What is the best method for performing nasal packing in a patient with midface fractures?

Nasal Packing Technique in Midface Fractures

For patients with midface fractures requiring nasal packing, use resorbable packing materials preferentially, apply topical anesthesia and vasoconstrictors prior to insertion, and ensure adequate compression of bleeding sites while minimizing mucosal trauma. 1

Pre-Packing Preparation

Anesthesia and Vasoconstriction

• Apply topical lidocaine or tetracaine via direct spray or cotton pledgets soaked with the agent 1
• Combine topical anesthetic with a vasoconstrictor (oxymetazoline is commonly used) 1
• Cotton pledgets impregnated with vasoconstrictors can be inserted intranasally for combined anesthesia and vasoconstriction 1
• For patients with uncontrolled epilepsy or those using class III antiarrhythmic agents, use lidocaine with caution 1

Equipment Setup

• Use a headlight, nasal speculum, and suction for direct visualization 1
• Have both resorbable and nonresorbable packing materials available 1

Packing Material Selection

Resorbable Packing (Preferred in Specific Populations)

Use resorbable packing for patients with suspected bleeding disorders or those taking anticoagulation/antiplatelet medications (excluding low-dose aspirin alone). 1

• Resorbable materials reduce the likelihood of additional bleeding during removal 1
• These materials eliminate the need for a removal procedure, improving patient comfort 1
• Common resorbable options include Nasopore and similar bioabsorbable materials 2

Combined Packing Technique

• A dual-layer approach using bioabsorbable material first (Nasopore), followed by nonbioabsorbable support (Merocel), significantly reduces pain and rhinorrhea compared to single-material methods 2
• The bioabsorbable layer protects injured mucosa from direct contact with the firmer nonbioabsorbable material 2
• This combination maximizes discharge absorption while providing adequate structural support 2

Nonresorbable Packing

• Traditional options include Merocel sponges or Vaseline-impregnated gauze 2
• Requires scheduled removal, typically within 1-5 days 3

Packing Technique

Insertion Method

• Insert packing material under direct visualization to ensure proper placement 1
• Pack systematically from posterior to anterior to ensure adequate compression of bleeding sites 4
• Avoid excessive force that could cause additional mucosal trauma or worsen fracture displacement 1
• Ensure packing reaches the bleeding site—inadequate positioning is a common cause of continued hemorrhage 4

Bilateral vs. Unilateral Considerations

• In midface fractures with bilateral nasal involvement, bilateral packing may be necessary 4
• Exercise caution with bilateral packing as it completely obstructs nasal airflow 1

Duration of Packing

Remove nonresorbable packing after 1 day for most nasal bone fractures, as this provides comparable outcomes to longer durations while significantly reducing patient discomfort. 3

• A prospective study of 530 patients demonstrated no difference in fracture stability, deviation, or contour between 1-day, 3-day, and 5-day packing durations 3
• One-day packing significantly reduced complaints of discomfort, headache, and nasal obstruction 3
• Resorbable packing dissolves over several days and does not require removal 1

Post-Packing Management

Patient Instructions

• Avoid straining, lifting over 10 pounds, bending over, and exercising 1
• Sleep with head elevated 1
• Do not blow the nose while packing is in place 1
• If sneezing occurs, sneeze with mouth open 1
• Avoid aspirin and ibuprofen; acetaminophen is safe for pain control 1

Nasal Hygiene

• Apply nasal saline sprays throughout the day to reduce crusting and help resorbable packing dissolve 1
• Continue saline spray after packing removal to facilitate healing 1

Warning Signs Requiring Immediate Evaluation

• Return of bleeding from nose or mouth 1
• Fever over 101°F 1
• Increasing pain 1
• Vision changes 1
• Shortness of breath or labored breathing 1
• Loss of color around the skin of the nose 1
• Facial swelling or diffuse skin rash 1

Management of Persistent Bleeding

Escalation Algorithm

• If bleeding continues despite adequate nasal packing, first verify that packing is properly positioned and reaching the bleeding site 4
• Consider repacking if initial packing was inadequate—this successfully controls bleeding in some cases 4
• For persistent hemorrhage after adequate packing, early surgical exploration can stop bleeding in approximately half of cases 4
• Angiography with embolization should be considered for refractory bleeding, either alone or as an adjunct to surgery 4
• Evaluate or refer for surgical arterial ligation or endovascular embolization for patients with persistent or recurrent bleeding not controlled by packing. 1

Common Pitfalls

Complications to Avoid

• Inadequate packing pressure failing to reach the bleeding site leads to continued hemorrhage 4
• Excessive packing pressure or prolonged duration increases risk of mucosal injury, septal perforation, and synechiae formation 1
• Airway obstruction from malpositioned or dislodged packing, particularly in patients with obstructive sleep apnea or chronic lung disease 1
• Infection risk increases with prolonged packing duration 1, 3

Technical Considerations

• Avoid simultaneous bilateral septal cautery if cautery is performed, as this increases perforation risk 1
• Ensure follow-up is arranged for nonresorbable packing removal 1
• Consider prophylactic antibiotics in high-risk patients, though this should be discussed given antibiotic-related risks 1