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Three Part Question

In [patients with post-tonsillectomy haemorrhage] does [nebulised tranexamic acid] [decrease the need for procedural intervention]?

Clinical Scenario

A 5 year old child presents to ED 5 days after tonsillectomy with bleeding from the tonsilar bed. You wonder if nebulised TXA plays an evidence based role in his management to minimise his bleeding and particularly his need for other intervention.

Search Strategy

Medline using Ovid interface, 1946 to 31-1-2025

("post-tonsillectomy" OR "post tonsillectomy") AND ("hemorrhage" OR "haemorrhage" or "bleeding") AND ("tranexamic acid" OR "TXA")

Search Outcome

19 papers, of which 9 are relevant to using nebulized TXA to treat at the time of presentation with post-tonsillectomy bleed. Of the 9, one (1) is a meta-analysis and four (4) are retrospective cohort studies which are included in the meta-analysis. The remaining 4 are case reports or case series, which are all also included in the meta-analysis. I will discuss the meta-analysis and the 4 retrospective cohort studies.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Alghamdi, AS, et al 2024 Oct 02 Saudi Arabia	Meta-analysis of 9 studies (3 retrospective comparative studies, 4 case series, and 2 case reports) totalling 448 patients.	Meta-analysis	Need for re-operation	Risk Ratio of need for re-operation 0.55 (95% CI 0.39-0.77)	small n, retrospective data without randomization, heterogeneous patient characteristics and adjunct therapies, lack of objective criteria for need for reoperation
Maksimoski, M, et al 2024 Aug USA	21 patients age 18-50 presenting with post-tonsillectomy bleeding between 5-15 days post-op, some of whom were treated with 500mg nebulized TXA	Retrospective Cohort	Need for re-operation	6 patient received nebulized TXA, none requiring re-operation. 15 patients did not received nebulized TXA, of whom 8 required re-operation. Absolute risk reduction 47.1% (95% CI 23%-71%). NNT 1.4-4.3.	small n, retrospective, non-standardized treatment, non-randomization, no objective criteria for requiring re-operation
Shin, TJ, et al 2023 Aug USA	1100 adult and pediatric patients, mean age 20.1 +/- 11.8yr of whom 83 (7.5%) received nebulized TXA (typically 500mg)	Retrospective Cohort	Need for re-operation	TXA Cohort 36.1% rate of OR intervention. Control group 60.2% rate of OR intervention. Odds ratio 0.37 (95% CI 0.22-0.63)	small n in TXA group, retrospective, non-standardized treatment, non-randomization, no objective criteria for requiring re-operation
Erwin, DZ, et al. 2021 June USA	58 pediatric patients with post-tonsillectomy hemorrhage, 44 patients presenting in one time frame did not receive TXA, whilst 14 patients presenting in a later time frame received TXA in addition to other treatments.	Retrospective Cohort	Need for re-operation	Control group: 32 of 44 required operative intervention (73%, 95% CI 59-86%). TXA group: 4 of 14 patients required operative intervention (29%, 95% CI 1.5-56%).	small n, retrospective, non-standardized treatment, non-randomization (time based cohorts), no objective criteria for requiring re-operation
Spencer, R, et al. 2022 Sep-Oct USA	82 adult and pediatric patients presenting with post-tonsillectomy hemorrhage at single facility. Of these, 55 were categorized as "non-active" and did not receive TXA and did not require intervention. 27 were regarded as active bleeds, some of which received either nebulized, intravenous, or topical TXA.	Retrospective Cohort	Need for re-operation	17 patients received nebulized TXA with a need for re-operation rate of 23.5%. 27 patients who received TXA by any route had need for re-operation rate of 22.2%. Control (no TXA) group had rate of 53.6%. p-value for any TXA vs no TXA 0.026.	small n, retrospective, non-standardized treatment, non-randomization, no objective criteria for requiring re-operation, multiple routes of administration

Comment(s)

Whilst there are no randomized studies, and the retrospective studies are small and have various confounders including variable adjunct treatments and doses and unclear objective criteria of success, there are promising indications that nebulized TXA, commonly at a dose of 500mg, may decrease need for re-operation in post-tonsillectomy hemorrhage.

Clinical Bottom Line

Given its general evidence of safety, there is reasonable evidence of benefit to support the use of nebulized TXA for post-tonsillectomy hemorrhage.

References

1. Alghamdi AS, et al Nebulized tranexamic acid for treatment of post-tonsillectomy bleeding: a systematic review and meta-analysis European Archives of Oto-Rhino-Laryngology 2024 Oct 02
2. Maksimoski, M, et al. Treatment of Post-Tonsillectomy Hemorrhage With Nebulized Tranexamic Acid: Initial Investigation of a Novel Therapeutic Modality Annals of Otology, Rhinology, & Laryngology 2024, 133(8) 729-734
3. Shin, TJ, et al. Treatment of post-tonsillectomy hemorrhage with nebulized tranexamic acid: a retrospective study International Journal of Pediatric Otorhinolaryngology 2023; 171, 111644
4. Erwin DZ, et al Post-tonsillectomy hemorrhage control with nebulized tranexamic acid: a retrospective cohort study International Journal of Pediatric Otorhinolaryngology 2021; 147:110802
5. Spencer, R, et al. Efficacy of tranexamic acid (TXA) for post-tonsillectomy hemorrhage American Journal of Otolaryngology 2022 Sep-Oct; 43:103582