An alternative to a postnasal pack for the arrest of perioperative hemorrhage following curettage adenoidectomy.

Abstract

Controlling bleeding with standard postnasal packing following curettage adenoidectomy is only occasionally warranted. Children find the packing experience unpleasant, and removal of the packing usually requires general anesthesia. We describe a simple technique for packing the nasopharynx with bilateral nasal tampons via an anterior approach. The tampons are much easier to insert than standard packing, they are well tolerated while in place, and they can be easily removed with perhaps only some light sedation rather than general anesthesia.

Introduction

Perioperative hemorrhage following curettage adenoidectomy is self-limiting in most cases. If bleeding persists, it can usually be controlled under direct visualization by bipolar cautery or by temporary packing with a swab impregnated with epinephrine. (1) Suction diathermy is becoming more popular, but it has yet to gain universal acceptance. (2) In centers where suction diathermy is not available, similar techniques with whatever equipment is available have been described. (3) On occasion, a child will continue to bleed despite these hemostatic measures and will require insertion of a traditional postnasal pack.

Postnasal packs are usually effective for achieving hemostasis, but children find them to be uncomfortable, and removal usually requires general anesthesia. Standard nasal packs are inserted through the mouth and secured by strips of tape that run anteriorly through both sides of the nose across the columella. Another piece of tape is brought out through the mouth and usually secured to the cheek.

These packs are uncomfortable and not well tolerated. Swallowing is difficult, and tying the tapes too high across the columella can result in pressure necrosis and an unsightly deformity, which is difficult to treat. In addition, removing a pack involves dividing the tapes at both anterior nares and pulling the pack through the mouth. Removal is a frightening and unpleasant experience in children who are not under general anesthesia.

A safe and well-tolerated alternative to standard postnasal packing for applying pressure to the adenoid pad is placement of nasal tampons. In this article, we describe our simple technique for placing these tampons.

Procedure

The decision to use nasal tampons is made while the patient is already in the appropriate position on the operating table, with a Boyle Davis gag inserted, opened, and suspended. Cut the nasal tampons to width to enable easy passage through the nares. Insert the tampons one at a time and make sure that they pass along the floor of the nose rather than upwardly toward the skull base. Obviously, once the posterior wall of the postnasal space is reached, resistance will be felt. When a tampon has been placed on one side, repeat the process on the other side. The tampons can then be infused with saline and, if desired, 1 ml of 1:1,000 epinephrine.

Cut excess tampon off at the anterior end and ensure that a suture (e.g., 2-0 silk) is attached to each to facilitate easy removal. Finally, check the position of the packs perorally by retracting the soft palate with a tonsillectomy pillar retractor or a warmed laryngeal mirror.

Discussion

Use of nasal tampons is not only easier than standard postnasal packing, it is more logical. A standard postnasal pack, once secured, is pulled anteriorly by the nasal tapes. This places maximum pressure on the posterior choanae, but it also pulls the pack away from the posteriorly located adenoid bed (figure, A). By contrast, well-positioned nasal tampons exert pressure on the posterior nasopharyngeal wall, which results in the application of firm pressure to the adenoid bed (figure, B).

[FIGURES A-B OMITTED]

Removal of nasal tampons is a much less uncomfortable and frightening procedure than removing a postnasal pack. Tampon removal can be achieved without an anesthetic in many cases and with only slight sedation in others. As is the case with standard postnasal packing, antibiotic coverage is recommended for patients who receive nasal tampons.

Our experience with nasal tampons has been encouraging, owing to the simplicity and logic of the technique and the tolerance shown by children to tampon removal.

Acknowledgment

The authors thank Russ Davidson of the Illustration and Design Centre at the Bristol Royal Infirmary for his illustrations.

References

(1.) Cowan DL, Hibbert J. Tonsils and adenoids. In: Adams DA, Cinnamond MJ, eds. Scott-Brown's Otolaryngology. Vol. 6. Paediatric Otolaryngology. 6th ed. London: Butterworths, 1997:18/12-15.

(2.) Hartley BE, Papsin BC, Albert DM. Suction diathermy adenoidectomy. Clin Otolaryngol Allied Sci 1998;23:308-9.

(3.) Sharp HR, Howson CT. A technique to control persistent haemorrhage following curettage adenoidectomy. J Laryngol Otol 2001;115:729.

Julian Savage, MRCS; Albert Pace-Balzan, FRCS 

From the ENT Department, Royal Devon & Exeter Hospital, Exeter, England (Dr. Savage), and the ENT Department, St. John's Hospital, Chelmsford, England (Dr. Pace-Balzan).

Reprint requests: Mr. Julian Savage, 84 Gras Lawn, Barrack Rd., St. Leonard's, Exeter, EX2 4SZ, UK. Phone: [phone]; fax: [phone]; e-mail: [e-mail]