Posterior nasal packing
Nasal packing is a second-line therapy. See Epistaxis for more guidance.
This page is for reference, not instruction: you should be shown how to do this before attempting it on your own.
- Bleeding is not controlled by adequate bilateral anterior nasal packing
- High clinical suspicion of a posterior bleed:
- Blood initially at the back of the mouth
- Bilateral profuse bleeding
- Previous posterior bleed
- But remember that posterior bleeds are rare
A posterior nasal pack aims to produce choanal obstruction and tamponade along with anterior packing. It is always placed with anterior packing. Some manufacturers produce double-balloon inflatable packs which are simpler to insert (Rapid Rhino 900® or Invotec Ultra Stat®). Posterior packing with a Foley catheter is still felt by many surgeons to be the go-to temporising measure in torrential epistaxis.
- Reassure the patient: torrential epistaxis is frightening for the patient
- You should have discussed this case with the ENT Registrar
- Get assistants and all the equipment you need: do not settle for less
- Explain the necessity of placing a posterior pack to the patient and the sensation of pressure or foreign body at the back of the nose, as well as a pressure headache
Wall suction and Yankauer catheters
12F or 14F Foley catheters
Tilley's nasal dressing forceps
Aqueous gel lubrication
Umbilical cord clamp/ tubing clamp
Disposable sick bowls
Glass of water
Co-phenylcaine ( 5% lidocaine and 0.5% phenylephrine)
Anterior packing options: Rapid Rhino®, Merocel®, bismuth iodoform paraffin paste (BIPP) impregnated ribbon gauze etc.
Look after yourself and your colleagues: everyone must wear visor mask, apron and gloves.
Before you continue you must prepare the Foley catheter:
- Check the balloon by inflating with 10ml air
- If desired, trim the tip of the catheter without bursting the balloon: this is more comfortable for the patient
- Deflate the balloon
- Place the patient in an upright position
- Suction the nose as best you can
- Have your assistant(s) continue to apply suction to the pharynx or nose while you are working
- Spray the nasal passages with co-phenylcaine or apply with soaked cotton pledgets
- Use a small amount of lubrication on the tip of the Foley catheter.
- Insert the Foley catheter into the side that is thought to be bleeding, directly horizontally along the floor of the nose towards the ipsilateral earlobe
- Ask the patient to keep their mouth open as you advance the Foley catheter until you see the tip dangling into the oropharynx
- When you see the tip of the Foley catheter, inflate the balloon
- Aim to fill with 10ml air * but do not exceed what the patient is able to tolerate
- Pull the catheter firmly forwards: the balloon should be pulled against the choana; this will hurt
- Ask your assistant to pull the Foley catheter firmly forwards while you proceed with bilateral anterior packing eg Rapid Rhinos
- While exerting firm traction, secure the Foley catheter with an umbilical clip (or tubing clamp) at the nostril to prevent the catheter slipping back
- You must place a wad of gauze between the clamp and the skin of the nose, as prolonged contact causes pressure necrosis
- The catheter should be secured to the patient's face with tape
For petroleum jelly- or BIPP-impregnated ribbon gauze:
- Materials can be found in ENT theatres: you can usually obtain packets of ribbon gauze pre-impregnated with BIPP or petroleum jelly but make sure you have long ribbons (most surgical ribbon gauze comes in packs of 1.25m x 1m)
- Hold one end of the ribbon outside the nose and layer a loop along the floor of the nose right to the back
- Then release your Tilley's and then lay another loop on top of this and repeat until the nose is full
- Cut the ribbon and ensure both ends are secured to the face
- Be warned that this is an incredibly uncomfortable procedure for the patient
- NB If a fluoroscopic embolisation is planned, do not use X-Ray detectable ribbon gauze or BIPP as both will cause significant artefact: we strongly recommend the use of inflatable or tampon packs instead
CHECK YOUR HAEMOSTASIS
To ensure adequate haemostasis, ask the patient to gargle and spit water to clean the back of the throat, then look for any ongoing bleeding in the oropharynx.
A nasal bolster is useful for catching the oozing and rhinitis and avoids constant fiddling the nose.
- Is the posterior pack properly sited?
- Are all balloons adequately inflated?
- Is there still traction of the Foley catheter forwards? If not, you can layer more gauze wadding between the cord clamp and the nostril
- Are the anterior packs adequate?
You should discuss all further bleeding with the ENT Registrar as your patient may need to go to theatre for surgical management (vessel ligation, septoplasty, formal packing) or neuroradiological embolisation.
Repeated posterior packing should not be undertaken without discussion with a senior, since it causes more mucosal trauma, which leads to more bleeding. It is probably only delaying definitive treatment in the operating theatre.
IN PARALLEL (USE YOUR ASSISTANTS)
- Full history and ABCDE assessment
- Secure wide bore IV access and send FBC, U&E, coagulation screen/INR and G&S (+/- fibrinogen and D-dimer if indicated)
- Be aware of coagulopathy and discuss with the appropriate specialties:
- Is it a primary coagulation or platelet disorder?
- Is it disseminated intravascular coagulopathy (DIC) - is the patient septic, or had major surgery or trauma, or is there active cancer?
- For patients with profuse bleeding requiring posterior packing, you should discuss the need for reversal of anticoagulation, conversion to unfractionated heparin or use of fresh frozen plasma/clotting factors
- Be kind and prescribe analgesia
- If analgesia is not effective, discussion with a senior or anaesthetist, a small dose of benzodiazepine may be warranted
- Similarly, after discussion (be careful if general anaesthetic is also on the cards), consider a titrated dose of antihypertensive if blood pressure is controlled
- Prescribe broad spectrum antibiotics to reduce the chances of sinusitis, otitis media, endocarditis etc.
- Consider a PPI as swallowed blood causes gastritis
- Admit to an ENT ward
- Packs are likely to need to stay in for >24 hour
- Talk to your patient - this is emotionally and physically traumatic
* We recommend air for the Foley catheter as 1) it is being used as an airway device; 2) the pressure applied is more consistent; 3) there is less confusion since air is also used for Rapid Rhino packs.
Page last reviewed: 23 September 2016