Septoplasty and submucosal resection (SMR) are common ENT surgical procedures performed to correct deviated nasal septum which is a frequent cause of nasal obstruction and impaired airflow. These procedures improve nasal breathing, enhance mucociliary function, and facilitate other nasal or sinus surgeries by creating a straighter septum and more open nasal airway [1, 2].  The importance of postoperative management is to maximize the result, avoid complications, and enhance the comfort of the patient. Historically, anterior nasal packing has been a quite common postoperative intervention following septoplasty or SMR to manage bleeding, avoid septal hematoma, and stabilize the septum during the early healing process [3, 4]. The anterior nasal packing has been known to be accompanied by some degree of patient discomfort, nasal congestion, pain, headache, skin and mucosal trauma, and difficulty in breathing especially in the immediate postoperative period. Patients often complain that removal of the nasal pack is the most uncomfortable part of the whole surgical process [5, 6]. In addition, there is a likelihood of nasal packing causing toxic shock syndrome in extreme instances, in addition to infection and mucosal necrosis [7]. These issues have prompted the recent interest in alternative forms of postoperative stabilization and hemostasis with minimal patient discomfort and complication rate. External nasal splints, (nasal clips or nasal clamps) have been proposed as an alternative to more invasive traditional nasal packing. The devices deliver external compression to keep the septal aligned and minimize postoperative bleeding and edema, without the pain of internal nasal packing [8]. The nasal clips do not block the nasal airway, and the patient can have better tolerance, respiration, and sleep quality during the immediate postoperative time [9]. Moreover, nasal clips do not require painful pack removal, and they are correlated with the reduced incidence of mucosal trauma and infection [10]. Despite these potential advantages, the application of nasal clips has not yet become standard practice, and data relating to their effectiveness when compared to anterior nasal packing is scant and inconclusive. Although equal hemostatic effect and septal stabilization with enhanced patient comfort have been noted in nasal clip groups, it has been felt that nasal packing is still better when it comes to controlling bleeding in high-risk scenarios [11, 12]. Thus, there is a need to compare the effectiveness of these two postoperative interventions comparatively regarding hemostasis, pain, patient satisfaction, complications, and the overall outcome of surgery. The present study aimed to compare nasal clips and anterior nasal packing following septoplasty or submucosal resection, focusing on postoperative pain, bleeding, patient comfort, and complication rates.

The present prospective study was conducted in the Department of ENT, Rajiv Gandhi Institute of Medical Sciences (RIMS), Adilabad, Telangana in coordination with the Department of Radiology and Microbiology which is a tertiary care teaching Institution. Institutional ethical approval was obtained for the study. Written consent was obtained from all the participants of the study after explaining the nature of the study in vernacular language. A total of 60 patients undergoing elective septoplasty or submucosal resection (SMR) for symptomatic deviated nasal septum were included.

Inclusion criteria

1. Age group 18 to 60 years
2. undergoing primary septal surgery, and free from systemic bleeding disorders or nasal infections
3. Males and females
4. Willing to participate in the study voluntarily

Exclusion criteria

1. History of previous nasal surgeries
2. Coagulopathies,
3. Nasal polyps
4. Sinonasal malignancies

Participants were randomly divided into two equal groups (n = 30 each) using computer-generated randomization:

• Group A (Nasal Clip Group): Received nasal clips externally applied to the nasal dorsum after surgery for septal stabilization and hemostasis.
• Group B (Anterior Nasal Packing Group): Received traditional anterior nasal packing using sterile ribbon gauze impregnated with antibiotic ointment, inserted bilaterally.

All surgeries were performed under general anesthesia by the same surgical team to minimize variability. Septoplasty or SMR was performed using standard techniques with mucoperichondrial flap elevation, septal deviation correction, and repositioning.

Postoperative Care:  In both groups, intravenous antibiotics and analgesics were administered postoperatively. In Group B, nasal packs were removed after 48 hours, while nasal clips in Group A were removed after 5 days. Saline nasal irrigation was advised in both groups after pack or clip removal.

Outcome Measures: Patients were assessed at 6 hours, 24 hours, 48 hours, and on postoperative day 7. The following parameters were recorded

1. Postoperative pain: assessed using the Visual Analog Scale (VAS) scale
2. Postoperative bleeding: graded as none, mild (self-limiting), moderate (requiring additional intervention), or severe (requiring repacking or surgical control).
3. Nasal obstruction and discomfort: assessed by patient-reported symptoms.
4. Complications: such as septal hematoma, mucosal injury, synechiae, or infection.
5. Patient satisfaction: assessed using a structured questionnaire on day 7.

Statistical Analysis: All the available data was segregated, refined, and uploaded to an MS Excel spreadsheet and analyzed by SPSS version 23 in Windows format. The continuous variables were represented as mean, standard deviation, and percentages. The categorical variables were calculated by Fisher’s exact test. A p-value of <0.05 was considered statistically significant.

A total of 60 patients were equally divided into two groups of 30 each and allotted to Group A (Nasal Clip), and Group B (Nasal Packing). The demographic profile of the study cases is included in Table 1. The age distribution was comparable between the groups across all age brackets, with no statistically significant differences (p > 0.05). The mean age was 29.8 ± 7.2 years in Group A and 30.3 ± 6.9 years in Group B (p = 0.72). Gender distribution was also similar, with 18 males and 12 females in Group A, and 17 males and 13 females in Group B (p = 0.79), indicating homogeneity in demographic variables across both groups.

Table 2 compares postoperative pain using the Visual Analog Scale (VAS) between Group A (Nasal Clip) and Group B (Nasal Packing). Initial pain scores at 1- and 3-hours post-op were slightly lower in Group A but not statistically significant (p = 0.191 and 0.071, respectively). However, from 6 hours onward, Group A reported significantly lower pain scores: at 6 hours (3.1 vs 5.7, p < 0.001), 24 hours (2.8 vs 4.9, p < 0.001), after removal (2.3 vs 6.1, p < 0.001), and on Day 7 (0.7 vs 1.2, p = 0.01), indicating superior comfort with nasal clips.

*Significant

Table 3 describes the severity and frequency of postoperative bleeding episodes in both groups. A critical analysis of the table showed that most patients in both groups had no or only mild bleeding. One patient in the packing group had moderate bleeding requiring further intervention. Although the difference was not statistically significant, nasal clips performed similarly in controlling bleeding, challenging the notion that packing is superior for hemostasis.

Table 4 shows the postoperative complications in both groups. Group A (Nasal Clip) had notably fewer complications compared to Group B (Nasal Packing). Septal hematoma occurred only in Group B (3.3%, p = 0.31), while mucosal trauma was higher in Group B (16.7%) versus 3.3% in Group A (p = 0.08). Synechiae and infections were also more frequent in Group B, though not statistically significant. Importantly, the total complication rate was significantly higher in the nasal packing group (26.7%) compared to the nasal clip group (6.7%), with a p-value of 0.04, indicating a clear safety advantage of nasal clips.

*Significant

Table 5 presents patient satisfaction levels on postoperative Day 7. A significantly higher proportion of patients in Group A (Nasal Clip) reported being highly satisfied (66.7%) compared to Group B (Nasal Packing) at 36.7% (p = 0.02). Moderate satisfaction was observed in 30.0% of Group A and 46.7% of Group B, while dissatisfaction was markedly lower in Group A (3.3%) versus Group B (16.7%). These findings suggest that patients experienced greater comfort and overall satisfaction with nasal clips, further supporting their preference and acceptability over traditional nasal packing post-septoplasty or submucosal resection.

*Significant

Septoplasty and submucosal resection (SMR) are widely used procedures for the correction of nasal septal deviation. Historically, postoperative Anterior nasal packing was the standard procedure to control bleeding and stabilize the septum. Nevertheless, packing is coupled with several disadvantages such as a high level of discomfort, mucosal injury, and such complications as infections or synechiae. The goal of the present study was to compare the effectiveness of nasal clips, which is a comparatively new option, with anterior nasal packing regarding pain, bleeding, complications, and patient satisfaction. The current study found that the patients in whom nasal clips were used (group A) had significantly lower postoperative pain than the patients with anterior nasal packing (Group B). It is interesting to note that the pain was significantly higher in the packing group at the time of pack removal, consistent with the other literature in this field which implies that pack removal is among the most painful postoperative events [13, 14]. As an external and non-invasive device, nasal clips avoid the traumatizing effect of intranasal manipulation and, therefore, are more comfortable after surgery.

In terms of bleeding management, there were no differences noted between the two groups, and the postoperative hemorrhage rate was also not significantly different. This obliterates the past assumption that effective hemostasis requires nasal packing [15, 16]. The use of modern surgical techniques, excellent intraoperative hemostasis, and electrocautery use could have contributed to the low rate of postoperative bleeding in both groups. The results of this study align with those of Nouraei et al. [17] and Shikani et al. [18] who also demonstrated similar bleeding control when using alternative strategies to packing. The rate of complications was lesser in the nasal clip group A as compared to group B. The frequency of mucosal trauma and infections was more common in the patients who received nasal packing. The pressure caused by the packs may cause ischemic injuries, crusting, and secondary infections [19]. Our results are in concordance with the study of Abdel-Aziz et al., who found a lower number of complications using splints or clip-like structures after septoplasty [20]. This strengthens the trend among ENT surgeons to seek less invasive options, which do not affect safety.

Notably, the nasal clip group had a significantly higher score in patient satisfaction. It is an important part of perioperative care because post-surgical pain could influence global recuperation, adherence, and experience of the intervention [21]. The low-invasive character of nasal clips, along with the good final results, is the probable contributor to such high levels of satisfaction. Despite its strengths, our study has a few limitations such as the sample size being relatively small, and the follow-up period being short. No evaluation of long-term results like septal stability and late complications was done. Prospective studies on a larger population and with long-term follow-up are required to corroborate the long-term effectiveness of nasal clips.

In conclusion, our study within its limitations found that nasal clips appear to offer a viable, less invasive alternative to anterior nasal packing following septoplasty or SMR, with advantages in terms of reduced pain, fewer complications, and better patient satisfaction

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