Post-tonsillectomy hemorrhage
Background
- Occurs after tonsillectomies in 3.9% of adults and 1.6% of children[1]
- Most common on POD 5-7
- Highest incidence in 21-30 year olds
- Lowest in <6 year olds
Clinical Features
- Hemoptysis
- Recent tonsillectomy
- Primary post-tonsillectomy hemorrhage from 0-24 hrs
- Secondary post-tonsillectomy hemorrhage from >24 hrs
Differential Diagnosis
- Post-op pain
Bacterial infections
- Streptococcal pharyngitis (Strep Throat)
- Neisseria gonorrhoeae
- Diphtheria (C. diptheriae)
- Bacterial Tracheitis
Viral infections
- Infectious mononucleosis (EBV)
- Patients with peritonsillar abscess have a 20% incidence of mononucleosis [2]
- Laryngitis
- Acute Bronchitis
- Rhinovirus
- Coronavirus
- Adenovirus
- Herpesvirus
- Influenza virus
- Coxsackie virus
- HIV (Acute Retroviral Syndrome)
Other
- Deep neck space infection
- Peritonsillar Abscess (PTA)
- Epiglottitis
- Kawasaki disease
- Penetrating injury
- Caustic ingestion
- Lemierre's syndrome
- Peritonsillar cellulitis
- Lymphoma
- Internal carotid artery aneurysm
- Oral Thrush
- Parotitis
- Post-tonsillectomy hemorrhage
- Vincent's angina
- Acute necrotizing ulcerative gingivitis
Evaluation
- Physical exam (do NOT remove any clots)
- H/H
- Type and screen if not already on file
Management
- Airway management as needed (anticipate difficulty and have surgical back up)
- IV, O2, Monitor, NPO, upright position
- ENT consult: Always, re-bleeding is common and may require surgical management
- Important things to discuss with ENT: patient age, level of cooperation, visible clot, hematemesis, bleeding diathesis
- If stable, no active bleeding, and clot is present - do not remove the clot[3]
Minor Bleeding
- For minor bleeding try benzocaine spray or rinse with cold water, TXA, or lidocaine with epinephrine
- Can also try direct pressure with tonsillar pack or gauze infused with TXA or lidocaine with epinephrine on a long clamp or Magill forceps
- In desperate situations may need to intubate patient and tightly pack oropharynx to tamponade bleeding
Uncontrolled Bleeding
No guidelines provide a stepwise approach so all of these therapies can be attempted in addition to emergent ENT consult aggressive suction, and direct pressure if possible.
- Nebulized Tranexamic acid - 250 mg for patients < 25kg and 500mg if > 25kg[4]
- Nebulized racemic epinephrine - 0.5 mL of 2.25% solution in 3 mL
- Lidocaine with epinephrine soaked pledgets
- Thrombin powder
See Also
References
- Windfuhr JP and Yue-Shih C. Incidence of post-tonsillectomy hemorrhage in children and adults: A study of 4,848 patients. Ear, Nose & Throat Journal. 2002; 81(9):626-628.
- Melio, Frantz, and Laurel Berge. “Upper Respiratory Tract Infection.” In Rosen’s Emergency Medicine., 8th ed. Vol. 1, n.d.
- Riviello R. Otolaryngologic Procedures. In: Roberts and Hedges' Clinical Procedures in Emergency Medicine. 6th ed. Philadelphia, PA: Elsevier; 2014.
- Schwarz W. et al. Nebulized Trnexamic acid use for pediatric secondary post tonsillectomy hemorrhage. Annals of Emergency Medicine. 73(3). 2019
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