Post-Tonsillectomy Haemorrhage

Essentials

• Post-tonsillectomy haemorrhage nearly always occurs about a fortnight after the surgery.
• Haemorrhage is caused by the shedding of the fibrin coating from the operated area before its final epithelialisation.
• The management of post-tonsillectomy haemorrhage is principally the responsibility of the unit that performed the surgery.
• Inform the receiving unit about referring the patient and confirm its emergency-care preparedness.
• Post-tonsillectomy haemorrhage may be the first sign of a coagulation disorder, particularly in children.
• Send the patient for specialist care if you are unsure whether the bleeding has stopped or if a patient presents with a recurring bleed.

Treatment

1. Reassure the patient.
   • Bleeding in the throat, and vomiting swallowed blood, can be very frightening. The patient should try not to swallow the blood.
2. Check the general condition of the patient and consider establishing venous access.
3. Arrange for an assisting nurse to be present and ensure appropriate equipment is available.
   • Headlamp
   • Metal tongue depressor
   • Suction apparatus with a stiff, thick and preferably metal tip
   • Electric cautery (bipolar or monopolar) if available
   • Forceps
   • Gauze balls or gauze squares that can be squeezed into a ball
   • Local anaesthetics (4% lidocaine-adrenaline solution or lidocaine spray 10 mg/dose for topical anaesthesia, or 1% lidocaine-adrenaline solution for infiltration anaesthesia) and a long needle.
4. Blood clots must be removed from the tonsillar bed even if bleeding appears to have stopped. Use suction and forceps to remove the clots from the tonsillar bed. Localise the bleeding point and apply pressure to it with a gauze ball soaked in 4% lidocaine-adrenaline solution for about 5 minutes. Hold the gauze ball at the end of long forceps (e.g. Kocher type) and apply firm pressure to the area. This should bring the situation under control and, moreover, will often stop the bleeding. If indicated, clotting may be enhanced by applying pressure with a gauze ball soaked in tranexamic acid solution Topical Application of Tranexamic Acid for the Reduction of Bleeding. After pressure has been applied, the bleeding area may also be anaesthetised by infiltrating the tissues under the mucous membrane with 1-2 ml of 1% lidocaine-adrenaline solution.
5. If the bleeding stops after the removal of the blood clots, monitor the patient at the clinic for at least a couple of hours before discharge home. If the bleeding point can be identified it should always be electrocauterized using either monopolar or bipolar diathermy. If the localisation of the bleeding point proves difficult, remember to also check carefully the inferior surface of the tonsillar bed. The bleeding most commonly originates from the medial or inferior parts of the tonsillar bed.
6. If the bleeding point is low, near the root of the tongue, it may be necessary to use considerable force to press the tongue down.
7. Observe the general condition of the patient during the procedure (a tendency to faint, haemorrhagic shock).
8. In children, the management of post-tonsillectomy haemorrhage may be difficult without general anaesthesia.
9. The application of sufficient pressure will stop even heavy bleeding. In some cases, particularly in profuse arterial bleeding, the physician will need to escort the patient to the receiving hospital whilst applying constant pressure to the tonsillar bed. The majority of bleedings can be managed by local anaesthesia at the emergency department.
10. If the bleeding responds normally to application of pressure and electrocautery, no blood clotting tests are required.