Nebulized Tranexamic Acid in Posttonsillectomy Hemorrhage: A Retrospective Study of a Standardized Treatment Algorithm

OBJECTIVE: To evaluate efficacy of nebulized tranexamic acid (TXA) in reducing the need for surgery after posttonsillectomy hemorrhage (PTH). STUDY DESIGN: Retrospective analysis of a treatment protocol for PTH with pre-protocol patients serving as historical comparisons. SETTING: Tertiary children's hospital. METHODS: Patients <18 years of age who presented to the emergency department (ED) with PTH from August 2022 through August 2025 were included. Beginning March 1, 2024 patients presenting with PTH in stable condition received nebulized TXA. Bleeding severity was categorized into active bleeding, small clot involving <50% of the fossa, large clot involving ≥50% of the tonsillar fossa, or no bleeding. Those with active bleeding or persistent large clot after TXA underwent surgery. Those with small clots or no bleeding were observed for 3 hours or 1 hour before discharge, respectively. RESULTS: 121 patients with PTH were evaluated. 80% of untreated patients required surgery versus 66% of the TXA group (P = .15). In patients with small clots, 88% of untreated patients required surgery versus 21% of patients in the TXA group (P = .003). No adverse events were reported with TXA use. We estimated 32 surgeries were avoided in the post-protocol period, with net cost savings of approximately $138,162. CONCLUSION: Nebulized TXA reduced the need for surgery in PTH, particularly in patients presenting with clots encompassing <50% of the tonsillar fossa. Our algorithm provides a reasonable framework for PTH treatment and can safely reduce the need for surgery and limit resource utilization.