Dear Sirs,
We read with great interest the article by Hesham and GhaliReference Hesham and Ghali1 entitled ‘Rapid Rhino versus Merocel nasal packs in septal surgery’.
Whilst we would also consider the use of Rapid Rhino packs following septal surgery, on account of their superior haemostatic quality and reduced pain, we thought it prudent to express a word of warning based on our experience. The Rapid Rhino pack, particularly if heavily inflated, will cause significant pressure on what remains of the nasal septum. Given that the septum will have been mobilised during surgery, this can lead to displacement of the septal cartilage into the contralateral nostril. Consequently, the cartilage may heal in this new position, increasing the risk of operative failure.
We have experienced poor outcomes following unilateral packing with Rapid Rhino nasal packs, such that revision surgery has been required. Our cases were not packed at the end of the operation; rather, packing was carried out by the ‘Hospital at Night’ on-call doctor, whose commitment to control the patient's post-operative epistaxis exceeded their understanding of the surgery. Overnight packing with a fully inflated, unilateral Rapid Rhino nasal pack led to permanent displacement of the septum, with persistent nasal obstruction in the contralateral nostril. Revision surgery was required, and was found to be more complicated than the original surgery because of dislocation of the caudal and basal aspects of the septum.
Out-of-hours ENT care is commonly managed by generic junior surgical doctors, who are often unfamiliar with the finer details of septal surgery. We would suggest that, in the early post-operative period after septal surgery, Rapid Rhino packs are always inserted bilaterally and inflated simultaneously. This will enable equal pressure distribution across the septum, preventing post-operative displacement.
Author's reply
Dear Sirs,
I thank the above authors for their interest in my and my colleague's article ‘Rapid Rhino versus Merocel nasal packs in septal surgery’, and for sharing their experience with readers.
In our series, we did not encounter the complication of septal cartilage displacement, as we did not use the cuffed Rapid Rhino pack but rather the non-cuffed pack (i.e. Mannheim Gel-Knit nasal pack), as mentioned in the methodology section of our article.
Moreover, we always pack both nasal cavities at the end of septal surgery; this assures even pressure on the nasal septum.
Finally, we would like to endorse the above authors' recommendations regarding bilateral and simultaneous inflation of Rapid Rhino nasal packs. Even so, we believe that use of the non-cuffed pack yields very satisfactory results with no side effects.
