Growing Use of Tranexamic Acid in Otolaryngology

“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).