Introduction

Tonsillectomy ranks among the most performed surgical procedures in the United States, with over 500,000 cases annually involving children under 15 years of age [1]. Though bleeding during the operation is infrequent, post-tonsillectomy hemorrhage (PTH) can occur at rates as high as 7.5% [2]. The peak incidence is between ages 5 and 7 with common indications being recurrent tonsillitis and obstructive sleep apnea [3]. Risk factors for PTH, as revealed by a historical review of a large Welsh population (17,000), include age over 12, male gender, and surgical techniques [4]. Management of PTH may involve observation, gargles, bedside treatment, or a return to the operating room (OR) [2]. Despite affecting one in every twenty tonsillectomy patients, there is a lack of controlled trials addressing its management and no established guidelines or consensus statements [5]. Apart from the risk of secondary PTH, there is a significant burden of costly interventions. Approximately half of the patients presenting to the Emergency Department (ED) with secondary PTH require procedural intervention, roughly doubling the cost of a routine tonsillectomy, in addition to the cost of an ED visit [6]. A survey of pediatric and general otolaryngologists performing tonsillectomies on children revealed that 75% would opt for OR intervention to control PTH, even in the absence of active bleeding at the time of examination [5]. Returning to the OR carries risks such as secondary exposure to anesthetics, heightening neurotoxicity and prolonging postoperative pain, anxiety, and complications [7]. Thus, it would be beneficial to establish effective non-operative treatments to prevent a second surgery. Antifibrinolytics, commonly used in various surgical specialties, including Otolaryngology, can aid in reducing perioperative bleeding [8]. Tranexamic acid (TXA), a synthetic, reversible, competitive inhibitor of the lysine receptor found on plasminogen, prevents the conversion of plasminogen into plasmin, thus maintaining the fibrin clot. Recent studies have demonstrated TXA’s effectiveness in reducing severe epistaxis in the emergency department [9]. However, there is limited knowledge about its use in perioperative tonsillectomy management, especially for children [10]. This lack of information justifies the aim of this scoping review protocol, to comprehensively identify what evidence is available in the existing scientific literature on tranexamic acid use for post-tonsillectomy hemorrhage, identifying research gaps and key trends in usage.

Materials and methods

This review is exempt from approval from the New York University (NYU) Langone Institutional Review Board and will follow the JBI Manuel for Evidence synthesis as a guide on scoping review methods [11]. We used Preferred Reporting Items for Systematic Reviews or Meta-Analysis Extension for Scoping Reviews (PRISMA-ScR) as a guideline for reporting how a scoping review has been conducted [12]. Any changes in the proposed protocol will be edited in the final review.

Discussion

While antifibrinolytics are established in achieving hemostasis across specialties, few studies focus on their use in preventing and managing PTH. Variability exists in the literature regarding administration timing and efficacy in reducing blood loss during tonsillectomy and preventing PTH. Although we used a comprehensive search, it is possible that we could have missed relevant publications because of our search strategy, especially if they were not written in English. This is a limitation of our study that we address with this protocol. This review aims to describe collective findings on PTH outcomes post-tranexamic acid use, informing future studies on PTH treatment. The results will be disseminated to a peer-reviewed journal, and any amendments or changes will be discussed by the group and handled according to recommended guidelines.

Supporting Information

Acknowledgments

Richard McGowan, a librarian at NYU Langone Health Science Library, for guidance in developing this protocol.