Nebulized Tranexamic Acid in Post-tonsillectomy Hemorrhage: A Retrospective Study of a Novel Treatment Algorithm

Introduction: In the treatment of post-tonsillectomy hemorrhage (PTH), nebulized tranexamic acid (TXA) has recently shown efficacy in reducing the need for operative hemorrhage control. While the existing data are promising, the sample sizes are small, and information on patient selection is lacking. In this study, we introduce a novel, standardized algorithm for the use of TXA in PTH to further define its efficacy and inform operative decisions.

Methods: A retrospective chart review was performed on patients < 18 years of age treated for PTH at a tertiary children’s hospital from January 2023 to May 2025. Collected data included age, sex, BMI, bleed severity, TXA dosing, rebleeding, and TXA complications. A treatment algorithm was introduced in March 2024 in which all stable patients with PTH in the emergency department (ED) received nebulized TXA and were re-examined in 15 minutes. Bleed severity was defined as active bleeding, large clot (>50% of the tonsillar fossa), small clot ( < 50% of the fossa), or no bleeding. Those with active bleeding or large clot after TXA underwent operative control, whereas those with small clot or no bleeding were observed for 3 hours before discharge. Controls who did not receive TXA were gathered from chart review of PTH patients prior to implementation of the algorithm.

Results: 94 patients received TXA for PTH after implementation of the algorithm. 42 controls with PTH who did not receive TXA were identified from the period before implementation. 81.9% (77/94) of TXA patients required operative intervention compared to 95.2% (40/42) of controls (p = 0.0582). Of patients with small clot who received TXA, 30% (6/20) required operative intervention compared to 85.7% (12/14) of controls with small clot (p = 0.0019). No adverse events were reported with TXA administration. There was no difference in rate of rebleeding.

Conclusions: Nebulized TXA appears to reduce the rate of operative control of PTH, particularly in those with less severe bleeding. Our novel treatment algorithm provides a framework for treatment of PTH in the ED and can safely reduce the risks of operative control and limit resource utilization.