Postnasal Packing Research Articles

CARBON DIOXIDE NARCOSIS-Reply

<i>To the Editor</i>.—We appreciate the opportunity of replying to Dr. Jaffe's criticism of our paper entitled "Carbon Dioxide Narcosis: An Unusual Complication of Postnasal Packing." We admit the diagnosis of carbon dioxide narcosis is ultimately made by an analysis of an arterial blood sample for PCO₂, PO₂and pH. In our case, as stated in the paper, the diagnosis was made on the basis of clinical manifestations: A change in the mental state of the patient with marked impairment of alveolar ventilation and mild congestive heart failure, cyanosis, and development of coma after administration of oxygen. The primary symptoms and findings of CO₂intoxication are those of a neurologic disorder. They may vary in both character and severity, depending upon the degree of hypercapnea. The patient may complain of headache and somnolence. As CO₂intoxication progresses, the patient develops weakness, lassitude, instability, marked mental

CARBON DIOXIDE NARCOSIS

<i>To the Editor</i>.—In the article by Dr. Yanagisawa and me in the February 1968Archives(<b>87</b>:165) entitled "Carbon Dioxide Narcosis," we described an unusual complication of postnasal packing. It has been brought to our attention that this is a clinical impression and that further evidence by blood gas studies should be used to substantiate our opinions. Recently we have treated another patient with a clinical history similar to the one reported in the paper. This patient was a 74-year-old man with a metastatic renal cell carcinoma in the nasopharynx which required bilateral posterior nasal packing to control hemorrhage. Thirty-six hours postpacking, the patient developed marked edema and progressive obstruction of the upper airway. It was elected to do a tracheotomy for relief of this obstruction, but prior to and following tracheotomy arterial blood gas studies were obtained. The preoperative values were: PO₂, 132; O₂saturation, 96.6%;

METHOD OF CONTROLLING HEMORRHAGE IN THE HYPOPHARYNX.

IGLAUER WAS the first man to describe the use of the postnasal pack in the control of posterior nasal bleeding. On searching the literature, no review describing a procedure for arresting uncontrolled hemorrhage in the hypopharynx short of radical surgery was found. Report of Case A 70-year-old white male was seen in consultation at the United States, Veterans Administration Hospital by the ENT Department because of hoarseness. On examination, a paralyzed right true vocal cord was found. An ulcerated area was seen in the lateral wall of the right pyriform sinus just superior to the apex. Biopsy of this area was performed. After this, there was a moderate amount of hemorrhage which appeared to be controlled with local pressure. However, after return to the ward, bleeding recurred. Several hours later, he was found to be bleeding profusely, the volume of loss being estimated at 1,000 ml. An attempt to control

WHAT THE GENERAL PRACTITIONER SHOULD KNOW WHEN TREATING PATIENTS FOR NOSEBLEED.

Six points concerning treatment for nosebleed merit emphasis: (1) All patients with severe nosebleed should be hospitalized and, if bleeding is not readily controlled, a rhinologist should be consulted. (2) An effort should be made to identify the bleeding point. (3) If spot packing controls bleeding, the rest of the nasal chamber should be left open. (4) Use of postnasal packs should be avoided if possible. (5) When indicated, early administration of blood transfusion is recommended for more prompt rehabilitation of the patient. (6) Every patient with severe nosebleed should have a complete general examination.

Nasal necrosis associated with postnasal packing for protracted epistaxis.

Nasal necrosis associated with postnasal packing for protracted epistaxis.

Effective control of postnasal hemorrhage.

The usual method of controlling epistaxis from the posterior nose is through use of a postnasal pack. Unfortunately, the postnasal pack has several serious disadvantages. First, it is exceedingly uncomfortable to the patient. Second, it commonly causes middleear complications. Third, postnasal packs are too often used as an expedient when a more careful examination might disclose bleeding from a site amenable to local packing. Recent articles by Hallberg, 1 Neivert, 2 and others emphasize the advantage of Postnasal packs which fit one choana only. Their packs are shaped so as to provide pressure in the posterior nose rather than in the nasopharynx, where a larger pack may obstruct the Eustachian tube. Directions and illustrations for the construction of packs accompany the articles. * Just as effective as the conventional postnasal pack and infinitely more pleasant is a small pack placed directly at the bleeding site. Fortunately, insofar as the use of

The control of adenoid hemorrhage with a Foley catheter (balloon type).

In the past the control of adenoid bleeding has been by the application of gauze sponges, cauterizing solutions, vasoconstrictors, and the tying of those vessels low enough in the nasopharynx to reach with a forceps. At times the bleeding persists, requiring the use of a postnasal pack. The routine with a postnasal pack is the use of a large gauze sponge with three strings, one for each nostril and the third coming out through the mouth, the third string to facilitate the removal of the pack at the end of a period to assure the control of the bleeding. The removal of the pack is most uncomfortable, requiring sedation and the use of an analgesic. In an effort to find a simpler procedure to control adenoid bleeding, a 30 cc. balloon Foley catheter has been used, with marked success. When it is seen that adenoid bleeding is not Foley balloon

Complications of postnasal packing for epistaxis.

Postnasal packing has been an accepted method in the management of epistaxis for many years and is widely used. It is often effective in instances of severe bleeding, especially from the posterior part of the nose, that are not controlled with anterior packing, spot or precision packing, cautery, and other simple measures. The usual methods have been described many times, and are a part of nearly every physician's training. * The purpose of this report is to describe certain complications and disadvantages of the usual methods, to discuss the principles involved in their use, and to bring further attention to a method that avoids these disadvantages and more logically fulfills the principles involved. THE ORDINARY POSTNASAL PACK The usual postnasal pack is a single large mass of gauze, cotton, air-filled rubber, or other material, which is of such size as to fill the superior nasopharynx snugly. It is maintained in position