الفهرس 
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Abstract
Nasal Obstruction is a common symptom that reaches 25% of the population. The main etiologies for nasal obstruction are: septal deviation, hypertrophy of the inferior and middle turbinates, nasal polyposis and hypertrophy of pharyngeal tonsils (Passali et al., 2003).
Among those etiologies the hypertrophy of the inferior turbinates figures as the main cause of the nasal obstruction. About 20% of European population has chronic nasal obstruction caused by the hypertrophy of the inferior turbinates ,Allergic rhinitis, vasomotor rhinitis and septal deviation (compensatory hypertrophy) figure as the main causes of hypertrophy of the inferior turbinates (Rodrigues et al., 2011).
The inferior turbinate plays a key role in the nasal airway. The structure consists of a bony core (conchal bone) with a soft tissue cover that consists of a fibro elastic stroma, sub mucosal glands, and cavernous sinusoids. The soft tissue portion of the inferior turbinate can be further broken down into medial and lateral portions that are separated by the internal conchal bone. Blood flow through the cavernous sinusoids is regulated by the autonomic nervous system and leads to subsequent enlargement or reduction in size of the inferior turbinate (Berger et al., 2006).
Several surgical techniques are available to treat concha hypertrophy, including the partial or total turbinectomy, submucosal or extramucosal electrocautery and reduction by radiofrequency, laser cryosurgery. Nowadays, there is no agreement in literature indicating the most suitable technique to reduce nasal conchae (Bhandarkar and Smith, 2010).
The nasal pack has been used to control primary bleeding in patients submitted to nasal surgery. Besides, the pack is used to stabilize the cartilaginous-osseous structure of the nose and avoid complications in the post-surgical period, such as septal hematoma, infection, and abscess development (Berlucchi et al., 2009).
Several complications have been related to the nasal pack, as vasovagal reflex (arrhythmia, hypotension and apnea), allergy, toxic shock syndrome, Eustachian tube dysfunction, infection and respiratory disorders (Lubianca-Neto et al., 2000).
This study was done as prospective randomized controlled study on 50 patients who presented to the E.N.T. out-patient clinic in Beni-Suef University hospital, Those patients complaining of bilateral nasal obstruction were subjected to a sufficient evaluation including history taking and clinical examination; to select those who were included in our study and underwent the operative procedure.
Operative procedure:
The following technique is used under general anesthesia: under endoscopic guidance using a 0º rigid nasal endoscope The inferior turbinate was inward fractured by Freer’s elevator, then crushing along the site of cutting till the posterior end ( leaving the anterior end ) by long tonsillectomy artery for 1 minute. After removing the long tonsillectomy artery, we cut the turbinate along the crushed area using turbinectomy scissors. Haemostasis was done by using bipolar diathermy and cauterization of the bleeding points under endoscopic guidance.
We classified the patients into 2 groups as following: group ”A” left the theatre without anterior nasal packing and group ”B” underwent turbinectomy with anterior nasal packing.
Post operative care:
Patients were hospitalized for 2 days during which they were observed for any nasal bleeding the bleeding intensity was scaled from 1 to 4 as following:
1- There was no bleeding
2- Minimum bleeding and it stopped spontaneously
3- Bleeding required a vasoconstriction
4- Nasal packing needed
Patients were kept on antibiotic injections and oral anti-inflammatory drugs.
Results:
All patients were followed up for 2 days for occurrence of post operative bleeding and the results were as following:
Patients in group A (without anterior nasal pack) were classified according to the degree of bleeding into the following categories :
1- Patients with no bleeding (24%).
2- Patients with minimal bleeding that stops without intervention (32%).
3- Patients with post operative bleeding that requires a vaso- constrictor agent (28%). in the form of anterior nasal pack with saline adrenaline 1:200.000
4- Patients with post operative bleeding that requires anterior nasal packing (16%) ” during the first 2 days follow up post operatively”.
Patients in group B ( with anterior nasal pack ): There was no post operative bleeding ( 100%)
Conclusion
The results of the study revealed that using the anterior nasal packing as post operative measure after partial inferior turbinectomy prevents the occurrence post operative bleeding totally . while partial inferior turbinctomy without using anterior nasal packing makes patient liable for occurrence of post-operative bleeding .
We also noticed that the post-operative nasal bleeding either not happened or was minimal bleeding, needs no or minimal intervention (84%) , So we can avoid the complications of using anterior nasal packing in this percentage by this technique.
The study also revealed that there is relation between the age of the patient and the severity of the bleeding ( the older the patient the more susceptible to bleeding of more intensity , grade 3 : vasoconstrictor agent needed and grade 4 : anterior nasal pack needed ) with p value which is statistically significant.