3 The soft palate and nasopharyngeal valve may hinder appropriate clearance of clots causing them to be trapped and hence aggravate discomfort. For doctors unwilling to perform direct suctioning, I suggest a safe and patient-friendly method by simply reversing the above procedure. It involves instructing the patient to block one nostril and blow the clots through the bleeding nostril into a bowl. Exhalation generates higher pressure and avoids alar collapse associated with sniffing action. It allows the clot to be expelled through the natural route. In my opinion, direct suctioning remains the most efficient and safest way1 as the above methods involve pressure changes inside the nasal cavity, which may cause rupture of vessels and invite further bleeding. K. Badran Department of Otolaryngology Addenbrookes Hospital, Cambridge, UK Email:
[email protected] Reference 1 Badran K. (2006) Blood clots should be evacuated before nasal packing: the problem of the Yankauer sucker. Clin. Otolaryngol. 31, 74–75 How to avoid accidental burns during anterior nasal cautery 10 February 2006 Sir, The problem of inadvertent burns to the nasal lining during chemical cautery is well recognised.1–3 Previous authors introduced safe methods to cauterise posterior epistaxis under endoscopic control by sheathing the cautery stick during insertion in the nose and re-exposing it just before cauterising the mucosa.1–3 No similar measures, however, exist to avoid this problem occurring during anterior nasal cautery. Burns do occur during the latter procedure despite the fact that it is performed under direct vision. This may occur to the nasal vestibule and/or the lateral nasal wall particularly when cautery is performed in a narrow cavity. Although they may seem trivial, burns have major influence on treatment outcome as they damage the normal mucosa, add more pain, invite more crusting, cause adhesions, and result in unpleasant blackish discoloration of the nasal entrance. We propose a simple method to overcome this problem. Method Our concept is to cover one side of the cautery tip which faces the nasal vestibule/lateral nasal wall with a piece of catheter to avoid inadvertent burns during anterior cautery. A 6-cm piece of 12F catheter is prepared and longitudinally split into two halves at one end (2-cm split). One half is trimmed off while the other is preserved to act as a cover. A cautery stick is then lubricated and retrogradely inserted inside the catheter from the C O R R E S P O N D E N C E Fig. 1. The sheath provides a safe and effective cover for the sliver nitrate tip. To utilise all sides of the tip, the stick can be easily rotated while inside the catheter (left). When the instrument is introduced in the nose, the cover is placed lateral to the tip to protect the nasal lining. Unlike posterior cautery, the tip is advanced under direct vision and hence does not require complete sheathing. This reduces the bulk of the instrument and hence improves exposure of the septum (right). 236 Correspondence � 2006 Blackwell Publishing Limited, Clinical Otolaryngology, 31, 233–244 fashioned end (Fig. 1). The cautery tip, while being covered on its outer side, is advanced inside the nose and cautery is performed. If more cautery is required, the stick is replaced with new one using the same catheter sheath. Although we initially used an ear speculum to protect the nasal lining, we felt it is not ideal as it offers limited view to the nasal cavity. This method was used in 14 patients with narrow nasal cavities, 12 of whom had clean and satisfactory cautery while only two had very narrow cavities that could not accommodate the device. Conclusion A new method ensures clean and safe anterior nasal cautery and avoids unintentional burns to the nasal lining. It is cheep and can be made from material already available in the work place. Badran K., & Jani P. Department of Otolaryngology, Addenbrooke’s Hospital, Cambridge, UK, e-mail:
[email protected] References 1 Eng C.Y., Hilmi O. & Ram B. (2004) Technical tips. ‘Sheathed’ silver nitrate stick to cauterise posterior epistaxis. Ann. R. Coll. Surg. Engl. 86, 475–476 2 Webb C.J. & Beer H. (2004) Posterior nasal cautery with silver nitrate. J. Laryngol. Otol. 118, 713–714 3 Alderson D. (2000) Simple device for chemical cauterization of pos- terior bleeding points in the nose. J. Laryngol. Otol. 114, 616–617 Nasal catheter insertion for suction diathermy adenoidectomy 21 February 2006 Sir, Adenoidectomy remains one of the most commonly performed ENT procedures in UK practice. The technique of suction diathermy adenoidectomy is increasing in popu- larity. When compared with conventional blind adenoid curettage, it allows a more controlled adenoidectomy to be performed under direct vision.1,2 Assessment of the post- nasal space, when compared with nasendoscopic examina- tion, has been reported to be more accurate with direct mirror examination than digital palpation.3 Both suction diathermy adenoidectomy and mirror examination of the post-nasal space require the soft palate to be retracted away from the posterior pharyngeal wall. This is achieved using one or two soft, flexible suction catheters of the type commonly used for airway suction. One catheter is inserted into each side of the nose, passed through the nasopharynx and retrieved through the mouth before tying each catheter to itself, so retracting each side of the soft palate. Fig. 1. Bent suction catheter. Fig. 2. Catheter insertion into nose. C O R R E S P O N D E N C E Correspondence 237 � 2006 Blackwell Publishing Limited, Clinical Otolaryngology, 31, 233–244