PVA Nasal Pack

What it is

A PVA nasal pack is a sterile, compressed polyvinyl alcohol sponge that expands on contact with blood or saline to fill and tamponade the nasal cavity. In its dry state the pack is a small, firm tablet that can be inserted without resistance; on contact with fluid it absorbs moisture and expands to many times its original volume, conforming to the contours of the nasal cavity and applying even, distributed pressure against the mucosa to achieve haemostasis. It is lint-free, non-adherent when fully hydrated, and designed for atraumatic removal after soaking with saline prior to extraction.

When & how it's used

PVA nasal packing is used post-operatively following septoplasty and functional endoscopic sinus surgery (FESS) to maintain haemostasis and support the septum and sinus mucosa during the immediate post-operative period. It is also used in the emergency management of anterior epistaxis when nasal packing is required. The 4.5cm length suits paediatric cavities and tighter anterior chambers; the 8cm length is standard for most adult nasal cavities; the 10cm length provides additional posterior reach in longer cavities or where more posterior haemostasis is required.

PVA nasal packs — widely known by the brand name Merocel® — have largely replaced traditional ribbon gauze packing in rhinological surgery across most centres. (Merocel is one manufacturer’s brand of polyvinyl-alcohol pack; the material and technique described here apply to PVA nasal packs generally.) Their primary advantage over ribbon gauze lies in the mechanism of haemostasis: rather than relying on mechanical pressure from manually packed layers of gauze, the PVA sponge expands to conform to the exact geometry of the nasal cavity, applying uniform tamponade pressure against the mucosa. This self-conforming fill distributes force more evenly and reduces the risk of localised pressure necrosis that can occur with tightly packed ribbon gauze. The lint-free composition eliminates the granuloma risk associated with gauze fibres retained in the cavity, and the material is non-adherent when fully saturated — so removal after pre-soaking does not strip the regenerating mucosal surface.

Ribbon gauze and BIPP packing, if removed dry, can avulse the healing mucosa from the septum and turbinates; a PVA pack that has been soaked with saline for 10–15 minutes before removal slides out without disturbing healing tissue. This difference in removal atraumaticity is clinically significant in the FESS context, where preserving the neo-mucosa over exposed bone and the sinus ostia during the early healing period directly affects long-term surgical outcomes.

In the post-FESS context, nasal packs serve a dual function: haemostasis in the immediate post-operative period and maintenance of the nasal airway geometry while mucosal healing begins. In septoplasty, the packs support the repositioned septal cartilage and mucoperiosteal flaps on both sides, preventing haematoma formation and maintaining the corrected septal position. Packs are typically removed at 24–48 hours post-operatively in FESS and at 24–72 hours in septoplasty, depending on the degree of intraoperative bleeding and surgeon preference. Their use alongside internal silicone nasal splints varies by surgeon — some use packs alone, others splints alone, and some combine both in the first 24 hours before replacing packs with splints for ongoing septal support.

Design features

• PVA (polyvinyl alcohol) composition — hydrophilic sponge that expands 5–8× in volume on contact with blood or saline; provides even, conforming tamponade pressure.
• Compressed dry form — small, firm tablet in the dry state allows easy insertion into the nasal cavity without premature expansion.
• Lint-free — no fibres shed into the nasal cavity; eliminates granuloma risk associated with gauze packing.
• Atraumatic when wet — pre-soaking with saline before removal makes extraction gentle and non-traumatic to healing mucosa.
• Three lengths — 4.5cm for paediatric and anterior epistaxis use; 8cm for standard adult cavities; 10cm for longer cavities or more posterior haemostasis.
• Sterile, single-use — individually sterile packs for single patient use.

Sizing guide

Bilateral cases — septoplasty and bilateral FESS — require simultaneous packing of both nasal cavities, so two units of the same length are used per patient, one per nostril.

Safety — toxic shock syndrome

Non-absorbable nasal packing carries a small but recognised risk of toxic shock syndrome (TSS), a rare, potentially life-threatening reaction driven by Staphylococcus aureus toxin in the packed cavity. The absolute risk is low — decision-analysis modelling puts the incidence below roughly 49 per 100,000 packing episodes (Maul et al., 2021) — but because the consequence is severe, a patient discharged with packing in place should be warned to seek urgent review if they develop fever, rash, vomiting, diarrhoea, or feel systemically unwell while the pack is in situ. Prophylactic antibiotics are widely prescribed alongside non-dissolvable packing on the strength of this risk — the large majority of rhinologists cite TSS as their rationale (Mallen et al., 2023) — though whether routine prophylaxis is worthwhile is debated. This is a decision for the treating clinician; the packing material itself is unmedicated.

Frequently Asked Questions

How is a PVA nasal pack removed post-operatively? The pack is soaked with 5–10 ml of normal saline instilled into the nostril via syringe 10–15 minutes before planned removal. Once saturated and softened, the pack is grasped with Tilley nasal packing forceps and withdrawn in the long axis of the nasal cavity with a smooth, continuous pull. Forcing a dry or partially wetted pack out causes mucosal stripping and significant pain.

How long is nasal packing left in place after septoplasty or FESS? In most protocols, packing is removed at 24–48 hours post-operatively. Some surgeons leave packs for up to 72 hours where significant intraoperative bleeding has occurred. Leaving packing beyond 72 hours increases infection risk and patient discomfort without additional haemostatic benefit in most cases.

Can PVA nasal packs be used in both nostrils simultaneously? Yes — in septoplasty and bilateral FESS, packs are placed in both nasal cavities simultaneously. This results in complete nasal obstruction during the packing period, requiring mouth breathing. Patients should be warned pre-operatively. Internal silicone splints with an integrated airway tube are an alternative that permits nasal breathing during the post-operative period.

Is a nasal pack the same as Merocel? Merocel is a widely recognised brand of PVA (polyvinyl alcohol) nasal pack — so a Merocel pack is a PVA nasal pack, but not every PVA pack is the Merocel brand. The name is often used generically, much as “Band-Aid” is used for any adhesive dressing. The expansion behaviour, insertion, saline-soaked removal, and post-operative role described on this page apply to PVA nasal packs from any manufacturer.

What is the difference between a PVA nasal pack and BIPP packing? BIPP (bismuth iodoform paraffin paste) is a medicated ribbon gauze impregnated with bismuth and iodoform for its antiseptic properties. It is predominantly used for infected sinuses and chronic middle ear disease packing. PVA nasal packs are unmedicated and used for haemostatic nasal packing in clean post-operative settings and anterior epistaxis.

Which length should I choose? The 8 cm length is appropriate for the majority of adult nasal cavities following routine septoplasty or FESS. The 10 cm length is chosen for patients with longer nasal cavities (typically taller adults or those with a history of prior nasal surgery that has altered cavity geometry), or where haemostasis needs to extend further posteriorly. The 4.5 cm length is reserved for paediatric patients and anterior-only epistaxis in adults with short nasal cavities.

Do nasal packs need antibiotic cover? Non-absorbable packing carries a small risk of toxic shock syndrome from Staphylococcus aureus, and many surgeons prescribe prophylactic antibiotics while the pack is in place for that reason. The absolute risk is low and whether routine prophylaxis is worthwhile is debated in the literature — it is a decision for the treating clinician, not a property of the pack itself. A patient sent home with packing should be told to return urgently if they develop fever, rash, vomiting, or feel systemically unwell.

The Nareseal PVA Nasal Pack is available from Netcare Instruments in 4.5 cm, 8 cm, and 10 cm lengths, in Pack of 1, 2, 5, 10, and 20.