Letters to the Editor

Alternate Nasal Packing Technique for Patients Experiencing Epistaxis


Am Fam Physician. 2019 Apr 1;99(7):408.

Original Article: Epistaxis: Outpatient Management

Issue Date: August 15, 2018

See additional reader comments at: https://www.aafp.org/afp/2018/0815/p240.html

To the Editor: The authors nicely described the traditional method for anterior-posterior nasal packing in patients with epistaxis. An alternative technique may improve posterior nosebleed management. The placement of expandable sponge or balloon packing has largely supplanted horizontally-layered gauze due to ease of use. The Rapid Rhino inflatable device has advantages over sponges because of its flexibility and smooth carboxymethyl cellulose hemostatic mesh envelope. Sponges, however, are rigid when dry and nasal abnormalities (e.g., septal deviation) may preclude passage into the nasal cavity or abrade nasal mucosa creating secondary bleeding sites.

The authors described a Foley urinary catheter as one option for the posterior pack, although they discuss more fully and illustrate the gauze technique. The catheter may be placed as the posterior pack much more easily and with less discomfort for the patient. Active posterior hemorrhage commonly provokes patient gagging, which complicates positioning of the gauze above the soft palate at the posterior nasal choana. In contrast, one visualizes the Foley balloon in the oropharynx, inflates it, and then retracts it into position.

The use of oxymetazoline (Afrin) avoids potential cardiovascular effects of phenylephrine and concentrated epinephrine. Oxymetazoline may be mixed at bedside in its own spray bottle with an equal amount of 4% liquid topical lidocaine. The combination may be sprayed into the nose or applied on unrolled cotton balls. Held horizontally, the bottle provides a generous stream rather than mist. Topical anesthetic/decongestant may be supplemented, as available, with intravenous ondansetron (Zofran) and an analgesic to improve patient comfort.

The Foley is passed, inflated, and retracted into the nasopharynx while the assistant maintains firm forward traction. The Rapid Rhino is wetted, inserted, and inflated. An unfolded four-inch gauze pad is wrapped around the Foley shaft to create a doughnut-shaped bolster and tape-wrapped around its circumference. This protects the nostril from pressure necrosis. An umbilical clamp is slid snuggly against the bolster to keep forward tension on the Foley shaft. Surgical ties placed around the Foley shaft prevent balloon deflation; the rest of the catheter shaft is trimmed (see accompanying figure). This reliable posterior packing method takes only a few minutes, and in my experience works better than commercial double-balloon products.


Posterior Foley/anterior Rapid Rhino nasal pack with protective nostril bolster.


Posterior Foley/anterior Rapid Rhino nasal pack with protective nostril bolster.

Author disclosure: No relevant financial affiliations.

Editor's Note: This letter was sent to the authors of “Epistaxis: Outpatient Management,” who declined to reply.


Send letters to afplet@aafp.org, or 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2680. Include your complete address, e-mail address, and telephone number. Letters should be fewer than 400 words and limited to six references, one table or figure, and three authors.

Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter will be construed as granting the AAFP permission to publish the letter in any of its publications in any form. The editors may edit letters to meet style and space requirements.

This series is coordinated by Kenny Lin, MD, MPH, Associate Deputy Editor for AFP Online.



Copyright © 2019 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions


Nov 2021

Access the latest issue of American Family Physician

Read the Issue

Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article