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Insertion of an anterior nasal pack

Equipment

• Gloves, apron, mask, and protective glasses

• Nasal speculum

• Water-based lubricant jelly

• Nasal tampon or inflatable nasal pack. Nasal packs are available as simple compressed surgical sponge tampons or gauze-covered inflatable balloons

• Sterile normal saline (if using a nasal tampon)

• Sterile water (if using an inflatable nasal pack)

• Sterile bowl

• 20 ml syringe

• Surgical tape

• Suction catheter

• Dressing gauze

• Spotlight or headlamp

Indications

Anterior nasal packs are used to control anterior epistaxis when more conservative measures (compression, vasoconstrictive agents, and silver nitrate cautery) have failed to control bleeding.

Contraindications

Anterior nasal packing should not be performed if the patient cannot protect their airway. The airway should be secured and the patient resuscitated. Anterior nasal packing may be performed when the patient has been stabilised.[37]Dehn R, Asprey D. Essential clinical procedures. 4th ed. Chapter 10: Epistaxis and nasal foreign body removal. Philadelphia, PA: Elsevier Saunders.​​​

Complications

Potential complications include:​[38]Kucik CJ, Clenney T. Management of epistaxis. Am Fam Physician. 2005 Jan 15;71(2):305-11. http://www.ncbi.nlm.nih.gov/pubmed/15686301?tool=bestpractice.com

• Pain on insertion and removal

• Infection (sinusitis, septic shock)

• Pressure necrosis of the nasal septum (if packing is bilateral)

• Pneumocephalus

• Neurogenic syncope (during packing)

• Airway compromise

• Failure to control bleeding.

Aftercare

The pack should be retained for 24 hours and the patient should remain in hospital because there is an ongoing risk of airway compromise. Some clinicians choose to give prophylactic oral antibiotics to reduce the risk of staphylococcal infection while the nasal pack is in situ. There is a small risk of toxic shock syndrome following postoperative nasal packing, which is estimated to be about 16 per 100,000 packings.[39]Biggs TC, Nightingale K, Patel NN, et al. Should prophylactic antibiotics be used routinely in epistaxis patients with nasal packs? Ann R Coll Surg Engl. 2013 Jan;95(1):40-2. https://www.doi.org/10.1308/003588413X13511609954734 http://www.ncbi.nlm.nih.gov/pubmed/23317726?tool=bestpractice.com ​ Definitive specialist treatment is planned after removing the pack.

If the anterior nasal pack does not control the epistaxis, the bleed may be posterior. The packing devices for posterior nasal bleeds are structurally different to anterior packing devices, and are technically more demanding to insert. ENT specialist advice should be sought.