Nasal Packing - Purpose, Requirements, Types, and Complications

Introduction:

Nosebleeds, also called epistaxis is a very common condition, and almost 60 percent of people worldwide will have at least one nosebleed in their lifetime. Nosebleeds are common because of the position of the nose and the presence of blood vessels in the lining of the nose. Most nosebleeds are not serious and can be managed at home. However, in cases where medical assistance is required, a nasal packing can be done to stop the bleeding, which is done by a medical professional.

Nasal packing means blocking the nose with a restorative material to stop the bleeding, such as gauze, foam, or cotton. In nasal packing, individual gauze strips or cotton pledgets are packed in the nose to form a plug. This may be coated with petroleum gel, antibiotics, or agents that help clot formation.

What Are the Causes of Nose Bleed?

The causes of nose bleeding include -

Local Causes -

• Chronic sinusitis.

• Nose picking (epistaxis digitorum).

• Foreign bodies.

• Trauma.

• Intranasal neoplasm or polyps.

• Medications such as topical corticosteroids.

• Rhinitis (inflammation of the mucous membrane of the nose).

• Irritants such as cigarette smoke.

• Nasal septal deviation or perforation.

Systemic Causes -

• Hemophilia (a bleeding disorder in which blood does not clot).

• Hypertension.

• Leukemia.

• Liver disease such as cirrhosis (liver scarring due to alcohol drinking).

• Thrombocytopenia (low level of platelets).

What Are the Types of Nose Bleeding?

Nose bleeding is of two types, based on the location of the bleeding, which includes -

1. Anterior Epistaxis - This type of nose bleeding starts in the front of the nose on the lower part of the wall that separates the two sides of the nose. This area of the nose consists of small blood vessels and capillaries, which are fragile and can break easily and bleed. This is the most common type of nosebleed commonly seen in children. However, it is not that serious and can be treated at home.

2. Posterior Epistaxis - This type of nosebleed occurs deep inside the nose, and the bleeding is caused due to the larger blood vessels in the posterior region of the nose. The posterior nosebleeds are more serious than the anterior and may result in heavy bleeding. Medical attention is required in case of heavy blood flow, and this type of nose bleeding is most commonly seen in adults.

What Is the Purpose of Nasal Packing?

Nasal packing can be anterior or posterior, depending on the location of the bleeding. The nasal packing helps in the following ways, which include -

• Apply pressure and fill preformed spaces.

• Function as a barrier.

• Provide hemostasis after nose bleeding or surgery.

• Provide support for the nasal structures.

• The packs are used after nasal surgeries and are left for longer to prevent nose stenosis.

What Are the Requirements of Nasal Packing?

Following are the characteristics required for the nasal packs, which include the -

• Non-toxic.

• Non-allergic.

• Easily placed and removed.

• Painless.

• Non-dislocating.

• Helps in hemostasis and wound healing.

• Apply uniform pressure to the membranes.

• Ensure breathing.

• Preserve smell.

What Are the Methods Used for Nasal Packing?

There are various types of packing available, which include -

Foley Catheter and Gelatin and Thrombin Matrix Combination -

The Foley catheter is commonly used for posterior epistaxis to tamponade the bleeding. The catheter is inserted into the posterior nasal cavity after administering topical anesthesia. It has a balloon at its tip, which is inflated at the region of bleeding in the nose with five milliliters of sterile water or saline.

Gelatin-thrombin matrix can also be used along with it, as the mixture is put on the balloon, inserted into the nasopharynx, and gets applied to the bleeding area, which helps in cessation of the bleeding.

Absorbable Packing -

• Surgical - It is a packing of oxidized cellulose polymer (polyanhydroglucuronic acid) placed in the anterior region for anterior nasal bleeding. This packing gets reabsorbed within one to two weeks and has to change accordingly.

• Nanopore - It is a biodegradable, synthetic foam. This can be cut into appropriate sizes and shapes with the help of scissors. This will expand on exposure to fluid and be inserted into the nasal cavity with the help of an endoscope or bayonets, depending on the location and condition.

• Floral or SurgiFlo - It is a hemostatic matrix (bovine gelatin- human thrombin matrix) of highly dense gel which adheres to irregular and moist surfaces like nasal sinuses. Applying this requires a mixing period and must be placed and held over the wound for appropriate clotting. It gets reabsorbed after six to eight weeks.

Temporary Packing - These packings can be placed for some duration and must be removed after some time. The duration can vary from two to five days and should include antibiotic prophylaxis to prevent infection. If the patient bleeds again, packing can be done again after removing the first one. However, even after the second packing, if the bleeding does not stop, a surgical procedure may have to be done to control the bleeding.

• Strip Gauze and Lamb’s Wool - This can be used in emergency conditions to control bleeding. These materials are a little bulky and may require the cooperation of the patient.

• Merocel - It is a polyvinyl alcohol sponge that is firm when dry and expands as it absorbs liquid. It can be cut into different sizes, and the original size may help in easy passage through the nasal canal, but when it gets wet, expansion can occur, and then it cannot be repositioned. A tape is attached to the cheek (pre-attached to the pack) to prevent any further migration of the pack posteriorly and also helps in the easy removal of the pack.

• Rhino Rocket - It is a medical-grade expandable sponge with a disposable plastic applicator for positioning. A safety string is pre-attached to the pack and taped to the cheek to prevent posterior migration and assist in easy removal from the nasal cavity.

• Rapid Rhino - This device comes in different sizes, such as unilateral 4.5 cm, 5.5 cm (for anterior), 7.5 cm (anterior or posterior), and bilateral 7.5 cm versions. These contain a balloon surrounded by hydrocolloid coating. The coating helps in easy insertion and removal and also helps in hemostasis. The balloon puts pressure on the nasal vessels, which helps prevent bleeding. Before insertion, the device must be soaked in sterile water, and the balloon must be taped to the cheek for easy removal and maintaining the positioning.

What Are the Complications of Nasal Packing?

Some of the complications that can occur with nasal packing include -

• Pain on insertion or removal.

• Failure to achieve hemostasis.

• Dislodgement and airway obstruction.

• Sinusitis (infection of sinuses).

• Rebleeding on removal.

• Otitis media (middle ear infection) due to eustachian tube obstruction.

• Toxic shock syndrome (a life-threatening complication of bacterial infection).

• Nasal alar necrosis (a rare condition that leads to cosmetic defects).

• Aspiration.

Conclusion:

Nasal packing is an effective method to stop epistaxis. A trained physician usually does it, and the patient is kept under observation through regular checkups to prevent complications. The packing can be left for an extended period to promote healing.