Introduction to the clinical stations
Sukhpreet Singh Dubb in Core Surgical Training Interviews, 2020
If the aforementioned treatment options fail with silver nitrate cautery, then ENT referral is usually advised since they are more experienced in delivering further treatment such as electrocautery. Nasal packing is an important treatment option that is effective in controlling most bleeding instances. New expanding nasal sponges are now available, which are inserted into a patient's nasal passages and – with the injection of normal saline – expanded to control bleeding. In severe uncontrolled bleeding, lidocaine with adrenaline can be injected into the bleeding site – strictly under experienced hands since it can cause catastrophic complications, including blindness. Posterior bleeding that is not controlled may be treated endoscopically. The most severe instances of uncontrolled bleeding may require open surgical ligation.
Data and Picture Interpretation Stations: Cases 1–45
Peter Kullar, Joseph Manjaly, Livy Kenyon, Joseph Manjaly, Peter Kullar, Joseph Manjaly, Peter Kullar in ENT OSCEs, 2023
Patient should be managed using an Airway, Breathing, Circulation approach recognising this is a medical emergency. Acquire intravenous access for intravenous fluid therapy and bloods, including FBC and group and save.Control bleeding using first aid. Examine the patient and try to find a bleeding spot which could be controlled with nasal cautery, topical agents such as Floseal. Consider nasal packing (dissolvable or non-dissolvable) if required.Take a full history asking specifically about risk factors (e.g. anticoagulation, trauma, bleeding diatheses).
Epistaxis
S. Musheer Hussain, Paul White, Kim W Ah-See, Patrick Spielmann, Mary-Louise Montague in ENT Head & Neck Emergencies, 2018
If no bleeding point is identified, indirect therapies are employed to control the epistaxis. Nasal packs are the most commonly used indirect techniques, but others such as hot water irrigation and topical haemostatic agents can be used (e.g. tranexamic acid or Floseal). Anterior nasal packing includes nasal tampons (Figure 1.5), ribbon gauze and inflatable packs (Rapid Rhino™, Figure 1.6). If bleeding persists despite anterior packing, posterior packs may be required. Once in place, nasal packing should be left in situ for 24–48 hours. Antibiotic cover should be considered, particularly in patients with prosthetic heart valves. Local complications of nasal packs include sinusitis, septal perforation and alar necrosis.
Intranasal drug delivery devices and interventions associated with post-operative endoscopic sinus surgery
Published in Pharmaceutical Development and Technology, 2018
Lari K. Dkhar, Jim Bartley, David White, Ali Seyfoddin
A variety of adjunctive devices has been applied to the sinuses during ESS to keep the middle meatus open with varying success. Following endonasal surgery various nasal packing materials are used to control bleeding, prevent hematoma formation, and support septal flap apposition (Zhao et al. 2013). These include packing materials, injectable space-filling gels, or structured stents (Karatzanis et al. 2017). Recent studies have shown that soaking these packing materials with drugs during surgery has shown inconsistent results in terms of wound healing, maintenance of ostium patency, and prevention of polyposis recurrence (Karatzanis et al. 2017). Moreover, drug release nasal packing materials is uncontrolled and inconsistent which may explain the erratic outcome of this treatment strategy (Deniz et al. 2014). Although typically effective, packing is uncomfortable and its removal is painful and commonly associated with bleeding (Zhao et al. 2013). Nasal packing is primarily, used to control bleeding in epistaxis and after surgical procedures to the nose such as septoplasty, conchotomy, and paranasal sinus surgery (Weber et al. 2001; Yan et al. 2014). It is also used for internal stabilization after operations involving the cartilaginous-bony skeleton of the nose (Deniz et al. 2014). In addition to haemostasis, packing is used to prevent synechiae or restenosis, particularly after surgery (Weber et al. 2001; Fong et al. 2017).
Effect of fentanyl nasal packing treatment on patients with acute postoperative pain after closed reduction of nasal bone fracture: a randomized double-blind controlled trial
Published in Journal of Plastic Surgery and Hand Surgery, 2019
Kwan-Sub Kim, Sung Chul Yu, Jung-Woo Han, Sung-Min Shim, Soohyun Kwak, Yong-Min Kim, Seong-Su Kim
Nasal packing is used in procedures with high bleeding risk such as closed nasal bone fracture reduction for hemostasis [1]. Non-absorbable nasal packing, such as Merocel® (Medtronic Inc., Minneapolis, MN), is commonly used to control postoperative hemorrhage, to maintain proper reduction and to prevent adhesion formation, middle turbinate lateralization and restenosis. However, most solid non-absorbable packing causes considerable discomfort and pain during packing and removal [2]. Although the advantages of postoperative nasal packing over stents or simple sutures is being debated in some aspects [3,4], various situations, such as in extensive sinus surgery, revision surgery, epistaxis due to anticoagulants or clotting disorder and complex fracture in which stability is crucial, still require the usage of nasal packing [5,6]. Accordingly, further research is needed to develop nasal packing that control pain in such cases.
Risk factors for postoperative bleeding after endoscopic sinus surgery to treat chronic rhinosinusitis
Published in Acta Oto-Laryngologica, 2021
Xuemei Qin, Qing Sun, Guohui Chen, Jian Liu, Tianle Gao, Guangping Bai, Zhiqiang Guo
Postoperative bleeding needed to be examined, and it was usually treated with shrinkage of the blood vessels by placing a cotton pledget soaked in epinephrine (1:100,000) + lidocaine (2%) for 5 min. In addition, routine anterior nasal packing with Vaseline gauze or PVA was performed. Patients with posterior bleeds usually present with significant amounts of blood draining down the pharynx. However, if the source of bleeding is too brisk or is posterior, anterior nasal packing is unlikely to gain control of the bleed, and thus posterior nasal packing is required to stop the bleeding. A posterior nasal pack consisting of a Foley urinary catheter in the nasopharynx along with a nonabsorbable nasal pack placed anterior to the Foley catheter balloon was used in these cases. Two patients had to be returned to the operating room due to refractory postoperative bleeding.