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Three Part Question

In [adult patients with anterior epistaxis] is [packing with an expanding nasal tampon more effective than packing with an inflatable nasal tampon] at [achieving haemostasis and patient comfort]?

Clinical Scenario

On a busy night shift, I was called to a cubicle because a patient had presented with epistaxis that had not responded to simple first aid measures. Visualisation of the bleeding point was difficult because of ongoing haemorrhage and that made cauterisation with silver nitrate impractical. I asked for a nasal pack and the nurse brought me a foam-based device, commonly known as “Merocel®”. The patient tolerated the insertion and expansion of this device extremely poorly, despite using 1% Xylocaine as anaesthetic. Although haemostasis was achieved, the patient required intravenous opioid medication after the procedure in order to alleviate their pain.

I had previously used inflation devices known as Rapid Rhino® and I wanted to know if there was a significant difference in the two types of nasal packs in achieving haemostasis and which device is more comfortable for the patient.

Search Strategy

1. Medline 1950 to present

(epistaxis).ti,ab OR (bleed* ADJ3 (nose OR nasal)).ti,ab OR (EPISTAXIS) AND
(expanding ADJ3 (device* OR foam)).ti, ab OR (Merocel).ti, ab OR (PVA).ti,ab OR ("polyvinyl acetal").ti,ab OR "TAMPONS, SURGICAL"/ OR "POLYVINYL ALCOHOL"/ AND (balloon).ti,ab OR (inflation ADJ3 (device* OR tampon)).ti,ab OR ("Rapid Rhino").ti,ab OR "BALLOON OCCLUSION" LIMIT to human and English Language

2. EMBASE 1950 to present

(epistaxis).ti,ab OR ((bleed* OR h?emorrhag*) ADJ4 (nose OR nasal))).ti,ab OR EPISTAXIS/ AND (expanding ADJ3 (device* OR foam)).ti,ab OR (Merocel).ti,ab OR (PVA).ti,ab OR ("polyvinyl acet*").ti,ab OR POLYVINYLALCOHOL/ OR "SURGICAL TAMPON'/ OR "POLYVINYL ALCOHOL SPONGE"/ AND (balloon).ti,ab OR ("balloon pack*").ti,ab OR (inflation ADJ3 (device* OR tampon)).ti,ab OR ("Rapid Rhino").ti,ab OR "EPISTAXIS BALLOON"/ LIMIT to human and English language

Search Outcome

40 papers identified in total, of which four randomised controlled trials deemed relevant to answer three part question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Iqbal et al 2017	various	Systematic Review	identify when and in which setting nasal packing should be used	re-bleed rates similar for both Rapid Rhino and Merocel ; Rapid Rhino packs are easier to insert; Rapid Rhino packs are better tolerated by patients compared to Merocel	paucity of high level evidence no sensitivity analysis performed
Moumouldilis et al 2006 England	42 patients, aged >16 years presenting with epistaxis to Otolaryngology department. Studied over two year period. Randomised to either Merocel or Rapid Rhino groups, all patients treated on inpatient basis	Prospective randomised controlled trial	Compare the effectiveness of Merocel and Rapid Rhino nasal packs in controlling haemorrhage; the subjective level of discomfort associated with each pack on insertion, in situ, and on removal, using Visual Analogue Scale	No significant difference in haemorrhage control was observed; Rapid Rhino is less painful to insert and remove than Merocel	Single centre Patients on anticoagulants were not excluded No objective measure of haemorrhage control was obtained No power calculation was performed.
Badran et al 2005 England	52 consecutive patients from ENT emergency room in a district general hospital recruited from both emergency department and ENT inpatients (elective nasal surgery). Age >16 years with refractory epistaxis, all aetiologies included	Prospective randomised controlled trial	Clinician graded difficulty of insertion and removal of nasal packs and haemotasis; patient graded pain on insertion and removal of nasal packs	No significant difference in insertion or removal graded by clinical; Merocel packs more painful to insert and remove for the patient; no significant difference in haemostatic ability	Single centre Included patients who had already had cautery performed No power calculation
Singer et al 2005 USA	40 patients with active ongoing epistaxis at two hospital Emergency Department sites randomised to receive Rapid Rhino or Rhino Rocket nasal tampons	Prospective randomised controlled trial	Compared pain on insertion and removal of the two devices using a visual analogue scale	Rapid Rhino significantly less painful to insert than Rhino rocket, but no significant difference in removal	Not blinded so physicians and patients were aware of treatment assignment

Comment(s)

Badran et al and Moumouldilis et al partly answer my three part question because all the patients had epistaxis and needed urgent haemostatic management. Moumouldilis et al found that Rapid Rhino is superior in reducing the patient’s pain on insertion and removal, however Badran et al concluded there was no significant difference in insertion or removal. Both studies recruited some post-operative patients so it is possible the pain level for these patients is not comparable to patients presenting to the Emergency Department. Singer et al is more robust because the patient group is solely from the Emergency Department and they conclude that Rapid Rhino is less painful to insert than Rocket Rhino, which is a similar device to Merocel nasal packs.

Clinical Bottom Line

There is statistical evidence that an inflation device such as Rapid Rhino is easier to insert and less painful for the patient than an expanding nasal pack such as Merocel. Both devices are equal in terms of haemostasis.

References

1. Iqbal I, Jones G, Dawe N et al Intranasal packs and haemostatic agents for the managment of adult epistaxis: systematic review The Journal of Laryngology & Otology 2017; 131: 1065-1092
2. Moumouldilis I, Draper M, Patel H et al A prospective randomised controlled trial compaing Merocel and Rapid Rhino nasal tampons in the treatment of epistaxis Eur Arch Otorhinolaryngology 2006; 263: 719-722
3. Badran K, Malik T, Belloso A et al. Randomised controlled trial comparing Merocel and Rapid Rhino packing in the management of anterior epistaxis. Clinical Otolaryngology 2005; 30: 333-337
4. Singer A, Blanda M, Cronin K et al Comparison of Nasal tampons for the treatment of epistaxis in the Emergency Department: A randomised controlled trial Annals of Emergency Medicine 2005; 45(2): 134-139