TECHNICAL NOTES

J Oral Maxillofac Surg 61:1231-1232, 2003

A Method to Control Epistaxis After Nasal Antrostomy and Caldwell-Luc Procedure

David M. White, DDS,* and Sheldon M. Mintz, DDS, MS, MS
The Caldwell-Luc procedure is commonly used in a number of surgical situations, including retrieval of foreign bodies from the maxillary sinus, treatment and resection of pathologic lesions in the maxillary sinus, treatment of chronic sinusitis, management of orantral stula, and repair of fractures of the antrum or zygoma.1 A nasal antrostomy is recommended to establish dependent drainage of the maxillary sinus after the Caldwell-Luc procedure is performed. This step is necessary because the maxillary osteum is placed superiorly in the sinus and depends on the ciliary action for drainage. Because the Caldwell-Luc procedure alters the normal ciliary ow, an alternative drainage system is necessary. A common method of performing a nasal antrostomy is by making a window in the inferior meatus of the nasal cavity, avoiding the inferior nasal turbinate.2 Once the window is established, a Dover Red Rubber Robinson catheter (Allegiance Healthcare Corp, McGraw Park, IL) is placed from the nasal cavity through the antrostomy site and curled in the maxillary sinus (Fig 1). The catheter is then secured to the internal sill of the nose with a suture. The function of the Dover Red Rubber Robinson catheter is to keep the opening patent. Unfortunately, a problem with this technique is that epistaxis may develop from the anterior lateral nasal wall. This is due to the rich blood supply present in the lateral nasal wall, including branches of the sphenopalatine, anterior ethmoidal, and lateral nasal branches of the facial artery. It is difcult to use standard anterior packing techniques due to the presence of the Dover Red Rubber Robin-

FIGURE 1. Sagittal section through a cadaver, showing Dover Red Rubber Robinson catheter encapsulated by Merocel nasal tampon in the nasal cavity. Dover Red Rubber Robinson catheter runs continually from external nares to maxillary sinus, through inferior meatus.

*Formerly, Fourth-Year Dental Student, University of Michigan School of Dentistry, Ann Arbor, MI. Adjunct Professor, Oral Maxillofacial Surgery, University of Michigan School of Dentistry, Ann Arbor, MI; Adjunct Professor, Oral Maxillofacial Surgery University of Detroit School of Dentistry, Detroit, MI; and Professor, Oral Maxillofacial Surgery, Nova Southeastern University, Davey, FL. Address correspondence and reprint requests to Dr White: 7848 Landings Dr, Indianapolis, IN 46240; e-mail: whitedav@umich.edu
2003 American Association of Oral and Maxillofacial Surgeons

son catheter. We have developed a method in which we use a combination of a standard Dover Red Rubber Robinson catheter for drainage and a Merocel nasal tampon (Helix Medical Inc, Carpinteria, CA) to control epistaxis. The Merocel nasal pack consists of a plastic airway that is surrounded by a foam polymer of hydroxylated polyvinyl acetate. (Fig 1). In these procedures the Dover Red Rubber Robinson catheter was threaded through the plastic airway of the Merocel nasal tampon using Vaseline (Chesebrough-Ponds USA, Greenwich, CT) as a lubricant. The function of the polymer is to absorb uids. As it expands in all dimensions, it compresses the nasal cavity and thus aids in stopping the epistaxis. The second component, the plastic airway with the Dover Red Rubber Robinson catheter, allows for the passage of air and drainage. The use of this nasal tampon (Merocel) allows the hemostasis and central drainage to be maintained without disturbing the Dover Red Rubber Robinson catheter.

Technique
After the nasal antrostomy window is made, a 6 Fr Dover Red Rubber Robinson catheter is curled in the maxillary sinus and passed through the antral window into the nasal cavity as described earlier. The Merocel

0278-2391/03/6110-0023$30.00/0 doi:10.1016/S0278-2391(03)00690-6

1231

1232

A METHOD TO CONTROL EPISTAXIS

the pack is placed into the nasal cavity parallel to the nasal oor. The exposed anterior extension of the catheter is secured to the internal sill of the lateral nose with vicryl suture. The Merocel pack may be removed without disturbing the catheter, once homeostasis is obtained

Discussion
Merocel, nasal packs were rst described in 1986 as an aid in treating epistaxis. The advantages of the Merocel pack have been well documented; these include easy insertion, decreased aspiration risk, adequate control of bleeding, and the ability to permit nasal respiration.3 In addition, the use of Merocel has been associated with a decreased risk of toxic shock syndrome compared with other nasal packing materials.4 This technique allows for the advantages of Merocel while maintaining the patency of the antrostomy window with the Dover Red Rubber Robinson catheter. We have used this technique effectively in more than 20 patients.

FIGURE 2. Frontal view with Dover Red Rubber Robinson catheter threaded through Merocel nasal pack, extending 3 to 4 mm anterior to the opening of the patients left nostril.

References
1. Blizer A, Lawson W: The Caldwell-Luc procedure in 1991. Otolaryngol Head Neck Surg 105:712, 1991 2. Buiter CT: Nasal antrostomy. Rhinology 26:5, 1988 3. Pringle MB, Beasley P, Brightwell AP: The use of Merocel nasal packs in the treatment of epistaxis. J Laryngol Otol 110:543, 1996 4. Breda SD, Jacobs JB, Lebowitz AS, et al: Toxic shock syndrome in nasal surgery: A physiochemical and microbiologic evaluation of Merocel and NuGauze nasal packing. Laryngoscope 97:1388, 1987

nasal pack has a tube-shaped central airway, which is surrounded by a foam polymer of hydroxylated polyvinyl acetate. The Dover Red Rubber Robinson catheter is placed through the posterior portal of the central airway in the Merocel pack. The Robinson catheter is pulled through the anterior portal extending 3 to 4 mm anterior to the opening (Fig 2). Then