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.