Triological Society Best Practice
Should intranasal splints be used after nasal septal surgery?†
The authors have no funding, financial relationships, or conflicts of interest to disclose.
Intranasal splints are widely used after nasal septal surgery for prevention of intranasal adhesions and support of septal position. However, they have been shown to cause significant discomfort to patients. Here we examine the evidence regarding the utility of using intranasal splints after septal surgery and address the question of whether the benefits of their use outweigh the risks.
In the last 20 years there have been six randomized controlled trials (RCTs) comparing outcomes of septal surgery with and without the use of intranasal splints. In three similar RCTs of 100 patients undergoing septoplasty or combined septal and inferior turbinate surgery,1–3 patients were randomized either to have splints inserted at the end of surgery or to have no splints. All patients had nasal packing removed on postoperative day 1 and splints removed at 1 week. Cook et al.1 used trimmed silicone Medasil (Leeds, UK) splints and found that septal position and airway patency at 6 weeks after surgery were improved to an equal degree between groups. There was also no significant difference in the rate of intranasal adhesions at 6 weeks. Pain scores over the first postoperative week were higher in the splint group. Malki et al.2 used trimmed Silastic (Dow Corning Corp., Midland, MI) or Cawoods type splints, and found that all patients experienced a similar degree of pain within the first 48 hours, but at 1 week the mean pain score was higher in the splints group (2.2 vs. 0.5, P < .0001). At 6 weeks, 1.8% of the splint group had intranasal adhesions compared to 7.7% of the no-splint group, but this difference was not significant. Von Schoenberg et al.3 used Exmoor Silastic (Exmoor Plastics Ltd., Taunton, UK) standard-sized splints and found that the splint group had greater pain (visual analog scale [VAS] score of 4.6 vs. 3.4, P < .001). The highest incidence of intranasal adhesions occurred in patients who had surgery concurrently on both the septum and the lateral nasal wall. Of these, 31.6% of the no-splint group had adhesions at 1 week compared to 3.6% in the splint group. At 3 months, both groups only had 1 patient each with adhesions, with this low incidence attributed to the nasal toilet completed at the 1-week visit. Notably, these authors include division of adhesions under topical anesthesia as part of routine postoperative nasal toilet.
Ardehali and Bastaninejad4 randomized 114 septoplasty patients to have either insertion of septal splints and antibiotic meshes or placement of transseptal horizontal mattress sutures. Antibiotic meshes were removed after 48 hours, and splints were removed at 1 week. Differences in the rates of mucosal adhesions between groups were found to be statistically insignificant. Postoperative pain on a 10-point VAS was found to be higher in the packing group (5 vs. 2.1, P = .01).
Jung et al.5 conducted a study of 40 patients undergoing septoplasty alone. A 0.03-inch Silastic splint (BioPlexus, Ventura, CA), trimmed to avoid touching either the nasal roof or floor, was inserted on one side only, with the contralateral side serving as a control. All patients had bilateral nasal packing removed on postoperative day 1 and the unilateral splint removed at 1 week. Pain and mucosal status at 1 and 2 weeks were compared between the splint side and the control side. Mucosal status was graded by one of the authors by a predetermined scale (1 = no erosion, 2 = focal erosion, 3 = multiple erosions, and 4 = synechia between septum and turbinate). At 1 week, the nasal discomfort score was not significantly different on the splint and control sides. Average mucosal status was found to be better on the splint side compared to the control side (1.5 vs. 2.5, P < .001). By 2 weeks, the splint side had a lower discomfort score (2.7 vs. 3.8, P < .001) and better mucosal status (1.5 vs. 1.9, P = .013).
Yilmaz et al.6 randomized 51 septoplasty patients to one group given Merocel (Mystic, CT) nasal packing, and a second group was given silicone splints with integral airway (Breathe-Easy; Diversified Biotech, Dedham, MA) to compare postoperative eustachian tube function. Both packs and splints were removed after 48 hours, at which point tympanometric middle ear pressures were found to be pathologically decreased in 74% of the packing group compared to 21% of the splint group. Altogether, 22% of the packing group and 7% of the splint group had subjective aural fullness, and this completely resolved after packs and splints were removed.
In the RTCs that report rates of other postoperative complications,1, 2, 4 the rate of septal perforation was higher in the splint group (2.2%–3.5%) compared to the no-splint group (0%–2.1%), but this difference did not reach significance. None of the studies reported septal hematomas in either group.
Conventional septal splints have been shown in multiple large RCTs to cause significantly increased postoperative pain without sufficient evidence of decreasing rates of intranasal adhesions or other clinically significant complications. However, one recent smaller RCT shows that a new thinner splint may result in both improved mucosal status and decreased postoperative discomfort.
LEVEL OF EVIDENCE
Evidence level is 1b (individual RCTs).