ORIGINAL ARTICLE Foley Catheter Action in the Nasopharynx A Cadaveric Study Wai Chung Lee, FRCS(ORL); Peter Ka Ming Ku, FRCSEd; Charles Andrew van Hasselt, FRCS Objectives: To determine the action of the Foley cath- eral side at appropriate inflation volumes in 17 (85%) of eter in the posterior nasal cavity in relation to balloon 20 nasal fossae. Complete sealing between volumes of 12 volume, and to deduce its implications in the treatment and 15 mL was achieved in 13 fossae (65%), between 11 of posterior epistaxis. and 15 mL in 10 nasal fossae (50%), and between 5 and 15 mL in 3 nasal fossae (15%). Failure to seal at any vol- Design: Human cadaveric study. ume occurred in 3 nasal fossae (15%). Bimodal seal (ie, complete seal at high [15 mL] and low volumes [4-7 mL], Materials: Twenty nasal fossae of 10 adult cadavers. but leakage in intermediate volumes) occurred in 3 na- sal fossae (15%). The balloon remained in the nasopha- Interventions: A Foley catheter (size 14) was inserted rynx under traction and did not slip past the choanal rim into the nasopharynx via each nostril. The catheter bal- to encroach on the middle and inferior turbinates until loon was inflated to its recommended maximum vol- the balloon volume was reduced to between 4 and 7 mL. ume with 15 mL of water. Firm traction was applied to The balloon slid out of the nose at a volume of 5 mL or the catheter. Colored liquid was instilled into the ipsi- less. The inflation volumes ranging from 8 to 12 mL were lateral aspect of the nasal cavity, and liquid leakage into statistically more effective in sealing the choana than lower the contralateral side was monitored using a nasoendo- volumes (4-7 mL) (P,.002, x2 test). scope. The balloon was reduced in volume by 1-mL steps, and the same fluid infusion and documentation proce- Conclusions: At different inflation volumes, the Foley dures were performed for each reduced volume until the catheter balloon acts primarily (1) as a platform for an balloon slipped out of the nose. The procedure was re- anterior gauze pack (at 4-15 mL); (2) as an effective seal peated in the opposite nostril. of the choana (at 8-15 mL usually and at 4-7 mL occa- sionally); and (3) as a compressor of the region behind Main Outcome Measures: Successful choanal seal- the middle and inferior turbinates (at 4-7 mL), pro- ing and anterior balloon shift into the nasal fossa in re- vided that the balloon under traction does not slip out lation to the balloon size. of the nose. Results: The Foley catheter balloon sealed the choana without any leakage of infused liquid into the contralat- Arch Otolaryngol Head Neck Surg. 2000;126:1130-1134 PISTAXIS IS a common clini- Several modes of action of the Foley cal condition, with many ef- catheter balloon in the treatment of pos- fective treatment options. The terior epistaxis have been discussed in most traditional and widely these textbooks. For instance, in one mode practiced treatment of the of action, the inflated Foley catheter bal- Eposterior type of epistaxis involves apply- loon may act as a stable platform in the na- ing an inflated Foley catheter balloon into sopharynx for the insertion of an ante- the nasopharynx in combination with an rior gauze packing, which is solely anterior gauze pack. The Foley catheter bal- responsible for arresting the epistaxis. In loon insertion procedure is well described another mode of action, with effective trac- in medical textbooks.1 A typical descrip- tion applied to the catheter, the balloon From the Division of Otorhinolaryngology, tion includes a balloon inflation volume of may compress the bleeding vessels and pre- Department of Surgery, The 10 to 15 mL and the application of trac- vent bleeding down the oropharynx. Al- Chinese University of Hong tion, which is maintained by sliding the though these theories, and others, pro- Kong, Prince of Wales Hospital, catheter over a piece of plastic tubing, and vide plausible explanations for the action Shatin. the 2 tubes are then clamped together. of the Foley balloon in the treatment of (REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 126, SEP 2000 WWW.ARCHOTO.COM 1130 ©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/24/2021 MATERIALS AND METHODS performed for each reduced volume until the balloon slipped out of the nose. We believed that withdrawing 1 mL of wa- ter from the balloon using the syringe each time would re- We studied 20 nasal fossae in 10 (6 male and 4 female) adult sult in inaccurate volume measurement because the bal- cadavers (mean age, 70 years; age range, 25-90 years) at loon was under pressure and some water loss could occur the mortuary of the Prince of Wales Hospital, Shatin, Hong from the catheter injection port, or because slightly exces- Kong, from April 1999 to May 1999. The cadavers were se- sive water loss could occur during syringe connection or lected according to the following criteria: each cadaver had disconnection. To avoid these possibilities, the water was be recruited within 24 hours of death, to maintain tissue completely emptied and measured at the end of each test, elasticity; each had to have a normal nose and nasopha- and an accurate amount of volume was injected into the rynx; and each had to have a nasal fossa that would allow catheter in 1 shot through the catheter injection port. the passage of a 4-mm 0° rigid nasoendoscope and a size Since repeated inflation and deflation of the balloon 14 Foley catheter via the nostril. as required in this study could lead to balloon valve dam- The cadavers were placed in a supine position with age, we used a new catheter after a run of tests in 2 or 3 the necks fully extended; then, the nasal fossae were thor- nasal fossae. When the catheter was used for the first time, oughly cleaned with water and suction dried. A Foley cath- it was always flushed with water and completely emptied eter was inserted along the floor of a nasal fossa to reach of air trapped in the tubing and the deflated balloon. the nasopharynx, as it would during clinical practice; its The position and conformity of the balloon and the location in the nasopharynx was confirmed by endos- site of leakage of colored liquid in the posterior aspect of copy. The catheter balloon was inflated with water to its the nose were noted. Choanal sealing and anterior bal- recommended maximum volume (15 mL) using a 20-mL loon shift into the nasal fossa were documented in rela- syringe. Gentle but firm traction was applied to the cath- tion to balloon size. Choanal sealing was always deter- eter by hand. While the balloon was under traction, the ip- mined when the catheter was under traction. Choanal leak silateral aspect of the nasal cavity was filled with colored was also tested after the traction was released. The rela- liquid (diluted povidone-iodine [Betadine] solution with tionship of the balloon with the posterior ends of the tur- a watery consistency) via a syringe. A 0° nasoendoscope binates was also recorded. placed in the contralateral aspect of the nasal cavity was The tests were performed in both nasal fossae for each used to observe any leakage of the colored liquid. If no leak- cadaver. x2 Tests were used to determined whether com- age occurred under traction, the traction was relaxed to de- plete choanal sealing by the balloon at a higher range of termine if leakage would then occur. inflation volumes is statistically more effective than at a lower The balloon volume was then reduced in 1-mL steps, range of inflation volumes. P,.05 was considered statis- and fluid infusion and documentation procedures were tically significant. posterior epistaxis, none of them has been properly plete seal at any volume was achieved at 12 to 15 mL in investigated or described in the literature. Therefore, 13 nasal fossae (65%), 11 to 15 mL in 10 nasal fossae our goals were (1) to elucidate how the Foley catheter (50%), and 5 to 15 mL in 3 nasal fossae (15%). In 3 na- balloon behaves in the posterior aspect of the nose at sal fossae (15%), a complete seal was only possible at maxi- different inflated volumes with or without catheter trac- mal or near-maximal volume (14 or 15 mL). In 3 nasal tion by applying it to a cadaveric model and (2) to fossae (both nasal fossae in 1 cadaver and 1 nasal fossa explain more accurately the action of the Foley balloon in another), a complete seal was not possible at any in- under different conditions in the treatment of posterior flation volume, with or without traction. Therefore, in epistaxis. our study, 15 mL was the only inflation volume that pro- duced a complete seal in all but 3 nasal fossae (85%). RESULTS Bimodal seal (ie, a complete seal at high [15 mL] and low [4-7 mL] volumes, but leakage at intermediate Typically, 16 individual tests were performed on each na- volumes) occurred in 3 nasal fossae (15%). However, in sal fossa, starting from a balloon volume of 15 mL, which all cases, whether bimodal or not, a low-volume seal was was reduced by 1-mL steps. The entire experiment on a achieved with traction in 6 nasal fossae (30%). The seal nasal fossa was completed when the balloon slipped out that was achieved at lower volumes was probably attrib- of the fossa under traction; this usually occurred when utable to the conformity of the less pressurized balloon the balloon volume reached 3 or 4 mL.