30 THE NOSE AND PARANASAL SINUSES TREATMENT. Minor attacks of epistaxis may cease spontaneously and are helped to do so by seating the patient with his head over a basin and applying wool soaked in very cold water to the dorsum of the nose. Pressure over the affected bleeding area is applied by the thumb compressing the ala nasi on to the nasal septum for at least 5 minutes. Gripping the nose between finger and thumb means that the patient has to breathe through the mouth, and this is often frightening to the child or to the nervous patient. Unilateral pressure may be applied with the thumb on the ala nasi of the affected side and the middle finger behind \the angle of the jaw on the opposite side. This allows the patient one side of the nose and the mouth for respira- tion. Such pressure is tiring after 5 minutes, both for the doctor and the patient. In cases in which bleeding is not so easily controlled the nasal cavity must be packed with a length of ribbon gauze saturated with liquid paraffin. The gauze should be 25 mm wide for adults and 12 mm wide for children, and 1 m should be prepared for each side, if both require packing. The first 10 cm should be folded double and inserted along the floor of the nose, and the nasal cavity packed as tightly as possible and as far backwards and upwards as possible. This is a painful procedure and thus should be done in a good light and as rapidly as feasible. The use of liquid paraffin is recommended because it is easy to insert and, as it does not dry off by evaporation, it is easy to remove. It achieves its effect by pressure. Hydrogen peroxide (lOvol), which is haemostatic, produces much frothing on contact with blood on inser- tion, and it is uncomfortable to remove because the peroxide has evaporated leaving dry gauze which may adhere to the raw mucosal surface. Adrenajine lr unsuitable b^ra ftl>":h it achieves a . ..... by, ani vasodnatation^ana itas the same peroxide on removal. The packing should be left undisturbed for 24 hours provided that the haemorrhage has been controlled. During this time the patient should remain in bed and an appropriate dose of heroin for children or morphine for adults should be injected. The packing is often easier to insert if the sedation has been given previously. Various thin rubber bags have been devised to overcome the discomfort of packing. The bag is inserted into the nasal cavity as far back as possible and then inflated to control the haemorrhage, in many instances quite effectively. It is easily removed after deflation. Anterior packing is usually successful in controlling epistaxis from the 'bleeding area' although on occasions it may have to be repeated if further bleeding occurs after its removal. It may be less successful in some cases of haemorrhage from the anterior ethmoidal artery or if epistaxis is due to one of the blood diseases. In such an event a postnasal pack may have to be inserted. This is extremely painful to the conscious patient. A fine catheter is inserted through each nostril and brought out through the mouth. A rolled-up gauze swab round the middle of which a tape is securely tied is insinuated into the nasopharynx by attaching the free ends of the tapes to the catheters which are withdrawn. When the swab has been inserted into the nasopharynx by pulling on the tapes and using the forefinger to ease the swab under the soft palate the ends of the tapes are tied across the columella over a small piece of gauze. Both nasal cavities are then tightly packed as described. The anterior and posterior packs are removed in 24 hours.