FloSeal is a biodegradable hemostatic sealant composed of cross-linked gelatin granules and topical human-derived thrombin that is applied as a high-viscosity gel. One of FloSeal’s advantages is that it does not require platelet activation, allowing it to function fully even in anticoagulated patients. The product comes in three separate components needing several minutes to mix. A specially designed applicator is used to apply the solution liberally to the bleeding surface. Using forceps, place a moistened piece of gauze over the FloSeal matrix for 1-2 minutes to ensure the material remains in contact with the bleeding tissue. In cases of persistent bleeding, the applicator tip is inserted through the center of the matrix to deliver fresh material as close as possible to the tissue surface.

One study of 70 patients showed FloSeal able to stop 97% of epistaxis within 2 minutes.4 It is safe and better tolerated than packing, and it avoids a return visit, as it begins to break down within 3-5 days. Cost is $1,079.40 for a 6-pack, or $180 per use.

The Thrombin-JMI Epistaxis Kit is a bovine-derived topical thrombin that was released in 2008. It requires mixing of the thrombin powder with the saline diluent prior to use. After it is drawn up in a 5-mL syringe, a special nasal drug delivery device is attached. The contoured tip is inserted into the naris, and the solution is sprayed as a fine mist across the nasal mucosa. Approximately half (2.5 mL) should be used initially and the remainder utilized after 3-5 minutes if bleeding persists. There are no published articles on this product. Cost is $60 per kit.

Anterior packing is often inadequate to control bleeding from the posterior nasal cavity. These bleeds can be difficult to treat and require either balloon insertion or a formal posterior pack. The most commonly used posterior pack is a Foley catheter (size 12 or 14 French), which is lubricated and then advanced until the tip and balloon are entirely in the nasopharynx. The balloon is filled with sterile saline (usually 5-10 cc) to allow it to be pulled snugly against the posterior nasal choana with anterior traction. The Foley is secured by placing an umbilical or c-clamp on the catheter at the level of the nasal ala with padding in between to prevent pressure injury.

An alternative posterior pack, the Epistat or Storz T3100 nasal catheter, has separate anterior and posterior balloons. The device is inserted until the posterior balloon enters the posterior nasal cavity, inflated with 5-10 mL of saline, and then gently pulled forward until snug. The anterior balloon is then filled with up to 15-30 mL of saline. The Epistat II has a posterior balloon and an anterior Merocel nasal tampon. Although quick and easy to place, the balloon packs may not always be successful as they tend to fill in areas of least resistance. The packs also sometimes put severe pressure on the septum and can be quite painful.