Unexpected Beneficial Effect of Dexamethasone Administration after Septoplasty Procedure: As Prospective Cohort Audit

Background and Objectives: Septoplasty is one of the most common surgical procedures in specialty of otorhinolaryngology. Therefore, there are frequent thoughts regarding this procedure to improve its conditions from different aspects, indications, time of surgery, techniques, safety measures, and postoperative care. One of big issues regarding this procedure is the post-operative sequel and complications namely post-operative pain, oro-facial edema, air way obstruction, epistaxis, nausea and vomiting, nasal obstruction, atrophic rhinitis, induction of allergic rhinitis, septal perforation and synachia formation. Therefore, this study was conducted prospectively to confirm the effect of intravenous administration of dexamethasone on outcomes of this procedure as compared to the effect of oral administration of ketoprofen as well as paracetamol after septoplasty procedure.

Patients and Methods: Two- thousands and two- hundred thirteen patients aged from 4 years to 65 years presented at ENT department-Althowra central teaching hospital as well as Altarahom private clinic-elbyda city-Libya at period in between September 2005 to January 2022 as cases of DNS with variable patterns of septal deformities for septoplasty. Five hundred thirty- one patients were received oral paracetamol who represent group-A, 753 received oral ketoprofen that constitutes group-B, while remaining 929 were administrated by intravenous dexamethasone and classified as group-C. As prospective analytic study, three groups compared in relation to significant postoperative complications risk namely post-operative pain, oro-facial edema, airway obstruction, epistaxis, nausea and vomiting, nasal obstruction, atrophic rhinitis, induction of allergic rhinitis, septal perforation and synachia formation. In addition, these groups compared for any significant difference regarding the period of postoperative hospitalization, which can be used, as objective indicator to measure the postoperative morbidity rate.

Results: Dexamethasone as well as ketoprofen administration caused significant improvement in pain intensity as compared to paracetamol group. On the other hand there was significant reduction in the incidence of post-operative oro-facial edema, air way obstruction, epistaxis, nausea and vomiting, nasal obstruction, atrophic rhinitis, induction of allergic rhinitis, septal perforation and synachia formation among group-B and C as compared to group-A.

Conclusion: Dexamethasone can be considered as potent analgesic drug after septoplasty procedure and in same time, it plays significant role in the improvement of outcomes of this common procedure as compared to the other commonly used non-steroidal anti-inflammatory drugs.

Septoplasty is one of the most common surgical procedure in the specialty of otorhinolaryngology [1,2]. Post-operative pain is a significant problem that continues to be untreated. This pain can be in the form of facial pain, facial fullness, or un-tolerated headache [1-5]. In addition to the pain there are other significant post-septoplasty problems, namely oro-facial edema, bleeding, air way obstruction, nausea and vomiting, pharyngitis, sore throat, dehydration, metabolic as well as nutritional deficiencies [1-5]. On the other hand there are other varieties of sequels which are considered as late complications namely nasal obstruction, atrophic rhinitis, induction of allergic rhinitis, septal perforation and synaechia formation [1-5]. Broadly speaking, and from the pathological point of view we can suggest that most of early complications after septoplasty can be correlated to the pain either in form of oro-facial pain, headache or throat pain. The oro-facial pain and edema, as well as local bleeding are mainly due to the local tissue trauma during the surgery itself. In accordance, the all edematous areas will heal later on by extensive fibrosis as the result of activation of fibroblasts leading to development of the late complications in form of atrophic changes, and synaechia formation as well-appreciated sequels of septoplasty procedure. From the other aspect, as the surgical nasal trauma is considered as one of well-established theories in pathogenesis of allergic rhinitis, the local mucosal trauma and enhancement of local inflammatory cells will result in the activation of local IgE-hypersensitivity reaction and subsequently the appearance of allergic rhinitis related symptoms and sings [1-15] .

For this reason there is continuous research for potent anti-inflammatory agent to be used post-operatively after septoplasty procedure. Although many studies have been carried out to evaluate the effect of diclofenac sodium as well as paracetamol and indomethacin on post-septoplasty pain [1-15], it was felt at the time of initiating this study that there is a lack of data and information regarding the effectiveness of intravenous administration of dexamethasone after septoplasty. The specific aims of this presenting study were (a): To assess the anti-inflammatory efficacy of dexamethasone on post-septoplasty early complication. ­(b): To compare the anti-inflammatory efficacy of dexamethasone with that of ketoprufen and paracetamol as most common NSAID drugs used after this surgery. ­(c): To postulate the effect of intravenous administration of dexamethasone on late outcomes of septoplasty procedure as compared to ketoprufen and paracetamol.

Two- thousands and two- hundred thirteen patients aged from 4 years to 65 years presented at ENT department- Althowra central teaching hospital as well as Altarahom private clinic-Albyda city-Libya at period in between September 2005 to January 2022 as cases of DNS with variable patterns of septal deformities for septoplasty. Patients with renal disease, gastro­intestinal disease, chronic pain states or daily intake of NSAID were excluded. Informed consent was obtained from all adult patients as well as from patients' parents for the children. All patients were admitted 6 to 24 hours prior to surgery after normal routine investigations. The patients were divided into three groups, on random distribution basis; each group contains variety of ages from selected age spectrum. Five hundred thirty- one patients, were received oral paracetamol (10-15 mg/kg), in four divided doses first dose after two hours from surgery, those represent group-A. On the other hand, 753 received oral ketoprufen (1-3 mg/kg) in three divided doses, first dose at the end of surgery be­fore wake-up from anesthesia, with the second dose eight hours postoperatively, those constitute group-B. However, while remaining 929 were administrated by intravenous dexamethasone (4-8 mg/dose) as three doses first dose was administrated intra-operatively, and this group was classified as group-C. Inhalation anesthesia was used and supplemented with intravenous Fentanyl 200-400 mg, and intubation was performed by oral endotracheal tube insertion.

septoplasty was carried out by two modalities of the technique, endoscopic as well as conventional, and in both techniques it was performed via the hemi-transfixion incision, followed by elevation of muco-perichondrial as well as mucoperiosteal flaps, the both superior and inferior tunnels prepared, and then the septal cartilage and\or vomer bone was separated then subsequently corrected. Sometimes the maxillary crest removed through the inferior tunnel. All patients under­went extubation in the operative room then transferred to the recovery station, vital signs were assessed and after ap­propriate care in recovery room, the patients were transferred to the in patient ward. During this interval, any instances of crying, shouting, vomiting or agitation were re­corded. The patients were assessed 6, 12, 18 and 24 hours after surgery to see whether they required anti-nociception medication. The pain was assessed subjectively by direct asking of patient as well as observation of facial expression of the patient during swallowing process according to the visual analog scale, which was used for the evaluation of pain severity among the adult and children too. Time of first oral intake and quantity was re­corded; temperature, nausea and vomit­ing were also recorded. Although there were some cases attained some degree of improvement in pain after administration of analgesic drug, they were considered as having pain, while those who im­proved completely were considered as having no pain. As prospective analytic study, three groups compared in relation to significant postoperative complications risk namely post-operative pain, oro-facial edema, air way obstruction, nasal bleeding, nausea and vomiting, nasal obstruction, and occasionally all patients followed for six weeks postoperatively to be assessed for any evidences of post-septoplasty atrophic rhinitis, induction of allergic rhinitis, and synachia formation. In addition, these groups compared for any significant difference regarding the period of postoperative hospitalization, which can be used, as objective indicator to measure the postoperative morbidity rate.

Data were expressed by using descriptive analysis as means ±, standard error of mean (s.e.m) and per­centages. Test of significance was carried out; using chi-square test and two-way analysis of variance ~.A probability less than 0.05 was consid­ered as significant, the degree of signifi­cance was determined by using level of standard deviation test. Student-t-test was used for dependent sample, as well as contingency coefficient was calculated as measurement of association between nominal variables.

The results presented sig­nificant reduction in post-septoplasty pain after ad­ministration of dexamethasone as well as ketoprufen in compari­son to paracetamol (p < 0.01), Therefore the amount of ingested fluids was increased significantly by admini­stration of dexamethasone as well as ketoprufen (p < 0.01) as compared to paracetamol. There was significant reduction in the incidence of post-operative vomiting tendency by administration of dexamethasone as well as ketoprufen as com­pared to paracetamol (p < 0.05). On the other hand this study showed significant decrease in the risk of post-septoplasty nasal bleeding after administration of dexamethasone as compared to ketoprufen as well as paracetamol (p < 0.1). Occasionally there was significant difference between the studied groups regarding the incidence of post-septoplasty dehydration; the hydration status was significantly improved after administration of dexamethasone as well as ketoprufen as compared to paracetamol (p < 0.01).

On the other hand, there was significant difference regarding the incidence of the post-septoplasty atrophic rhinitis, synaechia, and allergic rhinitis. The incidence of these three sequels was significantly reduced after administration of dexamethasone as compared to ketoprufen and paracetamol (p < 0.05).

In fact there was no any significant difference between three groups regarding the occurrence of post-septoplasty airway obstruction (p > 0.5) i.e. there was no any post- operative airway obstruction cases recorded by this presented study. By same manner, there was no any significant difference between three groups regarding the appearance of post-septoplasty metabolic or nutritional deficiencies (p > 0.5). In addition, there was no any significant difference between three groups in relation to post-operative hospitalization time, all patients among three groups were discharged from the hospital after 12 hours maximum from time of the surgery performance (p > 0.5) (Tables 1-9).

Septoplasty is one of most common surgical procedure in the spe­cialty of (ENT). Post-operative pain is a significant problem that continues to be untreated, which leads to the inability to tolerate oral intake and unplanned hospitaliza­tion [16-26].

Prostaglandins contribute to pain and in­flammation after tissue injury and the anti-nociceptive action of NSAID Drugs is attributed usually to the peripheral inhibition of prostaglandin synthesis [17-26].

It has been demonstrated that the admini­stration of diclofenac sodium decreases postoperative pain results in a lower in­cidence of nausea and vomiting, and in­creases oral intake as compared to paracetamol [26-29]. In the same studies, it has been shown that by the administration of diclofenac sodium still there is risk of post-septoplasty complications particularly the bleeding, this is most probably due to platelets dysfunction, which may be caused by the administration of di­clofenac sodium [29-33].

On the other hand; it was found that ketoprufen given (1-3 mg/kg) in three divided doses after septoplasty decreases pain, increases liquid intake in the first 24 hours and re­sulted in earlier discharge from hospital as compared to paracetamol. Although ketoprufen was given earlier with less frequency, but still it is show­ing more potent analgesic effect as com­pared to paracetamol. This can be ex­plained by longer duration of action of ketoprufen as compared to paraceta­mol [26-33].

In addition it was found that the intra-operative as well as postoperative intravenous administration of dexamethasone will help in the maintenance of air way as patent as much as possible due to the potent anti-inflammatory action of this agent. In same manner the systemic administration of dexamethasone was approved to relief the post-septoplasty throat pain thus it helps in the recovery of normal swallowing mechanism as soon as possible, and due to platelets aggregation stimulating effect of dexamethasone, its systemic administration was found to reduce the risk of post-septoplasty hemorrhage [26-33]. The protocol of dexamethasone administration which applied in this presenting study was 4-8mgs administered intravenously at time of anesthesia induction then followed by 4-8mgs administered intravenously every eight hours postoperatively for first 24 hours and after that the patient will continue with oral administration of dexamethasone as 1 mg / kg / day for 7-14 days accordingly [26-33].

Although there were multiple factors which usually affect severity of pain and tolerance of the patient to pain intensity, one of them is the age factor. The adult ages can tolerate pain more than children can. Other factor is the technique of the surgery whether there is many cartilage and bone manipulations or no [26-33]. But the effects of these factors on the results of the study were overcame by random selection of the patients involved in each group, and each group was including all age varie­ties in the presenting study. In addition, the ran­dom distribution of patients in each group was made regarding the technique that was used intra-operatively for septal correction.

On the other hand, the vomiting tendency can be correlated with the pain intensity, that the pain severity is directly proportionate to the induction of vomiting tendency [26-33]. This can be explained by the relationship between the pain and vasovagal attack i.e. the pain is an important inducing factor of vasovagal attack, thus the stimulation of vasovagal attack will in­duce vomiting [26-33]. This may explain the significant reduction of vomiting ten­dency after administration of dexamethasone as well as ketoprufen as compared to paracetamol.

Regarding the incidence of late complications, namely atrophic rhinitis, synaechia as well as allergic rhinitis, as it can be noted from the results at this study, the incidence of these three sequels was significantly reduced after administration of dexamethasone as compared to ketoprufen and paracetamol. This is simply can be explained by the potent anti-inflammatory effect of the steroids as compared to NSAID. Therefore, the administration of the dexamethasone will inhibit the secretion of local inflammatory mediators, which act to stimulate the activity of fibroblasts for further fibrosis, and by this action, the incidence of post-operative atrophic rhinitis and synaechia formation will be reduced. On the other hand, the administration of dexamethasone will inhibit macrophages as well as T-lymphocytes inflammatory mediators secretions thus no IgE antibodies will be formed and subsequently the incidence of post-septoplasty allergic rhinitis will be reduced [26-33].

As the septoplasty is one of common procedure in ENT specialty, thus continuous researches are recommended to resolve all problems that can be associated with it.

1. Bofares KM, Salem AM. Comparative study of indomethacin and paracetamol for treatment of pain after adeno-tonsillectomy in children. GMJ. 2006;2(23):41-47.
2. Nunez DA, Provan J, Crawford M. Postoperative tonsillectomy pain in pediatric patients: electrocautery (hot) vs cold dissection and snare tonsillectomy--a randomized trial. Arch Otolaryngol Head Neck Surg. 2000 Jul;126(7):837-41. doi: 10.1001/archotol.126.7.837. PMID: 10888995.
3. Baer GA, Rorarius MG, Kolehmainen S, Selin S. The effect of paracetamol or diclofenac administered before operation on postoperative pain and behaviour after adenoidectomy in small children. Anaesthesia. 1992 Dec;47(12):1078-80. doi: 10.1111/j.1365-2044.1992.tb04210.x. PMID: 1489038.
4. Arthur CG, John EH. Somatic sensation: II. Pain, headache.10th ed. Harcourt Health Sciences; 2000. p.554-556.
5. Tawalbeh MI, Nawasreh OO, Husban AM. Comparative study of diclofenac sodium and paracetamol for treatment of pain after adenotonsillectomy in children. Saudi Med J. 2001 Feb;22(2):121-3. PMID: 11299404.
6. Kargi E, Hoşnuter M, Babucçu O, Altunkaya H, Altinyazar C. Effect of steroids on edema, ecchymosis, and intraoperative bleeding in rhinoplasty. Ann Plast Surg. 2003 Dec;51(6):570-4. doi: 10.1097/01.sap.0000095652.35806.c5. PMID: 14646651.
7. Ofo E, Singh A, Marais J. Steroids in rhinoplasty: a survey of current UK otolaryngologists' practice. J Laryngol Otol. 2006 Feb;120(2):108-12. doi: 10.1017/S0022215105005396. Epub 2005 Nov 25. PMID: 16359159.
8. Schaberg SJ, Stuller CB, Edwards SM. Effect of methylprednisolone on swelling after orthognathic surgery. J Oral Maxillofac Surg. 1984 Jun;42(6):356-61. doi: 10.1016/s0278-2391(84)80006-3. PMID: 6585512.
9. Beirne OR, Hollander B. The effect of methylprednisolone on pain, trismus, and swelling after removal of third molars. Oral Surg Oral Med Oral Pathol. 1986 Feb;61(2):134-8. doi: 10.1016/0030-4220(86)90173-8. PMID: 3457335.
10. Habal MB. Prevention of postoperative facial edema with steroids after facial surgery. Aesthetic Plast Surg. 1985;9(2):69-71. doi: 10.1007/BF01570331. PMID: 4025052.
11. Micó-Llorens JM, Satorres-Nieto M, Gargallo-Albiol J, Arnabat-Domínguez J, Berini-Aytés L, Gay-Escoda C. Efficacy of methylprednisolone in controlling complications after impacted lower third molar surgical extraction. Eur J Clin Pharmacol. 2006 Sep;62(9):693-8. doi: 10.1007/s00228-006-0164-5. Epub 2006 Aug 11. PMID: 16902792.
12. Erisir F, Oktem F, Inci E. Effect of steroids on edema and ecchymosis in rhinoplasty. Turk Arch ORL. 2001:39(3):171-175. https://tinyurl.com/2p8hnped
13. Totonchi A, Guyuron B. A randomized, controlled comparison between arnica and steroids in the management of postrhinoplasty ecchymosis and edema. Plast Reconstr Surg. 2007 Jul;120(1):271-274. doi: 10.1097/01.prs.0000264397.80585.bd. PMID: 17572575.
14. Gilman AF, Rall TW, Nies AS. The Pharmacological Basis of Therapeutic. 8th ed. Goodman, Gilman, editors. New York: Pergamon Press; 1990. p.1442-1454.
15. Griffies WS, Kennedy K, Gasser C, Fankhauser C, Taylor R. Steroids in rhinoplasty. Laryngoscope. 1989 Nov;99(11):1161-4. doi: 10.1288/00005537-198911000-00010. PMID: 2811556.
16. Kara CO, Gökalan I. Effects of single-dose steroid usage on edema, ecchymosis, and intraoperative bleeding in rhinoplasty. Plast Reconstr Surg. 1999 Dec;104(7):2213-8. doi: 10.1097/00006534-199912000-00041. PMID: 11149790.
17. Gary AT, Kevin TP. Central Nervous system: In: Anatomy and physiology. 4th ed. Mosby and imprint of Elsevier science; 1999. p.384.
18. Colbert SA, McCrory C, O'Hanlon DM, Scully M, Tanner A, Doyle M. A prospective study comparing intravenous tenoxicam with rectal diclofenac for pain relief in day case surgery. Eur J Anaesthesiol. 1998 Sep;15(5):544-8. doi: 10.1046/j.1365-2346.1998.00350.x. PMID: 9785068.
19. Gonçalves AI, Rato C, de Vilhena D, Duarte D, Lopes G, Trigueiros N. Evaluation of post-tonsillectomy hemorrhage and assessment of risk factors. Eur Arch Otorhinolaryngol. 2020 Nov;277(11):3095-3102. doi: 10.1007/s00405-020-06060-1. Epub 2020 May 25. PMID: 32451667.
20. Elhakim M, Ali NM, Rashed I, Riad MK, Refat M. Dexamethasone reduces postoperative vomiting and pain after pediatric tonsillectomy. Can J Anaesth. 2003 Apr;50(4):392-7. English, French. doi: 10.1007/BF03021038. PMID: 12670818.
21. Stewart R, Bill R, Ullah R, McConaghy P, Hall SJ. Dexamethasone reduces pain after tonsillectomy in adults. Clin Otolaryngol Allied Sci. 2002 Oct;27(5):321-6. doi: 10.1046/j.1365-2273.2002.00588.x. PMID: 12383289.
22. Liu K, Hsu CC, Chia YY. Effect of dexamethasone on postoperative emesis and pain. British Journal of Aneaesthesia. 1998;(80):85-86. https://tinyurl.com/yntrrsy7
23. Kaygusuz I, Susaman N. The effects of dexamethasone, bupivacaine and topical lidocaine spray on pain after tonsillectomy. Int J Pediatr Otorhinolaryngol. 2003 Jul;67(7):737-42. doi: 10.1016/s0165-5876(03)00091-0. PMID: 12791448.
24. Tewary AK, Cable HR, Barr GS. Steroids and control of post-tonsillectomy pain. J Laryngol Otol. 1993 Jul;107(7):605-6. doi: 10.1017/s0022215100123837. PMID: 15125277.
25. Catlin FI, Grimes WJ. The effect of steroid therapy on recovery from tonsillectomy in children. Arch Otolaryngol Head Neck Surg. 1991 Jun;117(6):649-52. doi: 10.1001/archotol.1991.01870180085016. PMID: 2036187.
26. Khaled Mohamed Bofares.  Role of dexamethasone administration after septoplasty as comparative prospective audit. Pan Arab Journal of Rhinology. 2013;3.
27. Sari E, Simsek G. Comparison of the Effects of Total Nasal Block and Central Facial Block on Acute Postoperative Pain, Edema, and Ecchymosis After Septorhinoplasty. Aesthetic Plast Surg. 2015 Dec;39(6):877-80. doi: 10.1007/s00266-015-0565-x. Epub 2015 Sep 22. PMID: 26395094.
28. Fabritius ML, Strøm C, Koyuncu S, Jæger P, Petersen PL, Geisler A, Wetterslev J, Dahl JB, Mathiesen O. Benefit and harm of pregabalin in acute pain treatment: a systematic review with meta-analyses and trial sequential analyses. Br J Anaesth. 2017 Oct 1;119(4):775-791. doi: 10.1093/bja/aex227. PMID: 29121288.
29. Patel R, Dickenson AH. Mechanisms of the gabapentinoids and α 2 δ-1 calcium channel subunit in neuropathic pain. Pharmacol Res Perspect. 2016 Feb 27;4(2):e00205. doi: 10.1002/prp2.205. PMID: 27069626; PMCID: PMC4804325.
30. Eipe N, Penning J, Yazdi F, Mallick R, Turner L, Ahmadzai N, Ansari MT. Perioperative use of pregabalin for acute pain-a systematic review and meta-analysis. Pain. 2015 Jul;156(7):1284-1300. doi: 10.1097/j.pain.0000000000000173. PMID: 25830925.
31. Rezaeian A. Administering of pregabalin and acetaminophen on management of postoperative pain in patients with nasal polyposis undergoing functional endoscopic sinus surgery. Acta Otolaryngol. 2017 Dec;137(12):1249-1252. doi: 10.1080/00016489.2017.1358464. Epub 2017 Aug 8. PMID: 28784038.
32. Salama ER, Amer AF. The effect of pre-emptive gabapentin on anaesthetic and analgesic requirements in patients undergoing rhinoplasty: A prospective randomised study. Indian J Anaesth. 2018 Mar;62(3):197-201. doi: 10.4103/ija.IJA_736_17. PMID: 29643553; PMCID: PMC5881321.
33. Nguyen BK, Yuhan BT, Folbe E, Eloy JA, Zuliani GF, Hsueh WD, Paskhover B, Folbe AJ, Svider PF. Perioperative Analgesia for Patients Undergoing Septoplasty and Rhinoplasty: An Evidence-Based Review. Laryngoscope. 2019 Jun;129(6):E200-E212. doi: 10.1002/lary.27616. Epub 2018 Dec 25. PMID: 30585326.