Does Choice of Nasal Pack Matter? A Systematic Review and Meta‐Analysis of Merocel and Rapid Rhino

Authors: Camille Duggal, Kathleen Zang, Hanieh Tavakkoli, Dhatri Shukla, Japan Shukla, Leigh J. Sowerby

Abstract

Objectives

Epistaxis is one of the most common rhinological emergencies. Management often involves nasal packing when initial measures fail. This paper compares Rapid Rhino (RR) and Merocel in the management and prevention of epistaxis.

Data Sources

Studies from Embase, PubMed and Medline were included.

Review Methods

A systematic review and subsequent meta‐analysis were performed, pre‐registered on PROSPERO and adhering to PRISMA guidelines. Studies were screened, followed by data extraction and risk of bias assessment. The meta‐analysis was performed using Stata. Pain score effect size was based on raw means at packing removal, while rebleeding effect size used Freeman‐Tukey's proportion. Pain score at removal and rebleeding requiring repacking was assessed.

Results

The systematic review yielded 4637 studies for screening, with 51 meeting inclusion criteria. In primary epistaxis, RR was associated with less pain upon insertion and removal. In the surgical setting, RR demonstrated superior hemostasis and greater patient comfort. The meta‐analysis demonstrated that for post‐surgical packing, RR was significantly less painful on removal than Merocel (Mean = 2.50 [1.72, 3.28] vs. 6.34 [5.58, 7.10]; p = 0.00). Similarly, for primary epistaxis, RR removal was significantly less painful than Merocel (Mean = 2.28 [0.95, 3.61] vs. 4.14 [3.31, 4.97]; p = 0.02). All tests of group differences for rebleeding demonstrated no significant differences between nasal packs.

Conclusion

RR was found to be significantly less painful upon removal in primary and post‐surgical epistaxis. Although the systematic review demonstrates that RR is associated with less bleeding than Merocel, the meta‐analysis demonstrated no statistically significant difference.

Introduction

Effective strategies for nasal packing are essential given that approximately 60% of the population will experience at least one episode in their lifetime [1]. In fact, it is one of the most common head and neck‐related presentations to the emergency department (ED), accounting for 1 in every 200 ED visits [2]. Initial management of epistaxis involves applying pressure to the nasal ala for 10–15 min and tilting the patient's head down while sitting in an upright position. Despite the straightforward protocol, it is often implemented incorrectly [3]. If pressure proves ineffective, physicians can add topical vasoconstrictors or cauterize the source with silver nitrate [4]; if these approaches fail, nasal packing becomes the next course of intervention.

Merocel and Rapid Rhino (RR) are the most used nondissolvable nasal packs. Merocel is a polyvinyl acetate pack that is placed into the nasal cavity and advanced posteriorly along the nasal floor, expanding upon contact with blood to stop bleeding [5]. RR is an inflatable air‐filled high‐volume, low‐pressure balloon coated with a carboxymethylcellulose hydrocolloid compound acting as a lubricant and platelet aggregator for clot stabilization [5]. This device is also advanced posteriorly along the nasal floor and inflated to stop bleeding, and is available in four sizes depending on nasal size.

The most effective nasal packing has been the source of much debate, with several authors advocating for RR, while others have found no difference between Merocel and RR. One systematic review investigating pain related to nasal packing for epistaxis found that RR was the most comfortable option for patients [6]. In contrast, the prospective study by Moumoulidis et al. found that there was no significant difference between the two types of pack with respect to efficacy and patient comfort when in situ [7].

This review and meta‐analysis tests the hypothesis that RR is more effective than Merocel in reducing pain and rebleeding for patients with primary epistaxis and those with post‐surgical packing.

Methods

Protocol and Registration

This systematic review was reported as per Preferred Reporting Items for Systematic Reviews and Meta‐analyses (PRISMA) guidelines. This review protocol was registered on PROSPERO (CRD 42023426752).

Data Sources and Search Strategy

Studies were searched in Embase, PubMed, and Medline from inception to February 2, 2025. The keywords modified per database search syntax humans, tampons, hospital costs, emergency department, nosebleed, hemostatic, nose, packing, RR, Merocel, and epistaxis (see Appendix A: Keywords).

Eligibility Criteria

Randomized controlled trials (RCT), cohort studies, case–control studies, cross‐sectional studies, reviews, meta‐analysis, and clinical trials were included. Single case reports, retracted articles, and editorials were excluded. The search strategy was comprehensive but restricted to human subjects and studies published in the English language. There was no time restriction to capture as many studies as possible.

The inclusion criteria involved studies that examined either RR or Merocel nasal packs for nonsurgical epistaxis or post‐surgical packing. Articles were included if they addressed at least one of the primary patient comfort with nasal pack, cost of nasal pack, or rebleed rate. To ensure robust review quality, studies with pediatric patients (< 16 years old) were excluded, as were studies with no full text. Papers were also excluded if they were only descriptive in nature, recruited patients solely with clotting disorders (congenital or inherited), and had no distinction between nasal packs.

Study Selection

Three authors (H.T., D.S., C.D.) independently screened the titles and abstracts retrieved from the databases. A consensus between two researchers was required before continuing to full text screening. Any disagreement was resolved with consensus before full‐text review. The entire texts were then independently evaluated by the same three authors, with consensus required between two authors before the data extraction step. Three authors extracted the data independently, cross‐checking for discrepancies.

Data Extraction

Data extracted included the year of publication, first author, study design, and sample size, among other variables. To examine rebleed rates and pain scores, eligible papers were first divided into nonsurgical treatment of epistaxis and post‐surgical nasal packing. For rebleed analysis, several variables were examined including location of epistaxis, time to rebleed, bleeding scale, and rebleed rate. Similarly, for the pain analysis, timing of pain measurement, pain scales, and pain scores were reported.

Quality of Assessment

The Revised Cochrane risk‐of‐bias tool for randomized trials (RoB 2) tool was used for risk of bias assessment. This tool evaluates five domains that address various potential biases, including those related to randomization, missing data, and result reporting. Two reviewers independently assessed each study, and the results were compared using a traffic‐light table showing the overall ratings for each domain. Sensitivity analysis was guided by this assessment through a re‐analysis of the relevant studies after excluding high‐bias studies based on agreement between two reviewers.

Publication bias was assessed using funnel plots and Egger's test. If Egger's test indicated potential bias with a nonnull p value, the trim‐and‐fill method was applied to adjust for asymmetry and estimate the impact of missing studies. Funnel plots were generated for each outcome of interest with intervention subgroups. This approach was used to minimize the impact of overlapping studies.

Meta‐Analysis

Meta‐analysis was performed on three outcomes for both surgical procedures and primary epistaxis. Outcomes assessed included pain score at removal (10‐point VAS) and rebleeding requiring repacking. Studies that did not use consistent pain scales, studies that did not include a measure of rebleeding, and studies that did not specify the number of participants with rebleed events were excluded from the meta‐analysis.

Meta‐analysis was performed using the meta function in Stata/BE 18. Corresponding forest plots were created in Stata to visualize the data, subgrouping by intervention. Effect size for pain score used the raw mean of pain scores, which required some transformations of data for some studies that only provided certain statistics such as median (IQR). Effect size of proportions used Freeman‐Tukey's proportion (p) which applies the Freeman‐Tukey double arcsine transformation to stabilize the variance when proportions are near zero, as in this case.

Results

Study Selection and Characteristics of Included Studies

The complete study selection is shown in Figure S1. The databases yielded a total of 5971 studies, with 2036 duplicates removed either manually or through Covidence. A total of 3934 studies were screened by abstract and title, with 184 studies eligible for full‐text screening. Upon full‐text screening, 133 studies were excluded, resulting in 51 articles included (refer to Figure S1). Studies consisted of RCTs (n = 31), clinical trials (n = 2), prospective studies (n = 5), retrospective studies (n = 4), cohort studies (n = 3), reviews (n = 3), comparative studies (n = 1), case‐controlled study (n = 1), and a systematic review (n = 1).

For rebleed and pain analysis, studies were aggregated into two broad primary epistaxis (n = 612 patients) and surgical epistaxis (n = 2058 patients). The primary group consisted of patients who presented with primary epistaxis. The surgical group consisted of patients who underwent a variety of nasal procedures and required packing post‐operatively. For both primary epistaxis and surgical groups, two endpoints—rebleed rate and patient reported pain—were examined.

Cost‐analysis studies were not divided based on surgical or primary epistaxis, as this distinction does not influence the cost‐analysis. Of the 51 studies, 1 study was identified as relevant and used for cost‐analysis.

Risk of Bias Assessment

Most studies received an overall rating of high risk of bias owing to the brevity in methodological descriptions in each study and lack of clarity regarding certain domains (see Table S1). Most studies were RCTs and did not report pre‐specified protocols or whether intention‐to‐treat or per‐protocol analyses were conducted. Additionally, many trials scored poorly with regard to domains 1 and 2, as they did not report on allocation concealment processes or did not properly describe the randomization and blinding processes. Specifically for blinding, the blinding method of the outcome assessors and statisticians, investigators, participants, or administrators of the intervention was not always clear. The lack of clarity contributed to a high overall risk of bias, as many indicators were marked as “No information,” leading to ratings of “some concern” that accumulated across multiple domains. Due to the short nature of the studies, there was minimal loss to follow‐up (D3), which consistently scored low for risk of bias. Large differences between reviewer ratings were not observed, since overall ratings were not contrastingly different (i.e., a study being rated as simultaneously “low” and “high” risk of bias).

Rebleed Rates—Qualitative Results

Primary Epistaxis (See Table 1)

There were four studies that examined Merocel rebleed rate. The rebleed rates, from an anterior source, ranged from 8% to 26% [8, 9, 12, 13]. The only level 2 study in the group demonstrated a 26% rebleed rate from an anterior source in the first 24 h of placing the Merocel pack [13].

Two RCT studies assessed rebleed rate for RR [10, 11]. For anterior bleeds, the rate was 6%, and for posterior bleeds, the rebleed rate was 36% [10, 11].

Three RCTs and one retrospective study compared Merocel head‐to‐head with RR [7, 14, 15, 16]. Although these studies demonstrated no significant differences between the groups, the study by Badran et al. demonstrated that 20% of patients treated with Merocel were deemed to have uncontrollable rebleeding, while there were no such cases with RR [14].

Surgical (See Table 2)

For surgical patients requiring Merocel nasal packing, there were 17 relevant studies regarding rebleed rate. There was considerable heterogeneity between studies with respect to the scale used to assess severity of bleeding, the timing of nasal pack removal after surgery, and how the rebleed rates were calculated. Cukurova et al., having the largest sample size, found that 2% of patients had major bleeding requiring repacking [21]. In contrast, Yilmaz et al. described 45% of patients having grade 2 bleeding (moderate bleeding out of the nasal cavity) after removal of packs on the second post‐operative day [24].

There were two RCTs that evaluated rebleed rates using RR. In 2022, Mohammed et al. found a Grade 2 rebleed rate of 4% [18] while Chheda et al. found a 0% [31] rebleed rate.

There were two RCTs that performed a direct comparison of bleeding in patients treated with Merocel and RR. In the study by Hesham et al., there was significantly less bleeding noted in nasal cavities which had been packed with RR, compared with Merocel (p < 0.05) [33]. Pradhan et al. found that at 6 and 48 h after packing, Merocel had nearly two times greater blood loss than RR [34].

Pain—Qualitative Results

Primary Epistaxis (See Table 3)

There were two RCTs and one cohort study examining pain scores with the use of Merocel [8, 14, 36]. The studies demonstrated that Merocel has high pain scores upon insertion [8, 36]. In the study by Corbridge et al., 50 patients received Merocel and rated their pain during the insertion and removal of nasal pack in an acute epistaxis setting [36]. A 10‐point visual analog scale (VAS) was used to measure pain. The average pain score upon insertion and removal was 6.0 and 3.5, respectively [36]. Similarly, in the study by Pringle et al., 34 patients completed the 10‐point VAS questionnaire, with insertion proving to be most painful (5.3), followed by pack removal (3.4), and pain in situ (2.9) [8].

One RCT and one cohort study examined pain scores with RR in the setting of epistaxis [22, 37]. In the RCT by Singer et al., the patient's discomfort level upon pack insertion and removal was assessed using the 100‐point VAS scale [10]. Upon insertion, RR had a mean pain score of 30/100, which decreased to 11/100 at removal [10]. Nikolaou et al. compared patient discomfort of RR with other epistaxis management modalities [37]. This cohort study calculated RR to have a median pain score of 6 with respect to insertion and removal, being lower than other packing modalities [37].

There were two RCTs [7, 14] and one cohort [16] that directly compared Merocel and RR with respect to pain scores. Badran et al. compared patient‐reported pain upon insertion and removal of RR and Merocel using the 10‐point VAS questionnaire [14]. This study observed a significant difference in pain upon pack insertion between RR (5.0) and Merocel (6.9) [14]. A similar trend was observed upon removal, where RR had a mean score of 3.4 versus 4.6 for Merocel [14]. Similarly, Moumoulidis et al. conducted a RCT comparing pain with Merocel and RR on insertion, in situ, and removal, also utilizing a 10‐point VAS scale [7]. Upon insertion, RR (3.9) had significantly lower pain scores than Merocel (6.5) [7]. Upon removal, there was a significant difference with RR scores (2.5) and Merocel (5) [7]. Similarly, in the study by Mettias et al., RR was less painful than Merocel at pack insertion (6.74 vs. 7.08) and removal (4.05 vs. 6.09) [16]. Furthermore, a systematic review concluded that there was greater ease of insertion and reduced pain with the use of RR [6].

Surgical (See Table 4)

There were 25 studies that reported pain scores for Merocel in patients treated in the post‐operative period. There were 16 RCTs, five prospective studies, 1 comparative study, and 3 retrospective studies.

There were four RCTs that examined pain scores in surgical patients receiving RR [18, 31, 41, 43]. Cruise et al. demonstrated RR to have a mean in situ pain score of 1.73 and a mean removal score of 1.96 on a 10‐point VAS scale [41]. Another study reported a pain score of 1.2 during removal of RR [8]. Some studies did not specify the time of removal [41, 53] or had ambiguous removal times such as the morning of the first post‐operative day [43].

There were three RCTs that directly compared Merocel and RR with respect to pain scores. Arya et al. conducted a double‐blinded RCT and found that RR had lower pain scores during removal compared to Merocel [54]. Similarly, Hesham and Ghali also found lower pain scores during removal for RR compared with Merocel [33]. In the RCT by Pradhan et al., at 6‐h in situ, RR had significantly lower pain scores (1.97 ± 0.89) than Merocel (2.48 ± 0.92) (p = 0.03) [34]. Similarly, during pack removal, RR had significantly lower pain scores (0.09 ± 0.92) than Merocel (1.32 ± 0.70) (p = 0.04) [34].

Meta‐Analysis

A total of seven studies were removed from the pain meta‐analysis. Six studies were excluded from the pain meta‐analysis for using inconsistent pain scales—for surgical [24, 35, 53] and nonsurgical procedures [13, 16, 37]. One study was removed for not measuring pain at pack removal [55].

Two studies were excluded for the meta‐analysis examining rebleeding requiring repacking, as they did not include a measure of rebleeding [17, 34]. Lastly, one study was excluded for proportions of any rebleeding requiring repacking for nonsurgical procedures as it did not specify the number of participants who underwent each intervention [15].

Rebleeding

All tests of group differences between Merocel and RR for primary epistaxis and surgical procedures requiring repacking did not have statistically significant differences (see Figures 1 and 2, and respective p values of 0.1 and 0.18). This finding suggests that both Merocel and RR have similar effectiveness in terms of reducing rebleeding and the need for further interventions.

Pain Primary Epistaxis

The average effect size for pain scores during pack removal for primary epistaxis was higher for Merocel (4.14 [3.31, 4.97]) compared to RR (2.28 [0.95, 3.61]), see Figure 3. The test of group differences (Q b = 5.40, p = 0.02) confirms statistically significant differences between the two interventions, with RR demonstrating consistently lower pain scores. The heterogeneity across all studies was statistically significant (I ^2^ = 78.38% for Merocel and I ^2^ = 91.90% for RR), indicating substantial variability and supporting the use of a random‐effects model.

Pain Surgical

The average effect size for pain scores during pack removal for surgical epistaxis was higher for Merocel (6.34 [5.58, 7.10]) compared to RR (2.50 [1.72, 3.28]), see Figure 4. The test of group differences (Q b = 47.64, p = 0.00) confirms statistically significant differences between the two interventions, with RR consistently showing lower pain scores. The heterogeneity across all studies was statistically significant (I ^2^ = 99.64% for Merocel and I ^2^ = 96.57% for RR), indicating substantial variability and supporting the use of a random‐effects model.

Sensitivity Analysis

Although several studies had a high risk of bias, their impact on the final analysis was minimal, as many were excluded due to insufficient data for inclusion in the meta‐analysis. Two studies from the primary epistaxis [8, 36] and seven studies [29, 30, 43, 44, 47, 48, 49] from the surgical group were excluded from the pain analysis. One study from the primary epistaxis [8] and two studies from the surgical group [17, 29] were excluded for rebleeding analysis.

Rebleeding

In the primary epistaxis group, after removing the high bias studies, the effect size for Merocel increased slightly (0.93 [95% CI: 0.76, 1.09]), increasing the overall effect size of differences from 0.86 (0.52, 1.20) of the original meta‐analysis to 0.89 (0.72, 1.06). The RR group stayed identical as the only removed study came from the Merocel group. The overall results remained nonstatistically significant (p = 0.73) for between‐group differences for Merocel and RR (see Figure S2A).

Similarly, the surgical rebleeding group did not result in statistically significant changes after removing high‐bias studies (p = 0.27). The Merocel group's effect size decreased slightly from 0.79 (0.54, 1.04) to 0.75 (0.48, 1.03), lowering the overall effect size from 0.75 (0.53, 0.97) to 0.72 (0.48, 0.95). The RR group remained unchanged, as all excluded studies were from the Merocel group (see Figure S2B).

Pain

In the primary epistaxis group, after removal of the studies with high bias, the p value remained statistically significant (p = 0.00) for overall between‐group differences. The RR group remained unchanged, while the Merocel group experienced a slight increase in effect size to 4.91 (4.35, 5.46), shifting the overall effect size for between‐group differences to 3.29 (1.85, 4.73) (see Figure S3A).

In the surgical cohort, group differences remained statistically significant after removal of high bias studies (p = 0.00), with a slightly lower overall effect size of 5.03 (4.05, 6.02). Both Merocel and RR groups had slightly lower means of 6.03 (5.11, 6.95) and 2.30 (1.51, 3.08), respectively, but RR remained showing statistically significantly smaller pain at removal scores (see Figure S3B).

Cost Analysis

Due to the limited availability of data directly comparing the cost‐effectiveness of RR and Merocel, our analysis primarily focused on a single study. This RCT conducted by Badran et al. stands as the only instance where the costs of Merocel and RR nasal packing were directly compared in the management of anterior epistaxis.

Publication Bias

Rebleed

The funnel plots for primary epistaxis rebleeding for Merocel and RR demonstrated modest symmetry and a nonstatistically significant Egger's test results (p = 0.77 and p = 0.25), meaning no likely publication bias was present (see Figures S4A and S4B, respectively). Surgical rebleeding saw similar results for RR (p = 0.54); however, Merocel demonstrated an asymmetric distribution of studies in the funnel plot, and a statistically significant Egger's test result (p = 0.008) (see Figures S5A and S5B, respectively). This evidence necessitated the trim‐and‐fill method, which resulted in zero imputed studies. This outcome may indicate that heterogeneity in the studies may be driving the asymmetry rather than publication bias; Egger's test is sensitive to small study effects, which could arise from real variation and not selective reporting.

Pain

Furthermore, both the primary epistaxis group and the surgical group for RR demonstrated somewhat symmetric funnel plots in addition to nonstatistically significant Egger's test results (p = 0.96 and p = 0.73, respectively) (see Figures S6A and S6B, respectively). Similarly, the primary epistaxis group for Merocel also displayed symmetric funnel plots and a nonstatistically significant Egger's test result (p = 0.84) (see Figure S7A). Lastly, the surgical pain group for Merocel demonstrated nonsymmetrical results from the funnel plot, skewed to the top‐right side (see Figure S7B). However, the Egger's test result was not statistically significant, at p = 0.61. The trim‐and‐fill method was pursued to adjust for publication bias, which resulted in 7 studies being imputed (see Figure S7C). After trim‐and‐fill, the effect size for Merocel surgical pain decreased to 5.56 (4.79, 6.34) as compared to the original 6.34 (5.58, 7.10). These findings suggest that while publication bias may have influenced the original results, the adjustment for this bias strengthens the conclusion that Merocel still demonstrates a greater effect on surgical pain than RR.

Discussion

Nondissolvable nasal packs are used for the treatment of primary epistaxis and following operative procedures. To date, the literature has concentrated on either epistaxis or the surgical use of nasal packs. To our knowledge, this study is the first encompassing systematic review and meta‐analysis that has evaluated the use of Merocel and RR in both primary epistaxis and the surgical setting. Our meta‐analysis demonstrated that for primary epistaxis and post‐surgical packing, RR removal was significantly less painful than Merocel. There was no statistical difference in rebleed rates between the two packing products, despite a trend demonstrating lower rebleed rates with RR. Additionally, no significant nasal pack complications were reported in the trials. There have been case reports of CSF rhinorrhea, alar necrosis, and septal perforation, but not in the included studies in this meta‐analysis [56].

The management of epistaxis is nuanced, with the choice of packing subject to both availability and provider choice. Our analysis found no statistical differences in rebleed rates, although a greater severity of rebleeds was seen in patients treated with Merocel. There was heterogeneity in bleeding scales ranging from an ordinal scale from 0–2 [32], 0–3 [24] or 0–4 [14]. Other studies quantify bleeding as any presence of bleeding [21], the need to repack [54], or bleeding measured in grams [34]. In addition, there was a high degree of variance in the timing of the rebleed event.

The pain associated with the insertion of nasal packs during primary epistaxis and surgery plays an important role in determining how well the treatment plan is tolerated. The results from our meta‐analysis demonstrated that Merocel was significantly more painful than RR for primary epistaxis (Q b = 43.85, p = 0.00) and nasal packing during surgery (Q b = 43.85, p = 0.00). Our findings are consistent with the literature, which demonstrates a significant difference in pain upon pack insertion and removal between RR and Merocel [6, 7, 14, 33, 54]. The lower pain scores may be related to the mechanism of removal of RR, given that the balloon is deflated prior to removal.

There was heterogeneity in the timing of pain measurement and scale. In primary epistaxis, there were varying removal times, varying between 24 and 72 h [7, 10, 14, 16, 37]. Among surgical studies, the majority had removal times within 48 h of insertion; however, there were studies that ranged from post‐operative days 1–5 [22, 33, 38]. There was great consistency in terms of scale, with most studies (27/39) using the 10‐point VAS scale. Five studies used the 100‐point VAS score [10, 18, 22, 39, 43], while two studies used the 4‐point VAS scale [34, 45], amenable to conversion to a 10‐point scale. Four studies either used arbitrary pain definitions such as patients requiring analgesics 24 h post‐operation [53], split pain raw VAS scores into arbitrary groups [35], or did not specify scale [13, 33]. This variability likely contributed to the heterogeneity observed in outcomes, particularly pain, as reflected by high I ^2^ values.

While the literature suggests that the use of RR is consistently associated with lower pain scores, the prevailing question remains, “Why are Merocel packs still frequently used?” The determining factor may be related to the cost. Badran et al. highlighted the cost discrepancy between RR and Merocel [14]. This study revealed that Merocel packs were notably more economical, priced at £2.61 per pack, compared to RR packs at £8.50 per pack [14]. Although Merocel's cost per pack is less expensive than RR's, a long‐term cost analysis is needed to evaluate cost associated with rebleeding. Further evaluations regarding cost of the respective packing material, including a robust cost‐effectiveness analysis from a societal perspective may help further establish the preferred method of nasal packing.

Limitations

A limitation was the high and moderate risk of bias identified in a substantial number of the studies reviewed. This high risk of bias was mainly present due to a lack of transparent reporting. A conservative estimate of the risk of bias was noted, as the RoB‐2 tool, which focuses on RCT methodology, was applied despite the inclusion of non‐RCT studies in the review. Given that many studies were RCTs, a consistent framework was applied, which also helps mitigate the limitations and potential biases inherent in non‐RCT studies. Additionally, high heterogeneity was observed across multiple outcomes, especially pain scores (I ^2^ values exceeding 90% in several comparisons). This likely stems from inconsistencies in pain and bleeding measurement scales, timing of assessments, and differences in procedural protocols. Although random‐effects models were used to account for this, the variability limits the precision and generalizability of the pooled estimates.

Addressing the heterogeneity in bleeding and inconsistency in timing of pain assessments through standardized methodologies and reporting criteria will be crucial for enhancing the reliability and comparability of future research in this field.

Conclusion

RR is associated with reduced pain upon removal for management of primary and post‐surgical epistaxis. Although not significant, RR generally demonstrated lower rebleed rates. Given the high heterogeneity and presence of publication biases across several outcomes, further primary research is needed to comprehensively evaluate the overall rebleed, pain, and cost‐effectiveness of nasal packing modalities.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information