Anterior Epistaxis Nasal Pack: Overview, Technique, Preparation (2024)

Overview

Airway, breathing, and circulation (ABCs) take priority in the acute management of epistaxis. Less invasive approaches to controlling epistaxis should be attempted before anterior nasal packing is initiated. ^{[6, 7, 8, 9]}

Direct Pressure

Apply anterior nasal pressure to the cartilaginous part of the nose for 20 minutes (see the image below). If this maneuver does not control the bleeding, a more invasive approach is required.

Assemble equipment and put on gown, goggles, and gloves. A headlamp, if available, is helpful; its use enhances the visual field. Keep patient in an upright or minimally reclined position.

Topical anesthesia and vasoconstriction

Soak cotton balls in a mix of 2% lidocaine and 1:1000 epinephrine. Put 1–2 cotton balls into the bleeding nostril. (If bleeding is not clearly unilateral, put cotton balls into both nostrils.) Place a dry cotton ball at the external nares to prevent leakage and dripping. Leave the cotton balls in place for 10 minutes.

If these anesthetic supplies are unavailable, a commercially produced topical nasal decongestant may be quickly inhaled; then, place cotton balls and apply anterior nasal pressure.

Evacuation of blood and clot

Remove the cotton balls placed for local anesthesia. To evacuate clots, use suction or have patient blow gently. Previously accumulated blood comes out in a gush and then stops. Ongoing bleeding appears as steadily dripping, bright red blood.

Identification of bleeding source

Stabilize your hand on the patient’s face, and visualize the septum through the nasal speculum. Examine the Kiesselbach plexus for bleeders. If the offending vessel has stopped bleeding, it will appear as a red dot on the mucosa that may have a small amount of clot on it. If the vessel is still bleeding, active oozing will be visible.

Cauterization of bleeding source

A clear view of the bleeding source is mandatory for the use of cauterization methods. Cauterize to cease unilateral septal bleeding only. Bilateral cauterization, whether chemical or electrical, increases the risk of septal perforation.

For chemical cauterization, apply a silver nitrate stick to the red dot or oozing vessel for 5-10 seconds, then roll it over the surrounding area (1 cm) for 5–10 seconds to cauterize feeding vessels. Apply antibiotic ointment over cauterized area. This provides prophylaxis against infection and serves as a topical barrier to prevent desiccation and restart of bleeding.

Electrical cauterization is typically used by an otolaryngologist in the context of endoscopic visualization.

Nasal packing

Anterior nasal packing is required when external pressure and cauterization fail to control anterior bleeding, though some clinicians elect to use anterior nasal packing as their first-line approach. The goal is to place an intranasal device that applies constant local pressure to the nasal septum. Traditional gauze packing is sufficient if prefabricated nasal tampons like Rapid Rhino or Merocel are not available (see Equipment).

A prospective study of 42 patients was performed to compare the efficacy and patient tolerance of Merocel and Rapid Rhino nasal tampons. No significant difference in efficacy or patient comfort was revealed between the 2 types of packs. Rapid Rhino produced significantly lower scores for subjective patient discomfort during insertion and removal of pack. ^[10]

Packing with commercial products

Anterior packing with prefabricated nasal tampons begins with applying anesthetic to the nasal mucosa with cotton balls or via inhalation. Apply surgical lubricant to the tampon, and gently insert it to the maximum achievable depth. Advance the tampon almost horizontally, along the floor of the nasal cavity.

The Merocel nasal tampon is made of polyvinyl alcohol, which is a compressed foam polymer that is inserted into the nose and expanded by application of water. The nasal tampon swells and fills the nasal cavity and applies pressure over the bleeding point. The Merocel tampon is believed to aggregate clotting factors to reach a critical level, thereby promoting coagulation. The Merocel success rate is 85% (equal to that of traditional ribbon gauze).

The Rapid Rhino anterior balloon tampon is made of carboxymethylcellulose, a hydrocolloid material. It acts as a platelet aggregator and also forms a lubricant upon contact with water. Unlike Merocel, the Rapid Rhino balloon has a cuff that is inflated by air. The hydrocolloid or Gel-Knit reportedly preserves the newly-formed clot during tampon removal.

Packing with gauze

Anterior packing with gauze begins similarly, with the application of anesthetic to the nasal mucosa with cotton balls or via inhalation. Prepare a length of ribbon gauze impregnated with petrolatum jelly. Use bayonet forceps and a nasal speculum to place the gauze in a layered, accordion fashion, packing it from anterior to posterior (see the image below). The gauze should be placed as far posteriorly as is possible.

Failure of anterior nasal packing

If anterior packing failed to stop a confirmed and visualized anterior bleeding source, consider bilateral packing to increase the pressure on the nasal septum. If the anterior bleeding source was unconfirmed and bleeding continues, suspect posterior bleeding.

For a detailed description of posterior nasal packing, see Posterior Epistaxis Nasal Pack.