Post-tonsillectomy hemorrhage: Difference between revisions

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==Presentation==
==Background==
*Occurs in 1-6% of tonsillectomies
[[File:Gray1014.png|thumb|Anatomy of the posterior pharynx.]]
**Highest incidence in 21-30 year olds
*Occurs after tonsillectomies in 3.9% of adults and 1.6% of children<ref>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.</ref>
***Lowest in <6
*Most common on POD 5-7
*Highest incidence in 21-30 year olds
*Lowest in <6 year olds


===Work Up===
==Clinical Features==
[[File:PMC4273168 CTO-13-07-g-006.png|thumb|Intraoperative image after partial removal of the bilateral tonsils with bleeding controlled.]]
[[File:PMC2848321 ceo-3-56-g001.png|thumb|Intraoral photograph showing bleeding from the lower pole of the right tonsil (arrow).]]
*[[Hemoptysis]]
*Recent tonsillectomy
**Primary post-tonsillectomy hemorrhage from 0-24 hrs
**Secondary post-tonsillectomy hemorrhage from >24 hrs
 
==Differential Diagnosis==
*Post-op pain
{{Sore throat DDX}}
 
==Evaluation==
*Physical exam (do NOT remove any clots)
*Physical exam (do NOT remove any clots)
*CBC, T+S or T+C, coags
*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<ref name="Otolaryngologic Procedures">Riviello R. Otolaryngologic Procedures. In: Roberts and Hedges' Clinical Procedures in Emergency Medicine. 6th ed. Philadelphia, PA: Elsevier; 2014.</ref>
===Minor Bleeding===
*Hydrogen peroxide gargle<ref>Hydrogen peroxide as a hemostatic agent in tonsillectomy: Is it beneficial? Thejas Saai Ram, Vinayak Ravindranath, Sindu MohanYear : 2021 | Volume:  23 | Issue Number:  1 | Page: 36-40 </ref>
**50/50 3% Hydrogen Peroxide/Water gargle for 10 minutes.
*Can attempt [[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
 
===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<ref>Schwarz W. et al. Nebulized Trnexamic acid use for pediatric secondary post tonsillectomy hemorrhage. Annals of Emergency Medicine. 73(3). 2019</ref>
*Nebulized racemic [[epinephrine]] -  0.5 mL of 2.25% solution in 3 mL
*[[Lidocaine]] with epinephrine soaked pledgets
*Thrombin powder


====Management====
==See Also==
*ENT consult: Always, rebleeding is common and half of presentations require surgical management
*[[Pharyngitis]]
**Airway management (anticipate difficulty and have surgical back up)
***IV, O2, Monitor, NPO
****Can try direct pressure with tonsillar pack or gauze infused with lido with epi


=====Category=====
==References==
[[ENT]] [[Pharyngitis]]
<references/>


======Sources======
[[Category:ENT]]
Tintinalli

Latest revision as of 21:09, 16 November 2022

Background

Anatomy of the posterior pharynx.
  • 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

Intraoperative image after partial removal of the bilateral tonsils with bleeding controlled.
Intraoral photograph showing bleeding from the lower pole of the right tonsil (arrow).
  • Hemoptysis
  • Recent tonsillectomy
    • Primary post-tonsillectomy hemorrhage from 0-24 hrs
    • Secondary post-tonsillectomy hemorrhage from >24 hrs

Differential Diagnosis

  • Post-op pain

Acute Sore Throat

Bacterial infections

Viral infections

Noninfectious

Other

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

  • Hydrogen peroxide gargle[4]
    • 50/50 3% Hydrogen Peroxide/Water gargle for 10 minutes.
  • Can attempt 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

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[5]
  • Nebulized racemic epinephrine - 0.5 mL of 2.25% solution in 3 mL
  • Lidocaine with epinephrine soaked pledgets
  • Thrombin powder

See Also

References

  1. ↑ 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.
  2. ↑ Melio, Frantz, and Laurel Berge. “Upper Respiratory Tract Infection.” In Rosen’s Emergency Medicine., 8th ed. Vol. 1, n.d.
  3. ↑ Riviello R. Otolaryngologic Procedures. In: Roberts and Hedges' Clinical Procedures in Emergency Medicine. 6th ed. Philadelphia, PA: Elsevier; 2014.
  4. ↑ Hydrogen peroxide as a hemostatic agent in tonsillectomy: Is it beneficial? Thejas Saai Ram, Vinayak Ravindranath, Sindu MohanYear : 2021 | Volume: 23 | Issue Number: 1 | Page: 36-40
  5. ↑ 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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