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Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."
Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011
Dr. Shankar P.R.
"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."
Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011 Anuradha
Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.
Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020
Original article / research
Full Version
Comparison of the Efficacy of Ivalon® Nasal Pack and Ribbon Gauze Pack Following Nasal Surgeries- A Randomised Clinical Trial
Correspondence Address :
Dr. RB Namasivaya Navin,
Assistant Professor, Department of Otorhinolaryngology, Chettinad Academy of Research and Education, Chettinad Hospital and Research Institute, Chennai, Tamil Nadu, India.
E-mail: navin.rajasekar@gmail.com
Introduction: Nasal bleeding is one of the Ear, Nose and Throat (ENT) emergencies which are usually managed by the Hippocratic manoeuvre. Anterior nasal packing is unavoidable after nasal surgeries and refractory anterior nasal bleeding. There are wide variety of newer nasal packs available and easily acceptable by the patients. The most commonly used nasal packs in day to day practices are Ivalon® and vaseline soaked ribbon gauze pack.
Aim: To compare the difference between Ivalon® nasal pack with a traditional ribbon gauze pack in terms of efficacy, feasibility, patient comfort, cost and need for repacking postremoval in patients undergoing nasal surgeries.
Materials and Methods: This randomised clinical trial involved 144 patients who required nasal packing after nasal surgeries, like septoplasty, Functional Endoscopic Sinus Surgery (FESS) and nasal bone fracture reduction in the Department of ENT, Head and Neck surgery at a Tertiary Care Centre, Chennai, India. Patients were categorised into two groups- Ribbon gauze group and Ivalon® group. The patient’s comfort was quantified based on nasal discharge, pain on removing the pack, stuffiness of the nose, and irritability were compared. After pack removal, mucosal oedema, congestion, and synechiae formation were assessed by using a diagnostic nasal endoscopy after 1 week.
Results: Out of 144 patients, in Ivalon® group, 37 (51.4%) were males and 35 (48.6%) were females. The incidence of nasal symptoms with nasal surgery i.e nasal discharge was significantly higher in the ribbon gauze packing group (68.1%) compared to Ivalon® pack (31.9%) (p-value=0.044). Pain on pack removal was also more in the former (76.4%) compared to Ivalon® group (23.6%) which were statistically significant (p-value=0.005). Pain on pack removal was significantly more in the former (76.4%) compared to Ivalon® group (23.6%). Other symptoms like anxiety, discomfort, stuffiness, local irritation, and congestion were lesser in the Ivalon® group. Mucosal oedema was higher in ribbon gauze group (59.7%) compared to Ivalon® pack (40.3%) which was statistically significant (p-value=0.019).
Conclusion: As a postnasal surgery pack, Ivalon® pack is a better option due to less pain, anxiety, stuffiness, local irritation, congestion, synechiae formation and gives better comfort when compared to the ribbon gauze packs.
Anterior nasal packing, Pain, Repacking, Septoplasty, Synechiae
Epistaxis (‘nasal bleeding’ in Greek) is one of the most alarming symptoms and emergency situation which are being managed in the field of Otorhinolaryngology. Most nasal bleeds are managed by the Hippocratic manoeuvre (1). The initial conservative management is applying digital pressure, compression with ice, or cautery of the bleeding vessel (2). Hippocrates (5th century BC) found that the effective measure for control of nasal bleeding is to apply the pressure over the alae nasi (3). However, few cases of anterior nasal bleed and all postoperative nasal surgeries like septoplasty, Functional Endoscopic Sinus Surgeries (FESS), and nasal bone fracture reduction, nasal packs are used to control anterior nasal bleeding (4). Nasal packing is useful in the prevention of postoperative complications like bleeding, septal haematoma or synechiae formation, approximation of mucoperichondrial flap, and stabilisation of septal cartilage (5). These nasal packs also improve the healing of nasal mucosa, avoidance of mucosal adhesion, and re-establish normal mucociliary clearance after sinus surgery (6). Easy insertion and removal, less pain and discomfort are the characteristics of an ideal nasal pack (6). The advantage of postsurgery nasal packing is to give the tamponade effect to prevent the complications of surgery (2).
There are wide variety of nasal packs available worldwide. The removable nasal packs include ribbon gauze coated with either vaseline or antibiotic cream, custom-made glove pack, merocel or Ivalon® pack, and now-a-days biodegradable materials are available (6). The conventional nasal packing is ribbon gauze coated with vaseline or antibiotic cream, but the patient experiences pain and discomfort during insertion and removal. Absorbable materials are gel foam, oxicel, or surgicel (7). Pain during insertion and removal, discomfort, mouth breathing, dry mouth, reduced sleep, and anxiety are the commonly reported problems after packing (8).There are newer packs, foam type injected into the nasal cavity which dissolve after 24-48 hours with the effect of haemostasis, good healing and prevention of adhesion (9),(10). Surgicel is also used for postoperative nasal packing-which is oxidised regenerated cellulose and procoagulative causes platelet aggregation and activates clotting mechanism (11). Few patients stated the most painful experience in their lifetime is nasal pack removal (12). Recently some surgeons avoid nasal packing after minor nasal surgeries.
Merocel or Ivalon® pack material is the most commonly used, which is made of cross-linked polyvinyl alcohol (6). It is a foam-type non absorbable material that improves platelet aggregation and prevents bacteria or fungal growth (13). The expandable nasal tampons are available in three sizes: 6 cm, 8 cm, and 10 cm, 8 cm is used for anterior nasal packing and 10 cm is for posterior nasal packing (14).The advantage of Ivalon® pack is its easy insertion, less pain and discomfort for the patient and effectively control the bleeding. The disadvantage is chances of repacking after removal and expensive (Rs.375/-) compared to ribbon gauze (Rs.50/-).
The significance of the current study is the comparison of both conventional vaseline soaked ribbon gauze and Ivalon® nasal pack exclusively in patients undergoing major nasal surgeries. This study comprehensively assessed parameters like anxiety, comfort, pain, stuffiness, local irritation, chances of repacking during and immediately after pack removal and congestion, synechiae, and mucosal oedema were assessed endoscopically. The present study aimed to compare the difference between Ivalon® nasal packs with a traditional ribbon gauze pack in terms of efficacy, feasibility, patient comfort, cost and need for repacking postremoval in patients undergoing nasal surgeries. Primary outcome variable was patient comfort, and secondary outcome variables were efficacy, feasibility, cost, and need for repacking.
This randomised clinical trial included a total of 144 patients who underwent nasal surgeries in the Department of ENT, Head and Neck surgery at a Tertiary Care Centre, Chennai, Tamil Nadu, India. This study was conducted from May, 2021 to April 2022, after getting approval from the Ethical Committee (Proposal No. 158/IHEC/March 2021) and informed consent were obtained.
Inclusion criteria: Patients of any age group, both the sex, and patients who underwent transnasal surgeries like septoplasty, FESS, and nasal bone fracture reduction were included in this study.
Exclusion criteria: Patients having a postnasal bleed, any nasal or paranasal mass, anterior nasal bleeding due to causes other than surgeries, and patients who are not willing for the study were excluded from this study.
Sample size calculation: It is determined from discomfort score during pack removal by Mamta S et al., with mean scores of 3.6 and 4.65 in two groups (15). With 95% confidence interval and 80% power the sample size is calculated using OpenEpi Software and a sample size of 72 was arrived in each group.
Study Procedure
All patients were evaluated preoperatively using Computed Tomography Paranasal Sinuses (CT-PNS) to know which of the sinuses were involved and scoring was done using the Lund-Mackay score for chronic rhinosinusitis (16). All the patients were randomised into two groups by block method of randomisation. After nasal surgery, one group was packed with Ivalon® nasal pack and other group with ribbon gauze pack by the surgeon (Table/Fig 1),(Table/Fig 2).
After the nasal surgical procedure, when the patient was under general anaesthesia, ribbon gauze was packed. It was soaked with vaseline. Then, using Tilley’s forceps and nasal speculum, the gauze was packed in both the nasal cavities in a step ladder pattern from floor to the roof of the nasal cavity. Another group of patients were packed with Ivalon® nasal pack along the floor of nasal cavity in septoplasty and nasal bone fracture reduction, and between middle turbinate and lateral nasal wall in case of FESS. Ivalon® pack was injected with saline to keep it in position.
The anterior nasal pack was removed on the first postoperative day. Nasal discharge, pain on removing the pack, stuffiness of the nose, and irritability were analysed. The pain was analysed by a visual analog scale. Anxiety, discomfort, stuffiness, and local irritation were recorded. Score 1 was given if each of the symptoms was present and score 0 if asymptomatic. After pack removal, mucosal oedema, congestion, and synechiae formation were assessed by diagnostic nasal endoscopy after one week by the investigator.
Statistical Analysis
Statistical analysis was carried out using Statistical Package for the Social Sciences (SPSS) version 21.0 and Microsoft Excel software. The means and proportions were used. The association between two groups were assessed by Chi-square test. The statistical significance was considered when p-value <0.05.
In both the groups males constituted majority while, the mean age was similar (Table/Fig 3).
Based on the Lund-Mackay scoring, majority of the patients had a score of less than 5 (61.1%) in Ivalon® group and underwent septoplasty (43.1%) (Table/Fig 4) (15),(16).
After nasal packing, 23 (31.9%) patients complained about nasal discharge on the Ivalon® pack group and 49 (68.1%) patients complained on the ribbon gauze group (p-value=0.01). In the Ivalon® group, 17 (23.6%) patients experienced pain during pack removal whereas, 55 (76.4%) patients had pain on removal in the ribbon gauze group (p-value=0.01).
In the Ivalon® group anxiety was seen in 20 (27.8%), comfort in 57 (79.2%), stuffiness in 32 (44.5%), local irritation in 34 (47.2%), and the chance of repacking in 2 (2.8%) patients. In the ribbon gauze group, anxiety was seen in 52 (72.2%), comfort in 15 (20.8%), stuffiness in 40 (55.6%), local irritation in 38 (52.8%) patients (Table/Fig 5). The pain on removal was analysed by visual analog scale in which majority of patients belonged to scale 0 (55) and 1 (9) on Ivalon® group and scale 3 (26) and 4 (23) on ribbon gauze group (Table/Fig 6).
The patients were assessed using nasal endoscopy after one week and showed mucosal oedema (Table/Fig 7) in 29 (40.3%) patients, congestion (Table/Fig 8) in 31 (43.1%) patients, and synechiae formation (Table/Fig 9) in 33 (45.8%) patients on the Ivalon® pack group. On the ribbon gauze group, the mucosal oedema was seen in 43 (59.7%) patients, congestion in 41 (56.9%) patients and synechiae formation in 39 (54.2%) patients (Table/Fig 10). All these symptoms and endoscopic findings were evaluated and found independent of nasal surgeries like septoplasty, FESS, and nasal bone fracture reduction (Table/Fig 11),(Table/Fig 12). Patient’s comfort postoperative FESS, septoplasty, nasal bone fracture reduction are mentioned in (Table/Fig 11). In FESS the normal mucociliary mechanism and the mucosa is preserved as much as possible. Even though matching was not done, the prevalence of synechiae was more in nasal bone fracture reduction (57.14%) than FESS (55.56%) significantand septoplasty (51.61%) in ribbon gauze group. However, all these were statistically insignificant (Table/Fig 12). Pain on pack removal was more in septoplasty patients with ribbon gauze (90.32%) than FESS (55.56%) and nasal bone fracture reduction (85.71%) patients with ribbon gauze (Table/Fig 11). This study was done to assess and compare efficacy between Ivalon® and Ribbon gauze nasal pack in various nasal surgeries. It did not compare the symptoms and complications between nasal surgeries, hence the best surgery cannot be commented upon.
Nasal bleeding is a common symptom that affects all the age groups with an incidence of 5-10% per year (1). Nasal surgeries usually requires nasal packing to control the bleeding. Ribbon gauze soaked with vaseline or antibiotic cream and Ivalon® nasal pack are most commonly used nasal packs in the recent days. The current study was aimed to compare the difference between Ivalon® nasal packs with a traditional ribbon gauze pack in terms of efficacy, feasibility, patient comfort, cost and need for repacking post removal in patients undergoing nasal surgeries.
In this study, the incidence of nasal discharge (p=0.044) was significantly higher due to ribbon gauze packing (68.1%) compared to Ivalon® pack (31.9%) and pain on pack removal (p=0.005) also more in ribbon gauze side (76.4%) than Ivalon® pack (23.6) which were statistically significant. Other symptoms like anxiety and discomfort are lesser in Ivalon® pack compared to ribbon gauze but not statistically significant. Stuffiness, local irritation, mucosal oedema, and congestion due to Ivalon® pack is as the same as ribbon gauze. But the chance of repacking after removal is slightly higher in the Ivalon® pack. There is less chance of synechiae formation in the Ivalon® pack. Every patient experiences or perceives varied pain thresholds.
Shanmugam D compared the effectiveness of the conventional nasal pack with the Meroce® nasal pack and found that later to be a favourable technique in terms of easy insertion, lesser insertion time, and short learning curve. But the conventional pack had less chance of repacking (1). This study compared the conventional pack with Meroce®/Ivalon® in different patients with epistaxis but the current study compared both the ribbon gauze pack and Ivalon® pack in patients who underwent nasal surgeries.
Mohan A et al., compared the conventional framycetin ribbon packs with nasal tampons and found that both packs are equally effective in the control of postoperative bleeding and tampon were more comfortable among the patients. No difference in crusting and adhesions in the two packs. Less pain, less trauma, and less congestion and pain are seen in nasal tampons (4). The current study compared vaseline-soaked gauze pack with Ivalon® pack and concluded that there was less chance of nasal discharge, discomfort, anxiety, congestion, mucosal oedema, and synechiae in the Ivalon® nasal pack.
Alam MJ et al., compared the conventional anterior nasal pack with the modified ventilated nasal pack in terms of anxiety and concluded that ventilated nasal pack causes less anxiety than conventional nasal packs (8). In the current study, Ivalon® nasal pack caused less anxiety compared to vaseline-soaked gauze pack.
Thomas I et al., conducted a study on using a sponge for postoperative nasal packing and concluded that commonly available and commercially-prepared sponge was as good as Meroce® in terms of efficacy in haemostasis, less mucosal trauma, less pain during removal, and may be used in developing countries to reduce the cost (6). The current study results showed Ivalon® nasal pack caused less mucosal oedema, less pain on removal but expensive and chances of repacking was high compared to ribbon gauze pack.
Dutta S et al., studied the modified technique of anterior nasal packing and found that aluminium foil from the cover of suture material was very useful, cost-effective, and also reduces complications like synechiae formation, reducing mucosal injury and less chance of rebleeding after packing (2). In the current study, Ivalon® nasal pack was expensive and the high chances of rebleeding after removal but causes less synechiae formation and mucosal injury.
Watson MG et al., compared three packs, pneumatic balloon pack, paraffin ribbon gauze, and polythene glove packs, and found paraffin pack was more uncomfortable for the patients and the pneumatic balloon is easy to insert and comfortable but causes adhesion and crusting (17). In this study, Ivalon® nasal pack was easy to insert and more comfortable and acceptable to the patient compared to ribbon gauze pack.
These are the most commonly used packs in other similar studies. The novelty of this study was to compare the efficacy of Ivalon® and ribbon gauze in the patients who are exclusively undergoing nasal surgeries and it comprehensively assessed parameters like anxiety, comfort, pain, stuffiness, local irritation, chances of repacking during and immediately after pack removal and congestion, synechiae, mucosal oedema were assessed endoscopically.
Limitation(s)
Pain perception is subjective. Hence, pain scores could not be quantified better. Immunological and tissue reaction to nasal packs would be different for each individual. Patient’s acceptability and comfort level at the time of nasal packing was not assessed as all the patients were packed under general anaesthesia.
In the developing world, newly available packs are equally as efficacious as traditional packs and better accepted by patients. This study compared the efficacy of Ivalon® pack and conventional ribbon gauze following nasal surgeries. There is less chance of nasal discharge, discomfort, anxiety, congestion, mucosal oedema, and synechiae in the Ivalon® nasal pack. The disadvantage is the incidence of repacking and its cost. Ivalon® pack is acceptable to the patients due to less pain, anxiety, short learning time and provides better comfort when compared to the ribbon gauze.
DOI: 10.7860/JCDR/2022/57649.17272
Date of Submission: May 09, 2022
Date of Peer Review: Jun 20, 2022
Date of Acceptance: Jul 21, 2022
Date of Publishing: Dec 01, 2022
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes
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