The Usefulness of Nasal Packing with Vaseline Gauze and Airway Silicone Splint after Closed Reduction of Nasal Bone Fracture

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Abstract

INTRODUCTION

The packing method using paraffin mesh or Vaseline gauze after the reduction of a nasal bone [1,2] can trigger symptoms such as nasal obstruction, mucosal adhesion, sleep disturbance, headache, mouth dryness, and dysphagia. Nasal obstruction can give rise to especially severe discomfort in patients after surgery. Therefore, the ideal nasal packing method should include sufficient splinter support and result in less discomfort associated with nasal obstruction.

To reduce patient discomfort, studies have assessed the performance of packing methods that use an airway tube Merocel [3,4], a rolled silastic sheet [5], or a bronchodilator [6]. These studies, however, only evaluated results through patient surveys, lacking objective measures of nasal respiration. Furthermore, there is a dearth of studies comparing how well new and conventional methods support the reduced bone.

We developed a nasal bone support using Vaseline gauze in the superior meatus, and a Doyle Combo Splint (DCS, Boston Medical Products Inc., Westborough, MA, USA) (Fig. 1) combined with an airway tube, a silastic sheet, and Rhinocell (expandable sponge) in the middle meatus. The specific aims of this article were as follows: 1) Determine whether this method maintains nasal respiration, and determine whether the nasal-respiration volume can be measured quantitatively and objectively. 2) Determine whether support of the reduced bone is sufficient and similar to the conventional method. 3) Compare subjective patient discomfort to conventional Vaseline gauze packing.

Fig. 1

Airway silicone splint (Doyle Combo Splint)

METHODS

Surgical technique

After reducing the nasal fractures and supporting the superior meatus with Vaseline gauze, ointment was applied to the DCS, which was inserted into the middle meatus of both nasal cavities (Fig. 2). If nasal respiration decreased due to hematoma or intranasal discharge, the airway tube was sucked by applying negative pressure with a 10-Fr Nelaton tube. Ventilation was measured using an airway tube and through plain radiography on the day of the surgery (Fig. 3).

Fig. 2

Illustration of nasal packing with an airway silicone splint and Vaseline gauze

(A) Status of packing in the sagittal view. (B) Frontal view.

Fig. 3

Plain films 1 day after surgery

Ventilation was achieved through an airway tube. (A) Waters view. (B) Lateral view of the nasal bone.

Reduced-support comparison

To compare support of the reduced bone of each group, plain X-ray images (Waters view, both lateral views) were taken right after surgery and immediately after removing the packing. Two blinded plastic surgeons compared X-rays and scored the support on a scale of 1 to 3. The final score was derived based on a consensus of the 2 surgeons (Table 1). A displacement was defined as a depression or elevation in the bone fragment on the X-ray image taken after removing the packing. Gaps between the bone fragments that widened without displacement were evaluated as bony gap widening.

Table 1

Displacement scoring system

RESULTS

Measurement of the nasal respiration via spirometry

Packing accidentally fell out in 5 of the control patients, who were excluded from the analyses. The remaining 55 patients had a nasal respiration of 3.08±0.17 L before surgery and 0 L 1 day after surgery. Six patients in the experimental group had no nasal respiration, as measured via spirometry 1 day after surgery, and were excluded (see "DISCUSSION" section). The remaining 54 had nasal respiration of 3.05±0.15 L before surgery and 1.82±0.25 L 1 day after surgery. Nasal respiration after surgery was an average of 71.3%±6.84% of that before surgery. Nasal respiration after surgery was significantly different between the two groups (P<0.001) (Fig. 4).

Fig. 4

Comparison of the accumulated nasal respiration 1 day before surgery and 1 day after surgery

The nasal respiration volume after surgery remained at 72% of baseline when a complex ventilation splint was used.

Discomfort due to nasal packing

The VAS scores of nasal obstruction, dry mouth, sleep disturbance, headache, and swallowing difficulty were 44.6±15.1, 36.4±17.2, 40.8±16.2, 65.2±15.2, and 32.3±20.8, respectively, in the experimental group, excluding the 6 patients without nasal ventilation. The VAS scores were 79.6±10.7, 67.8±12, 68.9±17.4, 69.6±16.2, and 64.6±15.5, respectively, in the control group, excluding the 5 patients with accidental packing removal (Fig. 5). The experimental group had significantly lower scores than the control group for all items except headache (P<0.001). Although the headache score was lower in the experimental group, the 2 groups were not significantly different (P=0.502). No patients in the experimental group had accidental packing removal or filler extrusion to the nostrils or nasopharynx; however, as mentioned earlier, accidental packing removal occurred in a total of 5 patients (8.3%) in the control group. The details of the results are given in Table 2.

Fig. 5

Comparison of VAS scores according to surgical method

The experimental group had significantly less severe discomfort than the control group. VAS, visual analog scales.

Table 2

Results of preoperative and postoperative nasal respiration, support scores for reduced bone, and VAS scores due to packing

DISCUSSION

The existing nasal packing method can cause discomfort, such as nasal obstruction, headache, and dry mouth, and complications, such as nasal septal perforation and toxic shock syndrome [7]. Nasal obstruction not only causes severe discomfort but can also cause sleep apnea, high blood pressure, and nocturnal oxygen desaturation [8,9]. Therefore, various methods have been reported for supporting the reduced nasal bone without the standard packing [10,11]. In clinical practice, however, packing is used extensively to support reduced bone.

We devised a method to minimize discomfort by inserting DCS into the middle meatus to allow ventilation while supporting the reduced bone with Vaseline gauze. DCS, a complex airway silicone splint, is made of a 7×2 cm silicone sheet to support the nasal septum and a 0.8 cm diameter semicircular ventilating tube, and is surrounded by Rhinocell. The silicone sheet and ventilating tube enables smooth nasal respiration by filling the overall meatus.

Spirometry was used to quantify the nasal respiration through the ventilating tube. The natural expiratory flow is associated with the extent of patient discomfort, and was measured as the accumulated natural nasal expiration volume via unforced expiration for 6 seconds.

The accumulated expiratory flow in the experimental group after surgery remained at 71.3%±6.84% of that 1 day before surgery, excluding 6 patients who did not have expiratory flow. Before surgery, most patients had a great deal of expiratory flow at the initial stage, which flattened off. After surgery, the expiratory flow was consistent during the early and later stages. This difference is likely due to obstruction because expiration is carried out only through the ventilating tube. The relatively smooth ventilation, however, amounted to 71.3%±6.84% of that before surgery. A broader ventilating pipe could have improved these results to some extent, but the support and ease of use must be considered.

In the survey of patient discomfort, the experimental group had significantly lower VAS scores for nasal obstruction, dry mouth, sleep disturbance, headache, and swallowing than the control group. Negative pressure was prevented from building up in the nasopharynx and middle ear by enabling early nasal respiration, thus reducing uncomfortable symptoms [12]. In addition, because nasal respiration was possible, there was no need for oral respiration, which improved symptoms, such as dry mouth and swallowing difficulty. While the experimental group had lower headache scores, the difference was not statistically significant. Pressure in the sinuses when Vaseline gauze is used to pack the superior meatus can result in painful headaches. The displacement of the reduced bone between reduction and the time of packing removal in the experimental and control groups was not significantly different. Some suggest that sufficient support of reduced bone can only be achieved by packing the superior meatus and ethmoidal crest with Vaseline gauze. In the conventional method, the Vaseline gauze comes out of the nasal cavity or goes down to the nasopharynx. In some cases, patients remove the gauze due to discomfort, resulting in a lack of appropriate support for a sufficient time. In this study, 8.3% of the control group, but no one in the experimental group, removed the gauze. DCS packing of the middle meatus provides sufficient support, which prevents the Vaseline gauze from extruding.

Another advantage of the proposed method is that it has less pain and bleeding upon packing removal, and can be useful in providing support after reducing septal fractures. Merocel, which has been extensively used as a packing material of late, causes excessive pain and bleeding upon removal compared to Vaseline gauze because it tends to adhere to the mucosa [13,14]. Furthermore, Merocel is less flexible than Vaseline gauze, and it is difficult to accurately insert into the superior meatus due to its shape. The lateral side of DCS consists of Rhinocell (expandable sponge). Rhinocell, composed of polyvinyl, provides a smooth surface to minimize tissue in growth. In addition, its high tensile strength prevents shedding or tearing the mucosa. Rhinocell is expanded by normal saline, and delivers appropriate pressure to the nasal mucosa and septum. Thus, it has less risk of moving the DCS and provides support to the reduced nasal septum. The medial side of DCS stably maintains the corrected nasal septum along with Rhinocell because it is made of a silicone sheet. Furthermore, if damage occurs to the mucous membrane during surgery, it maintains moisture by covering the damaged site, and promotes quick healing by preventing additional mucosal damage and irritation.

There are some precautions, however, to using this method. In patients with a narrow nasal cavity, including children under 10 years old, it can be difficult to insert a splint. A portion of the silicone sheet and expandable sponge can be cut off, however, to reduce the size outside the ventilating tube.

Six patients had no nasal respiration volume in the spirometry despite having an airway silicone splint, but still recorded high VAS scores (data not shown). In these patients, there was likely severe nasal bleeding during reduction of the nasal bone, or the Vaseline gauze blocked the end of the ventilating opening. Their airway was not opened because the ventilating opening was blocked due to clotted blood or continuous discharge. Therefore, it is ideal to check whether the ventilating tube can be penetrated by a thin suction tip so that the airway can be appropriately maintained. On the day of the surgery, frequently checking nasal respiration and opening the ventilating tube by suction with a thin tube if blocked due to blood clotting or secretion will help ease discomfort.

A limitation of our study is that CT scanning was not used to compare the support of the reduced bone between groups. Although CT provides a more accurate evaluation, its use can be cost-ineffective. Several studies conducted closed reduction with a C-arm, achieving accurate results by observing the bone with continuous imaging. The results were confirmed by CT scanning [15,16]. Therefore, it is concluded that relatively suitable assessments can be obtained using plain film.

In conclusion, the authors were able to pack the superior meatus with Vaseline gauze after closed reduction, and maintained nasal ventilation of the middle meatus by filling it with DCS. This was quantitatively determined through spirometry. In addition, the decrease in uncomfortable symptoms was confirmed through a survey. The suitable support of this packing method was determined by X-ray. We conclude that this method of nasal packing is useful in reducing discomfort and providing appropriate support.

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