Post-Tonsillectomy Hemorrhage

Yuk!

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? Let’s review Post-Tonsillectomy Hemorrhage.

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

 

The procedure

  • Tonsillectomy

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

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

    • Tonsillectomy is very traumatic.
    • Edema of the uvula, tonsillar pillars, and tongue is common.
    • Within 24hrs a Fibrin clot on the tonsillar fossae develops.
    • By the 5th day post-op, the Fibrin clot has proliferated and made a thick cake (that looks terrible).
    • 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).
    • Wound healing may take ~ 2 weeks.

 

Post-Tonsillectomy Hemorrhage

    • 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

    • Occurs after more than 24 hours from the procedure.
    • 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.
    • In one study, patients with minor bleeding had a 41% rate of severe bleeding within 24hrs.
    • Adolescents and Adults may be treated slightly differently with trials of topical cautery under local anesthesia, but young children often require general anesthesia.
    • 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!

 

References

Isaacson G1. Tonsillectomy care for the pediatrician. Pediatrics. 2012 Aug;130(2):324-34. PMID: 22753552. [PubMed] [Read by QxMD]

Windfuhr JP1, Schloendorff G, Baburi D, Kremer B. Serious post-tonsillectomy hemorrhage with and without lethal outcome in children and adolescents. Int J Pediatr Otorhinolaryngol. 2008 Jul;72(7):1029-40. PMID: 18455808. [PubMed] [Read by QxMD]

Peterson J1, Losek JD. Post-tonsillectomy hemorrhage and pediatric emergency care. Clin Pediatr (Phila). 2004 Jun;43(5):445-8. PMID: 15208749. [PubMed] [Read by QxMD]

Steketee KG1, Reisdorff EJ. Emergency care for posttonsillectomy and postadenoidectomy hemorrhage. Am J Emerg Med. 1995 Sep;13(5):518-23. PMID: 7662054. [PubMed] [Read by QxMD]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

You may also like...

20 Responses

  1. David Kammer says:

    Tonight I had 18-year-old who had some pretty decent bleeding on post op day five after tonsillectomy. There was a big clot sitting on the right tonsil it was make me feel pretty uncomfortable. Wasn’t too sure about management and Up-to-Date was worthless, so I went to Dr. Google. Dr. Google sent me directly to the Ped EM Morsels on post tonsillectomy bleeding, which was, of course, incredibly helpful. Wanted to take the opportunity to give you a shout out.
    -Dr. Kammer

    • Sean Fox says:

      Dr. Kammer,
      Thank you so much for the feedback! I am glad that the PedEM Morsels have assisted you in your time of need.

      If there is ever a topic that you would find to be helpful for the Morsels to cover, feel free to let me know and I will see what I can do.

      Have a great day,
      sean

  2. Erin Mataj says:

    I’m the worried mom of an 8 year old boy. Day 9 after T & A removal, he bled 2 times during the day, we were able to stop it with ice etc. That night he bled so much, and so much of it went into his stomach he woke up throwing up several pints of blood and nearly passed out when totally pale. After observation with IV in the hospital after calling 911 our ENT said he could go home. Day 11 he started to bleed again, slow steady stream. We were able to stop it. After talking to ENT again via phone, he said, to observe more, if it starts again the only option is to put him under and cauterize it. Should I be worried? I don’t want to be pushy or crazy, but I don’t want to put my child at any risk. I’m sleeping with him every night to make sure he’s okay. Once bitten twice shy sort of thing. The only thing that keeps running in my mind, is when the Dr and nurse said that his adnoids were REALLY, REALLY large and they had to go further back to get it all, and that they were happy he had them out (for apnea reasons and recurring strep) So of course I found your site with the “let me be the Dr. Google” Thank you!

    • Sean Fox says:

      I’m sorry that you are going through this now, but know that you are not alone as this is a common issue after tonsillectomy.

      Given that bleeding can occur even after 1.5-2 weeks post-op, what you describe does require attention. That may be more observation or may be cauterization. Given that this is the Internet and I am not your doctor, I cannot give you real advice, but would encourage you to continue to keep your ENT surgeon informed and perhaps even advocate for a repeat examination.

      Hope that that helps,

      Sean

    • Becci says:

      Erin, how is your son doing now? My 8 year old is going to have surgery tomorrow and I’m worried of course. And how were you able to stop the bleeding?

      • Erin Mataj says:

        Hi Becci, I’m sorry I didn’t see this. After all that fun, he was done bleeding, we definitely kept him out of P.E and games with friends for a long while after that at least another 2 weeks minimum. But he is amazing now. Would I do it again…100% Yes. He is a new little boy. He can run longer without getting short-winded. Hasn’t had Strep or a sinus infections at all since then, even when his friends have been sick. He didn’t get sick all winter except for a tiny cold, which is WAY not the norm for him. He had to get used to speaking differently though. I think that since I went into this surgery very worried, I was ready for something to happen, but no one can ever be totally prepared. I really admire our ENT, he was always on hand, and even gave me his cell phone number and checked in with us on his own after the first incident. Being such an anti-surgery mom, this is the first time someone has cut into my boy, not even circumcision, but this was indeed a necessity for him. He looks back now and is also happy he had it done, and he loved being in the ER for the bleeding, he got real good treatment and “had cheesecake!” So all it well. How was your sons surgery?

  3. Crystal says:

    My son had 2 post op bleeds after day 12!

  4. Excellent, what a weblog it is! This blog presents valuable data to us, keep it up.

  5. Elaine Luther says:

    I am a medical student. Exactly what are the five primary arteries that perfuse the tonsillar fossa, and which one is most likely to rupture?

    • Sean Fox says:

      Elaine,
      Unsure about which most likely to bleed, but I imagine it doesn’t likely matter.
      The five arteries are:
      1) one branch off of the Lingual artery
      2) one branch off of the Maxillary artery
      3) one branch off of the Carotid artery
      4+5) two branches off of the Facial artery

  6. ILonai says:

    My daughter had a tonsillectomy on 12/2/16 and Her first post op bleed 12/9/16 from the right side. The ENT was available and cauterized it. Seven days later 12/16/16, the left side bled and had to be cauterized. The problem I am having is that it keeps bleeding. We are able to stop it with ice water, but she bleeds about 16-20 minutes before we stop it. We rushed to the ER twice and in both incidences, she had stopped bleeding by the time we got there, so it didn’t look like we had a real emergency. On the 2nd ER visit, her hemoglobin had dropped a little. I am really concerned. Any advice?

  7. Chris says:

    Hi there,
    I’m so grateful that I came across this post and the comments to know that we are not alone in this. My son is 3 years old and had a tonsillectomy due to having strep throat infections 5 times since August. (His older brother also had his tonsils removed at age 3, but for obstructive sleep apnea and had no complications recovering.) His surgery was on December 27. Early January 2 (Day 6), he had his first bleeding. He woke up in the middle of the night panicking and screaming and then started showing signs of blood in his mouth about 5 minutes afterwards. We gargled with ice water and got it to stop. When looking at his throat, I could see what I now know was a clot on the right side. After resting for 20 minutes and talking with the doctor on the phone, he threw up what I would amount to a cereal bowl-full of blood and clots and we headed to the ER. Walking into the ER, he threw up 3 more times, of similar amounts as before. He had a cautery surgery and we went home shortly after surgery. Day 7 had no bleeding. Day 8, in the early hours, we had another bleed. A mouth full of blood but we were able to get it to stop with ice water. We saw the ENT once the office opened for a professional look. He saw no active bleeding. The early hours of Day 9, we had 3 bleeds at midnight, 4am, and 8am – all big mouthfuls of blood. Each time we were able to get it to stop with ice water after about 10 minutes. We came into the ENT office again and he saw some “oozing”. We were going to take a wait-and-see approach to determine if we needed to go to the OR again. A few minutes later, he threw up again a large bowl-full of blood and the ENT met us promptly at the hospital and performed another cautery. Before the surgery his hematocrit was 24 (baseline numbers from the pediatrician were 36). The ENT ran some coagulation studies to determine if the bleeding was from a clotting issue and the blood for those tests had his hematocrit at 15. We spent the night at Children’s Hospital where he received a blood transfusion bringing his hematocrit back up to 24 (day 10). On Monday, Day 13, his hematocrit was 26.8 checked by his pediatrician. On Thursday, Day 17, he had his ENT follow up and the ENT said that he doesn’t expect any more bleeding, but to still not get his heart rate up with any activity and that he can return to school next week.
    I have several concerns and questions:
    1. Our ENT said 1:100 will bleed following a tonsillectomy. How common is this to have TWO cauteries following a tonsillectomy?
    2. My two oldest sons are 4th generation tonsillectomy patients. I have one more son who is 18 months old. How likely is he to have similar bleeding complications should he also require a tonsillectomy?
    3. And the elephant in the room: I realize even the best surgeons have “off” days and mistakes. How likely is this surgeon error?
    4. Would you recommend the same ENT doctor or switching if my youngest son required a tonsillectomy in the future?

  8. Chris says:

    Hi again, I just wanted to see if you saw my questions from the last comment. Thank you for any answers you may have.

    • Sean Fox says:

      Chris,
      I am sorry your family has been through such an ordeal.

      Naturally, I cannot comment on any particular surgeon and her/his proficiency. What I can say is that bleeding after tonsillectomy is common! This is why I wrote the post to help Emergency Care clinicians provide optimal care when it does become an issue.

      If you are not comfortable with a physician, any physician, it is your right to seek care with another provider.

      It is also possible that there is an underlying bleeding disorder, but that should be brought to the attention of your primary care provider.

      I hope that this helps… and that your family doesn’t have to go through this again.

      -sean

  9. Kristin says:

    I am 14 days post op T&A. I am 27. I just got my eleventh hemorrhage to stop. That’s right, eleventh. First occurred POD 3 on the left. Then 1-2 times daily POD 7-14. Each bleed is a gusher. The left was cauterized under local in the ED POD 7. However, the right has been difficult to tame. After three ED trips and one F/U with ENT to no avail of finding the troublesome vessel I just take care of it at home hovered over the sink until it slows enough that I can drink/swish ice water. It feels like I’m going to choke to death on my own blood every time it happens. How long post operatively is the risk for bleeding?

  1. July 7, 2014

    […] catches your attention in the Peds ED (or any ED for that matter).  We have previously covered Post-Tonsillectomy Hemorrhage, oropharyngeal trauma, Hemorrhagic Disease of the Newborn, ITP and the significance of Wet […]

  2. February 4, 2015

    […] following is a link to the excellent blog post Peds EM Morsels Post-Tonsillectomy Hemorrhage. It covers what to do for the patient with massive post op tonsillectomy […]

  3. August 14, 2015

    […] topics in the Ped EM Morsels over the past numerous years. Many are quite attention grabbing (ex, Tonsillectomy Hemorrhage, Delayed Sequence Intubation, and Submersion Injuries, and Lawn Mower Injuries), but that does not […]

  4. October 23, 2015

    […] the audience (you all) who read these Morsels love critical care topics (Post-Tonsillectomy Hemorrhage has been the most viewed Morsel since it was written in 2012), but excellent care in the Peds ED […]

Leave a Reply