Nasal Packing Research Articles

Nasal septal abscess in adult patients - A single center study

PurposesThe purpose of this study was to present and analyze the etiologic factors, clinical manifestations, bacteriology, and treatment outcomes of nasal septal abscess in a large cohort of adult patients. Material and methodsRetrospective analysis. Results36 adult patients, age from 19 to 85 (mean age, 51.83), with nasal septal abscesses were treated at Ear Nose Throat Hospital of Ho Chi Minh City from January 2020 to August 2022. The most common symptoms were nasal obstruction (75 %), headache/facial pain (58.33 %). Etiologic factors were found in 83.33 % of cases with the most common were diabetes mellitus (47.22 %), nose-picking (44.44 %). 75 % of cases had positive bacterial culture, of which 70.37 % were Staphylococcus aureus. Septal abscess was successfully treated in all cases using our treatment protocol, which involved an extended modified Killian's incision, irrigation with 1 % poviodine, placement of gauze in the abscess pocket, and nasal packing with Merocels. ConclusionsDiabetes and nose-picking were the most common etiologic factors; Staphylococcus aureus was the most common organism of nasal septal abscess in our study. Our treatment protocol is safe and effective.

Risk Factors for Rebleeding After Successful Rapid Rhino Packing in Epistaxis Patients

Background and Objectives: Epistaxis is one of the most common emergencies in otolaryngology, and the recently developed Rapid Rhino nasal pack, a balloon-type nasal packing device, is widely used in emergency departments. Rebleeding after initial treatment increases patients’ discomfort and medical costs. The aim of this study was to investigate risk factors for rebleeding in patients treated with Rapid Rhino packing.Methods: In this retrospective study, 93 patients with epistaxis treated with Rapid Rhino from January 2020 to November 2022 were divided into the well-controlled group (39 patients) and the rebleeding group (54 patients), and the baseline characteristics, management methods, and complications were compared between these groups. The rebleeding group was divided according to whether patients experienced a single episode of rebleeding (38 patients) or multiple rebleeding episodes (16 patients), and the differences between these two groups were compared.Results: Oral anticoagulation therapy was associated with a higher risk of rebleeding after Rapid Rhino packing (odds ratio [OR]=8.41, p=0.047). A history of nasal surgery was associated with multiple rebleeding (OR=22.55, p=0.009). Age, sex, the management method, complications, and the site of bleeding were not found to be related to rebleeding.Conclusion: Patients with rebleeding after Rapid Rhino nasal packing had a higher rate of concurrent oral anticoagulation therapy. A history of nasal surgery was strongly associated with multiple episodes of rebleeding. A detailed medical history can be important for assessing the risk of rebleeding in epistaxis patients treated with Rapid Rhino packing.

Comparison of Outcomes After Septoplasty With Non-Absorbable or Biodegradable Synthetic Polyurethane Foam Nasal Packing With a Focus on Pain and Cardiac Factors

Background and Objectives: We compared pain levels, cardiovascular parameters, and complications according to whether patients underwent nasal packing with non-absorbable or biodegradable materials.Methods: Patients who underwent septoplasty from May 2015 to April 2020 were retrospectively reviewed. Numeric rating scale (NRS) scores for pain, blood pressure, and heart rate were measured three times (immediately after surgery, 6 hours later, and on postoperative day [POD] 1). We collected data on complications, including postoperative bleeding, septal hematoma, adhesions, septal perforation, and the recurrence of septal deviation.Results: In total, 200 patients underwent septoplasty, of whom 100 underwent nasal packing with Merocel and 100 underwent packing with Nasopore. The summed NRS scores over the three time points did not differ significantly between the groups. The NRS scores at 6 hours after surgery were highest in both groups. The systolic and diastolic blood pressure and the heart rate immediately after surgery were significantly higher than before surgery in both groups. The blood pressure and heart rate at 6 hours after surgery and on POD 1 did not differ significantly from those before surgery in either group. The incidence of sleep disturbance, postoperative bleeding, septal hematoma, adhesions, septal perforation, and recurrence of septal deviation did not differ significantly between the two groups.Conclusion: Although the level of postoperative pain and the cardiovascular parameters changed over time, we found no significant differences in pain, blood pressure, heart rate, or the complication rate according to whether patients underwent nasal packing with Nasopore or Merocel.

A RARE PRESENTATION OF DELAYED EPISTAXIS: POST TRAUMATIC INTERNAL CAROTID ARTERY PSEUDOANEURYSM AT A TERTIARY CARE CENTRE IN EASTERN NEPAL

Epistaxis is a common ENT emergency. Various causes are mucosal trauma, anticoagulants and bleeding disorders. Vascular causes and trauma accounts for less than 5% causes. A 25-year-old man presented to emergency with intractable epistaxis. He had sustained road traffic accident 5 months back. His previous CT scan showed multiple facial bones fracture along with sinuses (frontal, maxillary and sphenoid sinus on right para clinoid area) fracture. Initial CT angiography showed no vascular defects. The latest episode of epistaxis was massive and he underwent nasal endoscopy and packing of nose. Pulsatile sphenoidal polyp was visualized, along with transmitted pulsations in the sphenoid sinus on the right side. Subsequent Magnetic Resonance Angiography (MRA) showed a 12x4 mm pseudoaneurysm of clinoidal portion of Internal Carotid Artery on the right side. Post-traumatic Pseudoaneurysm of the Internal Carotid Artery may be the differential diagnosis in traumatic epistaxis, especially the delayed type. If pseudoaneurysm is suspected, CT or MRI angiography should be performed immediately.

Nasal Packing in Septal Surgery: A Narrative Review.

Recently, alternatives to intranasal packing following septoplasty and rhinoseptoplasty have been widely used and promoted. Here, we aimed to systemically review and compare the different types of nasal packing used in these two surgeries. To assess patient comfortand surgical outcomes, we conducted a comprehensive search of multiple databases such as PubMed, MEDLINE, Web of Science, and Google Scholar to identify and evaluate relevant articles.A detailed and extensive search was performed with the help of the keywords "nasal packing,""septoplasty,""rhinoseptoplasty,""nasal splints," and "intranasal packing."Overall, our review findings indicate that alternative methods (e.g., trans-septal suturing and insertion of intranasal splints) are better options than intranasal packing.

Surgiflo® hemostatic matrix versus NasoPore® nasal packing following postassium titanyl phosphate laser surgery for hereditary hemorrhagic telangiectasia: A randomized controlled trial.

To help ensure adequate hemostasis immediately following potassium titanyl phosphate (KTP) laser treatment, many centres treating hereditary hemorrhagic telangiectasia (HHT) routinely use nasal packing post-operatively. The purpose of this study was to compare hemostatic thrombin matrix with standard packing for postoperative bleeding, patient pain, and comfort. A prospective, randomized, double-blinded, non-inferiority study was conducted with participants at an HHT centre of excellence (COE) and randomized to the treatment group with reconstituted thrombin gelatin matrix (Surgiflo®) or control group with a biodegradable synthetic polyurethane foam (NasoPore®). Adult subjects with confirmed HHT and moderate to severe epistaxis (a minimum calculated epistaxis severity score [ESS] of 4.0) warranting KTP laser treatment were recruited. Data was collected 2 weeks post operatively by a blinded reviewer completing a visual outcomes evaluation and each patient completing a subjective symptoms questionnaire. Non-parametric statistical analysis was employed. Twenty-eight adult patients were randomized to the treatment and control arms with comparable preoperative epistaxis severity scores. Postoperative nasal bleeding was equivalent. Significantly less pain was found in the treatment arm (p=.005). While there were trends towards less obstruction and increased satisfaction in the treatment group as well as less crusting in the control group, these findings were not statistically significant. Allocation to the treatment group was associated with an approximately $75 higher cost. When compared to NasoPore® for hemostasis, Surgiflo® hemostatic matrix performed equivalently while causing less discomfort in HHT patients following nasal KTP treatment. 1b.

Comparison of outcomes using conventional nasal pack with hydroxylated polyvinyl acetate pack following Septoplasty

Aim: To compare the conventional anterior nasal packing (CANP) with Hydroxylated polyvinyl acetate pack (Merocele) after septoplasty, in terms of pain, bleeding, and postoperative complications like synechia formation. Material and Methods: This study was a prospective, randomized, interventional study conducted among 48 patients. Patients underwent septoplasty under general anesthesia for symptomatic deviated nasal septum. In all the 48 patients, post-surgery, one nasal cavity was packed with a conventional nasal pack and the other cavity was packed with Merocele nasal pack. Pain and bleeding were evaluated during pack removal on the third post-operative day. Synechia was assessed at the 8th post-operative week (2 months) follow-up. The results were compared between the two groups. Result: Out of 48 patients who underwent surgery, 3 patients were lost to follow-up. So, results were compared between 45 patients. Pain and bleeding during removal of conventional and merocele packs were not seen to be statistically significant. Post-operative synechia was not seen in any of the nasal cavities, irrespective of the packing material used. Conclusion: Hence, in terms of pain, bleeding during pack removal, and post-operative synechia; conventional and merocele nasal packs were comparable and there was no significant difference in using either of the materials post-septoplasty.

Refractory Epistaxis: A Map is Enough!

Combined the big data from Chinese researches and our clinical experiences, we drew a concise "distributed map" of intractable epistaxis showing the concealed bleeding regions and offending vessels clearly (Figure 1). The bleeding site was located accurately according to the "distributed map," and bleeding was stopped via bipolar radiofrequency ablation under nasal endoscope without nasal packing, followed by five classic cases (Figure 2). It is our recommended precise mode of diagnosis and treatment of refractory epistaxis.

Effect of Anterior Nasal Packing on Middle Ear Pressure

Background: Bilateral anterior nasal packing is often done after septal surgery for hemostatic reasons and mechanical splinting. It has been suggested that nasal packing following septal surgery is a frequent cause of short term eustachian tube dysfunction such as ear fullness and mild pain.
 Objectives: To evaluate the effect of anterior nasal packing on middle ear pressure.
 Methods: For this prospective, longitudinal study, ninety-two (92) patients admitted for routine septal surgeries were selected according to inclusion and exclusion criteria from the in-patient Department of ENT and Head &Neck Surgery, Dhaka Medical College and Hospital, Dhaka during 1st January 2020 to 31st July 2021. Following informed written consent, the patients were interviewed three times: preoperative, after 24 hours of ANS pack and 6 days after pack removal. During each time, middle ear pressure was measured by an impedance audiometer. Any otological symptoms produced when ANS pack was in place for 24 hours and 6 days after pack removal were also observed and recorded.
 Results: Among 92 patients in this study, mean preoperative middle ear pressure was -5.5 (± 30.14) daPa. After 24 hours of anterior nasal packing, 70 ears (38%) showed abnormal middle ear pressure among 184 ears. Mean middle ear pressure after 24 hours of ANS pack was -76.5 (± 58.8) daPa. Middle ear pressure again measured after 6 days of removal of ANS pack and showed that the middle ear pressure of all the patients were within normal range. Mean middle ear pressure was -12.4(± 36.5) daPa after 6 days of pack removal. Some otological symptoms developed due to change in middle ear pressure following ANS pack like ear fullness, earache and tinnitus. All these symptoms subsided after 6 days of pack removal.
 Conclusion: Anterior nasal packing decreases middle ear pressure which is reversible and returns to normal 6 days after pack removal. Some otological symptoms developed due to change in middle ear pressure which were transient and all came to normal after 6 days of pack removal.
 Bangladesh J Otorhinolaryngol 2022; 28(2): 135-140

Use of nasal tampons for on-field management of nasal bleeds (epistaxis) in sports.

In a medical setting, such as the treatment of post-operative nosebleeds, nasal packing, including the use of nasal packs, nasal plugs or nasal tampons (NTs), is widely used to temporarily control anterior epistaxis. Although some literature has documented the use of NTs as a quick, easy and temporary solution to deal with anterior epistaxis in sports-induced nasal injuries, additional research is needed to appreciate on-field versus off-field efficacy, as well as the efficiency of different brands of NTs and packing materials.

Comparative effectiveness of various noninvasive local treatments in patients with epistaxis: A systematic review and network meta-analysis.

The best initial strategy for managing epistaxis is unclear. We performed a systematic review and network meta-analysis (NMA) to compare the effectiveness of various noninvasive treatments for patients with epistaxis. We searched PubMed, Embase, and the Cochrane Library from inception to September 2022 without language restrictions. Randomized controlled trials (RCTs) assessing immediate hemostasis, 2-day and 7-day rebleeding outcomes, as well as the use of noninvasive interventions for the treatment of epistaxis were selected. Frequentist NMA was performed. The systematic review included 20 RCTs (2994 participants) involving 12 different interventions. The NMA demonstrated that topical treatment with tranexamic acid (TXA) significantly reduced the odds of 2-day rebleeding compared with the control conservative treatment (odds ratio [OR] 0.36, 95% confidence interval [CI] 0.21-0.61) and traditional anterior nasal packing (OR 0.45, 95% CI 0.26-0.76). The sensitivity analysis yielded robust results, and the overall evidence was high. Topical TXA significantly reduced the odds of 7-day rebleeding compared with traditional nasal packing (OR 0.33, 95% CI 0.15-0.70), with moderate evidence owing to the heterogeneous results. Despite the significant effects of topical TXA on achieving immediate hemostasis and Rapid Rhino nasal packing on preventing 2-day rebleeding compared to the control and traditional nasal packing, the evidence is low to very low due to heterogeneity, inconsistency, and within-study bias. In the treatment of epistaxis, topical TXA may be superior to conservative treatment or traditional nasal packing, particularly in preventing 2-day rebleeding.

Merocel<sup>®</sup> in a Glove Finger Packing After Endoscopic Endonasal Reduction of Medial Blowout Fractures

Orbital blowout fracture (BOF) is quite common in maxillofacial trauma. In recent years, with the development of endoscopic technique, endoscopic endonasal reduction (EER) has been widely performed for medial BOFs by otolaryngologists. After EER for medial BOF, nasal packing may be necessary for sustaining the reduced orbital contents. When we applied the packing method using Merocel<sup>®</sup> (Medtronic) in a glove finger, we found that it could reduce the operation time as well as difficulty. In addition, pain and bleeding during packing removal was minimized. In this article, we share our experience by introducing this novel packing method using a glove with Merocel<sup>®</sup>.

Angioembolism for the Management of Refractory Epistaxis

A majority of the population will experience epistaxis at some time in their life. Most cases will be from an anterior source and can be treated with pressure, anterior nasal packing, or cautery. Intractable epistaxis is generally posterior in origin and may require endoscopic cauterization, posterior packing, ligation of external carotid artery or embolization. Here we report a case of bilateral posterior epistaxis in a 41 year old male patient with c/o spontaneous epistaxis from bilateral nostril. Digital Subtraction Angiography followed by Angioembolisation was done.

Efficacy of Steroid-Impregnated Spacers After Endoscopic Sinus Surgery in Chronic Rhinosinusitis: A Systematic Review and Meta-Analysis.

The aim of this study was to compare the effect of steroid-impregnated spacers to that of conventional management after endoscopic sinus surgery (ESS) in patients with chronic rhinosinusitis (CRS). Six databases were searched from inception until November 2022. Sixteen studies were found that compared the improvement of chronic sinusitis-related symptoms and postoperative outcomes between a steroid-impregnated spacer group and a control group (non-steroid-impregnated spacers). The Cochrane risk of bias tool (for randomized controlled studies) and the Newcastle-Ottawa Scale (for non-randomized controlled studies) were used to assess the quality of the works included. Regarding the endoscopic findings, the degree of mucosal edema, ethmoid inflammation, crust formation at 2-3 months postoperatively, nasal discharge, polyposis, and scarring/synechia were significantly lower in the steroid-impregnated spacer group. The steroid-impregnated spacer group also showed significantly lower Lund-Kennedy scores and perioperative sinus endoscopy scores than the control group at 2-3 weeks postoperatively. Furthermore, the steroid-impregnated spacer group had lower rates of adhesions, middle turbinate lateralization, polypoid changes, the need for oral steroid use, the need for postoperative therapeutic interventions, and lysis of adhesions than controls. However, no significant between-group differences were found in short-term (2-3 weeks postoperatively) endoscopic findings regarding nasal discharge, postoperative crusting, polyposis, or scarring/synechia. Steroid-impregnated nasal packing reduced the rates of postoperative intervention and recurrent polyposis and inflammation in CRS patients undergoing ESS.

Efficacy of Triamcinolone Nasal Packing on Post-Operative Outcome in Endoscopic Sinus Surgery.

The online version contains supplementary material available at 10.1007/s12070-023-03496-9.

EUSTACHIAN TUBE DYSFUNCTION FOLLOWING ANTERIOR NASAL PACKING

Background: Eustachian tube maintains middle ear pressure equal to that of atmosphere and helps in ventilation of middle ear. Its function may be deranged due to adenoids, cleft palate, nasogastric tubes, allergy and by nasal packing. Objectives:To evaluate the effect of anterior nasal packing on Eustachian tube function. Methods: A cross-sectional study including 50 patients with deviated nasal septum with or without external nasal deformity and nasal polyposis. Tympanometry was performed prior to surgery, second post-operative day before pack removal and on seventh post-operative day ve days after pack removal. Results: Out of 50 patients (100 ears) who had anterior nasal packing after nasal surgeries, 40 ears had abnormal middle ear pressure after 48 hours of anterior nasal packing just before the pack removal. Middle ear pressure 5 days after the pack removal was found abnormal in 4 ears. Conclusion: This study shows that anterior nasal packing result in Eustachian tube dysfunction and negative middle ear pressure which is reversible in nature.

Effect of Bilateral Nasal Packing on Systemic Blood Pressure in Patients Treated with Septoplasty

Aim: The primary aim of this research was to assess the impact of bilateral nasal packing on systolic blood pressure in individuals undergoing septoplasty. Study Design: Retrospective study. Place and Duration: This study was conducted at Hospital Dow International Medical College, Dow University of Health Sciences Karachi and Shahida Islam Medical College, Lodhran during in the period from March, 2022 to August, 2022. Methods:152 patients who had a clinically determined nasal septoplasty were included in this study. Patients in this ranged in age from 18 to 50. The patients were randomly split in two groups. Seventy-six patients were assigned to Group I, where no nasal packing was utilized, and Group II, where conventional anterior nasal packing was applied. One may say that there was a 50/50 split between the two groups. Before to and throughout septoplasty, all patients underwent round-the-clock ambulatory blood pressure monitoring. Statistical analysis was performed on all data using SPSS 24. Results: 90 (59.2%) of the 152 patients were male, and 62 (40.8%) of the patients were female. The patients which were under the age of 30 are 59(38.8 percent) of the total patients, 55 (36.2 percent) were between the ages of 31 and 40, and 38 (25 percent) were above the age of 40.50% of the patients are comprised of rural locale. Study participants in Group II were found to have higher mean blood pressure (p-Value 0.05) following septoplasty therapy than those in Group I (P-Value >0.05). Group II patients had bleeding, vestibulitis, and septal perforations as a result of their nasal packing procedure. Conclusion: The study determined that bilateral nasal packing was linked with the preferment in either systolic or diastolic blood pressure in individuals who had septoplasty treatment. There is no statistical significance change showed up with the patients who did not get nasal packing from the rest of the group. Keywords: Septoplasty, Bilateral Nasal Packing, systemic blood pressure

Influence of bilateral nasal packing on sleep oxygen saturation after general anesthesia: A prospective cohort study.

This study aims to evaluate the effect of bilateral nasal packing on sleep oxygen saturation and its influencing factors on the first night after general anesthesia. A total of 36 adult patients who underwent bilateral nasal packing with a nonabsorbable expanding sponge after general anesthesia surgery were prospectively studied. All these patients underwent overnight oximetry tests before and the first night after surgery. The following oximetry variables were collected for analysis: the lowest oxygen saturation (LSAT), the average oxygen saturation (ASAT), the oxygen desaturation index of ≥4% (ODI4), and the percentage of time with oxygen saturation below 90% (CT90). Among the 36 patients, the incidences of both sleep hypoxemia and moderate-to-severe sleep hypoxemia increased with bilateral nasal packing after general anesthesia surgery. All the pulse oximetry variables we studied deteriorated significantly after surgery: both LSAT and ASAT decreased significantly (P < 0.05), while both ODI4 and CT90 increased significantly (P < 0.05). In a multiple logistic regression analysis, body mass index (BMI), LSAT, and modified Mallampati grade were found to be independently predictive for a larger decrease in LSAT (≥5%) after surgery (all P's < 0.05). Bilateral nasal packing after general anesthesia could induce or aggravate sleep hypoxemia, especially in patients with obesity, relatively normal sleep oxygen saturation, and high modified Mallampati grades.

Laser nasal surgery (Review).

Laser nasal surgery has been an elusive subject in the last 10 to 15 years It was considered as a potential surgical staple for nasal surgery in the 1980s; however, it did not become one due to technical difficulties. Laser therapy has reemerged as an alternative to classical endoscopic surgery, and otorhinolaryngology surgeons are considering the benefits that it can offer. The advantages of this procedure are shorter hospitalization time, lack of nasal packing, high procedural precision with tissue sparing, and the unique capability of reducing both bacterial and fungal colonization at the level of the paranasal sinus. Therefore, laser therapy appears to be an invaluable tool for clinical practice. Due to the absence of a guaranteed cure for reoccurring nasal polyposis, laser therapy is worth investigating. For this therapy to evolve, an improved understanding of laser types and the effects that they produce is required. By investing in further developments of the equipment, the technique may become more widely used. With the current accelerated rate of technological evolution and robotic capabilities, laser nasal surgery may become a gold standard in future years. The aim of the present review is to evaluate whether it is worth investing in nasal laser surgery as a future alternative to current treatment standards.

CSF rhinorrhoea after endonasal intervention to the skull base (CRANIAL): A multicentre prospective observational study.

Despite progress in endonasal skull-base neurosurgery, cerebrospinal fluid (CSF) rhinorrhoea remains common and significant. The CRANIAL study sought to determine 1) the scope of skull-base repair methods used, and 2) corresponding rates of postoperative CSF rhinorrhoea in the endonasal transsphenoidal approach (TSA) and the expanded endonasal approach (EEA) for skull-base tumors. A prospective observational cohort study of 30 centres performing endonasal skull-base neurosurgery in the UK and Ireland (representing 91% of adult units). Patients were identified for 6 months and followed up for 6 months. Data collection and analysis was guided by our published protocol and pilot studies. Descriptive statistics, univariate and multivariable logistic regression models were used for analysis. A total of 866 patients were included - 726 TSA (84%) and 140 EEA (16%). There was significant heterogeneity in repair protocols across centres. In TSA cases, nasal packing (519/726, 72%), tissue glues (474/726, 65%) and hemostatic agents (439/726, 61%) were the most common skull base repair techniques. Comparatively, pedicled flaps (90/140, 64%), CSF diversion (38/140, 27%), buttresses (17/140, 12%) and gasket sealing (11/140, 9%) were more commonly used in EEA cases. CSF rhinorrhoea (biochemically confirmed or requiring re-operation) occurred in 3.9% of TSA (28/726) and 7.1% of EEA (10/140) cases. A significant number of patients with CSF rhinorrhoea (15/38, 39%) occurred when no intraoperative CSF leak was reported. On multivariate analysis, there may be marginal benefits with using tissue glues in TSA (OR: 0.2, CI: 0.1-0.7, p<0.01), but no other technique reached significance. There was evidence that certain characteristics make CSF rhinorrhoea more likely - such as previous endonasal surgery and the presence of intraoperative CSF leak. There is a wide range of skull base repair techniques used across centres. Overall, CSF rhinorrhoea rates across the UK and Ireland are lower than generally reported in the literature. A large proportion of postoperative leaks occurred in the context of occult intraoperative CSF leaks, and decisions for universal sellar repairs should consider the risks and cost-effectiveness of repair strategies. Future work could include longer-term, higher-volume studies, such as a registry; and high-quality interventional studies.