Post-tonsillectomy Bleed

Context

Tonsillectomy is a common procedure performed by ENT surgeons for recurrent infections or obstructive sleep apnoea. It is estimated that more than 50,000 tonsillectomies are performed per year in the UK alone.

Post-tonsillectomy haemorrhage occurs in around 5% of patients and represents the most common serious complication for a common operation. The majority of post-tonsillectomy bleeds are self-limiting. A minority (1%) will need to return to theatre for haemorrhage control. Whilst rare, sudden severe haemorrhage can occur and result in death from airway obstruction or hypovolaemic shock. Bleeding can be occult and early identification is important.

Due to shorter hospital stays and the trend towards no post-operative follow-up, patients often present via the emergency department if complications arise.

Learning bite

Post-tonsillectomy haemorrhage occurs in around 5% of patients. The majority of these patients will present to the emergency department.

Definition

Post-tonsillectomy bleeds are divided into two categories:

Primary haemorrhage

• Occurs within the first 24 hours of the procedure.

Secondary haemorrhage

• Occurs more than 24 hours after the procedure.
• Most commonly seen between days five and ten post-op, when the fibrin clot sloughs off.

Post-tonsillectomy haemorrhage occurs in 5% of patients. 95% of patients recover uneventfully. Approximately 1% of patients will require a return trip to theatre.

Learning bite

Secondary haemorrhage most commonly occurs five to ten days after tonsillectomy.

A fibrin clot develops on the tonsillar fossae within 24 hours of tonsillectomy. Proliferation of the fibrin clot occurs so that by day five there is a thick clot on the fossae. By day 10, mucosa from the periphery of the wound begins to grow inward and the clot begins to separate from the underlying tissue. The risk of a secondary bleed is at its highest at this point.

Risk factors for post-tonsillectomy haemorrhage include

• increasing age
• post-operative infection
• if the indication for surgery was recurrent tonsillitis

Various studies have looked at surgical technique, with conflicting data on rates of post-tonsillectomy bleed. Coblation (the use of radiofrequency) may cause higher rates of post-tonsillectomy bleed.

Learning bite

The risk of a secondary bleed is highest at day 10 post-tonsillectomy.

History

When assessing a patient with suspected post-tonsillectomy bleed, ask about the following signs:

• Haematemesis/haemoptysis
• Bleeding from the nose
• Patient reporting tasting blood/metallic taste
• Excessive swallowing in young children
• Parents of younger children may describe finding blood on the childs pillowcase
• Estimated amount of blood loss

In addition, ask about the surgical and medical history:

• Time of operation
• Post-operative analgesia specifically ibuprofen or aspirin
• Past medical history specifically inherited or acquired bleeding disorders
• Inter-current illnesses especially upper respiratory tract infections or other febrile illnesses

A full set of observations should be recorded. Be aware that young patients can compensate for large amounts of blood loss before registering a tachycardia or a drop in blood pressure.

Perform an ABCDE assessment specifically looking for:

• Airway compromise
• Haemodynamic instability
• Evidence of bleeding

To examine the tonsils, use a headlamp (if available). Otherwise, examine the patient in a well-lit environment:

• It is normal for the operative site to look yellow-white and sloughy after the operation. This does not mean there is infection.
• Examine the tonsillar fossae and the patients throat for fresh bleeding. Excess blood may need to be removed with suction under direct supervision. Do not disturb a formed clot. If active bleeding is present, try to localise the source as left or right, and inferior or superior pole.
• If the patient is not actively bleeding, look for an old bleeding point or a blood clot in the tonsillar fossae.

Be aware that a small, self-limiting bleed (a herald bleed) may be a prelude to a larger bleed.

Learning bites

• It is easy to underestimate blood loss, especially in children who are unable to give a full history and can compensate well haemodynamically.
• Small bleeds may be a prelude to a larger bleed.

Intravenous access should be obtained and the following bloods sent:

• Full blood count
• Coagulation profile
• Cross match or Group & save
• Venous Blood Gas

Imaging is rarely required. The exception is if embolisation of the bleeding vessel is being considered by interventional radiology. Remember, a CT scan of the neck delivers a high radiation dose to the underlying structures, particularly the thyroid in young children.

In a patient with active bleeding

1.Call for help

This may include seniors in the emergency department, ENT, or anaesthetics as soon as condition is recognised. The latter, if not for immediate intubation, would help to mobilise the theatre team and get them prepared if the patient requires an emergency operation. Have the difficult airway trolley available.

2.Patient positioning

If appropriate, move patient to the resuscitation area. Sit the patient up. Most patients will be alert and have intact airway reflexes. Maintain a calm manner and reassuring tone (for parents and child).

3.Volume resuscitation

• Two large-bore cannulae
• Consider resuscitation with packed cells
• Administer tranexamic acid at 15 mg/kg in children or 1 gram in adults, given intravenously over 10 minutes
• Correct any coagulopathy. This may require discussion with haematology, especially if there is a diagnosed or suspected clotting disorder.

4.Stem the bleeding

Evacuate as much blood as possible from the mouth with suction under direct vision. This should be done by an experienced senior clinician or ENT.

Consider applying co-phenylcaine (lidocarine with phenylephrine) spray or topical adrenaline to the oropharynx. The latter can be done by soaking a dental roll or gauze with 1:10,000 adrenaline and applying it to the bleeding point, firmly held with Magills forceps and directing the pressure laterally (not posteriorly) and with a tail of gauze held outside the mouth.

5.Additional measures/considerations

• Ensure the patient is nil by mouth
• Intravenous analgesia if required
• Consider intravenous antibiotics if indicated
• Consider sedation. This would be dependent on local set-up. In some instances, it may be better to intubate the patient to achieve airway control.
• Consider early intubation if haemostasis is not achieved. Intubation will be compounded by the lack of pre-oxygenation, difficult view (obscured by blood/oedema), distended stomach (filled with blood) and haemodynamic instability.

Learning bites

• Escalate early, especially if ENT is not on-site.
• Airway protection and bleeding control should occur simultaneously with volume resuscitation.

• Bleeding is often occult in children, as they swallow blood rather than spit it out. Children can also tolerate blood loss well before decompensating. The amount of blood loss is usually more than estimated.
• Younger children may not tolerate application of pressure to the oropharynx. Sedation may be needed but would be dependent on the skillset available as sedative agents could result in haemodynamic collapse or airway compromise.
• All patients should have a period of observation in hospital, even if the bleeding has stopped in the emergency department.

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