What is the management of post-tonsillectomy haemorrhage?

Management of Post-Tonsillectomy Hemorrhage

Post-tonsillectomy hemorrhage requires immediate assessment of hemodynamic stability and airway patency, with direct pressure to the bleeding site as first-line intervention, followed by urgent surgical consultation for patients with active bleeding or hemodynamic instability. 1

Initial Assessment and Risk Stratification

Classify the hemorrhage temporally to guide management:

• Primary hemorrhage (within 24 hours): occurs in 0.2-2.2% of cases 2, 3
• Secondary hemorrhage (after 24 hours): occurs in 0.1-3% of cases, typically around days 5-11 2, 3

Recognize that minor bleeding often precedes severe hemorrhage - any bleeding episode warrants serious attention as it may be a warning sign of impending life-threatening hemorrhage 1, 4

Immediate Management Algorithm

For Active Bleeding:

1. Assess airway and hemodynamic stability immediately 1

   • Hemorrhage accounts for approximately one-third of tonsillectomy-related deaths 2, 3
   • Aspiration is a major cause of mortality in these cases 4

2. Apply direct pressure to the tonsillar fossa with or without hemostatic agents 1

   • This is the first-line intervention while preparing for definitive management

3. Obtain immediate surgical consultation or initiate transfer to a facility with surgical capabilities 1

   • Delayed and repeated bleeding episodes are characteristic of tonsillectomy hemorrhage and require surgical intervention 4

4. Prepare for possible rapid sequence intubation if airway compromise is present 1

   • Have rigid instruments and tracheotomy equipment immediately available in case of intubation failure 4

5. Initiate volume resuscitation for hemodynamic instability 1

For Minor or Self-Resolving Bleeding:

Admit for inpatient observation rather than discharge 1, 4

• Patients with any bleeding episode, even if self-limited, should be observed in the emergency department or admitted for monitoring 1
• Inpatient observation is strongly recommended for repeated bleeding episodes to provide immediate treatment if severe hemorrhage occurs 4
• This approach is life-saving in underestimated cases 5

Definitive Management

Surgical intervention is required for:

• Active bleeding not controlled by direct pressure 1
• Hemodynamic instability 1
• Repeated bleeding episodes 4

In cases of excessive hemorrhage not controlled by standard surgical techniques:

• Ligation of the external carotid artery (LECA) is the method of choice 5
• LECA is typically performed 6-11 days after tonsillectomy in cases of excessive delayed bleeding 5
• Consider anatomical vascular abnormalities in severe cases 5

Critical Pitfalls to Avoid

Do not discharge patients with any bleeding episode, even if minor - approximately one-third of deaths are attributable to bleeding, and minor bleeding often precedes severe hemorrhage 2, 1, 4

Do not underestimate delayed bleeding - secondary hemorrhage typically occurs days 5-11 postoperatively and can be abrupt and life-threatening 5, 4

Ensure adequate airway management - outcome is highly dependent on airway protection, as aspiration is a predominant cause of death at autopsy 4

Risk Factors for Hemorrhage

Patient factors associated with higher bleeding risk: 6

• Increasing age
• Male gender
• History of recurrent acute tonsillitis (3.7% bleeding rate)
• Previous peritonsillar abscess (5.4% bleeding rate)

Surgical technique factors: 6

• Hot surgical techniques (diathermy or coblation) increase secondary hemorrhage risk 3-fold compared to cold steel tonsillectomy
• Cold steel with bipolar diathermy for hemostasis has 1.5 times higher secondary hemorrhage risk than cold steel with ties/packs alone

Preventive Considerations

Avoid aspirin postoperatively - it increases hemorrhage risk, though non-aspirin NSAIDs (ibuprofen, diclofenac) do not significantly increase bleeding 6

Perioperative antibiotics do not reduce hemorrhage rates and should not be used routinely for this purpose 6

Topical tranexamic acid does not significantly reduce postoperative hemorrhage and is not recommended 7