The Effect of Nasal Packing Removal on Patients Anxiety.

AIM: We aimed to investigate the effect of removal of merocel nasal packings on patients anxiety after septoplasty using Hamilton Anxiety Scale.
MATERIAL AND METHODS: Total amount of 50 patients who had septoplasty operation in the Department of Ear, Nose and Throat Clinic of our hospital were enrolled to the study. Patients anxiety determined using Hamilton Anxiety Scale. The patients anxiety levels were measured before 24 hours before the operation (Group 1), 48 hours after operation before nasal packing removal (Group 2) and 60 minutes after nasal packing removal (Group 3).
RESULTS: Patients were evaluated according to the Hamilton Anxiety Scale; in Group 1 15.3 ± 7.2, 19.3 ± 7 in Group 2, 14.6 ± 6,5 in Group 3 was measured.
CONCLUSION: There was no statistically significant difference between Groups 1 and 3. There is a statistically significant difference on patients anxiety levels 48 hours after operation before nasal packing removal (p<0.001). There is an statistically significant increase of patients anxiety before packing removal. We recommend using soluble packings or sewing techniques without nasal packings after septoplasty because of patient comfort after operation.

1. INTRODUCTION

Septoplasty is one of the most commonly applied surgery in Ear, Nose and Throat clinics. Intranasal packing is widely used postoperatively for the purpose of nasal septum stabilization and control of bleeding. Merocel (Medtronic Xomed, Jacksonville, FL, ABD) nasal tampons are often preferred after surgery because of ease of use and clinical efficacy (1).

Anxiety it is a symptom of man that can occur in cases where himself did not feel safe. The exact mechanism of anxiety disorder is unknown. Environmental factors and the physical effects may effect anxiety seizures. The process of the surgery is an physical effect that can increase anxiety levels of the patient. The prevention of anxiety may affect positively on patients life quality.

Patients suffer pain after septoplasty during removal of nasal packings (2). The patients may concern of pain before nasal packing removal. Anxiety levels of patients may increase because of this reason.

The anxiety levels of the patients can be measured objectively using different type of tests (State-Trait Anxiety Inventory clinical assessment scale (STAI-S), Hamilton Anxiety Scale, Hospital anxiety depression scale) (3). We used Hamilton Anxiety Scale in our study.

We aimed to investigate the effect of removing merocel nasal packings on patients anxiety after septoplasty in this study.

2. MATERIAL AND METHODS

The 50 patients who had septoplasty surgery with a diagnosis of nasal septum deviation were included our study. The study was planned as prospectively. The consent form was received from all the patients to participate in the study. Patients with nasal poliposis, concha bullosa or any additional nasal or paranasal pathology were excluded from study. All patients were operated under general anesthesia. All patient were operated and all nasal packings were removed by same surgeon. Postoperatively 8 cm Merocel nasal packing were placed into right and left nasal passages (Merocel standard nasal dressing without airway, Medtronic). Nasal packings were removed 48 hours after the surgery. All patients were evaluated by same Psychiatrist preoperatively. The patients with any psychological disorder were excluded from study. The timing of nasal packing removal and all operational details were described separately to all patients.

Anxiety levels of all patients were measured using Hamilton Anxiety Scale by same Psychiatrist. The patients anxiety levels were measured before 24 hours before the operation (Group 1, 48 hours after operation before nasal packing removal (Group 2) and 60 minutes after nasal packing removal (Group 3). The patients are classified according to education levels. They are classified as primary school graduates, secondary school graduates, high school graduates and university graduates.

The obtained data were compared statistically. The patients anxiety levels were compared using SPSS v.13 program with repeated measures ANOVA(RM-ANOVA) test. The patients anxiety levels between genders were compared using SPSS v.13 program with Student-t test. The patients anxiety levels between education subgroups were compared using SPSS v.13 program with Student-t test (p<0.001 is accepted as the difference is statistically significant).

3. RESULTS

Of a total of 50 patients 24 were female and 26 were male; age ranged from 18 to 56 years(mean 30). The Hamilton Anxiety Scale assessment were 15.3±7.2 in Group 1, 19.3±7 in Group 2 and 14.6±6.5 in Group 3 (Table 1). There was statistically significant difference in Group 2 regarding to others, p=0.00 (p<0.001). Patients anxiety levels increase significantly before nasal packing removal. Examination was carried out between male and female subgroups. p=0.314 (p>0.005) in Group 1 between genders, p=0.419 (p>0.005) in Group 2 between genders, p=0.778 (p>0.005) in Group 3 between genders. There was no statistically significant difference between genders in anxiety assessment (Table 2).

Table 1

Descriptive Statistics of Groups

Table 2

The statistical analysis of the groups

Examination was carried out between educational status of patients. There was no statistically significant difference between educational subgroups in anxiety assessment (p=0.516. p>0.001) (Table 3).

Table 3

Descriptive Statistics of education subgroups

4. DISCUSSION

Different nasal tampons or various suture techniques are applied to prevent formation of septal hematoma, control bleeding, to prevent formation of adhesion of nasal cavities and to stabilize the newly created septum after septoplasty surgery (2). Merocel packings, Doyle packing, Rapid Rhino tampons, gauze with vaseline can be applied as nasal packing after septal surgery (4-7). Transseptal sutures techniques, septal stapler techniques can be used as suture techniques without nasal packing after surgery. There are disadvantages such as the practical difficulty in the application, extend the duration of the operation and lack of control of bleeding after surgery with suture techniques (5). But using this techniques there was no tension and pain because of nasal packings. Also there was no concern and fear of nasal packing removal in patients (5). After the surgery the removal of the nasal packings in terms of the patient is a painful and scary process. For this reason there are many researches in the literature about the issue pointing the patient comfort. The process of packing removal can lead anxiety, fear and stress in patients. The patient may have a relative or friend who had septoplasty operation before. Because of this experience patients anxiety can increase before packing removal.

Merocel nasal packs are useful tampons with ease of use and effective control of bleeding after surgery. There are disadvantage of patient discomfort while removing the nasal packing. The packings can be removed 24-48 hours after operation (1). Researchers reports that removing Merocel nasal packing in 24 hour after surgery causes less pain when compared to removing it 48 hour after surgery (1). How long the nasal packing stays in nose patients comfort is disturbed and anxiety levels are increased. As the time of nasal packing removal elapsed difficulty breathing from the nose and mouth, dryness of the mouth, swallowing disorder and respiratory distress may occur.

Patients with have psychosomatic symptoms because of closure the respiratory tractus. Dryness of the mouth, flushing, vertigo and autonomic symptoms may develop. Insomnia and sleep disorders may disturb patients. The expectation of something bad will happen, concern and fearful anticipation may develop before packing removal. All this autonomic, psychosomatic and psychiatric symptoms will increase anxiety levels of the patients.

Hamilton anxiety scale is defined by Max Hamilton in 1959 to measure anxiety levels in patients objectively (3). Patients levels of anxiety are evaluated using scale. Patients Anxiety scores are scored between 0-56. A score of 17 or less indicates mild anxiety severity. A score from 18 to 24 indicates mild to moderate anxiety severity. Lastly, a score of 25 to 30 indicates a moderate to severe anxiety severity. In our study the anxiety levels were measured as mild anxiety levels in Group 1,2 and 4. There was mild to moderate anxiety in Group 3.

The patients level of education may change the perception of pain and anxiety because of the socio-cultural differences. But there was no statistically significant difference between educational subgroups in our study.

5. CONCLUSION

There are few studies in the literature about nose surgery and patients anxiety (8, 9). We investigate the anxiety levels of patients after septoplasty surgery. Patients develop mild to moderate anxiety before nasal packing removal in our study. We recommend using soluble packings or sewing techniques without nasal packings after septoplasty because of patient comfort after operation.