What is the procedure for posterior nasal packing using a Foley catheter?

Posterior Nasal Packing Using Foley Catheter Procedure

Posterior nasal packing using a Foley catheter is an effective and rapid non-surgical treatment option for controlling refractory posterior epistaxis when endoscopic treatments are not immediately available. 1

Indications

• Persistent or recurrent bleeding not controlled by anterior nasal packing or nasal cauterization 2
• Posterior bleeding sites where direct visualization and cauterization are not possible 2
• Emergency situations requiring temporary control before definitive treatment 3

Equipment Needed

• Foley catheter (typically 14-18 Fr) 1
• Topical anesthetic and decongestant (commonly lidocaine with a vasoconstrictor) 2
• Umbilical clamp or similar device to secure the catheter 2
• Anterior packing materials (may be needed in conjunction with posterior packing) 1

Procedure Steps

1. Preparation and Anesthesia

   • Apply topical anesthesia (lidocaine) and vasoconstrictor to the nasal cavity 2
   • Prepare the Foley catheter by marking it to help inflate the balloon in the correct position 1

2. Catheter Insertion

   • Insert the deflated Foley catheter through the bleeding nostril along the floor of the nasal cavity until the tip is visible in the oropharynx 1
   • Alternatively, the catheter can be passed through the nose and retrieved from the mouth 4

3. Balloon Inflation

   • Once properly positioned in the nasopharynx, inflate the balloon with 5-15 ml of water (volume depends on patient anatomy) 2
   • Gently pull the catheter forward until the inflated balloon is seated against the posterior choana 1

4. Securing the Catheter

   • Apply gentle traction to ensure proper tamponade of the posterior bleeding site 2
   • Secure the catheter at the nasal vestibule using an umbilical clamp or similar device 2
   • Position the clamp away from the nasal ala to prevent pressure necrosis 2

5. Additional Anterior Packing

   • If needed, place anterior packing to provide complete tamponade of both anterior and posterior bleeding sites 1

Duration and Aftercare

• Keep packing in place for 48-72 hours (typical duration) 2
• Monitor for potential complications including airway obstruction, especially in patients with sleep apnea or chronic lung disease 2
• Consider prophylactic antibiotics based on individual patient risk factors 2

Patient Education

• Explain the type of packing placed, expected duration, and removal plan 2
• Instruct on post-procedure care and signs/symptoms requiring prompt reassessment 2
• Advise on breathing techniques (mouth breathing) while packing is in place 2

Potential Complications

• Airway obstruction: Particularly concerning in patients with comorbidities such as obstructive sleep apnea 2
• Mucosal injury: Can result from insertion, overinflated balloons, or prolonged packing 2
• Pressure necrosis: Particularly of the nasal ala if the securing clamp is improperly positioned 2
• Intracranial migration: A rare but serious complication, especially in patients with skull base fractures 5
• Undeflatable balloon: May require catheter sectioning or removal via the oral route 4
• Synechiae formation: Can result from mucosal damage 2
• Septal perforation: Possible with bilateral nasal packings 2

Removal Technique

1. Deflate the balloon by cutting the inflation port or using the valve 4
2. If the balloon fails to deflate:
   • Try massaging the catheter segment that may be collapsed by the fixation device 4
   • Consider sectioning the catheter if necessary 4
   • In difficult cases, the balloon may need to be removed by the oral route after sectioning the catheter 4

Special Considerations

• For patients on anticoagulation or antiplatelet medications, consider using resorbable packing materials instead 2
• In patients with suspected bleeding disorders, resorbable packing is preferred 2
• Consider hospital admission for monitoring in patients with posterior packing due to risk of airway complications 2