Applied Evidence

Epistaxis: A guide to assessment and management

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Posterior packing may be required if epistaxis continues despite anterior packing and may take the form of a balloon or a formal pack. A Foley catheter inflated with 3 to 4 mL of water or air is inserted through the anterior nares, along the floor of the nasal cavity into the posterior pharynx and pulled forward until the balloon engages the posterior choana (FIGURE 4). This provides local tamponade and tamponade at the sphenopalatine foramen.2,4 The balloon is held firmly in place with an umbilical clamp at the anterior nares. To prevent pressure necrosis, the columella can be protected with a soft dressing that is regularly checked by the nursing staff. The nasal cavity is then packed anteriorly with ribbon gauze or a nasal sponge to stem any potential anterior bleeds.

Posterior nasal packing with a Foley catheter

Potential complications include posterior displacement of the balloon with potential airway compromise, deflation in situ, and rupture of the balloon—which could result in aspiration.4 It is important to note the Foley catheter is, in fact, not licensed for nasal use.4 Insertion only should be performed by a clinician who has been trained in this skill.

Traditional nasopharyngeal packs are rolled gauze attached to tapes or sutured to a catheter. Compared with balloons, they were found to be more effective in controlling epistaxis and produce less short- and long-term complications.2 However, they are rather uncomfortable and hence normally performed under general anesthesia.4 Posterior packing has many disadvantages. They have a 50% failure rate, which increases to 70% in patients with bleeding disorders.8

Complications vary from mild and self-limiting such as infection, hemorrhage, and pressure effects to severe such as toxic shock syndrome, myocardial infarction, and death (TABLE 32-4,6,8). There is little evidence supporting the use of prophylactic oral antibiotics after packing. Prophylactic antibiotics are reserved for those with posterior packs or if packs remain in situ for more than 24 hours.6

Complications of posterior packing

Warm water irrigation

Warm water irrigation via Foley catheter has a reported 82% success rate.8 It results in earlier discharge, less pain, less trauma to the nose, and reduced hospital length of stay.13 The balloon catheter is used to close off the posterior choana and water irrigation is applied at 45° C to 50° C for about 3 minutes with the help of a caloric stimulator.4,8 It helps clear blood clots from the nose and reduces local blood flow by causing mucosal edema, which compresses the bleeding vessels.

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