Epistaxis affects much of the population and accounts for 1 in 200 emergency room visits, with children and elderly being the most affected populations. [1] Currently, primary treatment includes standard measures such as silver nitrate cauterization, topical medication application with agents such as oxymetazoline, nasal packing, evaluation, and management by an otolaryngology specialist, and/or a combination of the above therapies [2] [3] . The use of tranexamic acid (TXA) is an emerging adjunct treatment for epistaxis, usually used to soak the packing material. However, the nebulized form of TXA is a leading alternative for definitive treatment of epistaxis which can also provide the patient with a more comfortable and less invasive option.

Tranexamic acid belongs to the class of medications called antifibrinolytics. It prevents excess blood loss by preventing blood clots from breaking down and achieves this by inhibiting the conversion of plasminogen into plasmin – the activated form of plasminogen that is responsible for the degradation of fibrin clots [4] . The drug is approved by the Federal Drug Administration for the treatment of heavy menstrual bleeding and short-term prevention for patients with hemophilia prior to dental procedures [5] . It also has many widely accepted off-label uses. Intravenously, it is used off-label in elective cesarean sections, non-traumatic subarachnoid hemorrhages, or orthognathic surgeries to reduce blood loss to name a few. Oral TXA is used off-label for hereditary angioedema, or tooth extractions in patients who are orally anticoagulated. Topically, it is used for treatment of traumatic hyphemas and epistaxis. It can also be used in the nebulized form to manage hemoptysis, post-tonsillectomy hemorrhages and epistaxis [5] .

The objective of this paper is to contrast the effectiveness of the currently available medical therapies in the management of uncomplicated epistaxis while highlighting the all-around benefit of using nebulized tranexamic acid as a primary option in the treatment of epistaxis.

A 64-year-old nonsmoker female who was not on any medications and without bleeding diatheses history presented to the emergency department with a 3-day history of spontaneous, intermittent non-traumatic left-sided epistaxis. Patient endorsed no fever, recent upper respiratory complaints, or headache. Three hours earlier patient was seen in the same emergency room with hours-long persistent epistaxis, where after failed topical oxymetazoline administration an anterior/posterior nasal packing Rapid Rhino^® was placed. At the time of initial presentation, physical examination revealed copious hemorrhage from left naris without sinus tenderness on exam. During the return visit, patient complained of difficulty swallowing that she attributed to anxiety from Rapid Rhino^® and being unable to breathe through either naris. She denied swallowing blood, nausea, vomiting, or headache. All vitals remained stable throughout the emergency room stay. At this point, the Rapid Rhino^® was removed and a physical reexamination revealed minimal bleeding without clear source point and the absence of septal hematoma. The patient was then treated with 2000 mg of nebulized tranexamic acid which led to prompt resolution of symptoms without need for repacking. Patient also reported a resolution of anxiety. A complete blood count and comprehensive metabolic panel did not reveal any gross abnormalities (Table 1). Patient was reexamined 30 minutes later. Her epistaxis was controlled, and she was discharged with a 10-day supply of cephalexin and an outpatient otolaryngology follow-up. Vitals at discharge remained stable. Since the epistaxis was nontraumatic, imaging was not deemed necessary.