Effect of infiltrating nasal packing with local anesthetics in postoperative pain and anxiety following sinonasal surgeries: a systemic review and meta-analysis

Abstract Introduction: Packing of the nasal cavity has traditionally been used for postoperative bleeding control and decreasing synechia formation in patients undergoing nasal surgeries. Although absorbable nasal packing has been gaining popularity in the recent years, nonabsorbable nasal packing is still often used in nasal surgeries in various parts of the world. It is known to be associated with pain and discomfort especially upon and during removal, and previous reviews have only evaluated the effects of local anesthetic infiltration of nasal packing in septal surgeries. Objective: To evaluate the effect of infiltrating nasal packing with local anesthetics in postoperative pain and anxiety following sinonasal surgeries Materials and methods: We searched the PubMed and Embase databases from their earliest record to April 27, 2019, randomized controlled trials and prospective controlled trials for review, and included only randomized controlled trials for data analysis. We included studies using topical anesthetics-infiltrated nasal packing following sinonasal surgeries and evaluated the effectiveness compared to placebo packing in pain reduction during postoperative follow up, as well as the effectiveness in anxiety reduction. Results: Among 15 studies included for review, 9 studies involving 765 participants contributed to the meta-analysis. In terms of pain reduction, our analysis showed significant standard mean differences regarding effectiveness at postoperative 1, 12, 24 h interval for all surgical groups combined, in the sinus surgery group, as well as during nasal packing removal. There was no consistent evidence to support the effectiveness in anxiety reduction. Conclusions: Our study supports anesthetics infiltration of nasal packing as an effective method in managing pain in patients with nasal packing after sinonasal surgeries. However, the level of evidence is low. More high-quality randomized controlled trials are needed to establish its effectiveness in reducing anxiety. We believe this review is of great clinical significance due to the vast patient population undergoing sinonasal surgeries. Postoperative local hemorrhage remains the greatest concern for ear nose and throat surgeons due to the rich vasculature of the nose and sinuses. Sinonasal packing provides structural support and serves as an important measure for hemostasis and synechia formation. Although absorbable packing has been gaining popularity in the recent years, nonabsorable packing materials are still used in many countries due to lower cost. Infiltration of nasal packing with local anesthetic provides a solution to the discomfort, nasal pressure and nasal pain experienced commonly by the patients as evidenced by our analysis.

摘要引言：传统上，鼻腔填塞（nasal packing）被用于鼻部手术患者的术后止血及减少粘连形成。尽管可吸收鼻腔填塞物近年来逐渐普及，但全球各地的鼻部手术仍常使用非可吸收鼻腔填塞（nonabsorbable nasal packing）。此类填塞物可引发疼痛与不适，尤其在取出过程中及取出时；既往综述仅评估了局部麻醉浸润（local anesthetic infiltration）鼻腔填塞在鼻中隔手术（septal surgeries）中的应用效果。

研究目的：本研究旨在评估鼻鼻窦手术（sinonasal surgeries）后，采用局部麻醉剂浸润鼻腔填塞对术后疼痛及焦虑的改善效果。

材料与方法：我们检索了PubMed数据库与Embase数据库自建库至2019年4月27日的文献，纳入随机对照试验（randomized controlled trials）与前瞻性对照试验（prospective controlled trials）进行综述，并仅纳入随机对照试验开展数据分析。本研究纳入的研究均为鼻鼻窦手术后使用局部麻醉剂浸润鼻腔填塞的试验，并以安慰剂填塞（placebo packing）组为对照，评估其在术后随访期间的镇痛效果及缓解焦虑的效果。

研究结果：本次综述共纳入15项研究，其中9项涉及765名受试者的研究被纳入荟萃分析（meta-analysis）。在镇痛效果方面，荟萃分析结果显示，在术后1小时、12小时、24小时三个时间点，所有手术组合并分析、鼻窦手术亚组分析，以及鼻腔填塞物取出过程中，镇痛效果均存在显著的标准化均数差（standard mean differences）。但未发现一致证据支持其缓解焦虑的效果。

研究结论：本研究证实，鼻鼻窦手术后采用局部麻醉剂浸润鼻腔填塞可有效缓解患者疼痛，但证据等级较低。未来仍需开展更多高质量随机对照试验，以明确其缓解焦虑的效果。鉴于接受鼻鼻窦手术的患者群体庞大，我们认为本综述具有重要的临床意义。由于鼻腔与鼻窦血供丰富，术后局部出血仍是耳鼻咽喉科（ear nose and throat）医师最关注的问题。鼻腔鼻窦填塞可提供结构支撑，是实现止血与预防粘连形成的重要手段。尽管可吸收填塞物近年来逐渐普及，但许多国家仍因成本较低而使用非可吸收填塞材料。正如本研究分析所示，局部麻醉剂浸润鼻腔填塞可有效解决患者常见的不适、鼻腔压迫感与鼻部疼痛问题。