Post-tonsillectomy hemorrhage


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




  • Physical exam (do NOT remove any clots)
  • H/H
  • Type and screen if not already on file


  • 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


  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