Purpose <p>Post-tonsillectomy haemorrhage (PTH) remains a daunting complication that continues to challenge otolaryngologic care, especially among paediatric and high-risk patients. Traditional interventions often involve invasive or pharmacological approaches. This review investigates the emerging role of nebulised tranexamic acid (TXA) as a non-invasive, effective alternative in managing PTH, focusing on its clinical utility, mechanism of action, and safety.</p> Methods <p>A comprehensive review of the current literature was conducted, including retrospective cohort studies, case reports, and observational studies that assessed the efficacy and safety of nebulised TXA in treating PTH. Pharmacokinetic evidence and mechanisms of action were also evaluated.</p> Results <p>The reviewed studies consistently report high success rates in controlling haemorrhage with nebulised TXA, frequently reducing or eliminating the need for surgical intervention. The treatment demonstrated a rapid onset of local action with minimal systemic absorption and a favourable safety profile, with few adverse events noted. Despite promising outcomes, a lack of standardised dosing protocols and large-scale randomised controlled trials remains.</p> Conclusion <p>Despite the lack of standardised protocols, current literature suggests a shift in clinical thinking, one where TXA might transition from a supporting role to a starring one in PTH management. However, further large-scale trials are essential to validate its efficacy, determine optimal dosing strategies, and establish long-term safety. In the meantime, nebulised TXA remains an intriguing, evidence-informed option in the clinician’s toolkit, one that may soon redefine the standard of care for PTH management.</p>