Prevention of nasal septoplasty surgical site infections by povidine-iod disinfection: proposal for a pragmatic randomized controlled study (Preprint)

UNSTRUCTURED Surgical site infections (SSIs) from nasal bacteria are an increasingly feared complication in general surgery, in implantation surgery and in intensive care units with consequences for the patient and society not only in the short, but also in the long run. The increasing hazard of antibiotic resistances may accelerate this problem. In rhinosurgery, SSIs as a complication consist of either local wound infections, septal perforation, pneumonia or life-threatening sepsis. Standard of care for rhinosurgery is surgical hand wash, sterile drapes, gloves and antiseptic disinfection of the skin around the mid-face. Surgeons perform septoplasties in a clean contaminated field and the disinfection of the surgical field in the nasal vestibule and nasal cavity at nasal surgery is not common practice. The infection rates for septorhinoplasty spread along the range of 1 to 27 % according to the literature. It is therefore unknown, whether endonasal disinfection at nasal surgery will prevent the rate of postoperative SSIs. For the proposed pragmatic randomized controlled trial (pRCT), we chose the following primary goal: The preventive effect of aqueous povidine-iod (PVP-I) disinfection on septoplasty related SSIs. As secondary goals serve (a) to determine the safety of endonasal disinfection using PVP-I, (b) to identify the risk of endonasal PVP-I toxicity on olfactory epithelium, (c) to characterize the endonasal microbiota dependent on endonasal PVP-I disinfection in the short- and the long-term and d) to identify the endonasal microbiota in septoplasty related SSI and in septoplasty related uneventful follow-up.

CUSTOM MADE INTERNAL AND EXTERNAL NASAL SPLINTS : A COST EFFECTIVE ALTERNATIVE

Objectives: To evaluate the usability and effectiveness of tailor made internal and external nasal splints after nasal surgery. Study Design: An observational study. Place and Duration of Study: Combined Military Hospital Kohat, from Nov 2015 to Aug 2017. Methodology: the study was carried out on 523 patients who underwent nasal surgery by the same team of surgeons. Custom made free of cost internal and external nasal splints were used as required. Complications pertaining to the use of nasal splints were recorded. Results: The custom made splints were found to be an excellent and cost effective alternative of commercially available expensive splints. The benefits and pitfalls were comparable. Conclusion: Where these free of cost splints does the job they as well save a lot of money and can be used as an effective alternative to commercially available splints.

Bioabsorbable dressing impregnated with betamethasone and ciprofloxacin after endoscopic sinus surgery: A randomized, double-blind, placebo-controlled study

Background In addition to its hemostatic and stabilization role, biodegradable nasal packing can be used as a carrier for drugs after functional endoscopic sinus surgery (FESS). The aim of this study was to compare the influence of biodegradable synthetic polyurethane foam (NasoPore) soaked with ciprofloxacin, or betamethasone, or both to the same foam soaked with saline after FESS. Methods 120 adults with chronic rhinosinusitis, with and without polyps, directed for bilateral full-house FESS were enrolled for the study. The patients were randomized and blinded into 3 groups, depending on the type of postoperative procedure applied. Thus, NasoPore soaked with antibiotic was provided to the first group; in the second group, the steroid was used; and the combination of both, in the third group. In each case, the aforementioned procedure was administered on one side of the nose, while NasoPore was soaked in saline on the other, at the end of the surgery, respectively. The patients were requested to complete a questionnaire during their postoperative visits at 2, 10, 30, 90, and 180 days, scoring the level of complaints on the VAS scale, separately for each side. The evaluation of the healing process was performed at each visit using rigid endoscopy and subsequently rated on numerical scales. Results Decreased mucosal edema and secretion; reduced Lund-Kennedy score; and favorable influences on facial pressure, nasal blockage, and smell were most evidently seen in the group receiving the antibioticsteroid combination. Conclusions The application of biodegradable nasal packing with betamethasone and ciprofloxacin in sino-nasal surgery has positive effects not only on the healing process but also impacts patient’s comfort. To optimize it, however, further research is needed.

Radiological study of the nasal septal body

Objectives The nasal septal body (NSB) is the thickened area of the septum located superior to the inferior turbinates and anterior to the middle turbinates. NSB contributes to nasal breathing via functionally and anatomically. The aim of the present study was to analyze NSB size and its association with such variables as age, septal deviation, and nasal turbinate size Material and Methods This retrospective study included 381 randomly selected patients that underwent paranasal sinus CT between 2014 and 2019. NSB size, septal deviation angle, and middle and inferior turbinate size were analyzed. Results NSB, inferior turbinate, middle turbinate, and inferior turbinate-P were significantly smaller on the deviated side. NSB, inferior turbinate, middle turbinate, and inferior turbinate-P size according to nasal septal angle was also significantly smaller on the deviated side. NSB and inferior turbinate size was positively correlated. Conclusion The NSB is an important structure for the regulation of air flow in the nose and should be evaluated in routine examination of the nose especially before the nasal surgery.

Assessment of the anterior superior alveolar nerve and its impact on surgery of the lateral nasal wall

Background: The anterior superior alveolar nerve (ASAN) plays a major role in innervation of the lateral nasal wall. Its damage during nasal surgery can cause dental paraesthesia and numbness around the upper lip. Methodology: Retrospective evaluation of the computed tomographic (CT) scans of 50 consecutive patients analysing 100 sides. We measured the mean distance from the shoulder of the inferior turbinate to the descending portion of the anterior superior alveolar nerve, to the anterior superior alveolar canal and the anterior-posterior distance between the “shoulder” of the inferior turbinate and the pyriform aperture. Results: The mean distance from the shoulder of the inferior turbinate to the descending portion of the anterior superior alveolar nerve was 6.4 ± 2.33 mm, with no difference between sides The mean relative height of the shoulder in relation to the anterior superior alveolar nerve canal was 4.78± 2.31mm with no significant difference between the two sides. The anterior-posterior distance between the “shoulder” of inferior turbinate and the pyriform aperture was 6.96± 2.28mm, with no significant difference between the two sides. Conclusions: We found the anterior superior alveolar nerve to be a constant landmark in the lateral nasal wall. Therefore, the course of the ASAN should be assessed on a CT scan when a surgical approach through the pyriform aperture or anterior medial wall of the maxillary sinus is planned.

The contribution of galenics to patients’ sensory perception of nasal sprays after nasal surgery – data from a prospective randomized, controlled, double-blind, cross-over, multi-centre study

Introduction:Postoperative care after nasal surgery is commonly achieved with nasal sprays. The current study compared two decongesting, wound healing nasal sprays in patients after nasal surgery in order to investigate their sensoric perception. One of the sprays presented a new galenic formulation (nasic® neo, Cassella-med GmbH & Co. KG).Methods:Using a cross-over design, patients who had undergone nasal surgery applied two different nasal sprays during two treatment periods of 4 days each, interrupted by 3 days wash out period. Sensoric perception of the nasal sprays was assessed with the nasal-spray-sensoric-scale. Throughout the study, nasal obstruction was evaluated by patients, and physical examinations, measurements of vital parameters and rhinoscopic examinations were carried out by investigators. Adverse events were documented during the entire study, and following treatment, patients judged the overall preference, efficacy and tolerability of both products.Results:Overall, no significant differences in sum scores of the assessments of the nasal-spray-sensoric-scale were observed between treatments. Significant periodic effect observed during the cross-over study limited the overall analysis. Nevertheless, it could be shown that significantly more patients preferred the new galenics nasal spray compared to the comparator spray (57.1% vs. 34.7%; p=0.031). Further, 10% more patients rated the efficacy of new galenics as ‘good’ to ‘very good’ compared to the comparator. Importantly, a subgroup population of patients with more pronounced signs of inflammation present at screening evaluated the sensoric perception of new galenics significantly better (p=0.033) compared to the comparator. Within this subgroup, no periodic effect was observed. The application of both nasal sprays was shown to be safe and well-tolerated.Conclusion:The current study showed that the overall sensoric perception of both nasal sprays was evaluated comparably well in patients after nasal surgery and that overall, the application of the new galenics nasal spray was preferred by significantly more patients compared to the comparator nasal spray. Patients with marked nasal abnormalities may have a greater benefit from the contribution of galenics as significant differences in the sensoric evaluation by the nasal-spray-sensoric-scale in favour of the new galenics product were shown for this subgroup.Trial registration: The current study was registered in the EU Clinical Trials Register with the EudraCT No: 2019-004936-52.

Postoperative Urinary Retention Following General Anesthesia for Endoscopic Nasal Surgery in Men Aged Older Than 60 Years: A Retrospective Study

Objectives: Postoperative urinary retention (POUR) is influenced by many factors, and its reported incidence rate varies widely. This study aimed to investigate the occurrence and risk factors for urinary retention following general anesthesia for endoscopic nasal surgery in male patients aged >60 years. Methods: A retrospective review of medical records between January 2015 and December 2019 identified 253 patients for inclusion in our study. Age, body mass index (BMI), a history of diabetes/hypertension, American Society of Anesthesiologists (ASA) classification, and urologic history were included as patient-related factors. Urologic history was subdivided into 3 groups according to history of benign prostate hyperplasia (BPH)/lower urinary tract symptoms (LUTS) and current medication. The following was analyzed as perioperative variables for POUR development: duration of anesthesia and surgery; amount of fluid administered; rate of fluid administration; intraoperative requirement for fentanyl, ephedrine, and dexamethasone; postoperative pain; and analgesic use. Preoperatively measured prostate size and uroflowmetry parameters of patients on medication for symptoms were compared according to the incidence of urinary retention. Results: Thirty-seven (15.7%) patients developed POUR. Age (71.4 vs 69.6 years), BMI (23.9 vs 24.9 kg/m2), a history of diabetes/hypertension, ASA classification, and perioperative variables were not significantly different between patients with and without POUR. Only urologic history was identified as a factor affecting the occurrence of POUR ( P = .03). The incidence rate among patients without urologic issues was 5.9%, whereas that among patients with BPH/LUTS history was 19.8%. Among patients taking medication for symptoms, the maximal and average velocity of urine flow were significantly lower in patients with POUR. Conclusions: General anesthesia for endoscopic nasal surgery may be a potent trigger for urinary retention in male patients aged >60 years. The patient’s urological history and urinary conditions appear to affect the occurrence of POUR.