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There two main situations in surgery where it is important to keep pressure held in some location.
I use a sponge type of packing when it is needed. They come in all shapes and sized and are made of cellulose sponge with very small pore size.
- Keeping pressure on the septum's mucous membrane so that it heals directly to the bone and doesn't accumulate blood under the surface.
- Holding pressure against areas to reduce bleeding is one common situation where packing is needed.
- To maintain pressure on the middle turbinate keeping it towards the middle
The most common use of packing is to maintain the mucous membranes of the septum tightly opposed to the bone and cartilage until it "sticks". This happens in 1 to 4 days, depending on the situation. Some septal deviations are such that the technical aspects of the repair require post operative packing material, some do not. This type of packing is placed on both sides and blocks your breathing completely until removed. I try to remove this type of packing on post operative day one or two.
There are three ways that packing can occasionally be omitted or left in only briefly after a septoplasty.
Some doctors will place packing under the middle turbinate to keep it pressed medially. The middle turbinate can cause a problem if it heals laterally in the post operative period. This type of packing may be left for 4 or 5 days and it generally doesn't block you breathing completely. It is usually attached to strings that aid its removal. I personally do not use packing for this purpose, I prefer to suture the middle turbinates to the septum using dissolving sutures.
- Carefully placing dissolvable stitches that go through the septum and tack the mucous membrane down can suffice in some cases. This has the benefits of maintaining pressure for a week or more, not blocking the airway post operatively, and not requiring removal. I do this in all cases, but it can't always replace packing.
- The other method that can avoid packing is when the septoplasty can be performed using an endoscope and directly accessing the deviations without extra dissection. This is usually used for septal bone spurs. In this situation, the mucous membranes can be sutured back in place using the endoscope.
- With some septoplasties, plastic splits are sutured to the septum to act sort of like a cast. This can be used with, or instead of packing.
The amount of bleeding that is encountered in sinus and nasal surgery varies greatly between patients. During surgery, cotton material that is soaked in Afrin type nasal spray reduces bleeding very well. One can always expect some post operative bleeding but if it appears that the bleeding will be too much, the surgeon can cauterize any specific bleeding sites or place packing against the area to hold pressure. Packing placed to reduce bleeding may be left from 2 to 4 nights. Cauterizing is avoided when possible because it causes crusting and delays healing. The inferior turbinate is the most likely site for me to use packing in this way. Also, if patients have a lot of active inflammation at the time of surgery, the sinus cavities can bleed. When this is the case, a small piece of sponge is often placed under the middle turbinate to provide pressure in this critical area.
People often hear stories of how unpleasant it can be to have packing removed after surgery. This has improved with the newer packing materials and since the modern surgical techniques are less traumatic. With the larger nasal packing, I use a type that has a tube through it that is supposed to let some air pass while the pack is in. It doesn't do this very well, but once it is time to remove the packing, the space that the tube occupies provides a place to squirt numbing medicine and decongestant. This reduces the discomfort and bleeding associated with removing packing. The worst part of packing is that you really don't breath through your nose while it is in place, it is more miserable than painful in most cases.
When you go to the office to have packing removed, consider taking a pain pill first, have someone drive you, and wear clothing that might get a small splatter of blood on it.
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