Indications for nasal packing

The initial management of epistaxis involves simple measures such as the application of pressure, followed by cautery. Epistaxis can either be anterior, which is often self-limiting, or posterior.Reference Pollice and Yoder ⁹ In most studies, packing was advocated for patients in whom such basic measures failed; however, no specific guidance was provided regarding the optimum duration for such measures. Singer et al. specified 15 minutes of pressure followed by a further 15 minutes of pressure after the application of a topical nasal decongestant if epistaxis persisted.Reference Singer, Blanda, Cronin, LoGiudice-Khwaja, Gulla and Bradshaw ¹⁰ Thereafter, epistaxis management was escalated. In the studies that did specify when packing should be employed, the range of time for simple pressure and cautery prior to nasal packing varied from 30 minutes to 2 hours.Reference McGlashan, Walsh, Dauod, Vowles and Gleeson ^{2 ,} Reference Badran, Malik, Belloso and Timms ^{7 ,} Reference Corbridge, Djazaeri, Hellier and Hadley ¹¹

The commonly used non-dissolvable packs include nasal tampons, alginate-covered nasal balloons, and ribbon gauze which may be impregnated with bismuth iodoform paraffin paste. To avoid gaps in evidence, topical gel agents (gelatine-thrombin matrix haemostatic sealants FloSeal^® and Surgiflo^®, and fibrin sealants Tisseel^® and Evicel^®) have been included in this dissolvable pack section.

There is a paucity of good quality evidence supporting the use of dissolvable packs. However, with no reported complications in the literature, dissolvable packs appear safe to use in acute epistaxis. A prospective randomised controlled trial (RCT), which included 70 patients, supported using FloSeal over Merocel^® packs following failed conservative measures such as nose pinching in anterior epistaxis (level 1b evidence).Reference Mathiasen and Cruz ¹² The re-bleed rate within the first 7 days was also lower in those treated with FloSeal (14 per cent vs 40 per cent; p < 0.05).Reference Mathiasen and Cruz ¹² Additionally, dissolvable packing can be used in anterior epistaxis following failed cautery or anterior pack use in an effort to avoid surgical intervention, although the evidence for this is weak (level 2b).Reference Kundra, Cho, Sahota, Pau and Conboy ^{13 ,} Reference Shikani, Chahine and Alqudah ¹⁴ There is evidence (level 2b) to support the use of dissolvable packing in posterior epistaxis.Reference Bhatnagar and Berry ^{15 –} Reference Kilty, Al-Hajry, Al-Mutairi, Bonaparte, Duval and Hwang ¹⁷ In selected coagulopathic patients who fail to respond to either silver nitrate cautery or non-dissolvable packs, fibrin sealant appears to be efficacious (level 4 evidence – weak cohort study);Reference Walshe ¹⁸ however, there are significant cost implications, as FloSeal is currently considerably more expensive than the non-dissolvable packs available, and the evidence we present is based on a single RCT.

Nasal packing should be performed in a setting with appropriate lighting and equipment.Reference Kundi and Raza ^{1 , 4} Epistaxis patients are usually managed by healthcare professionals other than otolaryngologists at first presentation, and often by junior members of the team who may not be experienced in nasal pack insertion.Reference Upile, Jerjes, Sipaul, El Maaytah, Singh and Hopper ¹⁹ Those patients who require escalation of treatment subsequently arrive under the care of the ENT team only once they have been packed.

Glicksman et al. performed an RCT, and demonstrated that both computer-assisted learning and text learning relating to nasal packing (ribbon gauze and nasal tampon) improved an individual’s ability to perform this procedure.Reference Glicksman, Brandt, Moukarbel, Rotenberg and Fung ²⁰ The computer-assisted learning group were able to learn the skill more effectively (level 1b evidence).Reference Glicksman, Brandt, Moukarbel, Rotenberg and Fung ²⁰ However, their training time was longer than those who received text-based learning. A study by Lammers (involving ribbon gauze packing on a training model) further supports the concept of training in nasal packing.Reference Lammers ²¹ The author concluded that practical training allows the individual to learn and retain the skills better than observational training. The group also noted that, over time, if the skill was not used, the ability to perform it diminished equally.

Training (computer-assisted learning and simulation) in both anterior and posterior nasal packing provides a significant benefit, by increasing the ability to adhere to a department protocol,Reference Lammers ²¹ improving practitioners’ confidence, enabling an increased amount of gauze to be packed,Reference Sugarman and Alderson ²² and improving non-specialists’ speed and efficacy in packing (level 1b).Reference Glicksman, Brandt, Moukarbel, Rotenberg and Fung ²⁰ A retrospective observational study by Evans et al. found that patients packed by emergency department staff were more likely to require further treatment in the form of either nasal packs or cautery when compared with patients packed by ENT department staff (p = 0.004; level 2c evidence).Reference Evans, Young and Adamson ⁶ Conversely, there was a significant difference in the length of admission, with ENT-packed patients having a longer admission (2.54 days vs 2.86 days; p = 0.0012; level 2c evidence).Reference Evans, Young and Adamson ⁶ This may be because those who required ENT input had more severe epistaxis or associated co-morbidities, though the authors did not expand upon this in the study.

FloSeal and fibrin sealants should only be applied by those experienced in their use. They are, however, simple to use and could be administered by appropriately trained non-specialists. In posterior bleeds, evidence supports the use of adjuncts with dissolvable packs, such as endoscopic identification of the specific bleeding pointsReference Shikani, Chahine and Alqudah ^{14 –} Reference Côté, Barber, Diamond and Wright ^{16 ,} Reference Walshe ¹⁸ or the use of a Foley catheter,Reference Mathiasen and Cruz ^{12 ,} Reference Kilty, Al-Hajry, Al-Mutairi, Bonaparte, Duval and Hwang ¹⁷ to prevent spillage posteriorly. In these cases, relevant expertise in such techniques is required. Techniques involving endoscopic instrumentation are likely to be beyond the competence of a non-specialist and should be reserved for suitably trained ENT specialists.

Effectiveness of nasal packing

Evidence for the efficacy of individual packs is limited to a small selection of studies. The reported re-bleed rates appear similar for Rapid Rhino^® and Merocel non-dissolvable packs.Reference Badran, Malik, Belloso and Timms ^{7 ,} Reference Moumoulidis, Draper, Patel, Jani and Price ²³ There was no significant difference in the proportion of patients requiring repacking for bleeding after the initial placement of either Merocel or bismuth iodoform paraffin paste packs for anterior epistaxis.Reference Corbridge, Djazaeri, Hellier and Hadley ¹¹

Two studies compared traditional non-dissolvable packing to Kaltostat^® (calcium alginate). Murthy et al. packed patients with bismuth iodoform paraffin paste during a five-month period, followed by Kaltostat during a six-month period, and they analysed re-bleed rates and other patient outcome measures.Reference Murthy, Christodoulou, Yatigammana and Datoo ²⁴ The use of bismuth iodoform paraffin paste led to a longer duration of packing and a higher rate of epistaxis recurrence (no statistical analyses were performed).Reference Murthy, Christodoulou, Yatigammana and Datoo ²⁴  Xeroform^® (bismuth tribromophenate), a non-dissolvable pack, had similar re-bleed rates and levels of patient-reported discomfort to those of Kaltostat.Reference McGlashan, Walsh, Dauod, Vowles and Gleeson ²

Rapid Rhino inflatable packs are reported to be easier to insert for healthcare professionals.Reference Badran, Malik, Belloso and Timms ⁷ There is no evidence of additional clinical benefit from the increased ipsilateral pack pressure when using a contralateral pack in the setting of unilateral bleeding.Reference Hettige, Mackeith, Falzon and Draper ²⁵ Although the volume of air used to inflate a Rapid Rhino corresponds to a linear increase in pressure, for a given volume of inflation, a wide variation exists in the intranasal pack pressure attained in different individuals.Reference Mackeith, Hettige, Falzon and Draper ²⁶

The literature suggests that Rapid Rhino packs are most tolerated by patients, with significantly less pain on insertion and removal compared with both the Merocel pack and the less commonly used Rhino Rocket^® pack (level 1b evidence).Reference Singer, Blanda, Cronin, LoGiudice-Khwaja, Gulla and Bradshaw ^{10 ,} Reference Moumoulidis, Draper, Patel, Jani and Price ²³ No differences in discomfort were observed between bismuth iodoform paraffin paste and Merocel packs.Reference Corbridge, Djazaeri, Hellier and Hadley ¹¹ In a study by Nikolaou et al., non-dissolvable packs were found to be more painful in comparison to nasal cautery.Reference Nikolaou, Holzmann and Soyka ²⁷

The cost implications of using non-dissolvable packs are difficult to determine from the literature. Retrospective analysis within a Swiss clinic revealed that the costs associated with Rapid Rhino pack use were primarily influenced by whether treatment was delivered on an in-patient or out-patient basis.Reference Nikolaou, Holzmann and Soyka ²⁷ There are no high-level studies reporting re-admission rates to recommend the use of one pack over another.

In the absence of any comparative study, we are unable to support the use of a specific dissolvable pack over any other. FloSeal is the most reported product in the literature. It appears to be superior to Merocel packing with respect to patient comfort, ease of use and control of bleeding in anterior epistaxis.Reference Mathiasen and Cruz ¹² There are studies, albeit less robust, that support its use in posterior epistaxis also.Reference Côté, Barber, Diamond and Wright ^{16 ,} Reference Kilty, Al-Hajry, Al-Mutairi, Bonaparte, Duval and Hwang ¹⁷ Unfortunately, no studies compare FloSeal to Rapid Rhino packs, which are seen by many as the optimal non-dissolvable packing.

Surgicel^® and Chitosan^® gauzes have also been successfully utilised, again with good patient tolerance. However, these appear to require more expertise because of the need for endoscopic insertion, possibly offsetting any monetary advantage that may be attained by admission avoidance.Reference Shikani, Chahine and Alqudah ^{14 ,} Reference Bhatnagar and Berry ¹⁵ FloSeal, on the other hand, can be used by emergency department staff without specialist input,Reference Mathiasen and Cruz ^{12 ,} Reference Kundra, Cho, Sahota, Pau and Conboy ¹³ and may have economic advantages with perceived lower admission and re-bleed rates.Reference Kundra, Cho, Sahota, Pau and Conboy ¹³ Dissolvable packs appear safe, with few, minor complications reported.Reference Wang, Tai, Tsou, Tsai, Li and Tsai ²⁸ Therefore, although a robust economic assessment of FloSeal and dissolvable packs more generally has not been reported, it would appear that there might be potential for their use earlier in the epistaxis management pathway.

Management after pack insertion

The NICE Clinical Knowledge Summary and British Medical Journal best practice guidelines both recommend admission of patients following nasal pack insertion, to monitor for complications and pack displacement when using traditional non-expandable packs.

High-level evidence within the literature regarding the management of patients after packing is limited. Not all patients managed with inflatable non-dissolvable packs require admission (level 2b evidence). Patients undergoing anterior nasal packing can be safely managed as out-patients with a pack in situ, with no adverse events.Reference Van Wyk, Massey, Worley and Brady ²⁹ Evidence to support this approach includes a 73 per cent reduced admission rate of patients undergoing anterior nasal packing placed by emergency staff, after the introduction of a new epistaxis protocol (level 2c).Reference Upile, Jerjes, Sipaul, El Maaytah, Singh and Hopper ¹⁹

Alternatively, early discharge following pack removal is acceptable, following a recommended 4-hour observation period in appropriate patients. In a small prospective study of 50 patients, 20 per cent experienced re-bleeding events, of which 96 per cent occurred within 4 hours.Reference Mehanna, Abdelkader, Albahnasawy and Johnston ³⁰

Complications associated with nasal pack placement include obstructive sleep apnoea (OSA) and infection. Obstructive sleep apnoea may be induced, or underlying OSA markedly exacerbated, following nasal packing.Reference Wetmore, Scrima and Hiller ³¹

The role of prophylactic antibiotics remains uncertain. Bacteraemia is reported in 12 per cent of patients with posterior packs.Reference Herzon ³² Use of topical antibiotics was associated with more single micro-organism, Gram-positive growth, in contrast to mixed and predominantly Gram-negative growth in the non-antibiotic group.Reference Herzon ³² Evidence for prophylactic systemic antibiotics is limited by sample size and study design. A blinded, pilot RCT on posterior packing reported increased rates of foul-smelling packs and predominantly Gram-negative growth in the control arm not receiving intravenous antibiotics, but no significant differences in infective complications (level 1b).Reference Derkay, Hirsch, Johnson and Wagner ³³ These findings were supported by the contemporary literature.Reference Pepper, Lo and Toma ³⁴ Further studies have not identified differences in bacterial growth following anterior packing for more than 24 hours.Reference Biswas and Mal ³ A protocol-led reduction in prophylactic oral antibiotic usage had no consequential increase in complication and re-bleed rates.Reference Biggs, Nightingale, Patel and Salib ³⁵

The literature reports pack removal at a wide range of times after insertion. Benefits of early removal may exist for the patient, with packing for 12 hours shown to be as effective as packing for 24 hours, with significantly less discomfort.Reference Kundi and Raza ¹ Nasal packing beyond 3–5 days had no additional benefits, with no significant impact on re-bleed rates.Reference Shargorodsky, Bleier, Holbrook, Cohen, Busaba and Metson ³⁶

There is no evidence to support the admission of patients in which epistaxis has been successfully arrested by dissolvable packs.Reference Mathiasen and Cruz ^{12 ,} Reference Kundra, Cho, Sahota, Pau and Conboy ^{13 ,} Reference Bhatnagar and Berry ^{15 ,} Reference Côté, Barber, Diamond and Wright ¹⁶ Patients with significant co-morbidities or those with a lack of social support may require admission. The number of epistaxis patients requiring admission for these reasons can be significant, with half the trial participants admitted only for these indications in one study.Reference Côté, Barber, Diamond and Wright ¹⁶ Only one study offered any suggestion on the length of observation required prior to discharge (1 hour).Reference Kilty, Al-Hajry, Al-Mutairi, Bonaparte, Duval and Hwang ¹⁷

There was little evidence to support the removal of dissolvable packs, with the majority of studies leaving the packing material in situ. One paper described washing out excess FloSeal with saline, without any reported complications.Reference Kilty, Al-Hajry, Al-Mutairi, Bonaparte, Duval and Hwang ¹⁷ In studies where large amounts of Surgicel or Kaltostat were used to completely fill the nasal cavity, packing was typically removed 24–72 hours later.Reference McGlashan, Walsh, Dauod, Vowles and Gleeson ^{2 ,} Reference Murthy, Christodoulou, Yatigammana and Datoo ^{24 ,} Reference Tibbels ³⁷