Introduction
Septoplasty is one of the most common surgical procedures performed in ENT clinics. Intranasal packing is widely used post-operatively for nasal septum stabilisation and bleeding control. Merocel nasal tampons (Medtronic-Xomed, Jacksonville, Florida, USA) are often preferred after surgery because of their ease of use and clinical efficacy.Reference Acioglu, Edizer, Yiğit, Onur and Alkan1 Patients experience pain after septoplasty during the removal of nasal packings.Reference Gencer, Ozkiriş, Gencer and Saydam2 These patients may be concerned about pain before nasal packing removal, thus increasing anxiety levels. Various methods are currently employed to reduce this pain, and research is ongoing.Reference Acioglu, Edizer, Yiğit, Onur and Alkan1 The infiltration of lidocaine before packing removal may reduce the pain experienced, which is an issue that has been investigated previously.Reference Gencer, Ozkiriş, Gencer and Saydam2
Anxiety is a symptom that occurs when an individual does not feel safe. The process of surgery can increase a patient's anxiety levels. The prevention of anxiety will have a positive impact on a patient's quality of life. Patients' anxiety levels can be measured objectively using various tests (e.g. State-Trait Anxiety Inventory for state anxiety, Hamilton Anxiety Scale, and Hospital Anxiety and Depression Scale).Reference Maier, Buller, Philipp and Heuser3 The Hamilton Anxiety Scale was used in this study.
This prospective, controlled study aimed to investigate the effect on patient anxiety of lidocaine infiltration into packing (before removal) following septoplasty.
Materials and methods
This planned, controlled, prospective study comprised 50 patients who underwent septoplasty for nasal septum deviation. Informed consent was obtained from all participants. Patients with nasal polyposis, concha bullosa, or any additional nasal or paranasal pathology, were excluded from the study.
All patients were evaluated by the same psychiatrist pre-operatively. Patients with any psychological disorder were excluded from the study. Patients' anxiety levels were measured, by the same psychiatrist, using the Hamilton Anxiety Scale. All patients were operated on (under general anaesthesia), and all nasal packing was removed, by the same surgeon. Post-operatively, 8 cm Merocel nasal packs (standard nasal dressing without airway) were placed into the right and left nasal passages. Nasal packing was removed 48 hours post-operatively. The timing of nasal packing removal and all operational details were described to all patients individually.
Patients were randomly divided into two groups after the operation. The nasal packs were infiltrated with 10 cc of 2 per cent lidocaine in 25 patients and with 10 cc of saline in the remaining 25 patients. The length of time between infiltration and pack removal was 15 minutes. Patient anxiety levels were measured at the following time points: 24 hours pre-operatively; 48 hours post-operatively, before saline or lidocaine infiltration; and 15 minutes after lidocaine or saline infiltration into the packing.
The needle of a syringe containing 10 cc of saline or 2 per cent lidocaine was inserted into each nasal tampon; 5 cc of saline or lidocaine was infiltrated into the left nasal tampon and 5 cc of saline or lidocaine was infiltrated into the right nasal tampon. The needle had no contact with the nasal mucosa or septum. The septum and nasal mucosa was in contact with the anaesthetic lidocaine or saline via the surface of the nasal tampons.
Patients were asked to mark their level of pain during pack removal on a visual analogue scale (VAS). The VAS was created as a column, 10 cm in length, with the lower end of the column representing no pain and the upper end representing the most severe pain. The patients were informed how to mark the VAS. The scores indicated by the marks on the scale were measured in millimetres.
The data obtained were compared statistically. Patient anxiety levels were compared using SPSS® software (version 13) with a repeated measures analysis of variance. The VAS scores were compared using a one-sample t-test. A value of p < 0.001 was accepted as statistically significant.
Results
Of the 50 patients, 21 were female and 29 were male, with a mean age of 30.4 years (range, 19–56 years).
The Hamilton Anxiety Scale scores overall, and those categorised by gender and level of education, are presented in Tables I–III. The Hamilton Anxiety Scale scores for patients with lidocaine infiltration were: 15.1 ± 7.4 at 24 hours pre-operatively, 16 ± 7.6 at 48 hours post-operatively, before lidocaine infiltration, and 13.7 ± 6.6 at 15 minutes after lidocaine infiltration into the packing. No statistically significant difference was determined between the scores at these time points (p = 0.647). The Hamilton Anxiety Scale scores for patients with saline infiltration were: 16.3 ± 6.8 at 24 hours pre-operatively, 16.4 ± 5.5 before infiltration and 16.1 ± 6.1 after infiltration. No statistically significant difference was determined between these scores (p = 0.766). Figure 1 shows the Hamilton Anxiety Scale scores for both groups at each time point.
Hamilton Anxiety Scale scores for both groups at the different time points. *Prior to infiltration. H = hours; pre-op = pre-operatively; post-op = post-operatively; m = minutes
Hamilton anxiety scale overall scores
* Prior to infiltration. Pts = patients; min = minimum; max = maximum; SD = standard deviation; h = hours; pre-op = pre-operatively; post-op = post-operatively; m = minutes
Hamilton anxiety scale scores by gender
Data represent mean scores ± standard deviations unless indicated otherwise. *Prior to infiltration. Pts = patients; h = hours; pre-op = pre-operatively; post-op = post-operatively; m = minutes
Hamilton anxiety scale scores by education
Data represent mean scores ± standard deviations unless indicated otherwise. *Prior to infiltration. Pts = patients; h = hours; pre-op = pre-operatively; post-op = post-operatively; m = minutes
The VAS score was 5.3 ± 2.0 in the lidocaine study group and was 7.5 ± 1.8 in the control saline group. A statistically significant difference was determined between the groups (p < 0.001) (Figure 2).
Visual analogue scale pain scores for both groups, indicating that infiltration of topical anaesthetics before nasal packing removal may reduce patients' pain.
Discussion
A range of nasal tampons and suturing techniques are utilised to prevent the formation of septal haematoma, to control bleeding, to prevent the formation of adhesions in the nasal cavities and to stabilise the newly created septum following septoplasty. Post-operative removal of nasal packing can be a painful and frightening process for the patient. Patients feel pain during removal of the nasal packs because of the contact surface between the nasal packs and nasal mucosa. There are many studies in the literature on this subject, indicating patient discomfort. The infiltration of topical anaesthetics prior to nasal packing removal may reduce the pain experienced.Reference Gencer, Ozkiriş, Gencer and Saydam2 This study investigated the effect on patient anxiety of lidocaine infiltration into packing (before removal) following septoplasty. The effect of lidocaine infiltration into packing was also evaluated in relation to patient pain.
Merocel nasal packs are easy-to-use tampons that provide effective control of bleeding after surgery.Reference Hesham and Ghali4 However, there is the disadvantage of patient discomfort when the nasal packing is removed. The timing of nasal pack removal is important with regard to patient pain.Reference Gencer, Ozkiriş, Gencer and Saydam2 It has been reported that removal of Merocel nasal packing 24 hours after surgery causes less pain compared to removal after 48 hours.Reference Gencer, Ozkiriş, Gencer and Saydam2 For as long as the nasal packing stays in the nose, the patient is uncomfortable and anxiety levels are increased. As the time to nasal packing removal increases, patients are more likely to suffer anxiety symptoms, which may be experienced as difficulty breathing from the nose and mouth, dryness of the mouth, difficulty in swallowing, and respiratory distress. Patients may have psychosomatic symptoms due to respiratory tract closure. Dryness of the mouth, facial flushing, vertigo, dizziness and autonomic symptoms may develop following surgery as a result of nasal packing. Patients may have disturbed sleep following surgery, due to the packing, and may suffer with insomnia, or experience difficulty in falling asleep or have interrupted sleep. The expectation of a negative event, worry and fearful anticipation may develop prior to packing removal. All these autonomic, psychosomatic and psychiatric symptoms will increase patients' anxiety levels.Reference Hosemann, Loew, Forster, Kuhnel and Beule5
Patients do not feel pain during septoplasty for nasal septum deviation because it is performed under general anaesthesia. The most painful stage of the post-operative period is the removal of the packing. Various techniques to optimise patient comfort have been reported.Reference Kim, Kim, Kim, Kim, Kim and Kim6–Reference Cukurova, Cetinkaya, Mercan, Demirhan and Gumussoy8 The use of intramuscular opiate before removal of the packing, infiltration of lidocaine into the packing before removal, the use of analgesics, and sphenopalatine ganglion blockade methods have all been described.Reference Durvasula, Brewis, Syeda and Leyong9, Reference Hwang, Liu, Liu and Hsu10 Sphenopalatine ganglion blockade methods are effective, although there are difficulties in the application process in practice.Reference Maier, Buller, Philipp and Heuser3, Reference Hwang, Liu, Liu and Hsu10 Infiltration of packing with lidocaine, bupivacaine and saline has been discussed in the literature. There is some debate about the effectiveness of such methods of pain reduction.Reference Durvasula, Brewis, Syeda and Leyong9 In the current study, the infiltration of lidocaine into the packing significantly reduced patient anxiety levels and pain scores (p < 0.001).
• Removal of nasal packing is a painful and frightening process for the patient
• Infiltration of topical anaesthetics prior to nasal packing removal may reduce patient pain
• In this study, patients developed mild to moderate anxiety before nasal packing removal
• Infiltration of lidocaine into nasal packing significantly reduced patient pain, according to visual analogue scores
• Soluble packing or sewing techniques without nasal packing after septoplasty can lessen patient discomfort post-operatively
• If nasal packing is used, local anaesthetic infiltration before nasal packing removal may reduce discomfort
The Hamilton Anxiety Scale was first described by Max Hamilton in 1959 as a means to objectively measure anxiety levels in patients.Reference Hosemann, Loew, Forster, Kuhnel and Beule5 Patient anxiety levels are evaluated using clinical assessment, with scores ranging from 0 to 56. A score of 17 or less indicates mild anxiety, 18–24 indicates mild to moderate anxiety, and 25–30 indicates moderate to severe anxiety.Reference Maier, Buller, Philipp and Heuser3 In the current study, the anxiety levels of patients in both the study group and control group were measured as mild to moderate. Avoiding nasal packs in all rhinological surgical operations would ensure a comfortable process for the patient.
Conclusion
There are few studies in the literature on nasal surgery and patient anxiety.Reference Hosemann, Loew, Forster, Kuhnel and Beule5, Reference Muluk, Oguzturk, Ekici and Koc11 This study investigated patients' anxiety levels following septoplasty surgery. Patients were observed to develop mild to moderate anxiety prior to nasal packing removal. Infiltration of lidocaine into the nasal packing significantly reduced patients' pain, according to VAS scores. The use of soluble packing or sewing techniques without nasal packing after septoplasty is recommended to provide post-operative patient comfort. If nasal packing is used, local anaesthetic infiltration before removal of the nasal packing may be useful to lessen patient discomfort.
