Fujiwara Takashi, Kuriyama Akira, Kato Yumi, Fukuoka Toshio, Ota Erika
Department of Otolaryngology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama, Japan, 710-8602.
Cochrane Database Syst Rev. 2018 Aug 23;8(8):CD012047. doi: 10.1002/14651858.CD012047.pub2.
Septal surgery is a well-established procedure used to treat nasal obstruction due to deviation of the nasal septum, which is carried out under local or general anaesthesia. Local anaesthesia is used for postoperative pain control, but its effectiveness and safety are unclear.
To assess the effectiveness of perioperative local anaesthesia for reducing pain in septal surgery and to evaluate the risk of associated complications.
The Cochrane ENT Information Specialist searched the Cochrane ENT Trial Register; Central Register of Controlled Trials; Ovid MEDLINE; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 9 January 2018.
Randomised controlled trials and cluster-randomised controlled trials involving adults or children (or both) who underwent septal surgery. We included studies comparing local anaesthesia versus no treatment/placebo. We also included studies comparing different types of local anaesthesia to each other (i.e. local injection, the addition of an anaesthetic agent to nasal packing, where used, and sphenopalatine ganglion block).
We used the standard methodological procedures expected by Cochrane. The primary outcome was postoperative pain intensity at 12, 24 and 48 hours measured by visual analogue scale (VAS) or another pain outcome tool including numerical or verbal rating scales. Secondary outcomes were requirement for additional analgesia, duration of hospitalisation and adverse effects (postoperative bleeding and postoperative vomiting). We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics.
We included seven randomised controlled trials involving 493 participants. In all studies the participants were adults undergoing septoplasty. These studies were heterogeneous and the quality of the body of evidence ranged from low to very low. Few of the studies provided reliable data for the primary outcome in this review.Local anaesthetic injection versus no treatment/placeboTwo studies (142 participants) compared local anaesthetic injection versus placebo but these studies did not report postoperative pain at 12, 24 or 48 hours. It is unclear whether local anaesthetic injection changed the risk of vomiting (odds ratio (OR) 3.10, 95% confidence interval (CI) 0.12 to 79.23; 60 participants; one study) (low-quality evidence). Neither study reported the requirement for additional analgesia, duration of hospitalisation or uncontrollable postoperative bleeding.Local anaesthetic application via nasal packing versus no packing/packing with placeboFour studies (301 participants) used nasal packing postoperatively and compared the addition of local anaesthetic to the pack versus packing with a placebo added. Compared with packing with placebo, the addition of local anaesthetic to nasal packing reduced the pain score on a VAS (ranging from 0 to 100) at 12 hours (mean difference (MD) -16.95, 95% CI -22.27 to -11.62; 151 participants; two studies; I = 49%) (low-quality evidence) and at 24 hours postoperatively (MD -7.53, 95% CI -9.76 to -5.29; 268 participants; four studies; I = 83%) (very low-quality evidence). These studies did not report postoperative pain at 48 hours. The addition of local anaesthetic to nasal packing decreased the requirement for additional analgesia (OR 0.15, 95% CI 0.07 to 0.34; 151 participants; two studies; I = 15%) (moderate-quality evidence). No studies reported duration of hospitalisation, postoperative vomiting or uncontrollable postoperative bleeding.No studies compared the addition of local anaesthetic to nasal packing versus no packing.Sphenopalatine ganglion block versus no treatment/placeboOne study (50 participants) compared sphenopalatine ganglion block versus no treatment but this study did not report postoperative pain, requirement for additional analgesia, duration of hospitalisation, vomiting or uncontrollable postoperative bleeding.
AUTHORS' CONCLUSIONS: The addition of local anaesthesia to nasal packs (if these are being used) following septal surgery may reduce postoperative pain within the first 12 hours, compared to nasal packing with a placebo added. The effect is uncertain at 24 hours because the quality of the evidence is very low. Evidence was lacking for other outcomes, including adverse effects. There is a lack of evidence about the effects of local anaesthesia added to nasal packing compared to no nasal packing. There is also a lack of evidence about the effects of local anaesthesia given by injection and the effects of sphenopalatine ganglion block.
鼻中隔手术是一种成熟的治疗鼻中隔偏曲所致鼻阻塞的手术，可在局部或全身麻醉下进行。局部麻醉用于术后疼痛控制，但其有效性和安全性尚不清楚。
评估围手术期局部麻醉减轻鼻中隔手术疼痛的有效性，并评估相关并发症的风险。
Cochrane耳鼻喉科信息专家检索了Cochrane耳鼻喉科试验注册库、对照试验中央注册库、Ovid MEDLINE、Ovid Embase、CINAHL、科学引文索引、ClinicalTrials.gov、国际临床试验注册平台及其他已发表和未发表试验的来源。检索日期为2018年1月9日。
涉及接受鼻中隔手术的成人或儿童（或两者皆有）的随机对照试验和整群随机对照试验。我们纳入了比较局部麻醉与未治疗/安慰剂的研究。我们还纳入了相互比较不同类型局部麻醉的研究（即局部注射、在使用鼻填塞时向鼻填塞物中添加麻醉剂以及蝶腭神经节阻滞）。
我们采用了Cochrane预期的标准方法程序。主要结局是术后12、24和48小时通过视觉模拟量表（VAS）或其他疼痛结局工具（包括数字或语言评定量表）测量的疼痛强度。次要结局是额外镇痛的需求、住院时间和不良反应（术后出血和术后呕吐）。我们使用GRADE评估每个结局的证据质量；以斜体表示。
我们纳入了7项随机对照试验，涉及493名参与者。在所有研究中，参与者均为接受鼻中隔成形术的成年人。这些研究具有异质性，证据质量从低到极低不等。很少有研究为本综述的主要结局提供可靠数据。
局部麻醉注射与未治疗/安慰剂
两项研究（142名参与者）比较了局部麻醉注射与安慰剂，但这些研究未报告术后12、24或48小时的疼痛情况。尚不清楚局部麻醉注射是否改变了呕吐风险（比值比（OR）3.10，95%置信区间（CI）0.12至79.23；60名参与者；一项研究）（低质量证据）。两项研究均未报告额外镇痛的需求、住院时间或无法控制的术后出血情况。
通过鼻填塞应用局部麻醉与未填塞/用安慰剂填塞
四项研究（301名参与者）术后使用了鼻填塞，并比较了在填塞物中添加局部麻醉剂与添加安慰剂填塞的情况。与添加安慰剂填塞相比，在鼻填塞物中添加局部麻醉剂可降低术后12小时（平均差（MD）-16.95，95%CI -22.27至-11.62；151名参与者；两项研究；I² = 49%）（低质量证据）和术后24小时（MD -7.53，95%CI -9.76至-5.29；268名参与者；四项研究；I² = 83%）（极低质量证据）时VAS（范围为0至100）上的疼痛评分。这些研究未报告术后48小时的疼痛情况。在鼻填塞物中添加局部麻醉剂可降低额外镇痛的需求（OR 0.15，95%CI 0.07至0.34；151名参与者；两项研究；I² = 15%）（中等质量证据）。没有研究报告住院时间、术后呕吐或无法控制的术后出血情况。
没有研究比较在鼻填塞物中添加局部麻醉剂与不填塞的情况。
蝶腭神经节阻滞与未治疗/安慰剂
一项研究（50名参与者）比较了蝶腭神经节阻滞与未治疗，但该研究未报告术后疼痛、额外镇痛的需求、住院时间、呕吐或无法控制的术后出血情况。
与添加安慰剂的鼻填塞相比，鼻中隔手术后在鼻填塞物（如果使用）中添加局部麻醉可能会在术后12小时内减轻疼痛。24小时时效果不确定，因为证据质量极低。对于其他结局，包括不良反应，缺乏证据。与不进行鼻填塞相比，缺乏关于在鼻填塞物中添加局部麻醉效果的证据。也缺乏关于注射局部麻醉的效果以及蝶腭神经节阻滞效果的证据。
