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POST-TONSILLECTOMY BLEED

Overview
Post-tonsillectomy hemorrhage often represents a surgical emergency. Hemorrhage can either occur within the first 24 hours following surgery (primary post-tonsillectomy hemorrhage) or in a delayed fashion, most commonly between days 7-10 following surgery (secondary hemorrhage). Secondary bleeds are the most common, occurring in anywhere between 0.1-4.8% of cases. 

Initial Management 
When initially consulted for post-tonsillectomy hemorrhage, the first concern is to verify the patient’s ABCs. It is important to ask the emergency department to urgently obtain sufficient intravenous access to allow resuscitation, and deliver fluids to the patient. In cases of more severe bleeding, it is recommended to obtain a blood type and screen. 

Physical exam is crucial to determine whether the patient is actively bleeding (bleeding typically occurs from either the inferior or superior tonsillar poles). Attention to the patient’s airway, vital signs, and pulse oximetry is paramount.

Generally, a child who is actively bleeding (visible hemorrhage or fresh clot in the tonsillar fossa) will require surgical control of hemorrhage. A select group of adults and teenagers without brisk bleeding may be able to tolerate a trial of bedside cautery. Prior to cauterization, gargling ice water may be helpful in slowing down bleeding. All patients should be considered to have a full stomach if sedation or general anesthesia are considered. If proceeding with bedside cauterization, topical anesthetic (e.g. bupivacaine or cetacaine spray) can be used prior to cauterization with silver nitrate. Prior to cauterization, compression with gauze or a tonsil ball soaked in oxymetazoline and local anesthetic may help with hemorrhage control and local numbing. When performing these procedures, it is important to be cognizant of airway stability. It is also important to avoid run-down of silver nitrate onto the larynx, which may cause laryngeal burns or edema.

Should conservative bedside measures fail, the patient will require a trip to the operating room for control of oropharyngeal hemorrhage. If the patient is not actively bleeding at the time they are seen or the bleeding is stopped at bedside, observation in the emergency department or admission for observation may be appropriate. Factors to consider include the severity of bleeding, patient age and comorbidities, hemoglobin level, reliability of patient to follow directions, and distance from the emergency department.

Key Supplies

  • Headlight

  • Tongue depressor or retractor

  • Kidney basin

  • Suction with Yankauer tip

  • Benzocaine or cetacaine (Hurricane) spray (be aware of risk for methemoglobinemia)

  • Silver nitrate

  • Ice water

  • Tonsil sponges

  • Curved ring forceps

Operative Management 
In the case of brisk or persistent bleeding in the emergency department, the operating room should be immediately prepared as the patient is rolled back. In some cases, it is possible to hold pressure on the bleeding area with a tonsil sponge on a clamp, but in many cases, patients cannot tolerate this. Informed consent should include discussion of damage to oral cavity structures (e.g., lips, teeth), inability to stop bleed, dysphagia, aspiration, and death. 

In the operating room, children should generally undergo rapid sequence intubation given the risk of emesis and aspiration. The adult patient who is vigorously bleeding, but actively protecting his/her airway may be managed with awake fiberoptic intubation. In rare situations, emergent cricothyroidotomy or awake tracheotomy may be required for airway control. Regardless of approach to securing the airway, several suctions, good lighting, and several airway management and rescue options should be ready for use. Remember, patients with postoperative oropharyngeal hemorrhage do not generally die from exsanguination, but from airway compromise. Ultimately, airway management in this setting is nuanced and requires the best collective judgment of the otolaryngology and anesthesia teams.  

Intraoperative technique for hemorrhage control includes use of suction cautery, bipolar cautery, silver nitrate, pillar suturing, and figure-8 suturing. 

The stomach should be suctioned clear with a large-bore sump tube at the end of the case; irrigation and suctioning through the tube may be necessary to clear clots from the stomach.

Example Operative Note 
After written informed consent was obtained, the patient was brought back to the operating room by anesthesia and placed supine on the operating room table. Timeout was performed.  Rapid sequence intubation was performed, and the patient was orotracheally intubated without difficulty. The bed was then turned 90 degrees. A Crowe-Davis retractor was placed with good visualization of the oropharynx. Eschar was noted in the [left/right] tonsil bed, partially dislodged, with [a small amount of/brisk/pulsatile] bleeding. After a clot was removed, the [left/right] [superior/inferior] tonsillar pole was found to be bleeding more briskly and was controlled with bipolar cautery set at 20. The [left/right] tonsil fossa was examined with no evidence of blood or clot.  Valsalva to 30 was performed with no bleeding. The stomach was suctioned with an orogastric tube.  The patient was then taken out of suspension and the Crowe-Davis retractor was removed. The patient was turned back to Anesthesia in stable condition. The patient was then extubated uneventfully. 

References

  1. Christian, J.M., et al (2020). Deep Neck and Odontogenic Infections. In P.W. Flint, et al (Eds.), Cummings Otolaryngology Head and Neck Surgery 7e (pp. 141-154). Philadelphia, PA: Elsevier.

  2. Jeyakumar, A., et al (2013). Adenotonsillar Disease in Children. In J.J. Johnson, C.A. Rosen. (Eds.), Bailey’s Head and Neck Surgery-Otolaryngology 5e (pp. 1430-1444). Baltimore, MD: Lippincott Williams & Wilkins.

  3. Mitchell, R. B., Archer, S. M., Ishman, S. L., Rosenfeld, R. M., Coles, S., Finestone, S. A., … Nnacheta, L. C. (2019). Clinical Practice Guideline: Tonsillectomy in Children (Update). Otolaryngology–Head and Neck Surgery, 160(1_suppl), S1–S42.https://doi.org/10.1177/0194599818801757