The CAVI-T Treatment
The CAVI-T device (dianosic@, Strasbourg, France) is a new, asymmetric, low-pressure balloon with European agreement for epistaxis treatment.
The introduction is very simple with a specific guide.
After nose cleaning, the asymmetric CAVI-T balloon is inserted with the guide placing the marker at the level of the columella - marker 1 (anterior bleeding) or the marker 2 (posterior bleeding) - picture. The balloon is inflated with air (around 10 cc) and then the guide is removed. If necessary, the balloon can be inflated up to 25 cc to control epistaxis. A balanced inflating is necessary to limit the risk of expulsion of a hyperinflated balloon.
After 48 hours, the asymmetric CAVI-T balloon can be deflated.
After epistaxis is controlled, the balloon is left in place for further 24 hours. With no epistaxis recurrence, the balloon can be withdrawn.
For our two patients, this balloon was easily introduced in each nasal fossa. The epistaxis was controlled and there was no recurrence after deflating the balloons.
Discussion
COVID-19 is a highly contagious pathology and otorhinolaryngologist can be easily infected. (3)
Epistaxis in ICU patients results from several associated factors including oxygen therapy, nasogastric tubes and the use of therapeutic anticoagulation. The oxygen therapy dries the nasal mucosa making it more fragile. Insertion of nasogastric tube may be traumatic. High proportion of ICU patients require therapeutic anticoagulation. (2)
Traditional techniques (packing) of epistaxis control must be tried before considering using nasal balloon. (1)
Numerous types of absorbable nasal packing are available in the market (1) and the use of one type over another is a personal choice. Non-absorbable nasal packing can also be used. The usage of such material seems to be more efficient for some ENT teams (1). However, it presents the risk of recurrence of epistaxis during the unpacking. (1)
Probes with double balloon are used when nasal packing is insufficient. While these devices carry the advantage of being efficient and easy to use, they could be a painful technique. These probes are stiff and the introduction can be traumatic.
The last alternative is a surgical or a radiological approach with ligation or embolization of the sphenopalatine artery. These procedures could expose the patient to major complications.(1)
In this therapeutic arsenal of epistaxis, the CAVI-T balloon can find its place in managing resistant epistaxis after traditional nasal packing.
In our experience, in ICU patients with Covid 19 the advantages of this new balloon were:
This paper has several limits relating to the small number of patients, the single institution report, and the novel tool used .However this device seems to be a very effective tool for COVID-19 patients with epistaxis and for the medical staff.
Conclusion: Epistaxis management in COVID-19 patients can be challenging. The asymmetric CAVI-T balloon can be a useful alternative due to its efficacy and the increased protection of medical staff while handling the device with the specific introducer.
Conflict of interest: None
Biblio
  1. Tunkel DE, Anne S, Payne SC, Ishman SL, Rosenfeld RM, Abramson PJ, Alikhaani JD, Benoit MM, Bercovitz RS, Brown MD, Chernobilsky B, Feldstein DA, Hackell JM, Holbrook EH, Holdsworth SM, Lin KW, Lind MM, Poetker DM, Riley CA, Schneider JS, Seidman MD, Vadlamudi V, Valdez TA, Nnacheta LC, Monjur TM. Clinical Practice Guideline: Nosebleed (Epistaxis). Otolaryngol Head Neck Surg. 2020 Jan;162(1_suppl):S1-S38.
  2. Nicola M, O’Neill N, Sohrabi C, Khan M, Agha M, Agha R. Evidence based management guideline for the COVID-19 pandemic - Review article. Int J Surg. 2020 May;77:206-216.
  3. Workman AD, Jafari A, Welling DB, et al. Airborne aerosol generation during endonasal procedures in the era of COVID-19: risks and recommendations. Otolaryngol Head Neck Surg. 2020. https://doi.org/10.1177/01945 99820 931805
Figure 1: the CAVI-T device
Figure 2: the asymmetric balloon