The objective of this case report is to increase awareness regarding a new category of drugs, new direct oral anticoagulants (specifically, rivaroxaban), which are increasingly being used instead of the more traditional vitamin K antagonists, to highlight the current recommendations for perioperative management of rivaroxaban, and to demonstrate a clinical scenario where a tonsillectomy was successfully performed in a patient requiring anticoagulation with rivaroxaban.A literature review and a case report are presented. PubMed was reviewed for evidence based recommendations regarding the perioperative management of rivaroxaban and the recommendations for reversal in the event of a hemorrhagic complication. There is no evidence in the literature regarding the use of rivaroxaban in patients undergoing tonsillectomy. We present the case of a 38year old female on rivaroxaban for history of deep vein thrombosis and pulmonary embolism who successfully underwent tonsillectomy using the current recommendations for perioperative management of rivaroxaban.Our patient had no thrombotic or hemorrhagic complications during the postoperative period. This is the first report in the literature regarding the use of a new direct oral anticoagulant, rivaroxaban, in the setting of tonsillectomy. This case report suggests that tonsillectomy can be performed in patients anticoagulated with rivaroxaban.With the increasingly common use of new direct oral anticoagulants for short and long-term anticoagulation, further research is necessary to compare the efficacy and safety profile of the new direct oral anticoagulants to the more traditional vitamin K antagonists when performing tonsillectomy. Otolaryngologists should be familiar with the new oral anticoagulants and understand the proposed perioperative management as practitioners are increasingly likely to encounter patients using this new class of medication in clinical practice.