Post-Tonsillectomy Bleed

Red flags

  • Any patient who reports bleeding from the mouth or nose following a recent tonsillectomy.
  • Young children who have recently undergone tonsillectomy who present with poor oral intake, malaise and/or any excessive swallowing or bloody sputum.

 

Why is this important?

  • In the UK overall, post-tonsillectomy haemorrhage occurs in 2-5% of patients and represents the most common serious complication for a common operation 
  • It is therefore taken very seriously by ENT surgeons
  • While the majority of post-tonsillectomy bleeds are self-limiting, a significant minority need return to theatre urgently for control of the haemorrhage
  • Whilst extremely rare, sudden severe haemorrhage is known to occur and can result in death from airway obstruction or hypovolaemic shock.

 

When to involve the ENT Registrar 

The ENT registrar on-call should be notified immediately about ALL patients admitted with active post-tonsillectomy bleeding.  If the patient is not actively bleeding, but attend with a history of bleeding, they should be discussed and admitted by the SHO. 

 

Who to admit

All patients who complain of fresh bleeding from the throat, whether or not this has stopped when the patient presents, should be admitted for observation for around 24 hours.

A small, self-limiting bleed (a 'herald bleed') may be a prelude to a larger bleed within the next 24 hours.  

 

Assessment and recognition 

  • Bleeding can occur in the first 24 hours following the operation (reactive), or later (secondary). Patients with secondary bleeds frequently present between five and nine days after their procedure. 
  • The cause of secondary post-tonsillectomy bleeding is not clear - there may be infection of the sloughy material in the tonsillar fossa 
  • Some evidence suggests that the rate of secondary haemorrhage may be related to the technique used.

 

  • Patients will present with either a history of bleeding or with active bleeding from the tonsillar fossa(e).
  • Parents of younger children may describe finding blood on the child’s pillowcase or an episode of haemoptysis or haematemesis. 
  • Excessive swallowing may also be an indicator of ongoing bleeding in young children.  Have a high index of suspicion - the amount of bleeding is frequently underestimated in young children.

 

In the day or two following a tonsillectomy, a child may vomit some old or altered blood. This may represent blood swallowed during or immediately after the operation, rather than ongoing bleeding. Nevertheless, these patients should still be assessed carefully and discussed with the ENT Registrar.

 

  • Examine the patient’s throat for fresh bleeding.  Remember that it is normal for the operative site to look yellow-white and sloughy after the operation.
  • Try to localise the source – left or right, 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.

 

Immediate and overnight management

  • Airway first – sit the patient up and encourage them to spit blood into a bowl
  • Suction should be available if needed
  • An atmosphere of calm helps – the patient is usually very distressed if they are actively bleeding
  • Insert large-bore IV access and send blood for FBC, coagulation screen and group-and-save (urgent crossmatch if the bleeding is severe or the patient is unstable)
  • Do not delay in calling for an anaesthetist for help in stabilising an actively bleeding patient (this is especially true in children)
  • Frequent haemodynamic observations
  • Nil by mouth
  • IV fluid resuscitation
  • IV analgesia
  • Ice pack on the back of the patient’s neck
  • IV tranexamic acid – there is no evidence in post-tonsillectomy bleed specifically, but there is strong evidence that it reduces the need for transfusion in surgical bleeding in general
  • If not heavily bleeding: hydrogen peroxide gargles – this is made up from a 3% solution diluted in three parts of water before being given to the patient to gargle: they should not swallow.  It can stop a slow bleed and may prevent re-bleeding (not evidence-based)

Keep the patient nil-by-mouth until assessed by a senior ENT surgeon, even if the bleeding has recently stopped.

 

If the patient continues to bleed, or starts to bleed after admission:

  • Contact the on-call ENT registrar +/- the on-call anaesthetic registrar 
  • Alert emergency theatre/anaesthetist that the patient may need an urgent arrest of post-tonsillectomy bleed

If the bleed is very slow and the patient is stable, it may be possible to observe the patient for a short period of time with hydrogen peroxide gargles and ice packs. 

If the bleeding is continuous or heavy, the patient will need to go to the operating theatre as soon as possible. This is a more controlled environment where the patient has a secure, definitive airway and you have definitive means to stop the bleeding.

 

If the bleeding is severe and the patient is awaiting transfer to theatre:

  • Consider applying topical adrenaline to the bleeding point to slow the rate of haemorrhage temporarily. Soak a dental roll or gauze with 1:10,000 adrenaline and apply it to the bleeding point, firmly held with Magill’s forceps and with a tail of gauze held outside the mouth. This may not be possible if the patient has a strong gag reflex. Make sure the patient's head is tilted to the side and/or forwards to minimise the chance of inhalation, and keep a Yankeur suction at hand.
  • If inexperienced or unsure, seek senior help rather than attempting the above on your own. What the patient really needs is a secure airway and surgical intervention.

 

Further management

Prescribe regular hydrogen peroxide gargles and monitor closely for bleeding.

They should remain nil-by-mouth until review by a senior ENT surgeon. Frequently, water and diet will be gently reintroduced.

After 24 hours without further bleeding, the risk of recurrence is lower. Patients are usually discharged at this point.  All patients should be reviewed by a senior before discharge, and advised to return if there is any more bleeding.

Patients should not be discharged with hydrogen peroxide gargles.

 

REFERENCES

National Prospective Tonsillectomy Audit 2003-4, Royal College of Surgeons of England and BAO-HNS

Effect of tranexamic acid on surgical bleeding: systematic review and cumulative meta-analysis. 

 

 

 

 Page last reviewed: 29 September 2018