Nasal packing: When a routine practice becomes a life-threat
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A correct fixation of Nasal packing is of uttermost importance to avoid posterior dislocation and aspiration. It is used to prevent bleeding and synechiae while helping to stabilize anatomical structures in nasal procedures. Aspiration is the most feared life threatening situation and it is prevented by choosing the correct type of NP and by securing the external threads outside the nose.

A 32 year old healthy woman underwent an elective endoscopic inferior turbinoplasty. A total intravenous anesthesia was administered, and the intraoperative follow up was uneventful. At the end of the surgery, an 8 cm Netcell NP with a nonstick outer surface, covered in nasal ointment, was inserted bilaterally. The external threads were tied over the columella and the exceeding length trimmed immediately over the knot as routinely performed. Following extubation, the patient presented agitation during the awakening phase with constant manipulation of the nose, requiring physical restraint by the medical team and sedation. Both NP were initially missing, and one was found in the hand of the patient. Facing the possibility of a pharyngeal dislocation of the Netcell despite normal, spontaneous breathing and ventilation, preparations were made for a pharyngeal examination and pack removal.

A sudden decrease in oxygenation with peripheral cyanosis shortly occurred, requiring orotracheal intubation. By means of high pressure ventilation, the SpO2 increased from 72% to 88% without CO2 signal recover, which raised the suspicion of aspiration. A complete tracheal obstruction due to aspiration of the Netcell was confirmed through a flexible endoscopy. A rigid bronchoscopy was immediately performed and the NP was removed. Following reintubation, a negative pressure pulmonary edema was prevented by ventilation with PEEP 10mmHg during one hour. The patient was discharged home 24 hours later with no long lasting complications.

In this regard, during both the anesthesia and awakening phase, there is an absence of the coughing and swallowing reflex. The absence of these reflexes leads to an unprotected and mostly unnoticed inhalation of the NP directly into the airway.

When suspecting aspiration, an immediate coordinated response from both anesthetists and ENT surgeons is mandatory to identify and quickly remove the NP by means of rigid bronchoscopy to avoid severe and potentially lethal complications.