Clin. Otolurygol. 1992. 17, 237-239

A randomized study to compare calcium sodium alginate fibre with two commonly used materials for packing after nasal surgery K.S.SIRIMANNA*, G.B.TODD7 & G.J.MADDEN$ Audiok?q~Deppcrrtniant, *University Hospitirl AIe.wndru Hospitul, Portsinoutli. U K

Accepted lor publication

$ i

Wcrles, Cardlffl t E N T Dipartrnents Odstock Hospital, Salisbury and $Queen

18 October 1991

SIRIMANNA K . S . , T O D D G . B . & M A D D E S G . J .

(1992) Clin. Otolrrvngol. 17, 237-239

A randomized study to compare calcium sodium alginate fibre with two commonly used materials for packing after nasal surgery A prospective randomized study was undertaken to compare the qualities of calcium sodium alginate (Kaltostat). trousered parafin gauze. and glove finger packs as nasal packing material following the operation of partial inferior turbinectomy. All three types of packing material were found to be similarly effective in preventing bleeding whilst the packs were in situ. Calcium sodium alginate (Kaltostat) was associated with significantly less bleeding on pack removal than the other two packing materials. Further, irrespective of the material used, leaving the packs in situ for 48 hours produced significantly less bleeding than when they were removed after 24 hours.

Keywords

haenlostasis

nasal surgery

nasal packs

Trimming of the inferior turbinates is a commonly performed nasal operation to deal with nasal obstruction caused by turbinate hypertrophy. It is usually associated with a variable degree of primary haemorrhage requiring nasal packing for its immediate control. A variety of packing materials has been used to control this primary haemorrhage, and the removal of thcsc packs between 24 and 48 hours following the procedure often results in a variable degree of further bleeding. Such bleeding usually settles quickly with conservative measures but it may result in blood clots being left in the nose. Such clots may delay the potential improvement in the nasal air flow following the operation and may also possibly contribute to secondary infection. This trial was designed primarily to compare the efficacy of three different nasal packing materials, both whilst in situ and following their removal.

Materials and methods A total of 92 patients were involved in this trial which was carried out in 2 centres. There were 58 males and 34 females,

Correspondence: K.S.Sirimanna, 65a Bells IIill, Barnet, Herts EN5 2ST. UK.

randomly allocated into one of 3 groups prior to their operation. Preoperatively, a history was taken to ensure that no patient had recently had an upper respiratory tract infection (i.e. within 2 weeks of the operation), and also that there was no history of uncontrolled hypertension. A full blood count and a clotting screen where appropriate were carried out. The operations were all performed under general anaesthesia by the first and third authors in hospital 1 and by the second author in hospital 2. Nasal packing materials were inserted so as to come into contact with the cut surface of the inferior turbinates. Packs were removed at 24 hours (hospital 1) and 48 hours (hospital 2) after surgery, and the severity of any resultant bleeding was scored as in Table 1. Table 1. Scoring of severity of bleeding 0 N o bleeding 1 Bleeding lasting less than 3 minutes 2 Bleeding lasting more than 3 minutes but responding to

conservative measures, e.g. ice-packs 3 Bleeding lasting for longer than 3 minutes and requiring repacking

for control

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238 K.S.Sirimanna et al.

The calcium sodium alginate packing material used was Kaltostat (calcium: sodium 80 : 20) 2-g fibre packs with a whole or part of a pack being used in each nasal cavity. The finger glove packs used involved removing a two finger segment from a 'Regent Dispo' surgical glove and tightly packing the fingers with 1 -inch ribbon gauze. Parafin gauze trouser packs were Jelonet l o x 10cm squares, folded and cut to a trouser shape.

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Results

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Figure I shows the number of nasal cavities which bled in each group and the severity of bleeding, whilst the packs were in sifu in both hospitals. There was no significant difference between the 3 types of packs in controlling bleeding whilst the packs were in situ, either whcn judged by the number of nasal cavities which blcd or the severity of bleeding scored according to Table 1, irrespective of whether the packs were kept in for 24 hours or 48 hours (see caption to Figure I). However. whcn packs were removed (24 hours later in hospital 1 and 48 hours later in hospital 2 ) the resultant bleeding was significantly less with calcium sodium alginate than the other two pack types-for both the number of nasal cavities which bled and the severity of bleeding (Figure 2 and caption). There was no significant difference between pack types 2 and 3 . Finally, the results obtained from hospital 1 where the packs were kept in situ for only 24 hours were compared with those from hospital 2 where the packs were kept in for 48 hours. This showed that leaving the packs in for 48 hours produced significantly less bleeding in all three groups of patients than when the packs were left only for 24 hours (for calcium sodium alginate, P < 0.05; for glove finger packs, P < 0.001; and for paraffin gauze, P < 0.01).

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Figure 2. Bleeding after pack. When the packs were removed calcium sodium alginate produced significantly less bleeding than the other two pack types in both hospitals in the number of nasal cavities which bled ( P< 0.02) and in the severity of bleeding ( P < 0.003) at 24 and 48 hours. There was no signilkant difference bctwcen pack 2 and pack 3 ( P> 0.7). Total nasal cavities; B,

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cavities bled; 0. severity. a, Kaltostat; b, glove finger; c, parafin gauze.

Discussion Alginic acid is a naturally occurring substance which may be extracted from brown sea weeds which grow off the Scottish and Irish coasts. Alginates are formed when the carboxyl group of the acid reacts with a metallic ion. Kaltostat used here contains calcium sodium alginate (calcium: sodium, 80 : 20). When in contact with blood it releases calcium ions which stimulate both platelet aggregation and whole blood coagulation.' Calcium alginate is known to shorten the whole blood clotting time' and has a long history of use as a haemostatic neurosurgi~al,~ and agent in epistaxis' as well as in general surgical"' procedures. A pilot study by author 1 earlier showed the effectiveness of calcium alginate in controlling haemorrhage following partial inferior turbinectomy in a group of 16 patients (32 nostrils).' This prospective randomized study designed to explore this further demonstrated the equal effectiveness of all 3 types of packing material in controlling post-operative nasal bleeding whilst the packs were in place. However, the use of calcium sodium alginate (Kaltostat) seemed to be associated with significantly less bleeding when the packs were removed. This reduction of bleeding has obvious advantages to the patient in the short term but in the longer term it may be advantageous in decreasing the amount of intra-nasal clot left behind. Such retained clots may not only delay improvements in the patient's nasal air flow, but may result in an increased incidence of post-operative infection.

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Figure 1. Bleeding with packs in sifu. No significant difference between packs I , 2 and 3 either in hospital i or hospital 2 at 24 and 48 hours in the number of nostrils bled (P> 0.99) or the severity of bleeding- .(P> 0.5). Total nasal cavities: B. cavities , 1. bled; 0, scverity. a, Kaltostat; h, glove finger; c. parafin gauze.

Acknowledgements Authors wish to thank Mr Grant Radcliffe FRCS, Mr MJ'Stearns FKCS and Mr Tony Wright DM, FRCS for their kind permission to usc their patients for this study.

Please supply headlines 239

References 1 HOFFBRANU A.V. & LEWISS.M. (1989) Normal haemostasis. In Postgraduate Haernalologv. Third edition, pp. 571-574,

Heinmann Medical Books, London 2 JARVISP.M.. GALVIND.A.J.. BLAIRS.D. & MCCOLLUM C.N. (1987) How does calcium alginate achieve haemostasis in surgery? Throtnhosis Harmosrasis 58, 80 (1977) Calgitex gauze and wool. In The Extra 3 MARTINDALE Pharmacopoeio. Twenty-seventh edition, p. 683. Pharmaceutical Press, London

4 RUMBLEJ.F.S. (1949) Twenty-five dental cases treated with absorbable alginate wool. Br. Denial J . 6, 203-205 5 OLIVER L.C. & BLAINEG. (1950) Haemostasis with absorbable alginates in neurosurgical practice. Br. J. Surg. 37, 307-310 6 BLAIRS.D., BACKHOUSE C.M., MATHEWS J.L. & MCCOLLUM C.N. (1988) A clinical trial of calcium alginate swabs for surgical

haemostasis. Presented at the Association of the surgeons of Great Britain and Ireland in Harrogate, 13-15 April 1988 7 SIKIMANNA K.S. (1989) Calcium alginate fibre (Kaltostat 2 g) for nasal packing after trimming of turbinates-a pilot study. J. Lurvngol. Ofol. 103, 1067-1068

A randomized study to compare calcium sodium alginate fibre with two commonly used materials for packing after nasal surgery.

A prospective randomized study was undertaken to compare the qualities of calcium sodium alginate (Kaltostat), trousered paraffin gauze, and glove fin...
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