Securing the Posterior Nasal Pack; A Technique to Prevent Alar Necrosis

BACKGROUND

Posterior epistaxis accounts for approximately 5% of all epistaxis.¹ It often requires packing with a balloon catheter, such as a Foley.² Clamps, such as umbilical clamps, are used for securing the pack, but may lead to pressure on the alar cartilage with subsequent necrosis.^3,4

TECHNIQUE

1. Cut drainage port off proximal end of catheter (Fig. 1).

2. Divide cylinder of latex to produce square to act as cushion.

3. Make cut into square, mid-point of one side, extending to the centre.

4. At tip of cut, in centre, cut ‘v’ shape and remove triangle of latex to form aperture (Fig. 2).

5. Place cushion around proximal end of catheter when in situ, through aperture.

6. Pull catheter to provide required pressure, ensure placement of cushion and apply cord clamp immediately proximal to cushion (Fig. 3).

Figure 1.

Cut port off catheter.

Figure 2.

Cut triangle out of centre of square cushion.

Figure 3.

Cushion in position.

DISCUSSION

Various methods for padding between clamp and alar rim have been described to prevent necrosis.⁵ However, if one has a patient with a brisk bleed, delay in finding padding could put the airway at risk. In the modern NHS where staffing out-of-hours is a problem, utilising our technique ensures the clinician can remain with the patient whilst fashioning the cushion, rather than leaving to find equipment, as the material is available with every catheter.

As an additional measure, the authors advocate packing with Bismuth Iodoform Paraffin Paste (BIPP) ribbon circumferentially around the catheter anteriorly, so as to prevent the catheter itself from coming into contact with the alar rim.