At the conclusion of septal surgery, a light nasal pack is placed to safeguard against large clot accumulation and to quiet light bleeding when turbinate surgery or osteotomies were included in the procedure. We have found that less bleeding translates to less nausea and, in turn, to a lessened incidence of postoperative vomiting; vomiting worsens the bleeding and increases the postoperative swelling. Use of a tight pack or gauze-like materials is still done by some, but we disagree with this practice because of the tendency of packing to adhere to the mucosa, cause pain, and create bleeding when removed. If neither osteotomy nor turbinate surgery was performed, the quilting stitch of 5-0 plain suture is adequate for preventing the formation of a septal hematoma. In our practice, a single-or double-folded nonstick cotton pad impregnated with Gentamicin cream is inserted before extubation and is removed on the day after surgery (Figure 44-31).55 The use of cream as compared with petro-leum-based ointment may decrease the initiation of petroleum cysts during this early healing phase.16,56,64,87 The use of sutures laden with antibiotic ointment product is also discouraged.
Figure 44-31. Quilting mattress sutures of the septal flaps prevent hematomas and bleeding and obviate the need for internal splints. To view this image in color, please go to www.oto-text.com or the Electronic Image Collection CD, bound into your copy of Cummings Otolaryngology—Head and Neck Surgery, 4th edition.
After the nasal packs are removed, a three-times-a-day regimen of saltwater flushing of the nose is initiated. Twenty-four hours after the procedure, when incisions are closed and sealed, the patient is instructed to start the instillation of antibiotic ointment in each vestibule. Gentle suctioning on postoperative days five through seven and continued local care for at least two to three weeks allows for adequate healing. Gentle nasal blowing is permitted after the third week, and strenuous exercise is discouraged for a total of five weeks.
Nasal splints are generally only used in septal perforation surgery or when the septal membrane is excoriated or perforated. Splints increase the degree of rhinorrhea, can be uncomfortable, and, if coapting sutures are too tight, can actually lead to perforation of the membrane themselves. When required, we advocate the use of soft, transparent silastic splints that are 0.02 inch thick and hand-sized from silastic sheets; these splints are not uncomfortable. Hard, thick nasal splints with airway tunnels hurt packing is not placed.
Septal perforations resulting from unrepaired contiguous septal mucoperichondrial fenestrations or failure to reskeletonize the mucoperichondrial envelope at the completion of the septal resection maneuver are possible. Nasal shape changes (e.g., tip ptosis, dorsal nasal saddling) may result from over-resection of the caudal septum or the loss of dorsal nasal support. Mild postoperative oozing is very common and not necessarily a complication during the early phase but rather something to be expected. Some patients may experience significant bleeding postoperatively, and this is usually seen in those who also underwent inferior Figure 44-32. A soft telfa pack coated in antibiotic cream is turbinate resection. inserted into the nose at the completion of the nasal operation to prevent clots.
Figure 44-32. A soft telfa pack coated in antibiotic cream is turbinate resection. inserted into the nose at the completion of the nasal operation to prevent clots.
