We read with interest the article ‘‘Preparation of nose for nasal endoscopy: cotton pledget packing versus topical spray. A prospective randomized blinded study’’ by Mishra et al. [1] because they have found similar results as we did [2]. Although Mishra et al. claimed that there is no randomized study comparing cotton pledget packing versus topical spray before, we actually performed a randomized controlled study (RCT) in our endoscopy suite 2 years ago [2]. We have published a novel method of nasal anesthesia named cotton-tipped applicator primed gauze pledgetting (CTGP) which was found to be superior to the endoscopicguided aerosolized spray (EGAS) in reducing nasal pain during anesthesia and transnasal insertion, unpleasant taste of anesthesia, throat pain after examination, gagging episodes, and overall tolerance [2]. The RCT conducted by Mishra et al. did not show any data following the CONSORT guideline [3] regarding how sample size was determined, method used to generate the random allocation sequence, statistical methods used to compare groups for primary outcome(s), no flow of participants through each stage, and no baseline demographic and clinical characteristics of each group. As the authors pointed out in the discussion section, the concentration of anesthetic/decongestant agents used for 50 patients in Group A (a cotton pledget soaked in 4 % lignocaine and xylometazoline nasal drops) was different from those used for another 50 patients in Group B (instilled xylometazoline nasal drops and 10 % lignocaine spray). The 10 % lignocaine would definitely induce strong mucosal irritation but its higher concentration did not achieve improved anesthetic effects. This interventional bias (and probably selection bias) in this study is associated with the study design from the beginning. In fact, they could have controlled the study conditions to be as similar as possible in both groups (for example, using same concentration of anesthetic/decongestant agents). Furthermore, 8 out of 50 patients in Group A had mucosal trauma or bleeding during cotton pledget packing but none of the 50 patients in group B suffered from this side effect (16 % vs 0 %, p = 0.01). On the contrary, as shown in our study, none of the 103 patients who received gauze pledgetting had nasal bleeding, whereas only 2 patients who received topical spray had epistaxis [2]. This discrepancy was attributable to how a cotton/gauze strip was delivered into the nasal cavity. In a strict RCT, the authors should also mention how they handled the trauma/ bleeding situation and the outcomes about this side effect. Although Mishra et al. did not mention how they delivered a cotton pledget into the nasal cavity, a pair of ENT forceps or biopsy forceps can induce nasal trauma or bleeding by an unstable doctor’s hand or in patients who are so nervous to move during the nasal preparation. We had abandoned using these rigid forceps and instead we use one ‘‘flexible’’ plastic shaft (not wood shaft) cotton-tipped applicator for delivering a soaked gauze strip and re-use the gauze strip immediately for packing when epistaxis occurs (Fig. 1). If the four patients who were anxious due to mild bleeding in C.-T. Hu (&) Division of Gastroenterology, Department of Internal Medicine, Buddhist Tzu Chi General Hospital and Graduate Institute of Clinical Medicine, School of Medicine, Tzu Chi University, No 707, Section 3, Chung Yang Road, Hualien 970, Taiwan e-mail: chitan.hu@msa.hinet.net