Whitehead's varnish is a little known but excellent nasal packing agent. We review available literature on the historical aspects and clinical use of Whitehead's varnish. Our personal experience with Whitehead's varnish is described, and we strongly recommend its use

Howard, D

Lew-Gor, S

Lim, M

Lund, VJ

Sandhu, G

UCL Discovery

The Journal of Laryngology &amp; Otologyhttp://journals.cambridge.org/JLOAdditional services for The Journal of Laryngology &amp; Otology:Email alerts: Click hereSubscriptions: Click hereCommercial reprints: Click hereTerms of use : Click hereWhitehead's varnish nasal packM Lim, S Lew­Gor, G Sandhu, D Howard and V J LundThe Journal of Laryngology & Otology / Volume 121 / Issue 06 / June 2007, pp 592 ­ 594DOI: 10.1017/S0022215106005305, Published online: 08 December 2006Link to this article: http://journals.cambridge.org/abstract_S0022215106005305How to cite this article:M Lim, S Lew­Gor, G Sandhu, D Howard and V J Lund (2007). Whitehead's varnish nasal pack. The Journal of Laryngology & Otology, 121, pp 592­594 doi:10.1017/S0022215106005305Request Permissions : Click hereDownloaded from http://journals.cambridge.org/JLO, IP address: 144.82.107.84 on 09 Oct 2012Short CommunicationWhitehead’s varnish nasal packM LIM, S LEW-GOR, G SANDHU, D HOWARD, V J LUNDAbstractWhitehead’s varnish is a little known but excellent nasal packing agent. We review available literature on thehistorical aspects and clinical use of Whitehead’s varnish. Our personal experience with Whitehead’s varnishis described, and we strongly recommend its use.Key words: Cavity Varnishes; Nasal Cavity; IodoformIntroductionThe ideal material for emergency nasal or paranasal sinuscavity packing for epistaxis, or in the post-surgicalcontext, should fulfil several criteria. It should aidhealing, be analgesic, and have haemostatic and antisepticproperties. It should also be cheap, with few undesirableside effects. Various packing material have been used,including Rapid Rhinow Riemann, Telfaw and Merogelw(hyaluronic acid pack). When bleeding is more likely (e.g.excision of a sinonasal tumour), other packing agentssuch as Merocelw and bismuth subnitrate–iodoform pastehave been employed.We describe the clinical use and explore the historicalbackground of Whitehead’s varnish pack – forgotten inmany parts of the country but, in our experience, a packingagent of tremendous value.The life of Walter WhiteheadWalter Whitehead was born at Haslam Hey, Bury, on 12October 1840. He came from an illustrious family of inven-tors, including Robert Kay (his maternal great great grand-father and inventor of the drop-box used in weaving), JohnKay (his maternal great great great grandfather and inven-tor of the fly-shuttle) and Robert Whitehead (his uncle andinventor of the torpedo).Whitehead attended Making Place School at Ripponden,Halifax, where he did well. At the age of 16 years, he enteredhis father’s bleaching business. However, he often foundmore pleasure in the company of medical students at theManchester Royal Infirmary, and soon enrolled into theChatham Street School of Medicine, Manchester. He quali-fied in 1864, and in 1866 became a Fellow of the RoyalCollege of Surgeons of Edinburgh. In 1873, he wasappointed honorary assistant surgeon to the ManchesterRoyal Infirmary, and became honorary surgeon there in1879. He served in the same hospital until 1900, when heretired at the age of 60. He died 13 years later (19 August1913).In 1894, Walter Whitehead was appointed professor ofclinical surgery in Owen’s College, Victoria University,Manchester. Although he certainly commanded therespect of his pupils, it is said that he did very littleteaching. However, when he did conduct bedside teaching,his ward classes were always well attended. In 1902, he waselected president of the British Medical Association, whichin the same year held its annual meeting in Manchester.The success of this meeting was largely attributed to White-head’s organisational skills and social spirit.During his career, Whitehead published nearly 50articles. In 1870, he established, together with a friend,the publication Manchester Medical and Surgical Reports.One of his most important early papers (on colitis) waspublished in this journal in 1870.Whitehead was a pioneer of several surgical procedures.The three most important of these include a modificationof a method for tracheostomy, removal of haemorrhoidsand excision of the tongue. In modifying the method fortracheostomy, he described the use of a raspatory to getdown to the trachea following incision through skin andfascia. He felt that this method was easier, caused lesshaemorrhage and required fewer instruments.1 Withregards to haemorrhoid excision, he wrote the originalpaper in 1882 describing in great detail his surgical method-ology.2 In 1887, he published a further paper reporting aseries of 300 cases, in which he proudly professed that ‘tothe best of my knowledge, every patient has been comple-tely and permanently cured’.3In 1891, Whitehead published a paper, in both theBritish Medical Journal and the Lancet,4,5 reporting 100cases of excision of the entire tongue. It was in this paperthat he described what we now know as Whitehead’sointment.Whitehead’s varnishHistoryIn his original 1891 article on excision of the tongue,Whitehead carefully described the treatment of the floorof the mouth after the tongue had been removed.4,5 First,he used a mercurial solution of biniodide to swab the rawsurface. After this had dried, he reported ‘finally paintingthe surface with the iodoform styptic varnish which I intro-duced in 1881’. He goes on to describe the preparation ofthis iodoform varnish, which consists of Friar’s balsamwithout its original spirit, a saturated ethereal solution ofFrom the Department of Otolaryngology, Royal National Throat, Nose and Ear Hospital, London, UK.Accepted for publication: 20 October 2006.The Journal of Laryngology & Otology (2007), 121, 592–594.# 2006 JLO (1984) Limiteddoi:10.1017/S0022215106005305Printed in the United KingdomFirst published online 8 December 2006592iodoform and, mixing with the ether, one volume in 10 ofturpentine. Whitehead wrote that this preparation hadantiseptic and anaesthetic properties, the anaesthetic prop-erties such that ‘it enables the patient to take food in theordinary manner almost immediately after the operation’.The addition of turpentine also had a ‘very marked influ-ence in promptly checking the capillary oozing’.Chemical propertiesWhitehead’s varnish is also known as Whitehead’s oint-ment, iodoform varnish and compound iodoform paint(Figure 1). The active ingredient in Whitehead’s varnishis iodoform, or tri-iodomethane. This consists of a centralcarbon atom with one hydrogen and three iodine atoms(CHI3). Iodoform exists as shining yellow crystals orpowder at room temperature and is practically insolublein water. Thus, it is prepared in topical form as ether, inwhich it is soluble one in eight.6 Other excipients includebenzoin (British preparation), storax (British preparation)and tolu balsam (British preparation), all constituents ofFriar’s balsam (tincture of benzoin).Pharmacodynamic and pharmocokinetic propertiesIodoform releases elemental iodine when applied totissues. Systemic absorption of iodine can occur on pro-longed or extensive application to open wounds. Thismay cause adverse effects, including sensitivity reactions,systemic toxicity and aggravation of thyroid disorders. Asa precaution, not more than 2 g (or 20 ml of Whitehead’sointment) should be administered to a wound.Clinical useWhitehead’s varnish forms a protective ‘skin’ covering forwounds and thus may be directly applied to wounds as adressing. Due to its adhesive properties, Whitehead’svarnish will also help in holding gauze dressings inposition. The iodoform released has a marked anaestheticaction when applied to mucosal membranes.6In a randomised, controlled trial on skin autograft donorsite management, subjects were randomised into twogroups: one group receiving Jelonetw to the donor siteand the other group being dressed with both Jelonet andWhitehead’s varnish.7 Whitehead’s varnish significantlyreduced donor site pain compared with the standard dres-sing (p ¼ 0.0006). Although overall healing time was notstatistically different in the two groups, larger donor sitestreated with Jelonet and Whitehead’s varnish healedmore quickly than those treated with the standard dressingalone. Interestingly, because of its anaesthetic action, it hasbeen reported that Whitehead’s varnish may affect peri-pheral nerve function and may be responsible for post-operative sensory disturbances,8 although we have had nocases with this problem in our experience.In our practice, we use 2.5 cm wide ribbon gauze soakedin Whitehead’s varnish to pack nasal cavities and neckwounds after surgery (Figure 2). A practical point to noteis that, once soaked in Whitehead’s varnish, the ribbongauze must be packed immediately, as the ether in the oint-ment evaporates quite quickly. In addition, the presence ofether in the varnish means that diathermy should not beused after the pack has been inserted.Following excision of sinonasal tumours, we routinelypack patients’ postsurgical nasal or paranasal cavities tosecure haemostasis. The pack is left in situ for five toseven days on average, but larger cavities (e.g. afterFIG. 1Whitehead’s varnishFIG. 22.5 cm ribbon gauze soaked in whitehead’s varnishWHITEHEAD’S VARNISH NASAL PACK 593craniofacial resection) may be packed for 10 days.Although Whitehead’s varnish has an antiseptic effect,antibiotics are prescribed for the duration of the pack, asthe ribbon gauze still represents a foreign body in thenasal cavity. Removal of the pack (Figure 3) should be per-formed under a general anaesthetic as it can be quitepainful.We reviewed all our cases receiving Whitehead’s varnishpack insertion over the previous four and a half years.There were 421 cases in total over this period. No adverseeffects were reported in any of the cases.The same soaked ribbon gauze can be used as emergencynasal packing in patients with epistaxis. In contrast to thecommonly used bismuth nitrate–iodoform paste, whichalso contains iodoform, Whitehead’s varnish on ribbongauze has the important advantage of being minimallyirritative to the mucosal lining of the nose. Additionally,iodoform toxicity has been reported following use ofbismuth nitrate–iodoform paste packing in large cavities,and it has been suggested that Whitehead’s varnish is asafer alternative in this instance.9The compressive effect of a Whitehead’s varnish packnot only secures haemostasis but may also be used toapply pressure on a skin/fascia graft used in cerebrospinalfluid (CSF) leak repair or septodermatoplasty. In thesecases, we first glue the graft into place with bioglue andthen interpose a layer of Gelfoamw between the graft andthe Whitehead’s pack to prevent adherence between thetwo.ConclusionThe use of Whitehead’s varnish in nasal or paranasal cavitypacking is safe and effective. It is especially useful forpacking following excision of sinonasal tumours, whichtend to bleed. It may also be employed in cases in whicha skin or fascia graft is used (e.g. septodermatoplasty orCSF leak repair), to aid in holding the graft in placewhilst concomitantly securing haemostasis. The advantageof the Whitehead’s pack in these instances is that it pro-vides firm compression without chemically damaging thenasal mucosa. It further provides an anaesthetic effectand may aid in the wound healing process. It is safe andrelatively inexpensive. We would strongly recommend itsuse in these instances. Indeed, it is pack worthy of thename by which it has been called.References1 Whitehead W. Tracheotomy. Lancet 1887;30 April:8732 Whitehead W. The surgical treatment of haemorrhoids.BMJ 1882;4 February:148–503 Whitehead W. Three hundred consecutive cases of haemor-rhoids cured by excision. BMJ 1887;26 February:449–514 Whitehead W. A hundred cases of entire excision of thetongue. BMJ 1891;961–45 Whitehead W. Report of 104 cases of entire excision of thetongue for cancer. Lancet 1891;1032–56 Martindale. The Extra Pharmacopoeia, 28th edn. London:Pharmaceutical Press, 19827 Stanley D, Emerson DJ, Daley JC. Whitehead’s varnish andJelonet – a better dressing for skin graft donor sites thanJelonet alone. Ann R Coll Surg Engl 1988;70:369–718 Loescher AR, Robinson PP. The effect of surgical medica-ments on peripheral nerve function. Br J Oral MaxillofacSurg 1998;36:327–329 O’Connor AF, Freeland AP, Heal DJ, Rossouw DS. Iodo-form toxicity following the use of B.I.P.P.: a potentialhazard. J Laryngol Otol 1977;91:903–7Address for correspondence:Mr Mingyann Lim,Department of Otolaryngology,Royal National Throat, Nose and Ear Hospital,330–336 Grays Inn Rd,London WC1X 8EE, UK.E-mail: mingyannl@yahoo.comMr M Lim takes responsibility for the integrityof the content of the paper.Competing interests: None declaredFIG. 3Removal of whitehead’s packM LIM, S LEW-GOR, G SANDHU et al.594

Whitehead's varnish nasal pack

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Whitehead's varnish nasal pack

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