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Is Tranexamic Acid Effective for Hemostasis During Endoscopic Sinus Surgery?

by Zachary H. Douglas, MD, Jay F. Piccirillo, MD, John Schneider, MD, Lauren T. Roland, MD, and Nyssa Fox Farrell, MD •

TRIO Best PracticeTRIO Best Practice articles are brief, structured reviews designed to provide the busy clinician with a handy outline and reference for day-to-day clinical decision making. The ENTtoday summaries below include the Background and Best Practice sections of the original article. To view the complete Laryngoscope articles free of charge, visit Laryngoscope.com.

BACKGROUND

Intraoperative bleeding during endoscopic sinus surgery (ESS) can obscure the surgical field, leading to difficulty identifying key anatomic landmarks, increasing operative time, and increasing the risk of complications secondary to poor visualization (Front Surg. 2021;8:771159; Laryngoscope. 2019;129:800–807). For this reason, methods to reduce intraoperative blood loss and improve visualization of the operative field are a significant area of study. Topical vasoconstrictive agents such as oxymetazoline or epinephrine are often utilized but are applied via a Cottonoid pledget and necessitate an interruption in surgery. Other methods such as controlled hypotension or total intravenous anesthesia also reduce bleeding but rely on close monitoring and medication titration by the anesthesia provider (Rhinology. 2013;51:291–297).

Tranexamic acid (TXA) is an antifibrinolytic agent that acts as a plasminogen activator antagonist, decreasing the conversion of plasminogen to plasmin and thereby inhibiting clot breakdown (Front Surg. 2021;8:771159; Laryngoscope. 2019;129:800–807; J Laryngol Otol. 2022;136:692–702). The use of antifibrinolytic agents to reduce bleeding has been shown to be effective in cardiac, trauma, dermatologic, and orthopedic surgeries. It is generally safe and well tolerated with few side effects, although thromboembolic events have been reported in patients with pre-existing risk factors (Laryngoscope. 2019;129:800–807). There are currently no formal guidelines for the role of TXA in ESS. This review covers relevant literature to elucidate the effect of TXA on intraoperative bleeding and surgical visualization in ESS.

BEST PRACTICE

Intravenous TXA can be used as an effective adjunctive medication to reduce intraoperative bleeding, improve visualization, and reduce operative time in ESS. TXA is most commonly administered as a 10–15 mg/kg bolus preoperatively, although topical application may also be effective. Benefit has been demonstrated in a number of randomized controlled trials and subsequent meta-analyses, although some data suggest the effects of TXA may only become clinically significant in cases of more severe sinonasal inflammatory disease. Because the severity of inflammatory diseases can vary regionally, the utility of routine TXA administration may vary by practice location.

TXA is generally safe and well tolerated with few side effects, but administration should be limited to patients with low risk for hypercoagulability due to a risk of thromboembolism. As such, current literature supports the use of TXA as an adjunctive for bleeding control during ESS given its intraoperative benefit and low-risk profile.