When it contacts nasal secretions, blood, or added sterile saline, the tampon expands to fill the nasal cavity and applies direct pressure to the walls of the nasal cavity The Rhino Rocket represents a compressed foam polymer tampon made of polyvinyl alcohol and a delivery device to aid insertion The nasal tampon comes loaded in a slim, syringe-like applicator, which is placed on the floor of the nose at the entrance or just inside the nose The tampon is expelled into the nose from the applicator expanding as it contacts blood and nasal fluid The retention strings should be secured to the side of the face The Rapid Rhino is a carboxymethyl cellulose pack with an inflatable balloon that secures it in the nasal cavity after insertion It facilitates platelet aggregation and also forms a gel-like lubricant over its surface to ease insertion and removal Classic anterior pack with ribbon gauze ( Fig 130.20 ) Using bayonet forceps, grasp a length of petroleum-jelly-impregnated gauze approximately to cm from its end, and insert it straight back along the floor of the nose for to cm This will form a loop in the nose, with the end of the gauze protruding from the nostril by to cm to prevent it from falling into the nasopharynx and causing the child to gag Withdraw the bayonet forceps and grasp the long end of the looped gauze approximately cm from where it is now exiting the nose This portion of the gauze should then be placed into the nose on top of the initial layer to form a second loop Repeat the process until the nasal cavity is filled with layers of gauze from bottom to top Any free end of gauze should be directed anteriorly so that it does not fall into the posterior nasopharynx and lead to gagging A small piece of tape can be used to cover the nostril and prevent the child from disturbing the pack Because the nasal pack causes stasis of the nasal secretions, oral antibiotics may be considered to prevent the occurrence of sinusitis Anterior packs should be removed in to days Posterior Pack If an anterior pack is not sufficient to stop an episode of epistaxis, a posterior pack may be required The placement of posterior packs is extremely uncomfortable; therefore, procedural sedation is strongly recommended Posterior packs can consist of a double-balloon catheter or a Foley catheter and are generally inserted by an otorhinolaryngology specialist Important note Toxic shock syndrome has been reported with nasal packing If a nasal pack is left in place, it is recommended that an oral antibiotic, such as amoxicillin–clavulanate, be initiated and continued until packing removal Posterior nasal packs are associated with hypoxia and hypercapnia In addition, the sedation often required in these patients may decrease respiratory effort and lead to significant hypoventilation Noninvasive capnography can be utilized to monitor ventilatory status in the ED Any child with a posterior pack should be admitted to the hospital and observed in an intensive care setting FIGURE 130.20 Anterior nasal packing with ribbon gauze REMOVAL OF A NASAL FOREIGN BODY Indications Presence of a nasal foreign body Complications Rhinosinusitis Mucosal laceration Epistaxis Aspiration Incomplete removal of the foreign body Procedure Preparation for the procedure to minimize pain and anxiety and maximize visualization is the key to success The patient must remain still during instrumentation of the nose to prevent injury to the internal nasal structures In most instances, it is useful to apply a topical vasoconstrictor (neosynephrine 0.25% or oxymetazoline 0.05%) to constrict the nasal vasculature A few drops of lidocaine with epinephrine may provide mucosal anesthesia as well as vasoconstriction The child should be supine and restrained Visualize the interior of the nose with a nasal speculum and a headlight or directed light source, as shown in Figure 130.21A Purulent secretions should be gently removed with the use of a Frazier suction tip until the foreign body is visualized Extract the object with suction, a hook, or alligator forceps as determined by the size, nature, and position of the object In some instances, procedural sedation may be necessary to facilitate the removal of the foreign body Figure 130.21B shows a hook being placed beyond a round foreign body Do not push the foreign body into the posterior nasopharynx because it may be aspirated by the struggling child The use of irrigation is not recommended because the foreign body may slip posteriorly and be aspirated, and hygroscopic foreign bodies (e.g., sponges) may swell, increasing the difficulty of removal The use of cyanoacrylate has been effective but requires the glue to directly contact the foreign body for up to 30 seconds against a wooden stick; contact with the mucosa can result in adherence of the stick to the nasal mucosa rather than the foreign body Katz Extractor or Foley Catheter Directly visualize the foreign body utilizing a nasal speculum if necessary Advance the deflated balloon of the Katz extractor or Foley catheter just beyond the foreign body Once the deflated balloon is beyond the foreign body, inflate the balloon and slowly withdraw with the balloon inflated from the nose The foreign body will be drawn out of the nasal cavity by the inflated balloon FIGURE 130.21 Removal of a nasal foreign body REIMPLANTATION OF AN AVULSED PERMANENT TOOTH Indications An injury resulting in a permanent (secondary) tooth that has been totally displaced from its socket and is not severely fractured Contraindications Avulsion of a deciduous (primary) tooth (its root may damage the developing permanent tooth during reimplantation) Complications Infection/Abscess formation