Electrical or chemical cautery is generally the first line treatment for continuous nosebleeds that do not respond to simple compression of the nose. It results in coagulating the blood and tissues to stop bleeding. If cautery is not desired or warranted other options are implemented depending on whether the bleed is originating at the front or back of the nose.
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Anterior bleeds are those located at the front of the nose. Most nose bleeds are anterior. First line treatment of these bleeds involves compressing the nose with the fingers for 10 to 15 minutes while the person is seated and leaning forward. If this fails to stop the bleed, the next step is usually electrical or chemical cautery. If cautery is not desired, then anterior nasal packing is the next step. Various foams and gels coated with antibiotic ointments can be used. For example, Merocel is a compressed foam inserted into the nose and expanded by water to compress the site of bleeding. Rapid Rhino is inserted into the nose and expanded with air. These are generally not left in for more than a day to prevent damage to the nose. If these methods fail, the nose can be packed with ribbon gauze. If the packs are left in for more than 48 hours antibiotics are started to prevent infection.
Nasal packing at the front of the nose is often insufficient to stop bleeding at the back of the nose. In the case of posterior bleeds, the first choice treatment is often the insertion of a balloon device. Specialized balloons include the Brighton balloon, Epistat nasal catheter and Simpson plug. Alternatively, a Foley urinary catheter with a balloon at the end can be used.
When more conservative methods fail to stop a nosebleed, intervention by a radiologist or surgeon may be required. Radiologists can often plug the bleeding vessels with coils or other methods. Surgical treatments include tying off, or ligating, the bleeding vessels.
Fibrin is a protein in the blood that helps to stop bleeding. A fibrin glue has been developed that can be sprayed over the site of bleeding. It binds to damaged blood vessels and helps to curtail bleeding. According to an article in Post Graduate Medical Journal, side effects such as swelling, shrinking of tissues, and excess nasal discharge were lower than nasal packing, chemical cautery and electrocautery. The rebleed rate was similar to electrocautery, about 15 percent.
In cases where nosebleeds recur over and over, laser treatment of the vessels has been used with success. In this procedure, the patient is placed under anesthetic, a small camera and laser are inserted into the nose and the laser is applied to the are of the offending vessels.