Post-surgery Instructions and What to Expect Information For Nasal (Septoplasty) Surgery and Sinus Surgery Willamette Ear, Nose, Throat, and Facial Plastic Surgery 1-31-2013 Nasal Drainage: Mucous mixed with blood is expected and may continue until your nasal packs or splints are removed. Blood clots may be noted for up to 2 weeks after packs are removed. At the surgery center you will be given gauze pads (dripper pads) and a holder to catch and absorb this drainage. Change your gauze pad as needed. Drainage slows over the first few days and may stop completely. When the drainage stops, then you may stop using the gauze pads. If bleeding seems excessive, e.g. a constant bright red drip for more than ten minutes, then squirt 3-4 sprays of Afrin in each nostril, sit up and tilt your head forward and catch any blood in a bowl or basin. Repeat the 3-4 sprays of Afrin again in 10 minutes. If the bleeding does not stop in 30 minutes, then call our office for further instructions. If you have internal splints, we recommend gently cleaning your nostrils twice daily with hydrogen peroxide using Q-tips, and then applying an antibiotic ointment such as Bacitracin or polysporin. These items are available over the counter at any pharmacy. Once your packs or splints are removed you will be given instructions on how to care for your nose by our nursing staff. Following your pack or splint removal, you can blow your nose lightly through both nostrils at the same time with your mouth open. Sneezing: Don t worry. Go ahead and sneeze with your mouth open. Do not pinch or cover both nostrils shut and hold a sneeze back. Nausea and Vomiting: This is common in the first 24 hours. You may have swallowed some blood when you were sedated or asleep in the surgicenter. This blood can be very nauseating, and many patients may vomit the first day or night after nasal surgery. Narcotics are another main cause of nausea. Please try to: a. Decrease the amount of narcotic medicine by reducing the number of pills or amount of liquid narcotic b. Increase the time between narcotic doses, or c. Use only plain acetaminophen (Tylenol). Acetaminophen can be taken either orally (pills or liquid) or rectally (suppository). All forms are available over the counter without a prescription d. Eat some non-fatty food with the narcotic. Swelling: Swelling occurs around the nostrils and upper lip area. Surgery causes swelling inside your nose, and that contributes to the pressure feeling in the nasal area. Most of the swelling inside your nose is resolved by 2 3 weeks. The final nasal breathing result is not achieved until 2-3 months following surgery. The nasal airway just gets better over time. You can decrease your swelling by elevating your head above your heart as much as possible. We recommend that for the first week or so that you try to sleep with her head and shoulders elevated at a 30 45 degree angle, especially while your nose is packed. Sleeping in a recliner is an easy way to accomplish this.
Bruising: Occasionally some bruising occurs around the lower eyelids and cheeks. If bruising occurs, it usually resolves in 10 14 days, fading from black to brown to yellow until gone. Fever: A low-grade temperature (100 degrees) and even an occasional elevation above 101.5 F is common. To decrease your temperature please: a. Take a deep breath and moderately cough once or twice every 15-30 minutes b. Increase your fluid intake c. Keep walking around the house as usual during the day, at least every 2 hours while awake. d. Take a full dose of acetaminophen and measure your temperature 1 hour later Note: There are rare reports of toxic shock syndrome developing with nasal packing. The symptom combination includes a sunburn-like rash on the palms or soles of the feet, diarrhea, extreme lightheadedness, and high fever. If you have this combination of symptoms, please call us immediately. Diet: Start with a non-fatty diet. Gradually resume your diet over a week. Avoid alcohol while you are taking any narcotics. The sense of smell contributes greatly to your taste. Your taste may be altered during this healing period due to nasal swelling. Bathing: If you have a nasal cast, try to keep it dry, DO NOT SHOWER. Avoid anything that may cause you to sweat, such as hot baths or hot tubs until the packing and/or splints are removed. You can always take a short bath and wash your hair in a sink. Dry Lips: Your lips will frequently feel dry due to your mouth breathing. You may use Vaseline, chap stick, etc. as needed. A humidifier and frequent sips of fluids may reduce the dryness of the mouth and throat while the mouth breathing occurs. Energy Level: You may feel fatigued for several reasons. First of all, surgery is a stress on your body. Secondly, your sleep will be disrupted by the nasal packing and swelling. In addition, narcotics are sedating. In general, most healthy patients regain 80% of their pre-operative energy level after one week, at which time you may return to work after you check with your doctor. It commonly takes 3-4 weeks to be at 100%. You should gradually increase your workload. Do not work 12 hours the first day back to get caught up. Do not do an extremely taxing activity your first week either (e.g. do your taxes, give a long presentation, meet your biggest client, etc.) Many patients feel more energetic after healing from the surgery than before surgery. Activity Level: Keep your head elevated 30 60 degrees above horizontal following surgery for the first 7 10 days. This will minimize your nasal swelling and pressure. An easy way is to sleep in a recliner. Two to three pillows is insufficient to achieve this elevation. For the first 10 days you are restricted to light activity. Do not lift objects greater than 10 pounds. Bend at the knees, not at the waist. Do not engage in activities
that will elevate your heart rate and blood pressure, and do not get overheated (e.g. sunbathing, sauna/hot tub, etc.) After 10 days, if you are doing well and not bleeding, then increase your activity level as tolerated. Please carry a bottle of Afrin decongestant spray during these few first weeks and use in case you have a nosebleed. Activities with a risk of nasal injury (diving, water/snow skiing, contact sports, etc.) should be deferred for two months. Return to Work: Most patients can return to work in 7 10 days; some patients will require additional time. Discuss returning to work with your doctor at your first postoperative visit. Injury to the Nose: Many patients sustain accidental blows to the nose from a variety of causes (pets, children, and other reasons) following surgery. Following surgery your nose is strong enough to tolerate mild blows. However, if nasal bleeding or new nasal obstruction occurs that does not improve with elevation of your head overnight, or a dramatic swelling occurs, then call our office during office hours for further instructions. Vision Changes: Any nasal packing will block your tear duct, causing your tears to back up, resulting in watery eyes with mildly blurry vision that resolves with gently drying your eyes. You should not see double or have severe eye pain when looking left and right. Call the office if you have either double vision or severe eye pain with looking left and right. Occasionally, blood will track up the tear duct from the nose, and be visible at the corner of the eye. Nosebleeds: Many areas of the nose and sinuses heal gradually after surgery. These areas will ooze some blood for up to a month. Elevated blood pressure, strenuous activity, use of ibuprofen (Motrin), naprosyn (Alleve), aspirin, warfarin (coumadin), and other anticoagulants increase your risk of bleeding. If you are experiencing a large nosebleed please try the following steps: 1. Stop any strenuous activity, sit upright with your head slightly tilted forward and down so the blood runs out the front of your nose and not down the back of your throat. This will decrease your coughing, nausea from swallowing blood, and let you collect and estimate your blood loss 2. If your nose is packed, try to relax to lower your blood pressure. 3. If your nose is not packed: a. Gently blow your nose with your mouth open to clear your nostrils b. Squirt 3-4 puffs of Afrin decongestant spray in the side that is bleeding c. Gently pinch the front of your nose, if not too painful d. Repeat these steps, every 10 minutes if the bleeding continues 4. Call our office if the bleeding does not stop in 20 30 minutes. One cannot predict the time and setting of an unexpected nosebleed, so please keep a bottle of Afrin decongestant (oxymetazoline) spray with you at all times during the healing period.
Sleep apnea/cpap usage: If you have sleep apnea and use CPAP, then discuss these with your surgeon before surgery. Your nasal swelling may make it difficult to use nasal masks. You may need to contact your CPAP machine provider 2 weeks before surgery and request a full face mask. Try to sleep with your head of bed elevated or in a recliner at 30-45 degrees for the first week after surgery. One must minimize the narcotics during your recovery and follow the instructions below. Pain: Pain can be moderate to moderately severe the first 24 48 hours, but usually declines thereafter. Discomfort falls dramatically after the removal of your nasal packs or splints. Pain medicine may reduce the pain, but it will not reduce the nasal obstruction from the packing. A realistic goal is to reduce the patient s pain to a manageable level, not to eliminate the pain. One cannot predict a patient s pain level or the necessary dose of pain medicine. One must approach each patient in a stepwise fashion for pain management. Specifically, when acetaminophen and/or ibuprofen do not lower the pain enough, then start with a lower dose of narcotic, and increase the dose if pain remains uncontrolled, or decrease the dose if the medication s side effects are too severe. Close monitoring of each patient for side effects of each medication is essential. 1. Try to use plain acetaminophen or plain ibuprofen before using the narcotics. 2. Always strive to either avoid the narcotics or give the lowest dose possible 3. Give the narcotic AS NEEDED but not more often than it states on the bottle 4. Do not give the narcotics automatically around the clock if the patient has minimal pain. 5. Never wake up a sleeping patient to give them narcotics 6. Avoid combining narcotics with another sedating drug: e.g. alcohol, sleeping pills, MUSCLE RELAXANTS or anti-anxiety pills (e.g. Valium and Xanax), antihistamines (e.g. Benadryl) unless instructed by your doctor. 7. Start with the lower dose that is prescribed, and take additional medication only if the pain is still not adequately controlled 45 minutes after taking the first dose. For example, if the prescription reads 1-2 tablets every 4 6 hours as needed for pain, then start with 1 tablet of pain medicine on the first dose. If the pain is not adequately controlled in 45 minutes, then add a second pain pill. 8. Every day try to decrease the total amount of narcotic medication given, by: a. increasing the time between doses, or b. decreasing the amount used each time, or c. substituting plain acetaminophen or ibuprofen for the narcotic 9. Observe for unusual sleepiness, confusion, difficult breathing. If these occur, then stop all narcotics, call WENT MD on call at 503-581-1567 or go to Salem Emergency Room if the office is closed. 10. Always measure the amount of liquid narcotic with a syringe or a marked medicine cup. Spoon sizes are not reliable. 11. Record the medication given with the date and time on the same piece of paper. This helps reduce medication errors.
Step 1: Acetaminophen (Tylenol) can decrease both pain and fever. The medication usually lasts for 4-6 hours. It is often combined with narcotics. It may be given orally as a liquid or pill or rectally (a suppository). One may wake a patient up after 4 hours and give him/her another dose of plain acetaminophen without fear of overly sedating them. One must add the amount of plain acetaminophen to the amount in a narcotic combination (e.g. acetaminophen with codeine or HYDROcodone with acetaminophen) when calculating the maximum next dose. For example: if the patient can have 650 mg of acetaminophen every 4 hours: then they may take 325 mg of plain acetaminophen and 1 tablet of 5 mg HYDROcodone/ 325 mg acetaminophen. Some patients who experience recurrent nausea or vomiting with narcotics do better using just plain acetaminophen or ibuprofen for pain relief. Step 2: Ibuprofen (Motrin, Advil) may last for 6-8 hours. It comes in liquid and pill form. Please use the instructions on the bottle for the dosing. Ibuprofen is a good pain reliever and fever reducer. Unfortunately, it may contribute to bleeding in a few patients. If the patient experiences moderate or severe bleeding, then stop the ibuprofen for at least 24 hours. Step 3: Narcotics: Acetaminophen with HYDROcodone (Lortab) or Acetaminophen with oxycodone (Percocet) are two commonly used narcotics. HYDROmorphone (Dilaudid) can be used by adult patients. ALL narcotics may result in these side effects: 1. Nausea and vomiting 2. Constipation, Difficulty urinating 3. Slowing of breathing rate, taking of shallow breaths, WORSENING SLEEP APNEA 4. Slowed or altered mental status: sleepiness, mood shifts Narcotic usage needs to be monitored due to these potentially serious side effects. General rules to follow include: 1. Never wake up a sleeping patient to give them narcotics 2. Avoid giving narcotics with another sedating drug: e.g. alcohol, sleeping pills, MUSCLE RELAXANTS or anti-anxiety pills such as Valium and Xanax 3. Start with the lower dose that is prescribed, and take additional medication only if the pain is still not adequately controlled 45 minutes after taking the first dose. For example, if the prescription reads 1-2 tablets every 4 6 hours as needed for pain, then start with 1 tablet of pain medicine on the first dose. If the pain is not adequately controlled in 45 minutes, then add a second tablet. When the pain begins to return in 4 6 hours, you may want to start with the 2 tablets of narcotic medicine the next time. 4. Every day try to decrease the total amount of narcotic medication given, by: a. increasing the time between doses or b. decreasing the amount used each time or c. substituting plain acetaminophen or ibuprofen for the narcotic Step 4: Call our office if the patient s pain is not controlled using the above guidelines.
General starting guidelines: Patient s weight: Pounds: Kg: A. Liquid option: ml of plain acetaminophen acetaminophen ml of plain AND If still painful AND ml of HYDROcodone/APAP HYDROcodone/APAP ml of B. Pill option: If nausea or side effects tablets/suppositories of acetaminophen mg AND / OR tablets of mg HYDROcodone with acetaminophen tablets of mg oxycodone with acetaminophen tablets of mg hydromorphone (1-4 mg every 4 hours for adults; use the lowest effective dose). Adjust the doses up or down depending on the patient s reaction, side effects, and pain level 45-60 minutes later. TO AVOID RUNNING OUT OF A NARCOTIC MEDICATION: 1.Please fill your narcotic prescriptions at a pharmacy that is open after hours and on weekends 2. Call our office by 2 pm the day BEFORE you will need a refill to give us time to process your request. A FAMILY MEMBER WILL NEED TO DRIVE TO OUR OFFICE TO PICK UP THE NARCOTIC PRESCRIPTION (DEA RULES). IF YOU ARE TAKING NARCOTICS, YOU CANNOT DRIVE. YOU COULD BE CITED FOR DRIVING UNDER THE INFLUENCE. S#31DRV 1/13