A growing number of otolaryngologists are now using tranexamic acid (TXA) to reduce intraoperative and postoperative bleeding. As a synthetic analog of the amino acid lysine, TXA promotes anti-fibrinolysis by binding to the lysine-binding sites on both plasminogen and plasmin, whereby attachment to fibrin is prevented and activation of plasminogen to plasmin and subsequent fibrin degradation by plasmin is precluded. Administered either intravenously or orally, TXA has a 30%-50% oral bioavailability and a relatively short half-life of two to three hours (World J Otorhinolaryngol Head Neck Surg. doi: 10.1016/j.wjorl.2020.05.010).
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December 2025Used off label, the antifibrinolytic agent is increasingly being used both in pediatric and adult otolaryngologic procedures. Its adoption in otolaryngology, as well as many other surgical specialties, comes from the strong evidence collected in emergency medicine, where TXA has long been adopted and well studied. Based on the current evidence, the National Association of EMS Physicians, the American College of Surgeons Committee on Trauma, and the American College of Emergency Physicians published a recent joint position statement in 2025 in the Annals of Emergency Medicine (see Recommendations for TXA Use below), in which they offer recommendations for TXA in the emergency room setting and offer resources and evidence to support their position (Transfusion. doi: 10.1111/ trf.17779).
In orthopedic surgery, evidence to date comes from two large meta-analyses, one that shows its efficacy in reducing peri-operative blood loss and requirements for transfusions without significantly effecting thromboembolic complication risk, and another looking specifically at the safety of TXA in major orthopedic surgery and showing no significant increase in venous thromboembolism (J Orthop Trauma. doi: 10.1097/BOT.0000000000000913; Blood Transfus. doi: 10.2450//2017.0219-17).
Although most uses of TXA are off label based on this evidence, recently the U.S. Food and Drug Administration approved its use in specific situations: in the postpartum setting to reduce the risk of life-threatening bleeding, and prophylactic use for dental procedures in patients with hemophilia (In StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan–. PMID: 30422504. Lancet. doi: 10.1016/ S0140-6736(24)02102-0).
While there is a paucity of evidence-based medicine specifically in the use of TXA in otolaryngology, the strong safety profile of TXA documented in the emergency setting and orthopedic surgery literature, as well as anecdotal evidence from the many otolaryngologists who use it in practice, has made it clear that this agent is a useful tool for reducing or preventing blood loss for many adult and pediatric patients.
A 2021 clinical review of the evidence on the use of TXA in otolaryngology concluded that TXA is safe for reducing bleeding in several otolaryngologic procedures, describing the evidence on its efficacy in reducing post-operative bleeding in tonsillectomy, reducing blood loss in head and neck surgery cases (although the data is very scarce), reducing post-operative peri-orbital edema and ecchymosis in rhinoplasty, significantly reducing intra-operative blood loss during endoscopic sinus surgery, and shortening the time to hemostasis and facilitating earlier discharge when used topically for epistaxis (World J Otorhinolaryngol Head Neck Surg. doi: 10.1016/j.wjorl.2020.05.010).
A more recent systematic review on the efficacy of TXA in head and neck surgery was conducted in 2022, given the variable results of individual studies on its efficacy in this setting (Clin Otolaryngol. doi.org/10.1111/coa.14059). The review included 16 studies, eight on major head and neck surgical studies and eight on tonsillectomy studies. Studies were not included if they lacked a control group, focused on animal populations, or focused on oropharyngeal surgeries or nasopharyngeal cancer surgeries. The studies in the review included both male and female patients undergoing head and neck surgeries, those with intra-operative blood loss, and information on the duration of surgery, volume of post-operative blood loss, volume of post-operative drain, and duration of post-operative drain. Outcomes reviewed included the mean volume of intra-operative and post-operative blood loss, mean duration of surgery, and post-operative drain duration.
The review found that TXA significantly reduces intraoperative bleeding in adults undergoing tonsillectomy, but without a significant difference in the rates of secondary post-tonsillectomy hemorrhage, which continues to be a challenge. All of the studies used intravenous TXA administration intra-operatively or pre-operatively at a dose of at least 10 mg/kg in 100 mL. For head and neck surgery, the review found no significant reduction in intra-operative bleeding benefit with TXA but found that TXA significantly reduced the rates of post-operative drainage volumes in major cases. The review also confirmed the safety of TXA, with no evidence showing increased risk of complications like thromboembolism.
A more recent study published in 2025 provides updated data on the use of TXA in head and neck surgery, specifically in patients who undergo free flap reconstruction (Microsurgery. doi: 10.1002/micr.70046). The study found decreased perioperative transfusion with the use of TXA in 397 patients undergoing free flap reconstruction, with no increase in flap vascular compromise or major thromboembolic events.
Although more research and data may be needed to provide evidence-based use of TXA in otolaryngology, Michael J. Marino, MD, associate professor in the department of otolaryngology–head and neck surgery at Mayo Clinic in Scottsdale, Ariz., who has long used TXA in his practice, said that although some studies in otolaryngology are published and in development, he thinks funding for evidence-based trials is difficult to secure given its already well-established safety. He doesn’t think more evidence is needed, given that the adverse events are very low and its use is established in otolaryngology as well as other surgical practices.
Experience in the Field
Several otolaryngologists who routinely use TXA provided their perspective on the sorts of procedures in which they use it, how they administer it, and their overall sense of the utility of TXA within otolaryngology in both the adult and pediatric settings.
Habib G. Zalzal, MD, a pediatric otolaryngologist at Children’s National Hospital in Washington, D.C., said that the best use of TXA is for post-tonsillectomy bleeding that occurs one to 14 days after a tonsillectomy. “Emergency department (ED) doctors play a pivotal role in using [TXA] because they are the first to see a lot of these post-tonsillectomy bleeding occurrences,” he said. “When TXA was being used intravenously in kids for active tonsil bleeding, it was working to reduce bleeding because of the clot-stabilizing effect of TXA, and then some EDs started using it topically.”
Dr. Zalzal said this well-documented experience of using TXA in the ED setting has significantly helped his and other institutions reduce the need for visits back to the operating room for bleeding. “When a child presents to the ED with an active bleed in their mouth, historically the child is most likely to be taken to the operating room,” he said. “Within the last couple of years, our ED started using TXA, and the need to take tonsil bleeds back to the operating room has been reduced by greater than 50%.” He said this benefit has helped to avoid further anesthesia and has brought relief to parents who know there is now a medication that can stop the bleeding without a return to the operating room. “When you put TXA in the mouth, it allows the tonsil bed to have a clot-stabilizing effect, so there is no need for an intervention,” he added.
As to complications, he said they include minor nausea, vomiting, abdominal pain, and headaches. He emphasized that there are not enough studies looking into the use of TXA in otolaryngology to know exactly what the complications are from an otolaryngology perspective. “This is a gap in the otolaryngology literature, but in the ED literature it seems to be very safe,” he said. Dr. Zalzal emphasized, however, that TXA should be avoided in children and adults with pro-clotting disorders, as giving TXA in these patients may lead to major complications like strokes.
What hasn’t been studied in the literature is whether TXA prospectively reduces the need to take children back to the operating room after tonsillectomy. “There is a need for guidelines on how to use this within otolaryngology,” he said, reiterating that “it does seem to be a strong medication to prevent repeat anesthesia procedure.”
Dr. Zalzal emphasized the need for more clinical trials on the use of TXA in otolaryngology and hopes that by 2026, more formal research and guidelines will be developed. Currently, he and his colleagues at Children’s National Hospital are finalizing a study on the use of TXA in pediatric patients for post-tonsillectomy bleeding and are working to bring other institutions on board for a larger, prospective randomized clinical trial.
Even without large-scale studies, he underscored that the safety profile and promising results from off-label and anecdotal use of TXA support its use in emergency situations. “Consider checking with the emergency department [to which] you refer your post-operative patients to see if they are using TXA, and how they are using it, and whether or not there is a role for using nebulized or at least topical TXA,” he said.
John Carter, MD, a pediatric otolaryngologist and system chair for the department of otolaryngology at Ochsner Health in Covington, La., said that his institution has a protocol to manage post-operative tonsillectomy hemorrhage. “We give nebulized TXA, and we found that it dramatically reduces the number of children who have to return to the operating room to control the bleed,” he said. “That is the biggest use of it in pediatric otolaryngology.”
Dr. Marino said in his practice, he uses TXA for two primary reasons. One, to stop nosebleeds, using TXA as a topical spray in the nose, and the second for nasal procedures for sinonasal surgery, in which they give TXA intravenously at a dose of one gram either before or during surgery, which, he said, may help with bleeding during surgery.
Although he said it is difficult to gauge the differences in bleeding control with the use of intravenous TXA for an individual experience, he said its efficacy in this type of situation aligns with what has been published.
He encouraged otolaryngologists to familiarize themselves with TXA, specifically when giving the one gram intra-operatively, to get comfortable with using it, and underscored its very good safety profile except in rare cases. “I think people who have a thrombotic stroke or are undergoing an elective procedure are not good candidates for this,” he said, reiterating that the safety of TXA is very, very good for most patients.
“TXA is a good option; it inhibits plasminogen, which breaks down clots, so TXA is a clot stabilizer that doesn’t promote clot formation, and that may worry people about it,” he said. “All that TXA is doing is stabilizing clots that are forming.
“That is why the safety profile is so good except for rare exceptions of clot-forming complications,” he emphasized.
Dr. Carter also works with his colleagues performing otolaryngologic procedures in which TXA is safe and effective. “Our adult colleagues use it for sinus and nasal cases, both intravenously and topically,” he said. Specifically, they use it prophylactically and intravenously in cases of patients at increased risk of bleeding during surgery, as well as intravenously and topically for patients who come to the emergency department with severe nosebleeds.
He also said that his head and neck cancer team routinely uses TXA intravenously and topically for cases of neck dissection or thyroidectomy that have more bleeding. They do not use it either intravenously or topically in cases of free flap reconstruction for head and neck surgery, however, because of worries of clotting at the vessel site. “That being said, there is a head and neck group in Pittsburgh showing no increased risk to free flap with their cases (Microsurgery. doi: 10.1002/ micr.70046), and they have a protocol for using TXA in head and neck cancer operations with or without free flap reconstruction,” he said.
Geetha Mahendran, MD, a resident in the department of otolaryngology–head and neck surgery at Harvard Medical School in Boston, said her institution uses TXA as a topical (often nebulized) for post-tonsillectomy or post-transoral robotic surgery (TORS) bleeds, or intra-operatively and intravenously during a procedure where there is a concern for higher volume bleed. Similar to the other sources, she said that anecdotal evidence shows that nebulized TXA slows down and even stops post-operative bleeding.
“We are currently working on a quality improvement project evaluating intra-operative use of topical TXA for children undergoing tonsillectomy to see if it reduces the rate of post-tonsillectomy hemorrhage, emergency room visits, readmission rates, and/or return to the operating room,” she said.
Recommendations for TXA Use
- Pre-hospital TXA administration may reduce mortality and improve long-term functional outcomes in adult trauma patients with hemorrhagic shock when administered after lifesaving interventions.
- Pre-hospital TXA administration appears safe, with low risk of thromboembolic events or seizure.
- The ideal dose, rate, and route of pre-hospital administration of TXA for adult trauma patients with hemorrhagic shock has not been determined. Current protocols suggest emergency medical service agencies may administer either a one-g intravenous or intraosseous dose (followed by a hospital-based one-g infusion over eight hours), or a two-g IV or IO dose as an infusion or slow push.
- Pre-hospital TXA administration, if used for adult trauma patients, should be given to those with clinical signs of hemorrhagic shock and no later than three hours post-injury. There is no evidence to date to suggest improved clinical outcomes from TXA initiation beyond this time or in those without clinically significant bleeding.
- The role of pre-hospital TXA in pediatric trauma patients with clinical signs of hemorrhagic shock has not been studied, and standardized dosing has not been established. If used, it should be given within three hours of injury.
- Pre-hospital TXA administration, if used, should be clearly communicated to receiving healthcare professionals to promote appropriate monitoring and to avoid duplicate administration(s).
- A multidisciplinary team, led by EMS physicians, that includes EMS clinicians, emergency physicians, and trauma surgeons, should be responsible for developing a quality improvement program to assess pre-hospital TXA administration for protocol compliance and identification of clinical complications.
Recommendations from the National Association of EMS Physicians, the American College of Surgeons Committee on Trauma, and the American College of Emergency Physicians (Annals of Emergency Medicine doi: 10.1016/j.annemergmed.2025.03.007).
Mary Beth Nierengarten is a freelance medical writer based in Minnesota.
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