoperative pain are summarized in

Table II. Only two studies measured pain at multiple

timepoints.9,26 The study by Malki et al.,9 which com-pared nasal packing to nasal splints, also reportedpatient pain levels at 48 hours postoperatively using a1–10 (1 being absence of pain and 10 being severe pain)visual analogue scale (VAS) scale. However, this studydid not find a statistically significant difference in painat this time point. The study by Cukurova et al.26 meas-ured pain at 24 and 48 hours postoperatively, butreported only one set of pain scores, and did not specifywhich time point these pain scores represent. The studyby Awan and Iqbal6 comparing nasal packing to quiltingsutures immediately postoperatively did not report aprobability value; however, the authors did state thatquilting sutures were associated with less pain and thatstatistical significance was obtained.

Patient ComfortTwo studies19,20 provided data on patient comfort

postoperatively with nasal packing, but both of thesestudies compared different types of nasal packs. Onestudy comparing pain among three types of nasal pack-ing at the time of removal found no difference in patientcomfort measured on a VAS (1 being absence of discom-fort and 10 being severe discomfort).20 A second studycompared petroleum jelly with antibiotic-impregnatedgauze placed for 24 versus 48 hours and found signifi-cantly increased patient discomfort at the 36- and

Fig. 7. Nasal packing versus nasal splints: relative risk of perforation. CI ¼ confidence interval; RCT ¼ randomized clinical trial.

Fig. 8. Nasal packing versus nasal splints: relative risk of adhesions. CI ¼ confidence interval; RCT ¼ randomized clinical trial.

TABLE II.Postoperative Pain With the Septal Treatment Methods Standardized on a 1–10 Visual Analog Scale.

TreatmentMethod Versus (b) Study Time Point*

MeanScore (a)

MeanScore (b) Favors Significance

Sutures (a) Packs Nunez and Martin 199125 24 hours 2.9 4.1 Sutures P < .05

Packs Awan and Iqbal 20086 Immediate 2.14 7.32 Sutures Not provided

Packs Cukurova et al. 201226 Unclear 2.3 4.8 Sutures P < .05

Packs Gunaydin et al. 20118 Day 1 3.58 5.90 Sutures P < .001

Splints Ardehali and Bastaninejad20092

Day 1 2.1 5.0 Sutures P < .01

Packs (a) Splints Cook et al. 19923 1 week 3.52 4.8 Packs P < .001

Splints Malki et al. 19999 1 week 0.5 2.2 Packs P < .0001

Fibrin Glue Habesoglu et al. 201018 Day 3 6.09 2.43 Glue P < .001

*Postoperative.

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48-hour time points in the group with a pack placed for48 hours.19 The only complication of interest reported onwas hematoma, and this did not occur in either group.

DISCUSSIONVarious methods have been employed to treat the

nasal septum postoperatively following septoplasty withthe goal of decreasing complications. Due to the highlevel of bias in the included studies, a formal statisticalmeta-analysis was not possible; therefore, we are unableto conclude whether one method is significantly more ef-ficacious than any other of the methods. Although biasis high, the majority of studies failed to demonstrate anyclinically significant benefit of nasal packing, septalsplints, or fibrin glue over the use of quilting suturesalone. Furthermore, the use of quilting sutures is associ-ated with significantly less pain in the postoperativeperiod. Although one study6 did find a significantdecrease in the adhesion rate when quilting sutureswere compared to nasal packing, it appears unlikelythat this finding is of significant consequence, consider-ing the broad CI (RR, 0.06; 95% CI, 0.0-0.99) and failureto reproduce this finding in any of the five studiesassessing this outcome. Given the ease and low morbid-ity associated with quilting sutures, there does notappear to be adequate evidence to recommend additionalmethods to manage the nasal septum.

When assessing postoperative pain, the availableevidence provides support for the use of quilting sutures(Table II). Although these results suffer the same limita-tions as those associated with complications, it isnoteworthy that they were reproducible. Similarly, fibringlue was shown to be associated with significantly lesspain than nasal packing, and although indirect compari-son to nasal splints would suggest it to be superior tothem as well, its efficacy relative to quilting sutures willremain unclear until a direct comparison study isperformed.18

Although this systematic review is of high quality,it is limited by the low level of evidence of studies thatexist in the literature. For this reason, a meta-analysiscould not be performed due to the low quality of evi-dence as assessed with the Newcastle–Ottawa qualityassessment scale and the Cochrane risk of bias tool.Without being able to pool participants from studies, itis difficult to assess the overall result of each interven-tion. In addition to this, it would be difficult forindividual studies to demonstrate a significant differencebetween groups due to both the low incidence of compli-cation rates and the low individual study power.Excluding the two larger studies by Gunaydin et al.8

and Cukurova et al.26 (200 and 697 participants, respec-tively), the mean group size was relatively small at only34.8. Demonstrating a significant reduction in rare com-plications would require a significantly larger samplesize. It is noteworthy, however, that the primary out-come of interest for many studies was not postoperativecomplications, which accounts in part for the inadequatepowering of most studies with respect to complications.Few studies were available to assess some methods of

postoperative management, and when taken in conjunc-tion with poor reporting on complications, as well as alack of occurrence of events due to small group sizes, theavailable data on septal hematomas and perforationswere very limited.

Methods employed to prevent complications follow-ing septoplasty are generally presumed to functionthrough the reduction of dead space between adjacentmucoperichondrial flaps and/or internal stabilization ofthe nasal septum. The results of this review do notfurther our understanding, as most studies comparedtechniques that are presumed to operate on the sameunderlying mechanism. Nasal packing may impair endo-nasal lymph and venous drainage and actuallycontribute to increased edema and postoperative compli-cations.2 This theory would then apply, to a lesserextent, to the use of septal splints and quilting sutures,as both techniques maintain tissue position through theapplication of pressure. Only one trial looked at compli-cations in patients who had no intervention incomparison to nasal packing, and this study did not pro-vide support for either theory, as the study did not allowfor comparison between techniques due to a lack ofreporting and low complication rates.23

Given the theoretical basis for the use of quiltingsutures, nasal packing, and septal splints, as well as thelack of supporting empirical evidence, the authors of thisstudy believe future trials should focus on outcomes asso-ciated with no intervention. Only one trial was identifiedthat looked at no intervention and despite a small sam-ple size, it is noteworthy that it was not associated withhigher complication rates.23 Although the results of thisstudy offer weak evidence for the use of quilting suturesover additional treatment methods, it remains unclear ifthey themselves offer any benefit over no sutures, as astudy comparing this has yet to be conducted. However,given the low morbidity, low complication rates, ease ofperforming the quilting suture, and relatively low cost ofa suture, it seems reasonable to conclude that thismethod of septal management may be applicable in allpatients. Furthermore, future research should focus onthe quality of the study methodology and ensuringadequate powering. It is equally important that furtherstudies on postoperative septal management techniquesinclude outcomes for septal hematoma, perforation, andadhesions or synechiae. Lastly, assessing and reportingon the resultant pain for the participant from the septalintervention would be of benefit.

CONCLUSIONAlthough the results of this systematic review failed

to demonstrate a clear benefit associated with anymethod of managing the nasal septum postoperatively,the majority of studies were of a low level of evidencewith a high potential bias. Because of the low rate ofcomplications as well as the low level of evidence of thestudies, the relative benefit of each septal treatmentmethod in the prevention of postoperative complicationsremains unclear. However, the results do demonstratethat septal sutures are associated with less postoperative

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pain versus the other methods of septal management inthis review.

AcknowledgmentsThe authors would like to thank Lee-Anne Ufholz and

Karine Fournier at the University of Ottawa Health Scien-ces Library for assistance with literature search, and theOttawa Methods Centre for Statistical and MethodologicalConsultation at the Ottawa Hospital Research Institute.

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