Introduction

Packs are commonly inserted by ENT surgeons after nasal surgery. This practice is justified by a belief that packing reduces postoperative haemorrhage, adhesions and septal haematoma formation [1].

There is disagreement over the ideal length of time packs should remain in situ, however, and some evidence that packing is unnecessary [1].

Packing is associated with complications, such as pain, profound vagal response, soft palate laceration, septal perforation and toxic-shock syndrome [2–4].

It has been the authors’ anecdotal experience that there is a considerable variation in consultant practice relating to nasal packing. This national postal survey aims to identify and report consultant packing practices following routine nasal surgery.

Materials and methods

A questionnaire was sent to 648 consultant ENT surgeons identified from the Medical Register 2002–2003 [5], inquiring about their packing practice after routine nasal surgery. The results were collated using Excel® 2003—(Microsoft Corp, Redmond, WA) and exported into SPSS v. 11.0 (Statistical Package for the Social Sciences, Chicago, Illinois) for analysis. An NHS statistician’s advice was sought for statistical analysis.

Results

Of the 648 questionnaires sent, 282 (43.5%) were returned. Sixty-nine (24.5%) respondents classified themselves as rhinologists, and 215 (76.2%) as non-rhinologists. In all, 54 (78.3%) of rhinologists claimed to perform more than 100 nasal operations per year, versus 64 (31.8%) of the non-rhinologists (Fig. 1). This difference was statistically significant (P < 0.005). Most non-rhinologists (73%) performed over 50 nasal operations per year (Fig. 1).

Fig. 1
figure 1

Volume of nasal operations by ENT subspecialty

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For specific operations, there was a universal trend towards less routine packing (>70% frequency) in the rhinologist group versus others (Fig. 2). This was significant at P < 0.005 for septal surgery and rhinoplasty. In operations where surgeons used packs rarely (defined as <25% of occasions), rhinologists were also less likely to pack than non-rhinologists for all operations considered (Fig. 3); this difference reached P < 0.005% for turbinate reduction, septal surgery, rhinoplasty and FESS.

Fig. 2
figure 2

Percentage of surgeons who routinely (>70% of occasions) pack after specific nasal operations

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Fig. 3
figure 3

Percentage of surgeons who rarely (<25% of occasions) pack after specific nasal operations

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When we questioned respondents about their packing habits for specific nasal operations, our results show that the submucous diathermy was associated with the smallest percentage of surgeons routinely packing. We defined “routinely pack” as on more than 70% of occasions. This finding was corroborated by the answers to our question “In which procedure do you rarely (<25% of the time) pack the nose?” Of note, rhinologists were less likely to routinely pack than non-rhinologists for every procedure (Fig. 2).

Data were also collected regarding which packs surgeons generally preferred. Merocel™ was the most popular pack used in 405 of respondents (Fig. 4). Where rhinologists did use packing, they were more likely to use new, specialist packs, rather than the conventional packs specified in our questionnaire (Merocel™, Vaseline™ gauze, Jelonet™, BIPP, Kaltostat™ and glove-finger).

Fig. 4
figure 4

Types of packs used by ENT subspecialtly

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Discussion

Synopsis of key findings

Our survey demonstrates that there is little concordance in nasal packing among UK ENT consultants. There have been many other studies comparing specific packing strategies [2, 3, 6], but this is the first to investigate the packing practice of a large group of surgeons for routine nasal surgery.

The consultants who specified a subspecialty interest in rhinology packed less often than the non-rhinologists for all common nasal operations. There was a great variation in the type of pack favoured.

We included a section for free-text comments at the end of the questionnaire which was not formally analysed. However, some consultants mentioned specifically that they only pack if bleeding is unusually heavy. One consultant only packed private patients.

Comparison with other studies

A Canadian survey in 2003 looked specifically at FESS [7]. The results revealed that overall 52% of Canadian surgeons routinely placed nasal packs following sinus surgery, but this practice was significantly less common among professed rhinology specialists.

To date, studies investigating the effect of nasal packing have not demonstrated a significant difference in bleeding, adhesions, nasal crusting or atrophy [4]. Suturing has been described as an equally efficacious alternative to packing for septal surgery [8]. A study using a rabbit model, septal sutures and packs have been shown to cause similar histological effects [9].

Limitations of the study

The questionnaire was sent out once and achieved a response rate of (43.5%). Although this is a minority of the UK ENT consultant population, it nevertheless, represents a substantial number. Apart from the free-text section, the respondents were not asked to justify any of their nasal packing preferences.

Clinical applicability of the study

The accepted rationale is that packing reduces the incidence of early postoperative bleeding and formation of adhesions. To test this hypothesis, a large trial would be required as these are relatively rare complications. A national audit may, therefore, be a more practical method of answering this question.

Conclusions

Our results revealed that the surgeons who specified a subspecialty interest in rhinology packed significantly less often than the non-rhinologists for common nasal operations. There was a great variation in the type of pack favoured by different surgeons.