ACADEMIC EMERGENCY MEDICINE • September 2000, Volume 7, Number 9 1073

at eight weeks showed no residual

air and only mild cerebral atrophy.
Massive Pneumocephalus Following Merocel At neurosurgical follow-up, she re-
mained well and no intervention
Nasal Tamponade for Epistaxis was planned. At phone follow-up at
three months, she remains well. Her
GREGORY JOHN HOLLIS, BSC, MB BS, FACEM only recollection of previous facial
trauma was a fall down two steps
two years previously. She recalled
badly bruising her nose, being seen
Abstract. Anterior epistaxis is commonly treated with Merocel nasal by a general practitioner, but no x-
tampon insertion in preference to gauze packing. An 89-year-old pa- rays being taken.
tient was found to have cerebrospinal fluid rhinorrhea and massive
pneumocephalus immediately after removal of a Merocel tampon used
for spontaneous anterior epistaxis. She later developed fever and mild DISCUSSION
confusion, but was well at three-month follow-up. The advantages and
complications of Merocel nasal tamponade are briefly reviewed and To the best of our knowledge, this is
compared with those of other methods of control of anterior epistaxis. the first reported case of pneumo-
Key words: epistaxis; Merocel; nasal tamponade; pneumocephalus. cephalus following nasal tampon in-
ACADEMIC EMERGENCY MEDICINE 2000; 7:1073–1074 sertion for epistaxis. The mecha-
nism is presumably fracture of the
ethmoid plate. In this case, the age
of the patient and possibly previous
CASE PRESENTATION reported only mild discomfort at in-
injury may have contributed. The
sertion, but did develop a mild head-
case was immediately reviewed with
An 89-year-old woman presented to ache.
the emergency physician on duty
the emergency department (ED) of a The bleeding ceased and two
when the clear nasal discharge was
metropolitan teaching hospital with hours later the tampon was removed
noted. No errors in insertion tech-
her first episode of spontaneous ep- after discussion with the on-call ear, nique were detected. The nasal tam-
istaxis. She had a past history of nose, and throat registrar. Immedi- pon was not moistened with saline
peptic ulceration but was otherwise ately following removal, a clear na- or water prior to removal (as has
well, lived alone and independently, sal discharge began and persisted. been recommended); however, this is
and had no allergies. Her only med- The patient’s bifrontal headache
ication was ranitidine, 300 milli- persisted and she developed some
grams daily. There was no history of nausea. Neurologic examination was
trauma. normal, other than marked reduc-
On arrival she had continued ep- tion in sense of smell from the right
istaxis from the right nostril. The nostril.
resident medical officer controlled Skull x-ray and cerebral com-
the bleeding using a commercially puted tomography (CT) scan were
available nasal tampon (‘‘Merocel obtained (Figs. 2 and 3). These
Pope Flex-Pak, pierced with draw- showed a large amount of intracra-
string,’’ Xomed Surgical Products, nial air, predominantly over the
Jacksonville, FL; Fig. 1). This is a frontal lobes. There was no fracture
9.5 cm long semirigid synthetic ma- seen.
terial made from an open foam cell
Neurosurgical consultation was
polymer of hydroxylated polyvinyl-
obtained; the patient was admitted, Figure 1. The Merocel nasal tam-
acetal that expands on contact with
treated with oral cephalexin, 500 pon.
moisture. It is commonly used for
milligrams qid for four weeks, and
treatment of epistaxis as an alter-
observed. She developed a low-grade
native to gauze packing. The patient
fever and mild confusion at days 5–
7, which resolved but necessitated a
From the Department of Emergency prolonged hospital stay. There was
Medicine, St. George Hospital, Sydney, recurrent epistaxis at day 10,
Australia (GJH). treated with cauterization. She had
Received March 17, 2000; accepted persistent hypertension, treated
March 28, 2000. with atenolol, 25 milligrams bid. A
Address for correspondence: Gregory repeat cerebral CT scan was per-
John Hollis, MD, BSc, MB BS, Depart-
formed at day 17. It showed a
ment of Emergency Medicine, St. George
Hospital, Gray Street, Kogarah, Sydney,
marked reduction in the amount of
NSW, 2117, Australia. Fax: 61 2 intracranial air. Again, no fracture
93503946; e-mail: hollisg@sesahs.nsw. was seen. She was discharged on
gov.au. Reprints are not available. day 19. Follow-up cerebral CT scan Figure 2. The skull x-ray.
1074 MEROCEL TAMPONADE
Figure 3. The cerebral computed tomography (CT) scan.
unlikely to have contributed because
it was only in situ for two hours.
There has been a previous report
of ethmoid fracture (lamina papyra-
cea) and proptosis following anterior
nasal packing with gauze,1 and an-
other following the use of an intra-
nasal balloon.2 Merocel nasal tam-
pons are commonly advocated in the
medical literature as an alternative
to anterior nasal packing with
gauze,3–5 but no similar cases were
identified on literature review.
Pneumocephalus most commonly oc-
curs following trauma, other causes
described being iatrogenic, tumor,
congenital defect, and idiopathic.6,7
Eighty percent of nasal hemor-
rhage is from the anterior nose,5 and
there are various other options for
control. Electrocautery of silver ni-
trate paste can be used as the initial
method when bleeding is not con-
trolled by simple pressure.5,8 How-
ever, these do carry risks of tissue
damage and septal perforation. An-
terior nasal packing with gauze im-
pregnated with paraffin is still often
used, but Merocel nasal tampons are
now an attractive alternative.
Merocel nasal packs have been
used since the early 1980s.5 They
Hollis • PNEUMOCEPHALUS AFTER NASAL TAMPONADE
are now in common use as the pri-
mary form of packing in many EDs.
Pringle et al.3 reported that Merocel
nasal packs controlled bleeding in
91.5% of patients even when per-
formed by inexperienced doctors.
They have a number of advantages,
including very rapid insertion (only
a few seconds), little discomfort,
ease of use even if relatively inex-
perienced, and possible inhibition of
bacterial proliferation.3–5
Corbridge et al.9 found in a pro-
spective randomized controlled trial
that there was no significant differ-
ence in efficacy, patient tolerance, or
complications when compared with
paraffin-impregnated gauze. Garth
and Brightwell10 compared Merocel
tampons, paraffin gauze, bismuth
subnitrate and iodoform paste
(BIPP) impregnated gauze, and
Telfa in postoperative nasal packing.
They found no significant difference
in patient comfort, control of bleed-
ing, or ease of removal. However,
they found that on removal, Telfa
and paraffin gauze were associated
with less discomfort and less bleed-
ing than BIPP or Merocel tampons.
Posterior nasal bleeding is man-
aged differently, with Foley catheter
balloons filled with water or saline
most commonly advocated in pref-
erence to posterior packing.8,11 Hos-
pital admission and consultation are
usually considered for posterior
bleeding.
CONCLUSIONS
It is difficult to make any recommen-
dations on the basis of one case.
However, with any method of pack-
ing, great care should be taken with
elders and those with previous facial
injury. Merocel nasal tamponade re-
mains a simple, effective, and safe
method of control of anterior epi-
staxis.
References
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