What is the management of post adenoidectomy (removal of adenoids) bleeding?

Management of Post-Adenoidectomy Bleeding

Immediate surgical intervention is required for significant post-adenoidectomy bleeding, with most cases occurring within the first 24 hours after surgery and requiring return to the operating room for control. 1, 2

Initial Assessment

• Evaluate hemodynamic stability including vital signs, mental status, and extent of bleeding using an established grading system 3
• Determine timing of bleeding (primary vs. secondary hemorrhage):
  • Primary hemorrhage occurs within 24 hours and accounts for 86% of post-adenoidectomy bleeding cases 1
  • Secondary hemorrhage (after 24 hours) is extremely rare following adenoidectomy compared to tonsillectomy 2

Management Algorithm

For Hemodynamically Unstable Patients

• Immediate return to operating room for surgical control of bleeding 2, 1
• Secure airway with appropriate-sized endotracheal tube 4
• Have rigid instruments and consider tracheotomy preparation in case of difficult intubation 4
• Initiate fluid resuscitation with crystalloids (0.9% NaCl or balanced solution) 3
• Target hemoglobin of 70-90 g/L if transfusion is necessary 3

For Hemodynamically Stable Patients with Active Bleeding

• Careful inspection of the nasopharynx to identify bleeding source 4
• Consider topical application of tranexamic acid which has been shown to significantly reduce post-adenoidectomy bleeding 5
• Implement early measures to maintain normothermia 3
• Monitor for signs of deterioration that would necessitate surgical intervention 1

Surgical Management Techniques

• Return to operating room for direct visualization and control of bleeding source 2
• Options for hemostasis include:
  • Electrocautery (either unipolar or bipolar) 6
  • Packing of the nasopharynx for persistent bleeding 5
  • Suture ligation for identified vascular injury 4

Post-Bleeding Care

• Inpatient observation is strongly recommended after a bleeding episode 4
• Monitor for repeated episodes of bleeding, which may indicate need for additional intervention 4
• The risk of primary hemorrhage following adenotonsillectomy is double that of either procedure when performed alone (0.9% vs 0.4-0.5%) 2

Prevention Strategies

• Careful inspection of the nasopharynx immediately before adenoidectomy 4
• Curettage in a piecemeal fashion under visual control to prevent direct injury to aberrant arteries 4
• Consider prophylactic topical application of tranexamic acid (10-15 mg/kg) which has been shown to reduce both intraoperative blood loss and postoperative bleeding 5, 3

Special Considerations

• Be aware that adenoidectomy in children with 22q11.2 deletion syndrome carries risk of causing or worsening hypernasality and should involve consultation with a cleft-palate team 6
• The latest reported post-adenoidectomy bleeding occurred 6 days after surgery, compared to 18 days for tonsillectomy 1
• The overall rate of post-adenoidectomy hemorrhage requiring return to operating room is approximately 0.2-0.4% 2, 1