DİSCUSSİON
Tobacco consumption is the leading preventable cause of morbidity and mortality in the world.7 The most common way of tobacco consumption is cigarette smoking. On the other hand, hookah smoking is gaining popularity, especially among young and female tobacco consumers.8 Hookah smoking is also believed to promote social interaction; there are ‘hookah cafes’ serving hookah where people socialize together and even share hookah pipes. However, these settings lead to underestimating health risks associated with this habit and a false belief that hookah smoking is less harmful than cigarette smoking. Nevertheless, in addition to the anticipated tobacco consumption-related effects of hookah, pipe sharing can lead to the spread of infections. Besides, alcohol or psycho-active drugs that might be added to the tobacco during the preparation of hookah can cause other unanticipated deleterious effects.9
The relationship between cigarette smoking and respiratory system diseases has been extensively addressed.7 However, the effect of hookah smoking on patients who undergo upper respiratory system surgeries has not been widely evaluated in the literature.3 Septoplasty is a frequently performed surgery in the otolaryngology practice with favorable outcomes.2 However, delayed healing and septal perforation can be encountered during the postoperative period; these complications can significantly impair this procedure’s success and diminish patient satisfaction.2-4 Several clinical studies emphasized the role of cigarette smoking on the emergence of these complications while –to the best of our knowledge- the relationship of hookah smoking with these complications has not yet been reported in the literature.3,4
The main adverse effect of smoking is diminishing mucociliary clearance in the nasal mucosa by exerting ciliotoxic effects and changing the viscoelasticity of the mucus.10 Furthermore, the nicotine in tobacco causes acute intimal damage and desquamation in vascular endothelial cells. This intimal damage, combined with the cyclooxygenase inhibition through its effects on the thrombocytes, promotes vascular thrombosis and tissue hypoxia.11These mechanisms may explain the significantly prolonged healing time we found in our patients who smoke both hookah and cigarette. Of note, cigarette non-smokers who smoke hookah were also found to have significantly delayed healing. This finding indicates that hookah smoking can be even more deleterious than cigarette smoking in healing after septoplasty.
Although tobacco consumption was found to disrupt wound healing, Yazici and associates reported that active cigarette smoking did not increase the complication rates after septoplasty.6 Since septal perforation is the most critical complication encountered in patients who undergo septoplasty, we analyzed septal perforation rates.3,4,6 A comparison of our cigarette smoker patient group with the cigarette non-smoker patient group did not reveal any difference in septal perforation rates. Therefore, our findings are consistent with the findings of Yazici et al.6However, we found that the healing time was significantly longer in the cigarette smoking patient group than the cigarette non-smoking patient group.
In our study, although cigarette smoking did not increase the frequency of septal perforation significantly, the frequency of septal perforation was significantly higher in the hookah smoking group compared with the hookah non-smoking group. Aricigil et al. showed that even once a week hookah smoking prolonged the nasal mucociliary clearance.10 Mucociliary clearance is the primary defense mechanism against external harmful stimulants and helps particles move towards pharynx by ciliary transport.11These particles are then eliminated by coughing or swallowing.10 Hookah smoking disrupts this fundamental defense mechanism.10,11
Moreover, since hookah contains nicotine like cigarette, it can cause the potentially deleterious effects of cigarette smoking.11,12 On the other hand, aroma is usually added to hookah.13,14 Erbaydar and associates demonstrated that 86.3% of hookah smokers preferred aromatic products.12 We speculate that these aromatic additives may contain detrimental chemicals different and more deleterious than those included in cigarettes. Therefore, inhalation of these chemicals may lead to more severe effects in the upper respiratory tract than cigarette smoking. Prolonged healing time and increased septal perforation rate in our patients who were hookah smokers can be ascribed to this theory. As per the current literature, the relationship between hookah smoking and upper respiratory tract problems has not yet been studied in detail.15,16 Studies investigating this topic are needed to further detail the impact of hookah smoking on the recovery period of the patients who underwent a septoplasty procedure.
Our study has some weaknesses that need to be considered while evaluating its findings. First, it does not have a large sample size. Second, the smoking history of the patients is not detailed. These stories cover only the one-year period before the surgery; therefore, they ignore the prior history of smoking and equate the patients who had a 10-year history of smoking with the patients who had only two-year smoking history. The frequency of smoking was also omitted.