Nasal Packing

1. See Also
   1. Epistaxis
   2. Posterior Nasal Hemorrhage Management
2. Indications
   1. Epistaxis not controlled with basic measure
   2. Recurrent Epistaxis
3. Complications: Nasal Packing
   1. Septal Hematoma or abscess
      1. Avoid excessive Trauma on Nasal Packing insertion
   2. Septal pressure necrosis
      1. Avoid overly tight Nasal Packing
   3. Risk of Sinusitis or Toxic Shock Syndrome
      1. Apply Bactroban Topical Ointment in nares
      2. Oral antibiotic prophylaxis indications are patient specific
         1. Optional in otherwise healthy patients
         2. Recommended if SBE Prophylaxis would otherwise be indicated
         3. Amoxicillin at standard treatment doses is reasonable option
         4. Derkay (1989) Arch Otolaryngol Head Neck Surg 115: 439-441 [PubMed]
         5. Bandhauer (2002) Am J Rhinol 16(3): 135-139 [PubMed]
4. Preparation
   1. Local Anesthetic and Topical Decongestant
      1. Lidocaine 2% and Phenylephrine 4% mix 1:1 on cotton ball inserted into nose or
      2. Oxymetazoline (or Phenylephrine) and Cetacaine sprayed into nare separately or
      3. Lidocaine 2% with Epinephrine atomized with MADD atomizer into nare or
      4. Lidocaine/Epinephrine/Tetracaine (LET solution) on cotton ball inserted into nose or
      5. Cocaine soaked 2x2 gauze rolled or cotton ball inserted into nose
   2. Hemostatic Agents (apply to mucosa via MADD atomizer, cotton ball or on soaked Rhinorocket)
      1. Topical Tranexamic Acid (TXA)
      2. Topical Thrombin (if on Warfarin)
5. General
   1. Gown prior to Nasal Packing (bloody procedure)
   2. Use topical Bactroban in nares with packing
   3. Remove non-absorbable nasal packs after 2-3 days
      1. Prolonged Nasal Packing has been associated with Toxic Shock Syndrome
      2. Jacobson (1986) Arch Otolaryngol Head Neck Surg 112: 329-32 [PubMed]
   4. The packing tip should be barely visible in the posterior pharynx when the patient opens their mouth
6. Preparations: Nasal Packing options
   1. Rocket pack (Rhino Rocket)
      1. Easiest of all methods and most common in Emergency Departments
      2. Two lengths (short for anterior bleed, long for posterior or unknown)
      3. Soak for 30 seconds in sterile water, insert and inflate
   2. Vaseline Gauze pack or 0.5 x 72 inch strips
      1. Use Bayonet forceps with nasal speculum
      2. Layer (accordion-fold) from bottom to top
      3. Start each layer as far posterior as possible
      4. Press down each layer before inserting next one
   3. Absorbable Gelatin foam (Gelfoam)
   4. Oxidized Cellulose (Surgicel)
   5. Nasal tampon (Merocel or Doyle sponge)
      1. Easier to insert then gauze pack method
      2. Gently insert along floor of nose
      3. Expand with saline or Phenylephrine
      4. Absorbable oxidized cellulose
         1. Effective for those on Anticoagulants
         2. Do not need to be removed (will absorb)
7. Patient Instructions
   1. Return for removal of non-absorbable packs in 2-3 days
   2. Apply Bactroban Topical Ointment in nares
   3. Avoid vasodilating actions
      1. Physical exertion
      2. Spicy foods
      3. Alcohol
   4. Avoid Nasal manipulation or nose blowing
   5. Sneeze with mouth open
   6. Alleviate drying
      1. Saline Nasal Sprays several times per day
      2. Apply Bacitracin ointment qd to bid
      3. Vaseline does not appear effective in children
         1. Loughran (2004) Clin Otolaryngol 29:266-9 [PubMed]