Growing Use of Tranexamic Acid in Otolaryngology

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.