Intranasal Topical Application of Tranexamic Acid in Atraumatic Anterior Epistaxis

Original paper





  • Intranasal topical TXA is associated with a lower rate of need for anterior nasal packing and a shortened stay in the ED

Bottom line

  • Topical TXA for epistaxis is slowly gaining traction despite recent negative study (NoPAC)
  • This RCT fits author’s own experience- ineffective for posterior bleeding, delayed presentations or traumatic epistaxis, but no harm and better tolerated than balloon tamponade device (RapidRhino etc)

What is this paper about

  • Double blinded, randomized controlled trial of 240 patients
  • Direct comparison of topical tranexamic acid + phenylephrine + 10% lidocaine for 15 minutes vs phenylephrine + 10% lidocaine, in the acute setting
  • Older studies and systemic review has demonstrated superiority compared to topical vasoconstrictor alone but methods were flaw. This is a quality RCT

Study design

  • Author’s stated goal is to reduce need for anterior nasal packing in adult patients with spontaneous atraumatic anterior epistaxis
  • Secondary outcome include
    • Staying in ED for > 2hours
    • Needing electrical cauterization
    • Re-bleeding within 24 hours after referral to ENT ED
    • Re-bleeding within 1 to 7 days
  • Single site study (a ENT walk-in acute clinic and regional referral center with procedural rooms and admission bed) based in a tertiary ENT hospital in Iran
  • Pt sequentially randomized at triage, numbered boxes at triage assigned to treating doctors to administered to pt
  • First aid is first applied – squeezing soft part of nose, cold water mouth gurgle 10 mins and ice pack to back of neck
  • Both study and control arm received 10mls phenylephrine hydrochloride and 5 puffs of 10% lidocaine spray, study arm also received 5mls of tranexamic acid solution (100mg/mL)


  • Pt 18 years or older
  • All must receive first aid (describe above), those who fail first aid is then recruit into this study
  • Definition of “persistent epistaxis” is well described
  • Excluded from study:- unstable hemodynamic, allergic to study drug, lack of consent, known upper airway malignancy, pregnancy, already had nasal packing prior to arrival, trauma (which include nose picking), known bleeding disorder, use of anticoagulant drugs (heparin, warfarin, NOAC and DOAC) and clopidogrel. Prisoners are excluded from this study
  • Important exclusion:- pt with known or suspected posterior epistaxis
  • Follow-up phone call or revisit, on 7th day of treatment









  • As shown on table 2, patients treated with TXA were significantly less likely to need anterior nasal packing (OR 0.56), stay in ED more than 2 hours (OR 0.38) or re-bleed within 24hours of admission (OR 0.41)

Weakness of study design

  • Pt selection in this paper may not be applicable to general settings – research doctors are all ENT trained. Research center sees 4500 pt monthly, 300 are epistaxis! Exclusion of posterior epistaxis is important and may explain lack of efficacy of TXA in previous studies
  • As author pointed out, enrolment only occurring during office hours (by research assistant) – ? characteristic of pt presenting during office hours ? more severe bleeding after hours