Nasal bleeding, also known as epistaxis, is among the most common emergencies in otolaryngology. A range of bleeding can be seen: from mild, self-limited bleeding to severe bleeding requiring emergency care [1]. An abundant population-based study estimates it affects around 10-12% of the general population at some point in their lifetime and has a bimodal distribution: a peak in children younger than 10 years, and another in adults older than 50 years. Most epistaxis is anterior and is benign. Posterior epistaxis, while less frequently seen, carries a potentially more severe hemorrhagic burden and is harder to control [2]. The anterior nasal septum is the most common site for epistaxis, with Kiesselbach’s plexus (also commonly referred to as Little’s area) considered the most common vascular source. Most common inciting factors for epistaxis are local trauma (nose picking, nasal instrumentation), dry mucosa, infection, septal deviation, hypertension, and anticoagulant use. Environmental causes of low humidity and sudden temperature changes make the nasal mucosa more fragile. The primary objectives of epistaxis management are to control the bleeding, prevent future recurrence, and make the patient comfortable [3]. Standard management for anterior nasal hemorrhage is anterior nasal packing which mechanically tamponades the bleeding source and obtain hemostasis. Although this is effective, there are a number of disadvantages. Patients experience a high degree of discomfort, nasal obstruction, and difficulty breathing during the packing time [4]. Additionally, anterior nasal packing has many side effects, including mucosal trauma, infection, pressure necrosis, synechiae, and then rebleeding when it is removed. All of these drawbacks led to looking for alternative, less invasive equally effective methods of hemostasis [5]. Tranexamic acid (TXA), a synthetic lysine analogue, is an antifibrinolytic by competitively inhibiting the plasminogen-to-plasmin activation, stabilizes the fibrin clot, and maintains hemostasis. While traditionally used for systemic control of bleeding during surgical or trauma cases, TXA has of late been employed as a topical application in nosebleeds [6]. Because of its topical application on the nasal mucosa using pledgets soaked in TXA, it establishes clot stabilization at the site without any systemic side effects. Studies have shown topical TXA leads to faster hemostasis, improved patient tolerance and less time in the hospital compared with the traditional anterior nasal packing protocol [7]. The topical method is exceptionally simple, which makes it particularly appropriate for use in the emergency department and nonemergency situations. This method avoids the complications and discomfort associated with nasal packing while achieving equivalent hemostatic efficacy. Additionally, it represents a safe and cost-effective option, particularly in patients who have contraindications to nasal packing or comorbidities affecting their systemic status. Even with the increasing body of data supporting topical use of TXA, anterior nasal packing remains the standard and preferred first line management for many centers. The availability of comparative data from controlled studies in India and our local vicinity is still limited, especially regarding comfort to the patient, complications, and recurrences. As such, it is worthwhile to conduct a comparative study of topical application of injection tranexamic acid and either anterior nasal packing in the care of patients with nose bleeds with respect to their efficacy, comfort, recurrences, and overall clinical outcomes, to establish an evidenced based alternative to nasal packing.

Study design and setting This was a comparative clinical study designated as prospective and randomized which was carried out in the Department of Otorhinolaryngology in a tertiary medical teaching institution over twelve months (January 2024 to December 2024). The purpose of the study was to compare the therapeutic motive and safety of the topical application of injection tranexamic acid with conventional anterior nasal packing in patients with anterior epistaxis. Ethical approval for the study was obtained from the Institutional Ethics Committee prior to the study beginning, and all participants provided informed consent. Study population A total of 120 patients aged between 18 and 70 years who presented with anterior nasal bleeding were included. Patients with posterior epistaxis, bleeding diathesis, trauma-related fractures, nasal tumors, uncontrolled hypertension, or those on anticoagulant therapy were excluded to maintain uniformity in case selection. Randomization and grouping Eligible patients were randomly allocated into two equal groups (n = 60 each) using a computer-generated randomization sequence: • Group A: Treated with topical application of injection tranexamic acid (TXA). • Group B: Treated with conventional anterior nasal packing using ribbon gauze impregnated with antibiotic ointment. Intervention procedures • Group A (Topical TXA application): A sterile cotton pledget soaked in 5 mL of injection tranexamic acid (500 mg/5 mL) was applied directly to the identified bleeding site or the suspected anterior septal region (Kiesselbach’s plexus) for 10 minutes under aseptic precautions. Gentle pressure was maintained externally over the nasal alae. After removal, the nasal cavity was re-examined for active bleeding. If hemostasis was achieved, no further intervention was done. • Group B (Anterior nasal packing): Local anesthesia with 4% lignocaine and 1:100,000 adrenaline was applied using cotton pledgets. A sterile ribbon gauze impregnated with antibiotic ointment was carefully packed into the affected nasal cavity layer by layer until adequate tamponade was achieved. The pack was left in place for 48 hours, and patients received systemic antibiotics and analgesics during this period. Outcome measures The following parameters were recorded and compared between both groups: 1. Time to achieve hemostasis: Measured from the initiation of treatment until complete cessation of bleeding. 2. Patient discomfort: Evaluated using a 10-point Visual Analog Scale (VAS), where 0 represented no discomfort and 10 represented unbearable pain or discomfort. 3. Recurrence of bleeding: Monitored within 48 hours after initial hemostasis. 4. Complications: Including mucosal trauma, infection, rebleeding upon pack removal, and nasal obstruction. 5. Duration of hospital stay: Recorded in hours from admission until discharge after hemostatic stability. Post-procedure care and follow-up All patients were observed for a minimum of six hours after the procedure. In the TXA group, patients were discharged once hemostasis was stable and there was no evidence of rebleeding within the observation period of at least six hours. For the packing group, the packs were removed after 48 hours, and patients were re-evaluated for rebleeding. Follow-up was done at one week and two weeks post-procedure to assess for delayed complications or rebleeding. Statistical analysis Data were compiled in Microsoft Excel and analyzed using IBM SPSS Statistics version 26. Quantitative variables were expressed as mean ± standard deviation (SD) and compared using the independent sample t-test. Categorical variables were expressed as frequencies and percentages and analyzed using the chi-square test. A p-value of less than 0.05 was considered statistically significant.

A total of 120 patients with anterior epistaxis were included in this study, divided equally into two groups Group A (topical application of injection tranexamic acid) and Group B (anterior nasal packing). Both groups were comparable in terms of demographic characteristics, comorbidities, and bleeding etiology. The results demonstrated that topical tranexamic acid was significantly more effective in achieving faster hemostasis, caused less patient discomfort, and reduced hospital stay compared to traditional nasal packing, while maintaining similar recurrence rates. Table 1: Demographic characteristics of the study population Table 1 shows that both groups were comparable in age, gender, and presence of systemic comorbidities, eliminating baseline demographic bias. Variable Group A (TXA) (n = 60) Group B (Packing) (n = 60) p-value Mean age (years) 45.8 ± 13.2 46.5 ± 12.8 0.78 Gender (Male/Female) 37/23 35/25 0.69 Hypertension (%) 16 (26.6%) 17 (28.3%) 0.84 Diabetes mellitus (%) 9 (15%) 10 (16.6%) 0.79 Smoking history (%) 11 (18.3%) 10 (16.6%) 0.82 Table 2: Distribution of etiology of anterior epistaxis Table 2 represents the causes of epistaxis, showing trauma and idiopathic factors as the leading causes in both groups. Etiology Group A (n = 60) Group B (n = 60) Digital trauma/nose picking 22 (36.6%) 20 (33.3%) Hypertension 10 (16.6%) 12 (20%) Upper respiratory infection 9 (15%) 10 (16.6%) Dryness/crusting 8 (13.3%) 7 (11.6%) Idiopathic 11 (18.3%) 11 (18.3%) Table 3: Site of bleeding Table 3 shows that the anterior septal region (Kiesselbach’s plexus) was the most frequent bleeding site in both groups. Site Group A (n = 60) Group B (n = 60) Anterior septum (Little’s area) 49 (81.6%) 50 (83.3%) Inferior turbinate 8 (13.3%) 7 (11.6%) Lateral nasal wall 3 (5%) 3 (5%) Table 4: Time to achieve hemostasis (minutes) Table 4 indicates that patients treated with topical tranexamic acid achieved hemostasis significantly faster than those treated with nasal packing. Parameter Group A (TXA) Group B (Packing) p-value Mean time to achieve hemostasis (minutes) 4.6 ± 1.2 8.9 ± 2.7 <0.001 Table 5: Patient discomfort scores (VAS 0–10) Table 5 demonstrates that patients treated with topical TXA reported significantly lower discomfort compared to those who underwent nasal packing. Parameter Group A (TXA) Group B (Packing) p-value Mean discomfort score 2.3 ± 1.1 6.8 ± 1.6 <0.001 Table 6: Recurrence of bleeding within 48 hours Table 6 shows a slightly lower recurrence rate in the TXA group, though the difference was not statistically significant. Recurrence Group A (TXA) Group B (Packing) p-value Yes 4 (6.7%) 8 (13.3%) 0.21 No 56 (93.3%) 52 (86.7%) — Table 7: Complications observed during treatment Table 7 represents the frequency of complications, highlighting that nasal packing was associated with higher mucosal trauma and infection rates. Complication Group A (TXA) Group B (Packing) Mucosal trauma 1 (1.6%) 7 (11.6%) Secondary infection 0 5 (8.3%) Rebleeding after removal 2 (3.3%) 6 (10%) Nasal obstruction 1 (1.6%) 12 (20%) Table 8: Duration of hospital stay (days) Table 8 indicates that patients treated with topical TXA had significantly shorter hospital stays compared to those receiving nasal packing. Parameter Group A (TXA) Group B (Packing) p-value Mean hospital stay (days) 0.9 ± 0.4 2.1 ± 0.7 <0.001 Table 9: Need for additional interventions Table 9 shows that the requirement for additional procedures such as cautery or repacking was lower in the TXA group. Intervention required Group A (TXA) Group B (Packing) p-value Yes 3 (5%) 9 (15%) 0.08 No 57 (95%) 51 (85%) — Table 10: Patient satisfaction scores (0–10 scale) Table 10 reflects higher satisfaction among patients in the TXA group due to faster relief and less discomfort. Parameter Group A (TXA) Group B (Packing) p-value Mean satisfaction score 9.0 ± 0.7 6.5 ± 1.3 <0.001 Table 11: Follow-up outcomes at 2 weeks Table 11 shows that no delayed complications or recurrent episodes were reported in either group during follow-up. Parameter Group A (TXA) Group B (Packing) Recurrence 1 (1.6%) 2 (3.3%) Infection 0 1 (1.6%) Septal crusting 2 (3.3%) 3 (5%) Table 12: Summary of comparative outcomes Table 12 consolidates the overall findings, highlighting the clinical advantages of topical TXA over conventional nasal packing. Parameter Topical TXA Nasal Packing Significance Hemostasis time Faster Slower p < 0.001 Patient discomfort Minimal High p < 0.001 Recurrence Lower Slightly higher NS Complications Rare Frequent p < 0.05 Hospital stay Shorter Longer p < 0.001 Satisfaction High Moderate p < 0.001 Table 1 confirms demographic parity between both groups, ensuring reliable comparison. Table 2 establishes that trauma and idiopathic factors were the primary causes of anterior epistaxis. Table 3 indicates the anterior septum as the predominant bleeding site, consistent with known anatomical patterns. Table 4 highlights that topical TXA achieved significantly faster hemostasis than nasal packing. Table 5 shows that topical TXA provided far greater comfort, reflected by lower discomfort scores. Table 6 indicates a lower recurrence rate with topical TXA, though statistically insignificant. Table 7 demonstrates that nasal packing was associated with higher rates of mucosal trauma and infection. Table 8 establishes that hospital stay was significantly shorter with topical TXA due to rapid recovery. Table 9 reveals fewer additional interventions were required in the TXA group, reflecting effective primary control. Table 10 confirms superior patient satisfaction in the TXA group owing to faster relief and minimal discomfort. Table 11 shows favorable follow-up outcomes with minimal delayed complications in both groups. Table 12 consolidates the results, clearly favoring topical TXA as a safer, more efficient, and patient-friendly approach for managing anterior epistaxis.

The present comparative study evaluated the effectiveness of topical application of injection tranexamic acid versus conventional anterior nasal packing in the management of anterior epistaxis. The findings clearly demonstrated that the topical use of tranexamic acid achieved faster hemostasis, greater patient comfort, fewer complications, and a shorter hospital stay compared to traditional nasal packing, while maintaining comparable control of rebleeding. These results strongly suggest that topical tranexamic acid is a superior, minimally invasive, and patient-friendly alternative for managing anterior nasal bleeding [9]. Epistaxis is one of the most frequently encountered ENT emergencies, and while anterior nasal bleeding is usually benign, it can cause significant anxiety for patients and requires immediate, effective management. Conventional anterior nasal packing has long been considered the gold standard for initial control of bleeding, primarily through mechanical tamponade [10]. However, despite its effectiveness, nasal packing is associated with considerable discomfort, nasal obstruction, infection, and potential mucosal injury. In contrast, topical tranexamic acid achieves hemostasis pharmacologically by stabilizing the fibrin clot through antifibrinolytic activity, thereby avoiding many of the complications linked to physical packing [11]. In the current study, the mean time to achieve hemostasis was significantly shorter in the tranexamic acid group, averaging around five minutes, compared to nearly nine minutes in the packing group. This difference highlights the rapid clot-stabilizing action of topical TXA, which provides effective local hemostasis without requiring mechanical compression. The quicker control of bleeding also allowed early discharge and reduced the need for hospital observation, reflecting an important practical advantage, especially in busy emergency settings [12]. Patient comfort emerged as another key differentiating factor between the two modalities. The topical TXA group reported very low discomfort scores on the visual analog scale, while the nasal packing group experienced substantial pain and nasal obstruction during the intervention and subsequent 48-hour packing period. The discomfort associated with packing often results from mucosal pressure, impaired breathing, and crust formation. Eliminating the need for packing thus directly improves patient tolerance and overall satisfaction with treatment [13]. The TXA group had a lower rate of re-bleeding within 48 hours compared to the packing group, but the difference was not statistically significant. Both modalities performed comparably in transient hemostasis. The TXA group also had fewer complications leading to a higher level of efficacy, since they experienced less support at the level of clot formation and secondary trauma, likely due to a much lower incidence of any of the mucosa being dislodged as a result of displacing the packing. These findings suggest that the addition of TXA to control bleeding provides similar efficacy as mechanical tamponade but with more stable clot formation and less mucosal disruption [14]. The rate of complications in the TXA group continued to be low compared to the packing group. Rates of complications in the packing group included: mucosal trauma, secondary infection, nasal obstruction, or rebleeding upon removal of packing. These complications lead to longer recovery time and may lead to unnecessary prescribing of antibiotics or extended lengths of stay from the hospital. These considerations and complications associated with the packing group were not noted with the TXA group and further demonstrates the safety and atraumatic nature of topical antifibrinolytic therapy [15]. The shorter length of hospital stay seen in the tranexamic acid group is likely due to the fact the intervention was minimally invasive and hemostatic response was rapid. TXA patients were, on average, able to go home within 24 hours of receiving treatment, while patients who had nasal packing required more observation time due to the time commitment associated with nasal packing, including removal and reassessment after removal. The ability to manage patients effectively from an outpatient or short-stay approach may have important ramifications on healthcare resource allocation and patient convenience [16]. Patients who received tranexamic acid also had higher satisfaction rates after receiving treatment. Positive aspects included the absence of discomfort, immediate hemostatic control of bleeding, and recovery profile. In contrast, patients receiving nasal packing frequently reported pain, disturbed sleep, mouth breathing, and anxiety after removing the nasal packs. These findings support the need to prioritize patient comfort as well as clinical effectiveness in emergency ENT [17]. This study proved that it is possible to use topical TXA in an emergent setting. The method is sufficiently simple and quick and does not require advanced technical ability, making it appropriate for use in both tertiary care hospitals and primary care settings. Because tranexamic acid can be purchased in a preloaded syringe, it can easily be applied with a sterile pledget, and quickly accessed and used, as appropriate. The potential benefit of the topical application is also that it has a minimal systemic absorption, which may allow use in patients with contraindications to systemic antifibrinolytics, such as in patients with hypertension or cardiovascular disease [18,19]. Additionally, the results of this study may suggest tranexamic acid would be beneficial to any elderly patients and/or patients who may be at a higher risk for recurrences of anterior epistaxis related to antiplatelet therapy. Because of the non-invasive nature of application of TXA, risk may be decreased of having additional trauma to the mucosa; and may also decrease delay and discomfort of prolonged anterior nasal packing in these aforementioned populations. Its cost-effectiveness and rapid time of action would also make this preferred as a first-line treatment in resource-limited care settings [20]. In conclusion, this study demonstrates strong evidence supporting the safety and efficacy of using topically-administered tranexamic acid as an alternative treatment for anterior epistaxis. Tranexamic acid appears faster to achieve hemostasis, more comfortable, and has lower complication rates in compared to nasal packing, thus making this a more practical solution while in the ED. Tranexamic acid and nasal packing did have comparable long-term control of bleeding despite the ease of TXA making it favorable. Large-scale multi-center studies with larger sample sizes and longer follow-up could further substantiate our findings and examine the use of topical tranexamic acid as a treatment option for posterior or recurrent epistaxis. Incorporation of TXA into the formal emergency protocol could enhance future outcomes when managing nasal bleeding in the emergency room or outpatient settings.

In conclusion, this comparative study demonstrates that topical injection tranexamic acid therapy is a safe and effective patient-centered approach to managing anterior epistaxis. Topical tranexamic acid therapy leads to significantly faster hemostasis and has been shown to reduce discomfort and complications related to the procedure (eg, trauma, infection, and rebleeding). Rapid hemostatic response allows for rapid discharge and time in the emergency department or outpatient clinic, which makes this treatment useful in either milieu. Patient satisfaction was significantly increased over conventional packing, likely due to the comfort and ease of the treatment. The efficacy of tranexamic acid, rather than packing relying on mechanical pressure, is attributed to tranexamic acid physiologically stabilizing and strengthening the clot, maintaining hemostasis without injury to normal tissue. Its availability, affordability, and ease of application eliminates barriers, particularly in health systems that lack sufficient funds. Importantly, topical tranexamic acid does not expose the patient to systemic tranexamic acid and can be utilized in patients with comorbidities, where traditional packing may not be recommended. The recurrence rates found with the topical tranexamic acid therapy suggest the treatment is an acceptable definitive therapy. Therefore, the topical use of injection tranexamic acid should be considered a first-line therapy in managing anterior epistaxis, offering a modern, comfortable, and clinically more successful treatment option compared to routine nasal packing.

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