1

Introduction

Maxillofacial and ENT specialties often manage facial trauma and epistaxis, with cross-cover highlighting the need for cross-specialty awareness. This incident underscores the importance of maxillofacial team members being prepared as first responders in shared wards.

2

Case report

A 91-year-old male with Waldenstrom’s Macroglobulinemia presented to the emergency department with bilateral epistaxis, requiring Rapid Rhino nasal packs inflated to 8mL each. He was not on anti-coagulation or anti-platelet therapy. There was no indication of product malfunction but several hours later he experienced severe airway distress. Examination revealed a clot-like mass in the oropharynx. It was stabilised with Tilly’s forceps trans-orally and identified as a herniated, inflated Rapid Rhino pack. Deflation and removal of the pack nasally normalised breathing. Prior to the incident the patient was forcefully sniffing likely contributing to the herniation. A retrospective review of the patient’s CT scan revealed lateralised inferior turbinates though this could have been caused by the bilateral packing in place. At older ages reduced soft palate tone and elasticity may facilitate herniation even with anatomical dimensions.

3

Discussion

There has been one documented case of airway issues related to devices used for controlling epistaxis involving a Rapid Rhino pack [ ]. OMFS doctors might need to place these devices to control bleeding while managing facial trauma, ensuring the patient is stabilised for further investigations such as a CT scan. The close working relationship between otolaryngology and OMFS on the ward should prompt awareness of potential emergencies related to these commonly used devices.

Several factors could have contributed to the herniation of the Rapid Rhino pack in this case.

• 1.

  Anatomical Variations in Elderly Patients : There are often anatomical changes such as atrophy of the nasal mucosa and septal deviations [ ]. The patient’s CT scan showed anatomical variation. Age-related changes in tissue elasticity can predispose elderly patients to adverse outcomes. The reduced resilience of the tissues might have facilitated the herniation of the pack [ ].

• 2.

  Defective Pack : Product defects are rare, and there was no evidence of product failure. It is crucial to ensure that the integrity of nasal packs by inflation and deflation are checked prior to use.

• 3.

  Overinflation : The packs were inflated to 8 mL each. Overinflation remains a potential risk and there are no clear guidelines on the volume of air to be inflated in epistaxis. A study found that there was a linear relationship between volume and pack pressure but there was a variation between individuals likely due to variation in nasal anatomy. ⁴

4

Conclusion

This case report emphasises the importance of prompt response in managing airway emergencies. The patient experienced severe airway compromise, and the swift actions of the team were crucial to resolve the airway obstruction.

This incident highlights several key considerations for OMFS doctors.

• 1.

  Cross-Specialty Awareness: Given the shared responsibilities and close collaboration of teams, it is imperative that practitioners are aware of the potential complications of nasal packing devices and are prepared and familiar to act promptly in emergencies.

• 2.

  Proper Device Handling: Ensuring that nasal packs are inflated to the recommended volume and securely taped. Prior to insertion checks for product defects is preventative.

• 3.

  Monitoring: Monitoring of patients with nasal packs is crucial, particularly in older patients or those with known anatomical.

This case is a reminder of the potential for severe complications from seemingly routine procedures. By adhering to best practices healthcare teams can enhance patient safety and reduce the incidence of adverse events related to nasal packing devices.

Consent was obtained from the patient to publish this case report.