III. Complications: Nasal Packing
-
Septal Hematoma or abscess
- Avoid excessive Trauma on Nasal Packing insertion
- Septal pressure necrosis
- Avoid overly tight Nasal Packing
- Risk of Sinusitis or Toxic Shock Syndrome
- Apply Bactroban Topical Ointment in nares
- Oral Antibiotic prophylaxis indications are patient specific
- Optional in otherwise healthy patients
- Recommended if SBE Prophylaxis would otherwise be indicated
- Amoxicillin at standard treatment doses is reasonable option
- Derkay (1989) Arch Otolaryngol Head Neck Surg 115: 439-441 [PubMed]
- Bandhauer (2002) Am J Rhinol 16(3): 135-139 [PubMed]
IV. Preparation
-
Local Anesthetic and Topical Decongestant
- Lidocaine 2% and Phenylephrine 4% mix 1:1 on cotton ball inserted into nose or
- Oxymetazoline (or Phenylephrine) and Cetacaine sprayed into nare separately or
- Lidocaine 2% with Epinephrine atomized with MADD atomizer into nare or
- Lidocaine/Epinephrine/Tetracaine (LET solution) on cotton ball inserted into nose or
- Cocaine soaked 2x2 gauze rolled or cotton ball inserted into nose
-
Hemostatic Agents (apply to mucosa via MADD atomizer, cotton ball or on soaked Rhinorocket)
- Topical Tranexamic Acid (TXA)
- Topical Thrombin (if on Warfarin)
V. General
- Gown prior to Nasal Packing (bloody procedure)
- Use topical Bactroban in nares with packing
- Remove non-absorbable nasal packs after 2-3 days
- Prolonged Nasal Packing has been associated with Toxic Shock Syndrome
- Jacobson (1986) Arch Otolaryngol Head Neck Surg 112: 329-32 [PubMed]
- The packing tip should be barely visible in the posterior pharynx when the patient opens their mouth
VI. Preparations: Nasal Packing options
- Rocket pack (Rhino Rocket)
- Easiest of all methods and most common in Emergency Departments
- Two lengths (short for anterior bleed, long for posterior or unknown)
- Soak for 30 seconds in sterile water, insert and inflate
-
Vaseline Gauze pack or 0.5 x 72 inch strips
- Use Bayonet forceps with nasal speculum
- Layer (accordion-fold) from bottom to top
- Start each layer as far posterior as possible
- Press down each layer before inserting next one
- Absorbable Gelatin foam (Gelfoam)
- Oxidized Cellulose (Surgicel)
- Nasal tampon (Merocel or Doyle sponge)
- Easier to insert then gauze pack method
- Gently insert along floor of nose
- Expand with saline or Phenylephrine
- Absorbable oxidized cellulose
- Effective for those on Anticoagulants
- Do not need to be removed (will absorb)
VII. Patient Instructions
- Return for removal of non-absorbable packs in 2-3 days
- Apply Bactroban Topical Ointment in nares
- Avoid vasodilating actions
- Physical exertion
- Spicy foods
- Alcohol
- Avoid Nasal manipulation or nose blowing
- Sneeze with mouth open
- Alleviate drying
- Saline Nasal Sprays several times per day
- Apply Bacitracin ointment qd to bid
- Vaseline does not appear effective in children