Anterior Packing Research Articles

A study to determine the benefits of bilateral versus unilateral nasal packing with Rapid Rhino® packs

There is little evidence to suggest that bilateral nasal packing increases intra-nasal pressures compared to a single pack (or is well tolerated) for uncontrolled unilateral epistaxis, but it is often performed and justified on those grounds. 15 volunteers were recruited according to strict criteria. Rapid Rhino(®) 5.5 cm anterior packs were inserted bilaterally following topical nasal preparation with co-phenylcaine. The first pack was inflated to a pre-determined pressure. The contralateral pack was inflated to match, and any intra-nasal pressure change on the first side was measured. The subject's level of discomfort was scored on a visual analogue scale. This procedure was repeated at incremental pressures. Higher ipsilateral intra-nasal pressures are achieved when additional contralateral nasal packs are inflated. This change in ipsilateral intra-nasal pressure is greater at higher total inflation pressures. At higher pressures, the subjects reported lower mean pain scores when bilateral packs were used compared to unilateral. This effect was only statistically significant at intra-nasal pressures of 140 mmHg and above (Wilcoxon Signed-Rank test, p < 0.02). It is possible to increase the ipsilateral nasal cavity pressure by inserting a contralateral nasal pack. Although this extra pressure may be enough to tamponade further venous bleeding without significantly increasing a subject's discomfort, the high levels of pack pressure required, make this unlikely to be of significant use in the clinical setting.

Ciało obce nosa, zatok sitowych i oczodołu penetrujące do środkowego dołu czaszki

We present the case of wooden foreign body penetrating the nasal cavity, ethmoid sinus, orbit and brain, complicated by the right eye blindness.29-year-old man was admitted because of the foreign body penetrating by the bridge of the nose. Exophthalmos, lack of mobility and reaction to light and loss of vision of the right eye were found. The CT showed the foreign body penetrating through the open left nasal bone fracture to the nasal cavity, by the nasal septum and ethmoid sinus into the right orbit and the middle cranial fossa, modeling the right internal carotid artery. The foreign body was removed under general anesthesia. The CT showed no intracranial bleeding. The lacerated wound and the fracture of the nose were treated, bilateral anterior pack was inserted.The arteriography revealed partial right cavernous sinus thrombosis. In the MRI after a month of treatment cavernous sinus was normally contrasted. In the neuro-ophthalmological examination the right CN II, III, IV, VI and V1 damage were found.The patients was qualified to septoplasty because of the deviation of the nasal septum and nasal synechiae.Foreign bodies of facial skeleton are associated with danger of severe complications and permanent disability and require close cooperation of the laryngologist, neurosurgeon, radiologist and ophthalmologist.

A Case of Aggressive NK-Cell Leukemia Diagnosed with Severe Epistaxis

We report a case of severe epistaxis resulting in an unfortunate clinical course. A 35-year-old man seen for bilateral nasal obstruction, a top-heavy feeling, and general fatigue was found to have bilateral swollen nasal mucosae and a completely obstructed nasal airway. Sinonasal X-ray showed the pansinuses to be occupied. Nasal treatment caused such immediate excessive bilateral epistaxis. Disturbance of consciousness occurred. The bleeding could not be arrested completely even under general anesthesia. Astriction was done using anterior packing and posterior balloon tamponade. Perioperative blood examination showed thrombocytopenia, disseminated intravascular coagulation (DIC), electrolyte abnormality, hepatic dysfunction, and overwhelming acidosis, requiring that the man be managed in the intensive care unit (ICU), where he also suffered hemophagocytic syndrome and multiple organ failure (MOF). The diagnosis from bone-marrow biopsy and flow cytometry was aggressive natural killer (NK) cell leukemia (ANKL). Despite chemotherapy with steroids, etoposide, and L-asparaginase, he died of hemorrhagic pneumonia one month after the final diagnosis. Given such nasal symptoms with a worsening general condition due to latent blood dyscrasia, blood examinations should be done even before attempting nasal treatment.

Clinical Study of 1304 Patients with Epistaxis for Recent 5 Years

Objective: Epistaxis is one of the most common symptoms encountered in the ENT clinic. In this study, we reviewed our recent clinical experience of patients with epistaxis and discussed important lessons for the management of cases of epistaxis. Method: Between 2005 and 2009, 1304 patients with epistaxis were treated at our department. There were 795 men and 509 women. Mean age was 57 years (range, 0-99 years). Clinical features: situations at the first visit; pathogenesis; bleeding points; methods of treatments; and clinical courses were retrospectively investigated. Results: The 700 patients (54%) first visited in the nighttime. The most common condition was hypertension in 388 patients (30%) followed by cardiovascular disease in 262 patients (20%). The 630 patients (48%) were on medication with hypotensors and/or antithrombotic drugs. Kiesselbach’s plexus was the mostly observed, as it was observed in 679 patients (52%). In 225 patients (17%), bleeding point was not confirmed. The 424 patients (33%) were primarily treated by anterior packing, followed by electrocauterization in 365 patients (28%). Re-bleedings within 14 days after the primary treatments were found in 181 patients (14%). Hospitalized surgical treatments were required in 3% (6/181 patients). Conclusion: Outpatient therapy is usually enough to arrest hemorrhage in major cases. However, we have encountered patients with repeating arterial pulsing bleedings who require emergent hospitalized surgical therapy. Risk of re-bleeding within a day should be considered if patients had uncertain bleeding point and circulatory diseases.

Radiology Quiz Case 3

A 15-YEAR-OLD BOY PRESENTED WITH right-sided anterior epistaxis after undergoing anterior packing at an outside hospital. He had experienced approximately 4 episodes of right-sided epistaxis per year for 10 years. He had no history of antecedent trauma, nasal surgery, or bleeding diatheses and no facial numbness or pressure. His medical and family histories were noncontributory. The patient had age-appropriate vital signs, and the results of examination of his eyes, face, oral cavity, larynx, neck, and cranial nerves were normal. After his nasal packing was removed, he developed brisk anterior bleeding from the right side. The bleeding was localized to the lateral nasal wall, near the middle meatus. No discrete mass was seen, but the site appeared purpuric. Hematologic laboratory tests showed no abnormalities. Computed tomographic and magnetic resonance imaging was performed (Figures 1, 2, and 3). A formal endoscopic examination showed a lesion superior to the inferior turbinate, anterior to the horizontal attachment of the middle turbinate. The lesion was soft and purpuric, with a fibrous capsule, extending into the middle meatus. Biopsy specimens and cultures were obtained. Before the results returned, infraorbital numbness developed. The biopsy specimens showed only inflammatory changes, and the cultures were negative for organisms. Because of the patient’s paresthesia and radiologic infraorbital dehiscence, he was taken back to the operating room for complete excision of the mass. The histopathologic features are shown in Figure 4. The patient has done well since surgery, with no further episodes of bleeding and complete resolution of the paresthesias. What is your diagnosis?

Use of trans-septal mattress suture of Little's area for anterior epistaxis

In some cases of epistaxis, anterior packing and/or electrocoagulation are not sufficient and suturing is needed. However, standard suturing techniques are sometimes ineffective. This paper reports the use of a new kind of trans-septal mattress suture, based on regional vascular anatomy, in this clinical context. Four adult patients with haemorrhage in Little's area underwent standard suturing, but bleeding persisted. These patients were successfully treated with trans-septal mattress suturing, using four punctures around the haemorrhage site. No relapses or complications were observed over a six-month follow-up period. In cases of persistent bleeding from Little's area, suturing should surround the bleeding area. The described suturing method is simple, efficacious and cheap.

Endovascular Treatment of Epistaxis

Epistaxis is a common condition that can be managed conservatively in most cases. When these measures, including anterior and posterior packing of the nasal cavity, are unsuccessful at controlling the bleeding, interruption of the blood supply to the sinonasal area can be performed, either by surgical ligation or by transarterial embolization. Embolization should be preceded by thorough diagnostic angiography. Aside from aiding with subsequent selective catheterization and embolization, such angiography may reveal significant anatomic anomalies, anastomoses, or an unsuspected cause of epistaxis. Taking these findings into account, the interventionalist may decide to refrain from embolization or adjust the technique to minimize the risk of adverse events, which are mostly related to inadvertent embolization of the internal carotid artery or ophthalmic artery. We present a review of the various causes of epistaxis and the treatment options, with emphasis on endovascular embolization. We also describe the protocol of our institution for endovascular management of this condition.

Utilidad del tratamiento quirúrgico de la epistaxis grave mediante abordaje endoscópico de las arterias esfenopalatina y etmoidal anterior

Introduction:To evaluate the efficacy and cost-effectiveness of the treatments used for controlling epistaxis, particularly compared with the surgical endoscopic ligation or cauterization of sphenopalatine (SP) and anterior ethmoid (AE) arteries, a intervention prospective-retrospective study is presented with the aim of assessing the feasibility of these surgical techniques as an alternative to conventional treatments. Patients and methods:184 consecutive patients admitted in the ENT ward between the years 1997 and 2005 were included in the study, and distributed into three groups depending on the last treatment applied to control their bleeding: AP group.- anterior packing (n=98); PP group.- posterior packing (n=66), and ES group.- endoscopic ligation and/or cauterization of SP or AE (n=20). Results:Highly significant differences were found between the groups, not only regarding the efficacy (90% for surgical treatment compared with 41.3% for AP and 63.1% for PP), but also the length of postreatment hospital stay (AP.- 4.92 days; PP.- 6.3 days; ES.- 2.15 days). Discussion and conclusions:the lack of efficacy of conventional treatment and the increasing risk factors that condition nasal bleeding, together with the advance of endoscopic and anesthesic procedures have brought along the possibility of a surgical solution for these patients. Our results demonstrate the feasibility of these techniques as alternative for nasal packing in the treatment of posterior epistaxis, and even its ethical and economical convenience as a substitutive to posterior packing.

Endoscopic sphenopalatine artery ligation for refractory posterior epistaxis

Intractable posterior epistaxis remains a challenging problem for our specialty. Conventional management options in the form of anterior and posterior packing, arterial ligation of the internal maxillary or the external carotid artery and embolization, are not entirely satisfactory because of morbidity, high failure rates and occasional significant complication. Our experience with endoscopic sphenopalatine artery ligation for four patients with posterior epistaxis is described. All patients had epistaxis refractory to anterior and posterior nasal packing, which was rapidly controlled following the procedure. The technique of spheno-palatine artery ligation is described.The technique is simple and effective and prevents the morbidity and complications of nasal packing. It is especially useful in systemically compromised individuals who otherwise tolerate nasal packing poorly. and should be one of the treatment options to be considered relatively early in the management of epistaxis refractory to anterior and posterior nasal packing.

Endoscopic sphenopalatine artery ligation for refractory posterior epistaxis

Intractable posterior epistaxis remains a challenging problem for our specialty Conventional management options in the form of anterior and posterior packing, arterial ligation of the internal maxillary or the external carotid artery and embolization, are not entively satisfactory because of morbidity, high failure rates, and occasional significant complication. Our experience with endoscopic sphenopalatine artery ligation for four patients with posterior existaxis is described. All patients had epistaxis refractory to anterior and posterior nasal packing, which was rapidly controlled following the procedure. The technique of spheno-palatine artery ligation is described. The technique is simple and effective and prevents the morbidity and complications of nasal packing. It is especially useful in systemically compromised individuals who otherwise tolerate nasal packing poorly. and should be one of the treatment options to be considered relatively early in the management of epistaxis refractory to anterior & posterior nasal packing.

Auto-anticorps anti-facteur VIII et infection à Chlamydia pneumoniae

We report the case of a 64-year-old man without haemorragic history experiencing epistaxis. The standard haemostasis assessment including prothrombin index, activated partial thromboplastin time (APTT) and platelet count found an isolated abnormal APTT (105 sec vs 33 sec). Therefore, coagulation factors were explored. An acquired factor VIII deficiency (5%) with anti-FVIII antibody (4.5 Bethesda unit·mL –1) was recognised. This anti-FVIII antibody was related to a Chlamydia pneumoniae pulmonary infection. Treatment consisted of : i) Four successive anterior packing and activated factor VII infusion (Novoseven®) ; ii) steroids injection and bi-antibiotherapy. The time course of the epistaxis was favourable under treatment.

Abordaje directo de la malformación arteriovenosa dural tipo fistula carotidacavernosa. Presentación de un caso y revisión de la literatura

Barrow's D type carotid cavernosa fistula (FCC) with progressive symptoms and in whom endovascular procedures have failed meet criteria for a direct approach. We report a case of this type of vascular lesion in whom partial endovascular embolization was done together with a direct approach to the FCC, using a method of localization involving a transoperative imaging guide. Digital subtraction angiography and Estereoflex stereotactic system was used. A female patient had had a previous minor head injury. She had a progressive neurological disorder with marked visual defect, and had been diagnosed on angiography as having FCC with afferents from branches of the internal carotid artery (ACI) and external carotid artery (ACE). After failure of endovascular treatment orbito zygomatic craniotomy was done with extra intradural dissection and exposure of the antero lateral triangle of the cavernous sinus (SC). The fistula was closed completely by anterior packing with the venous component. Transoperative stereotactic angiographic checks were done to localize and control the packing. The Barrow's type D FCC in which embolization treatment has failed may be treated using a direct approach to the anterolateral triangle of the SC. The AC1 remained permeable, fistula was occluded and there was minimal morbidity.

Foley catheter action in the nasopharynx: a cadaveric study.

To determine the action of the Foley catheter in the posterior nasal cavity in relation to balloon volume, and to deduce its implications in the treatment of posterior epistaxis. Human cadaveric study. Twenty nasal fossae of 10 adult cadavers. A Foley catheter (size 14) was inserted into the nasopharynx via each nostril. The catheter balloon was inflated to its recommended maximum volume with 15 mL of water. Firm traction was applied to the catheter. Colored liquid was instilled into the ipsilateral aspect of the nasal cavity, and liquid leakage into the contralateral side was monitored using a nasoendoscope. The balloon was reduced in volume by 1-mL steps, and the same fluid infusion and documentation procedures were performed for each reduced volume until the balloon slipped out of the nose. The procedure was repeated in the opposite nostril. Successful choanal sealing and anterior balloon shift into the nasal fossa in relation to the balloon size. The Foley catheter balloon sealed the choana without any leakage of infused liquid into the contralateral side at appropriate inflation volumes in 17 (85%) of 20 nasal fossae. Complete sealing between volumes of 12 and 15 mL was achieved in 13 fossae (65%), between 11 and 15 mL in 10 nasal fossae (50%), and between 5 and 15 mL in 3 nasal fossae (15%). Failure to seal at any volume occurred in 3 nasal fossae (15%). Bimodal seal (ie, complete seal at high [15 mL] and low volumes [4-7 mL], but leakage in intermediate volumes) occurred in 3 nasal fossae (15%). The balloon remained in the nasopharynx under traction and did not slip past the choanal rim to encroach on the middle and inferior turbinates until the balloon volume was reduced to between 4 and 7 mL. The balloon slid out of the nose at a volume of 5 mL or less. The inflation volumes ranging from 8 to 12 mL were statistically more effective in sealing the choana than lower volumes (4-7 mL) (P<.002, chi(2) test). At different inflation volumes, the Foley catheter balloon acts primarily (1) as a platform for an anterior gauze pack (at 4-15 mL); (2) as an effective seal of the choana (at 8-15 mL usually and at 4-7 mL occasionally); and (3) as a compressor of the region behind the middle and inferior turbinates (at 4-7 mL), provided that the balloon under traction does not slip out of the nose.

Epistaxis strategy--experiences with the last 360 hospitalizations

The purpose of this study was to analyze the therapy concept used in the management of severe epistaxis in order to optimize the quality of our treatment and to arrive at an optimal therapeutic concept. The study was performed as a retrospective analysis of the charts of all 335 patients treated as inpatients for epistaxis over a period of 6 years. An increased rate of complications was found in the following three situations: 1. Age > 65 years, 2. chronic obstructive pulmonary disease, 3. several systemic illnesses. Recurrence was increased with septal perforations and Osler's disease. Localization of the site of bleeding is the first priority and allows treatment of bleeding with bipolar electrocautery. If the bleeding vessel is not found, insertion of a Merocel pack is recommended. Patients with persistent or recurrent bleeding are treated in the operating theater under general anesthesia if they are at an elevated risk for complications or have a septal deviation which is clinically significant. The nose is systematically visualized with the endoscope, bleeding vessels are coagulated under endoscopic control, and, where appropriate, a septoplasty is performed. In the remaining cases an epipharynx balloon is inserted, combined with an anterior pack. Angiography with superselective embolization, external ligation of the ethmoidal arteries, and endonasal obliteration of the sphenopalatine artery is reserved for cases where the measures discussed above have failed.

Posterior Epistaxis: Clinical Features and Acute Complications

Study objective: To describe the clinical features, evaluate the incidence of serious complications, and identify factors associated with rebleeding in adults with acute posterior epistaxis. Design: Retrospective chart review. Setting: University-affiliated community teaching hospital. Participants: We studied 88 episodes of posterior epistaxis in 81 patients (mean age, 64.3 years; range, 27 to 96 years) who were treated in the emergency department and hospitalized during a 6-year period. Inclusion criterion was active hemorrhage into the posterior pharynx without identifiable anterior bleeding or severe nasal hemorrhage refractory to anterior packing. Patients with anterior epistaxis were excluded. Results: Posterior epistaxis accounted for 5% of all cases of epistaxis. The most common factors associated with posterior epistaxis were a history of hypertension in 39 patients (48%) and previous epistaxis in 30 (37%). Of 57 patients who reported duration of epistaxis, 39 (68.4%) had nasal hemorrhage for less than 12 hours before ED presentation, and 13 patients (22.8%) had nasal bleeding that lasted more than 24 hours. Bleeding was recorded as moderate or severe for 88% of patients. All patients were treated with posterior nasal packing in the ED (73% with traditional gauze packing, 15% with balloon, and 12% with tampon). After admission, 16 patients (19.8%) required surgical intervention, 17 (21%) experienced acute sinusitis, 10 (12.3%) received blood transfusions, and 3 (3.7%) were intubated. Rebleeding occurred in 24 patients (29.6%), with 13 episodes (44.1%) occurring less than 24 hours after admission. Factors associated with rebleeding were posterior epistaxis described as "severe" (OR, 2.53; 95% CI, .88 to 7.39; χ 2=2.84, 1 df , P =.92) and pack removal within 48 hours after admission (OR, 3.07; 95% CI, .98 to 9.88; χ 2=3.66, 1 df , P =.056). Factors that failed to predict rebleeding included age, prior hypertension, anticoagulant use, vital signs, and type of posterior pack used (gauze or balloon). Conclusion: Although posterior epistaxis is an uncommon otolaryngologic emergency, many patients experience clinically significant complications. Rebleeding was associated with severe posterior epistaxis and pack removal within 48 hours after admission. [Viducich RA, Blanda MP, Gerson LW: Posterior epistaxis: Clinical features and acute complications. Ann Emerg Med May 1995;25:592-596.]

Angiographic Embolization for the Treatment of Epistaxis: A Review of 108 Cases

Ninety-seven patients were referred to the Toronto Hospital (Western Division) between January 1984 and January 1992 for selective angiographic embolization (108 embolizations, including repeat procedures) to control intractable or recurrent severe epistaxis. Eighty-one patients (comprising 94 embolizations) were referred on an emergent basis because of failure of conventional conservative therapy, consisting of anterior and posterior packing. The remaining 16 patients (14 embolizations) were referred electively for recurrent epistaxis. A retrospective review of these cases was performed, with long-term telephone follow-up achieved in over 95% of cases. Embolization safely controlled active hemorrhage in 88% of the emergent cases. The success rate increased to 90% when two cases in which the source of epistaxis was found to be from the internal carotid artery were excluded (because these vessels could not be safely embolized). Of the patients whose epistaxis was initially controlled by embolization, 82% had no further nosebleeds (follow-up time ranged from 2 to 82 months; average, 26.8 months). More than half of the long-term failures were seen in patients with Osler-Weber-Rendu disease. Overall, the mortality rate was 0% and the long-term morbidity rate was 2% (one cerebral vascular accident and one case of skin slough in the territory of the superficial temporal artery.

The use of balloon catheters in the treatment of epistaxis.

Inflatable balloon catheters are widely used in the treatment of severe epistaxis and are designed to be filled either with air or liquid. A postal survey revealed that 87 per cent of respondents used an inflatant which was deemed inappropriate by the manufacturer. When balloons designed for water or saline were filled with air, they deflated rapidly, in some cases being virtually empty after 24 hours. Better and more accessible instruction leaflets are required if the balloons are to be used as intended. Foley catheters are frequently used as nasopharyngeal packs, in conjunction with anterior nasal packs. Paraffin in the commonly used anterior packs damages the rubber of the catheter, resulting in the balloon bursting. This should be recognized by clinicians as a possible cause of rebleeding.

A New Posterior Nasal Pack

On September 24, 1991, during the annual meeting of the American Academy of Otolaryngology—Head and Neck Surgery in Kansas City, Mo, Richard L. Goode, MD, Stanford, Calif, demonstrated his new posterior nasal balloon pack. Dr Goode explained his design to attendees at the 24th annual meeting of "Biotechnology in Otolaryngology." The pack uses an oval-shaped silicone balloon to occlude the posterior choana. This configuration provides a good fit using several milliliters of fluid without placing the painful pressure on the soft palate that is often associated with Foley catheters. A suction channel is opened when the stylette, which allows accurate placement along the floor of the nose or around a septal deviation, is removed. To control epistaxis, an anterior pack may be placed easily, since the parallel suction and inflation channels have a narrow diameter. A soft disk and locking device (similar to that used on intravenous tubing to adjust

A New Posterior Nasal Pack

On September 24,1991, during the annual meeting of the American Academy of Otolaryngology—Head and Neck Surgery in Kansas City, Mo, Richard L. Goode, MD, Stanford, Calif, demostrated his new posterior nasal balloon pack. Dr Goode explained his design to attendees at the 24th annual meeting of Biotechnology in Otolaryngology. The pack uses an oval-shaped silicone balloon to occlude the posterior choana. This configuration provides a good fit using several mililiters of fluid without placing the painful pressure on the soft palate that is often associated with Foley catheters. A suction channel is opened when the stylette, which allows accurate placement along the floor of the nose or around a septal deviation, is removed. To control epistaxis, an anterior pack may be placed easily, since the parallel suction and inflation channels have a narrow diameter. A soft disk and locking device (similar to that used on intravenous tubing to adjust flow

Sleep apnea in epistaxis patients treated with nasal packs.

The presence of anterior and posterior nasal packs in patients with epistaxis is known to be associated with cardiorespiratory problems and sometimes death, although the mechanism has not been well understood. To determine the incidence and severity of obstructive sleep apnea in patients with epistaxis treated with both anterior and posterior nasal packs, we obtained polysomnograms on twelve patients while the packs were in place. Ten of these patients demonstrated obstructive sleep apnea. The apnea index (apneas/hour sleep) ranged from 1 to 83, with a mean of 29; the hypopnea index (hypopneas/hour sleep) ranged from 9 to 33, with a mean of 20; and the lowest oxygen saturation (SaO2) ranged from 17% to 91%, with a mean of 77%. Ten patients returned for another polysomnogram after removal of the packs. These baseline studies showed improvement in the apnea index and in the lowest SaO2 in all patients, although four patients still demonstrated at least mild obstructive sleep apnea. This study demonstrates that nasal packs used for the treatment of epistaxis may induce obstructive sleep apnea or markedly exacerbate underlying obstructive sleep apnea and, therefore, contribute to the sudden deaths that have been reported in epistaxis patients.