Post-Tonsillectomy Hemorrhage

Originally published at Pediatric EM Morsels on August 17, 2012. Reposted with permission.

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We know that all bleeding eventually stops: ideally, by means that we have imposed rather than by exhaustion of the patient’s RBC resources. We also know that the easiest, and often most efficacious, way to halt bleeding is to put some manual pressure on the source of bleeding. Well, that isn’t always so easy to accomplish. How do you put your finger on a bleeding tonsil?

TONSILLECTOMY

• Rates of tonsillectomies have decreased slightly over time (it seemed like having tonsils used to be a good reason to have them removed).
• Current reasons for tonsillectomy include:

1. Sleep-disordered breathing and sleep apnea
   1. Tonsillar hypertrophy is most prominent between 3 and 6 years
   2. Tonsils involute after age 8 in most.
   3. Children with sleep apnea benefit from tonsillectomy.
   4. Unfortunately, obese children with sleep-disordered breathing are less often cured by tonsillectomy.
1. Severe recurrent sore throats
   1. It is shown that children have less sore throats after the tonsillectomy.
   2. It is not proven that this improvement is due to the tonsillectomy though.
2. Various other relative indications (ex, Peritonsillar cellulitis/abscess, dental malocclusion, hemorrhagic tonsillitis, prevention of secondary rheumatic fever)

THE PROCEDURE

• Tonsillectomy

1. Gold Standard (since 1910’s) – used in all major studies
2. “Hot” and “cold” techniques
3. “en bloc” excision of the entire palatine tonsil and its capsule
4. Removes tonsil completely
5. Leaves relatively large wound with exposed muscle and bridging blood vessels.
6. Glossopharyngeal nerve, fat, tongue base muscles can also be exposed.

• Tonsillotomy

1. Less radical approach, but still majority of US surgeons do the former.
2. Removal of only the exophytic portion of the tonsil (“partial tonsillectomy”).
3. Reports of slightly less pain and less bleeding compared to other.

• Typical Healing Course

1. Tonsillectomy is very traumatic.
2. Edema of the uvula, tonsillar pillars, and tongue is common.
3. Within 24hrs a Fibrin clot on the tonsillar fossae develops.
4. By the 5th day post-op, the Fibrin clot has proliferated and made a thick cake (that looks terrible).
5. Mucosa from the periphery of the wound begin to grow inward and the clot begins to separate from the underlying tissue after ~1week (this is the point when secondary bleeding risk is the highest).
6. Wound healing may take ~ 2 weeks.

Post-tonsillectomy Bleeding

• The vascular supply to the tonsil is robust (5 primary arteries).
• The surrounding tissues do not compress upon themselves.
• Tonsillectomy is said to be “the ultimate test of hemostasis.”
•  Post-Tonsillectomy hemorrhage rates = 2.5 – 7
•  Hemorrhage can lead to shock, airway obstruction, and death (those sound bad).
• Primary hemorrhage
• Occurs within first 24 hours of the procedure.
• With procedures being done as outpatients, these may present to your ED.

•  Secondary hemorrhage

1.  Occurs after more than 24 hours from the procedure.
2. Most commonly seen at Post-op Days #5 – #10, when the fibrin clot sloughs off.

Management

1. Air, Breathing, Circulation (when in doubt, ABCs).
2. Assess hemodynamic stability … get access if necessary.
3. Inspect the area for signs of hemorrhage or blood blot.
4. Most are not actively bleeding on arrival to the ED (yeah!).
5. Those who have bleeding or have a visible clot usually are treated with surgery.
   1. In one study, patients with minor bleeding had a 41% rate of severe bleeding within 24hrs.
   2. Adolescents and Adults may be treated slightly differently with trials of topical cautery under local anesthesia, but young children often require general anesthesia.
   3. Those without evidence of bleeding or blood clot formation should be observed to define stability. Any repeated bleeding should be viewed as a warning sign of serious hemorrhage.

Major bleeding management

• Mobilize the troops up in the OR.
• Have child lean forward (to help keep blood out of airway).
• Shed lots of light on the subject (headlamp will be vital for you).
• Grab your Magill Forceps and a ton of gauze and suction.
• Try to evacuate as much of the clotted blood as possible so you can get to the tonsillar fossae.
• Now apply direct pressure on the tonsillar fossae with the gauze wrapped around the end of the Magill’s.
• Adding some epinephrine (1:10,000) to the gauze has been shown to help (but I wouldn’t wait around … start with direct pressure).
• Remember to push out laterally onto the tonsillar fossae (do not aim posteriorly).
• Expect that the child will not tolerate this well… consider KETAMINE! (man, I love ketamine!)
• Also, expect that you may need to manage the airway. This will be difficult as once you lay the patient supine all of the blood is going to be in the airway (so ideally you would have some control of the bleeding prior to this… but your job is never as easy as you would like it to be).
• Type and Cross!