Manegment of major bleeds
- Early intubation of any major post tonsillectomy bleed should be considered for airway protection
- Return to OT for ligation of bleeding vessel
- Electrocautery, chemical cautery
- Suture ties
- Suture tonsillar pillars together for persistent oozing
- Arterial bleeding may require angiographic embolisation or external carotid ligation
- Blood transfusion
Other potential risk factors for haemorrhage
- NSAIDs - inhibit platelet aggregation and prolong bleeding time.
- Non significant increase in risk of bleeding needing surgical intervention OR 1.69 (0.71-4.01)
- No alteration of risk of bleeding managed conservatively OR 0.99 (0.41-2.40)
- Reduce vomiting RR 0.72 (0.61-0.85)
- Recent acute tonsillitis
- Weight <15kg
- Older age
Post tonsillectomy Haemorrhage
Bleeding disorders
- Von Willebrands disease - mutated vWF causes abnormal platelet function and low factor VIII activity
- Mx: Tranexamic acid, vasopressin, recombinant factor VIII
- Haemophilia - deficiency of F VIII (type A) or F IX (type B)
- Mx: Recombinant factor VIII, vasopressin (mobilises factor VIII), tranexamic acid
Need closer observation for a longer duration
Epidemiology
Surgical technique
From the UK/Ireland audit:
- 3.5% had post op haemorrhage
- 0.6% primary haemorrhage (within 24 hours of surgery)
- 3% secondary haemorrhage (>24 hours after surgery, usually 5-10 days)
From Uptodate:
- Primary haemorrhage 0.2-2.2%
- Secondary haemorrhage 0.1-3% - caused by premature separation of the eschar due to underlying infection or dehydration
- 29% of bleeds required OT
- (UK audit) Cold steel + ties vs bipolar diathermy - increased risk with bipolar OR 2.47 (1.81-3.36)
- (Cochrane review) Dissection vs diathermy - mean 21.56mL less blood loss with diathermy, no difference in post op bleed rates.
- Coblation - similar risk of primary bleeding RR 0.99 (0.48-2.05), possible increased risk of secondary bleeding RR 1.36 (0.95-1.95)
- Haemostatic glues - no statistical difference compared to electrocautery
Vascular Anatomy
- Inferior pole - tonsillar artery (branch of the facial artery)
- Branches from ascending palatine, lingual, descending palatine and ascending pharyngeal arteries
- External palatine vein (paratonsillar vein) - descends from the soft palate and passes close to the lateral surface of the tonsil before it enters the pharyngeal venous plexus
Initial measures
- Airway protection
- Apply pressure to tonsillar bed with gauze
- Inject lignocaine/adrenaline
- Cauterize with silver nitrate
- Observation
- IV line, check haemoglobin, group and crossmatch
- ?Tranexamic acid
References
- Yuen S, Kawai K, Roberson DW, and Murray R. Do post-tonsillectomy patients who report bleeding require observation if no bleeding is present on exam? Int J Pediar Otorhinolargol. 95. 75-79 2017 Apr.
- Pynnonen M, Brinkmeier J, Thorne M, Chong LY, Burton M. Coblation versus other surgical techniques for tonsillectomy. The Cochrane Library. Aug 2017.
- Sproat R, Radford P, Hunt A. Haemostatic glues in tonsillectomy: A systematic review. Largynoscope. 126(1): 236-42, 2016 Jan.
- Pinder DK, Wilson H, Hilton MP. Dissection versus diathermy for tonsillectomy. Cochrane Database of Systematic Reviews. 2011, 3 Art. No.:CD002211.
- Lewis S, Nicholson A, Cardwell M, Siviter G, Smith A. Nonsteroidal anti-inflammatory drugs and perioperative bleeding in paediatric tonsillectomy. The Cochrane Library. July 2013.
- https://www-clinicalkey-com-au.ezproxy.surgeons.org/#!/content/book/3-s2.0-B9780702044199000039?scrollTo=%23hl0002001
- Lowe D, Van der Meulen J, Cromwell D, Lewsey J, Copley L, Browne J, Yung M, Brown P. Key Messages from the National Prospective Tonsillectomy Audit. Laryngoscope. 117(4) 717-724. April 2007.
- Uptodate - Tonsillectomy (with or without adenoidectomy) in children: postoperative care and complications.
- Uptodate - Tonsilectomy in adults
Bleeding - clinical features to look for
- Alteration in vital signs
- Active bleeding
- Clot in the fossa
- Hx of bleeding but normal exam - ?admit for observation: 11% subsequently need cauterization, 84% of those bleed within 24 hrs of presentation
- Signs of infection (febrile, raised inflammatory markers - antibiotics
- Drop in haemoglobin