Three Part Question
In [adult patients with active epistaxis presenting to the emergency department], are [moistened, gel-coated, balloon inflated nasal tampons or dry hydrophilic nasal tampons] [less painful on insertion and removal?]
A 45-year-old male presents to the emergency department with active epistaxis. It is determined he will require nasal packing. You have a choice of using a moistened, gel-coated, balloon inflated nasal tampon or a dry hydrophilic nasal tampon, and wonder which is less painful on insertion and removal?
MEDLINE 1950–2010 November Week 2 and EMBASE 19809—2010 Week 46
(exp epistaxis/OR epistaxis.mp. OR nosebleed.mp.) AND (exp tampons, surgical/OR exp tampons/OR tampon$.mp. OR nasal pack$.mp. OR rapid rhino.mp. OR merocel.mp. OR gelfoam.mp. OR surgicel.mp. OR rocket rhino.mp.) AND (exp pain/OR exp facial pain/ OR pain$.mp.). Cochrane: (epistaxis OR nosebleed) AND (tampon* OR nasal pack* OR merocel OR rapid rhino OR rocket rhino OR surgical OR gelfoam).
Twenty-nine papers were identified in MEDLINE, 46 in EMBASE and 46 in the Cochrane Library. Of these 4 were relevant to the three part question
|Author, date and country
||Study type (level of evidence)
|Singer et al,|
|A convenience sample of hemodynamically stable adult ED patients with active epistaxis requiring insertion of a nasal tampon, regardless of coagulation status.|
Randomised to either a moistened, gel coated, balloon inflated nasal tampon (Rapid Rhino) or a dry hydrophilic nasal tampon (Rocket Rhino)
|Prospective randomized controlled trial||Mean pain on insertion of two types of nasal tampon was compared using a visual analog scale (VAS)||Rapid Rhino 30 mm (95% CI 18 to 41); Rocket Rhino 48 mm (95% CI 34 to 61). Mean difference 18 mm (95% CI 1 to 35 mm), ie, statistically significant||Not blinded (although this would be practically difficult). Relative cost not evaluated. Relative safety not evaluated. Study received funding from the manufacturer of Rapid Rhino. No power calculation for detecting differences in haemostasis or rebleeding rates |
|Pain on removal (VAS)||Rapid Rhino 11 mm (1–21) versus Rocket Rhino 23 mm (13–33 mm). Mean difference 12 mm (−1–25 mm), ie, not statistically significant|
|Hemostasis||No difference, RR = 1.0|
|Rebleeding after removal||Rapid Rhino 6%, Rocket Rhino 39%, RR 0.2 (95% CI 0.01–1.3), ie, not statistically significant|
|Badran et al,|
|52 consecutive patients with anterior epistaxis for >1 h (not controlled by digital pressure or cautery)|
Randomised to either Merocel (expandable nasal tampon) or Rapid Rhino
|Prospective randomised controlled trial||Difficulty of insertion (0–3)||Lower with Rapid Rhino, p=0.0003||No details about the training of doctors during the study period. No sample size calculation. No blinding (although this would be practically difficult) |
|Difficulty of removal (0–3)||Lower with Rapid Rhino (p<0.0001)|
|Patient discomfort on insertion (0–10)||Lower with Rapid Rhino (p=0.01)|
|Patient discomfort on removal (0–10)||Lower with Rapid Rhino (p=0.05)|
|Bleeding after pack removal (0–4)||No difference|
|Moumoulidis et al,|
|42 consecutive adult patients with epistaxis unresponsive to first aid measures or unsuitable for cautery. Packs inserted by the on-call ENT officer ||Prospective randomised controlled trial||Mean pain score on insertion (VAS)||Rapid Rhino 3.85 (range 1–7); Merocel 6.47 (3–9). p<0.001||Baseline characteristics not adequately described. Safety and recurrence rate not formally assessed and probably underpowered to do so. No sample size calculation |
|Mean pain score while pack in situ (VAS)||No significant difference (p=0.979)|
|Mean pain score on removal (VAS)||Rapid Rhino 2.47 (range 0–5); Merocel 5.04 (2–8). p<0.001|
The available evidence clearly suggests that the Rapid Rhino nasal tampon (which is gel coated and balloon inflated) causes less pain on insertion and removal than the dry hydrophilic alternatives. In the randomised controlled trials identified (table), there was no difference in effectiveness between these two approaches. However, it is important to acknowledge that, in the absence of power calculations for the outcomes of haemostasis or rebleeding rates in any of the three trials, these analyses may have been underpowered to detect a clinically significant difference.
Comments from external reader on: 00908 - Inflatable nasal tampons are less painful than dry hydrophilic nasal tampons
As an otolaryngologist and someone with a history of epistaxis - I can definitely say that the inflatable nasal tampon is far less painful on insertion and removal than the standard tampons - be kind to your patients and use the inflatable packs!
ENT, ears, nose and throat; VAS, visual analogue scale.
Clinical Bottom Line
A moistened, gel coated, balloon inflated nasal tampon is less painful than a dry hydrophilic nasal tampon in controlling active epistaxis in adults. The available evidence suggests that both approaches are equally effective although these analyses may have been underpowered to detect a difference.
- Singer AJ, Blanda M, Cronin K, et al. Comparison of nasal tampons for the treatment of epistaxis in the emergency department: a randomized controlled trial. Annals of Emergency Medicine. 2005 ;45:134–9.
- Badran K, Malik TH, Belloso A, et al. Randomized controlled trial comparing Merocel and Rapid Rhino packing in the management of anterior epistaxis. Clin Otolaryngol 2005;30:333–7.
- Moumoulidis I, Draper MR, Patel H, et al. A prospective randomised controlled trial comparing Merocel and Rapid Rhino nasal tampons in the treatment of epistaxis. Eur Arch Otorhinolaryngol 2006;263:719–22.