Economic evaluation of intranasal wound dressings used in inferior turbinate reduction surgery

Introduction

Inferior turbinate hypertrophy is a common cause of nasal obstruction. It can result from inflammation secondary to allergies, occupational exposures, hormonal abnormalities, or idiopathic vasomotor changes and can significantly impair patients’ quality of life (1). As such, inferior turbinate reduction (ITR) surgery ranks among the most frequently performed procedures by otolaryngologists and is generally regarded as a safe and effective operation (2). Complications from ITR surgery range from 1–10%, with post-operative bleeding among the most significant issues associated with the procedure, together with synechiae, infection and prolonged crusting. Rates of post-operative bleeding vary in the literature, ranging from 0.04% to 20% (1-5). Risk factors include patient co-morbidities (e.g., hypertension, coagulopathies), use of antithrombotic medication, infection, suboptimal surgical technique, and poor compliance with post-operative care. Due to concerns of secondary haemorrhage and ooze, surgeons develop strong preferences for specific intranasal wound dressings, with the goal of promoting haemostasis, aiding mucosal healing and preventing formation of nasal synechiae. A multitude of dressings exist, each with distinct characteristics, purported benefits, and associated costs (6). However, whether these differences influence the rate of complications is contested in the literature, with little consensus on the optimal choice of intranasal dressings or whether their routine use is necessary at all (7). In an era of rising healthcare expenditure and increasing scrutiny of procedural costs, the economic implications of routinely used surgical consumables, such as intranasal dressings, warrant critical evaluation. This study aimed to: (I) describe the type and cost of intranasal wound dressings in ITR surgery; and (II) describe the rate of secondary haemorrhage, crusting and adhesions, and post-operative infection.

Methods

This study is reported according to the STROBE reporting guidelines (available at https://www.theajo.com/article/view/10.21037/ajo-25-54/rc). A retrospective clinical audit with prospective follow-up was conducted on patients who underwent ITR surgery. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Macquarie University Human Research Ethics Committee (No. MQCIAC2022008) and informed consent was obtained from all participants.

Study population and surgical technique

Adult and paediatric patients who underwent ITR surgery (either in isolation or in conjunction with septoplasty and/or other minor surgical procedures) between June 2021 and December 2022 at Macquarie University Hospital were consecutively recruited (n=258). The primary operating surgeon in all cases was a consultant otolaryngologist. All included cases (both adult and paediatric) were formal medial flap ITRs performed using a microdebrider technique (1). No radiofrequency or cautery-only turbinate reductions were included. Patients undergoing simultaneous endoscopic sinus surgery (ESS) were excluded from the study.

Data collection

Demographic data were collected for sex and age at surgery. Comorbidities sought were hypertension (defined as current antihypertensive use or anaesthetic record documentation), any known coagulopathy, chronic kidney disease, and chronic liver disease. Medication use was recorded as any antithrombotic drugs. Concomitant procedures of the nasal cavity (septal surgery, adenoidectomy, concha bullosa reduction, and eustachian tube procedures) were also recorded.

The primary outcome recorded was the type and cost of intranasal dressings used in ITR surgery. The type of intranasal dressing used at the time of surgery was collected from the hospital electronic medical record. The costs of intranasal dressings were obtained from the hospital’s Inventory and Prosthesis department and reflect the actual procurement price to the hospital. In Australia, pricing and reimbursement of surgical prostheses, including intranasal dressings, are governed by the Prostheses List, published as the Private Health Insurance (Prostheses) Rules, which is maintained by the Department of Health, Disability and Ageing (8). This list specifies which products are eligible for reimbursement by private health insurers and sets a maximum benefit amount for each item. Manufacturers apply to have their products listed, providing clinical and economic evidence, and prices are negotiated based on submissions and market comparisons. Hospitals typically source dressings listed under this scheme, and their internal procurement costs reflect negotiated rates, supplier contracts, and rebates where applicable.

The secondary outcome examined was the rate of secondary haemorrhage and other complications in patients undergoing ITR. Patients (or their parents/legal guardians for paediatric patients) were prospectively contacted by phone or email to complete a three-question survey to determine rates of secondary haemorrhage and other complications at least 90 days post-surgery. Secondary haemorrhage was categorised as (I) those requiring additional medical care; and (II) those requiring operative management. Additional medical care was defined as requiring a post-operative review, in person, that was outside of the scheduled reviews. Crusting was defined as formal debridement of the nasal cavity outside of a planned post-operative review and infection was defined as requiring additional antibiotic treatment.

Statistical analysis

Statistical analysis was conducted with SPSS Statistics software, version 29.0 (SPSS Inc., Chicago). Parametric results were expressed as mean ± standard deviation, non-parametric results as median [interquartile range (IQR)], and categorical data as percentages. Student’s t-test, Mann-Whitney U test, and chi-squared or Fisher’s exact tests were used for parametric, non-parametric and categorical variables, respectively. All costs were expressed in Australian dollars. Binary logistic regression analyses were performed to identify any independent predictors of post-operative haemorrhage.

Results

Two hundred patients responded to the survey (response rate 77.5%) and were included in the analysis (32.5% female, 27.9±17.6 years). All key outcome variables were complete for all respondents. Hypertension was documented in 5.5% of patients and aspirin use in 1%. No coagulopathies or other bleeding-related comorbidities were identified, and no additional antithrombotic medications were recorded. Surgery was performed by 17 consultant otolaryngologists within the institution. Of the total cohort, 17% underwent isolated ITR surgery while 83% underwent concomitant nasal procedures, comprising septal surgery (55.5%), adenoidectomy (26%), concha bullosa reduction (9.5%) and eustachian tube procedures (4%). Several patients underwent more than one concomitant procedure.

Use and expense of intranasal dressings

Seven different intranasal wound dressings were employed according to surgeon preference, with costs ranging from $28 to $700 (Table 1). Of all the patients, 85.5% received some form of intranasal dressing, with a median cost of $45 (IQR, $34–634); 14.5% did not receive any wound dressing. All surgeons used intranasal wound dressings in at least some cases, with 82% (14 out of 17) applying them routinely in every case. The majority (59%) consistently used a single type of dressing, while 35% alternated between two types, and 6% employed three different dressing types across cases.

Complications

The overall complication rate was 5.0% [95% confidence interval (CI): 2.4–9.0%], with a secondary haemorrhage rate of 3.0% (95% CI: 1.1–6.4%). One patient had secondary haemorrhage requiring operative management (0.5%), with the remainder managed conservatively (Table 2). Other post-operative complications requiring additional follow up appointments were reported in 2.0% of cases, comprising crusting (0.5%) and post-operative infection (1.5%) (Table 3).

The age of patients with and without secondary haemorrhage was similar (27.8±17.7 vs. 28.4±16.3 years; P=0.94). While not statistically significant, there was a trend toward a higher proportion of females in the secondary haemorrhage group (% female: 66.7% vs. 31.4%, P=0.09). The overall use of intranasal dressings was similar between patients with and without secondary haemorrhage (83.3% vs. 85.6%, P=1.00). However, Arista™ (BD, USA) was used disproportionately more in patients who experienced secondary haemorrhage compared to those who did not (33.3% vs. 2.6%, P=0.015). The median cost of wound dressings did not differ between patients with and without haemorrhage [$45 (IQR, $34–136) vs. $45 (IQR, $34–634), P=0.92] (Figure 1).

Figure 1 Average cost of dressings for patients who had an uneventful outcome vs. those who had secondary haemorrhage. $, price in Australian Dollars as of June 2022. *, extreme outlier (>3× IQR). IQR, interquartile range.

Similarly, patient age was similar between those with and without any complication (31.1±21.8 vs. 27.8±17.6 years; P=0.77). There was a non-significant trend toward a higher proportion of females in the complication group (60% vs. 31.1%; P=0.08). Overall use of dressings was similar between patients with complications and those with uneventful courses (80% vs. 85.8%; P=0.61). Arista™ was again more frequently used in patients with any complication compared to those without (30% vs. 2.1%, P=0.003). Costs of intranasal dressings for patients with any complication compared to those with an uneventful course were similar [$45 (IQR, 25.5–260) vs. $45 (IQR, $34–634); P=0.90] (Figure 2).

Figure 2 Average cost of dressings for patients who had an uneventful outcome vs. those who had any complication. $, price in Australian Dollars as of June 2022. *, extreme outlier (>3× IQR). IQR, interquartile range.

Regression analyses

Binary logistic regression was performed to explore predictors of postoperative haemorrhage (Figure 3). A primary model included all patients and assessed age, sex, concomitant surgery, and dressing use (any vs. none) as potential predictors. Comorbidities and antithrombotic medication were excluded from regression modelling because no patients in these categories experienced a haemorrhage. In this model, none of the variables were statistically significant (P>0.05 for all variables).

Figure 3 Forest plot of odds ratios (95% CIs) for predictors of postoperative haemorrhage. CI, confidence interval; OR, odds ratio.

Because several dressing types had no recorded haemorrhage events, a secondary model was run, including only dressing types with at least one event (Purastat, Nasopore, Arista, and Surgicel Fibrillar). The overall effect of dressing type was not significant (P=0.20), although Arista showed a non-significant trend toward higher odds of bleeding (OR =11.2, 95% CI: 0.85–148.13, P=0.07).

Discussion

This study found no significant association between the use or cost of intranasal dressings and rates of post-operative complications following ITR surgery. Despite the wide variation in dressing choice and cost, complication rates remained low with a secondary haemorrhage rate of 3%, and no dressing type was clearly associated with improved outcomes. The small sample size and low event rate inherently limit the power to detect subtle differences between groups; however, this also provides important context for interpreting the findings. Assuming a two-arm 1:1 design comparing any dressing versus nothing (two-sided =0.05, 80% power), a study would require approximately 3,068 (»1,543 per group) to detect a halving of the bleed rate from 3% to 1.5% (absolute reduction 1.5%). In contrast, with 100 patients per group, the minimum detectable difference would be an absolute reduction of approximately 4.7%, corresponding to a number needed to treat (NNT) of 21. The NNT, from this data in our study, is therefore likely between 21 (if a full 4.7% benefit truly exists) and potentially >100 if the actual benefit is ≤1% absolute reduction. The absence of a detectable difference in this 200-patient audit therefore establishes a high minimum NNT, indicating that any true benefit, if present, is likely small and of limited clinical relevance.

From a health-economic perspective, even a modest reduction in bleeding would be difficult to justify. For instance, demonstrating a benefit of the most expensive dressing used ($700 per unit) would require its application in around 100 cases, equating to an expenditure of approximately $70,000 to potentially prevent a single postoperative bleed. This highlights the need to critically evaluate the clinical and economic value of routine intranasal dressing use in ITR surgery.

Previous studies, primarily in the context of ESS, have questioned the routine application of nasal packing to prevent bleeding. For example, Orlandi and Lanza assessed rates of post-operative bleeding in 165 patients who underwent ESS, with 2.4% of patients receiving Floseal^® (Baxter, Deerfield, USA), 11.2% of patients receiving Merocel^® (Medtronic, Minneapolis, USA) packing and 87% of patients having no material left in the nose. No patients had bleeding complications post-operatively (9). Similarly, Eliashar et al. avoided nasal packing in 92% of patients who underwent ESS, reserving it only for those with persistent bleeding five minutes after the completion of surgery. No post-operative bleeding was observed in either group (10). A literature review by Weitzel et al. likewise found no dressing type superior in preventing secondary haemorrhage (11).

The evidence surrounding wound healing is similarly mixed. Several animal and human studies have reported no clear advantage—and in some cases, potential harm—associated with absorbable packing materials (7,12-19). Kastl et al. examined sinonasal mucosal healing in 26 patients who were randomised to receive carboxymethylcellulose mesh or gel packing on one side and no packing on the contralateral side following bilateral ESS. No significant differences were found between the two sides with respect to healing, with the authors concluding that the anticipated benefit of nasal packing may reflect clinician optimism rather than empirical evidence (20). Shoman et al. randomised 30 ESS patients to receive NasoPore^® (Stryker, Canada) as a middle meatal spacer on one side and Merocel^® on the other. Post-operatively, no significant differences in bleeding, nasal blockage, swelling, pain or pressure were observed between the two sides. However, NasoPore^® was associated with significantly worse mucosal scores at one month compared to Merocel^® packing (1.17 vs. 0.77; P=0.03), an effect that resolved by the three-month follow-up (13). Chandra et al. applied FloSeal^® to the operated ethmoid cavity on one side and thrombin-soaked Gelfoam^® (Pfizer, New York, USA) to the other at the conclusion of surgery in 20 consecutive bilateral ESS patients. They found a significant increase in adhesions (P=0.0004) and granulation tissue formation (P=0.004) in the FloSeal^® group. Biopsy of an adhesion in one patient demonstrated histological evidence of incorporation of the FloSeal^® material into the healed mucosa, raising concerns about its effect on long-term healing.

Our study identified overrepresentation of Arista™ use among patients who experienced secondary haemorrhage (33.3%) and those who developed any complication (30%). Arista™ is an absorbable, plant-derived haemostatic powder composed of microporous polysaccharide hemospheres. It functions as a mechanical haemostat, absorbing coagulation factors and attracting platelets to form a stable fibrin clot at the wound site (21). Despite its use across different surgical specialities, there is limited published evidence evaluating its efficacy in sinonasal surgery. Antisdel and Denning randomised forty ESS patients to unilateral treatment with Arista™. While significantly less ooze was observed on post-operative day one in the Arista™-treated side (bleeding score 22.5 vs. 39.0, P<0.0001), no differences were noted on subsequent days, and there were no major bleeding complications or significant differences in other measured outcomes (22). One large published abstract of 514 consecutive patients undergoing septal or sinus surgery reported no cases of secondary haemorrhage requiring repacking or scarring requiring revision surgery (21). Sindwani’s series of 65 ESS patients treated with Arista™ found no significant haemorrhage, but reported synechiae in 12.3% of patients, comparable to rates reported in the literature following ESS (23). These findings contrast with our results, where increased complication rates were observed in the Arista™ cohort. However, binary logistic regression did not identify Arista use as a statistically significant predictor of post-operative haemorrhage (P=0.07). Given the small sample size, wide confidence intervals, and the borderline P value, this apparent trend likely represents a Type I error. Nonetheless, it warrants further investigation through prospective, controlled studies to better understand the risk-benefit profile of Arista™ in ITR surgery.

Despite the lack of robust evidence and the high cost of many intranasal dressings, their use remains widespread. Indeed, all 17 surgeons in our study elected to use them in at least some cases, with fourteen surgeons applying them routinely in every case. This practice may reflect factors other than evidence, including training, institutional culture, or perceived benefit. Surgeon preference likely plays a dominant role, influenced by cognitive biases such as anchor bias—the tendency to rely on initial experience or ingrained habits when making decisions, even when new evidence emerges (24). In procedures such as ITR surgery, infrequent complications and limited direct feedback loops may perpetuate the routine use of high-cost dressings in the absence of demonstrable benefit.

This study also highlights a critical gap in the literature regarding the cost-effectiveness of absorbable intranasal dressings. While clinical outcomes have been the primary focus of most research, our economic analysis demonstrates substantial cost variability among products, without correlation to improved outcomes. This finding is especially salient in the current healthcare climate, where rising costs of single-use surgical consumables, including nasal dressings, represent a growing concern. In private health systems, these expenses contribute directly to increasing insurance premiums and patient out-of-pocket costs, underscoring the need for cost-conscious, evidence-based decision-making. Given that any plausible benefit of haemostatic dressings is likely small (NNT >20–100), the cost per bleed is disproportionately high. Greater transparency in dressing costs, institutional procurement oversight, and evidence-informed guidelines could help reduce unnecessary variation and promote efficient resource utilisation.

Limitations of this study include its modest sample size and low event rate, which restricts statistical power and precludes detection of small effect sizes, increasing susceptibility to type I error. While the inclusion of a diverse cohort and multiple operating surgeons enhances applicability to broader ear, nose, and throat (ENT) practice, the generalisability of findings may still be limited by the single-centre, private hospital setting. The rationale behind intranasal dressing choice, post-operative follow-up protocols, and patient adherence to post-operative instructions were not captured, all of which may influence outcomes. Finally, reliance on patient-reported complications may introduce recall or reporting bias. Nevertheless, the absence of any clinically meaningful difference across all comparisons supports the broader conclusion that routine use of expensive intranasal dressings offers limited benefit in ITR surgery. Given the low incidence of complications, demonstrating a statistically significant benefit of intranasal wound dressings in ITR surgery would require very large sample sizes, rendering such trials logistically difficult and economically impractical. Future research should prioritise multi-centre collaboration with standardised reporting frameworks, or cost-effectiveness modelling rather than attempting to power large randomised trials. Such approaches would better clarify real-world value while maintaining feasibility and relevance to everyday surgical practice.

Conclusions

This study highlights significant variation in the cost and selection of intranasal wound dressings used in ITR surgery, without demonstrating corresponding improvement in post-operative outcomes. These findings suggest that routine dressing use may be driven more by habit than evidence, and echo broader concerns regarding the cost-effectiveness of routinely used surgical consumables. The potential influence of cognitive biases such as surgeon anchor bias further underscores the need for critical appraisal and evidence-based practice. In an era of rising healthcare expenditure with a growing focus on value and sustainability, this study reinforces the imperative to pursue cost-conscious, outcome-driven models of care. It offers real-world insight into current practice patterns, revealing a disconnect between perceived benefit and measurable outcomes in intranasal dressing use. Larger, prospective studies are needed to validate these findings and guide evidence-based recommendations for intranasal dressing use in ITR surgery.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://www.theajo.com/article/view/10.21037/ajo-25-54/rc

Data Sharing Statement: Available at https://www.theajo.com/article/view/10.21037/ajo-25-54/dss

Peer Review File: Available at https://www.theajo.com/article/view/10.21037/ajo-25-54/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://www.theajo.com/article/view/10.21037/ajo-25-54/coif). R.G.C., P.M., F.R. and R.J.H. serve as the unpaid editorial board members of Australian Journal of Otolaryngology from January 2025 to December 2027. Y.N. is a consultant and advisory board member with Stryker and 3D Matrix Medical Technology. R.J.H. is consultant and advisory board with Medtronic, Novartis, Sanofi, Glaxo-Smith-Kline and NeilMed Pharmaceuticals. He has been on the speakers’ bureau for Viatris, Stryker, Glaxo-Smith-Kline, Astra-Zeneca, Stallergnes, and Proctor and Gamble. He is a grant recipient from Glaxo-Smith-Kline, Sanofi and Stallergenes. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Macquarie University Human Research Ethics Committee (No. MQCIAC2022008) and informed consent was taken from all participants.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Barham HP, Knisely A, Harvey RJ, et al. How I Do It: Medial Flap Inferior Turbinoplasty. Am J Rhinol Allergy 2015;29:314-5. [Crossref] [PubMed]
2. Zhang K, Pipaliya RM, Miglani A, et al. Systematic Review of Surgical Interventions for Inferior Turbinate Hypertrophy. Am J Rhinol Allergy 2023;37:110-22. [Crossref] [PubMed]
3. Fradis M, Golz A, Danino J, et al. Inferior turbinectomy versus submucosal diathermy for inferior turbinate hypertrophy. Ann Otol Rhinol Laryngol 2000;109:1040-5. [Crossref] [PubMed]
4. Batra PS, Seiden AM, Smith TL. Surgical management of adult inferior turbinate hypertrophy: a systematic review of the evidence. Laryngoscope 2009;119:1819-27. [Crossref] [PubMed]
5. Gupta A, Mercurio E, Bielamowicz S. Endoscopic inferior turbinate reduction: an outcomes analysis. Laryngoscope 2001;111:1957-9. [Crossref] [PubMed]
6. Valentine R, Wormald PJ. Nasal dressings after endoscopic sinus surgery: what and why? Curr Opin Otolaryngol Head Neck Surg 2010;18:44-8. [Crossref] [PubMed]
7. Valentine R, Wormald PJ. Are routine dissolvable nasal dressings necessary following endoscopic sinus surgery? Laryngoscope 2010;120:1920-1. [Crossref] [PubMed]
8. Private Health Insurance Legislation Amendment Rules (No. 3) 2025. Available online: https://www.legislation.gov.au/F2025L00206/latest/text
9. Orlandi RR, Lanza DC. Is nasal packing necessary following endoscopic sinus surgery? Laryngoscope 2004;114:1541-4. [Crossref] [PubMed]
10. Eliashar R, Gross M, Wohlgelernter J, et al. Packing in endoscopic sinus surgery: is it really required? Otolaryngol Head Neck Surg 2006;134:276-9. [Crossref] [PubMed]
11. Weitzel EK, Wormald PJ. A scientific review of middle meatal packing/stents. Am J Rhinol 2008;22:302-7. [Crossref] [PubMed]
12. Chandra RK, Conley DB, Haines GK 3rd, et al. Long-term effects of FloSeal packing after endoscopic sinus surgery. Am J Rhinol 2005;19:240-3.
13. Shoman N, Gheriani H, Flamer D, et al. Prospective, double-blind, randomized trial evaluating patient satisfaction, bleeding, and wound healing using biodegradable synthetic polyurethane foam (NasoPore) as a middle meatal spacer in functional endoscopic sinus surgery. J Otolaryngol Head Neck Surg 2009;38:112-8.
14. McIntosh D, Cowin A, Adams D, et al. The effect of an expandable polyvinyl acetate (Merocel) pack on the healing of the nasal mucosa of sheep. Am J Rhinol 2005;19:577-81.
15. Rajapaksa SP, Cowin A, Adams D, et al. The effect of a hyaluronic acid-based nasal pack on mucosal healing in a sheep model of sinusitis. Am J Rhinol 2005;19:572-6.
16. Hosemann W, Wigand ME, Göde U, et al. Normal wound healing of the paranasal sinuses: clinical and experimental investigations. Eur Arch Otorhinolaryngol 1991;248:390-4. [Crossref] [PubMed]
17. Maccabee MS, Trune DR, Hwang PH. Effects of topically applied biomaterials on paranasal sinus mucosal healing. Am J Rhinol 2003;17:203-7.
18. McIntosh D, Cowin A, Adams D, et al. The effect of a dissolvable hyaluronic acid-based pack on the healing of the nasal mucosa of sheep. Am J Rhinol 2002;16:85-90.
19. Chandra RK, Kern RC. Advantages and disadvantages of topical packing in endoscopic sinus surgery. Curr Opin Otolaryngol Head Neck Surg 2004;12:21-6. [Crossref] [PubMed]
20. Kastl KG, Betz CS, Siedek V, et al. Effect of carboxymethylcellulose nasal packing on wound healing after functional endoscopic sinus surgery. Am J Rhinol Allergy 2009;23:80-4. [Crossref] [PubMed]
21. Phillips PP. Safety and Efficacy of Arista Powder in 514 Nasal Septal and Sinus Surgery Patients. Otolaryngology Head and Neck Surgery 2013;149:135.
22. Antisdel JL, West-Denning JL, Sindwani R. Effect of microporous polysaccharide hemospheres (MPH) on bleeding after endoscopic sinus surgery: randomized controlled study. Otolaryngol Head Neck Surg 2009;141:353-7. [Crossref] [PubMed]
23. Sindwani R. Use of novel hemostatic powder MPH for endoscopic sinus surgery: initial impressions. Otolaryngol Head Neck Surg 2009;140:262-3. [Crossref] [PubMed]
24. Armstrong BA, Dutescu IA, Tung A, et al. Cognitive biases in surgery: systematic review. Br J Surg 2023;110:645-54. [Crossref] [PubMed]