Day: July 19, 2021

When is Post-Operative Bleeding Most Likely to Occur after a Tonsillectomy?

Patient Presentation
A 6-year-old male came to the emergency room because of oral bleeding the evening after having a tonsillectomy. His father said that the child seemed very uncomfortable and in pain and was refusing to drink. He had vomited and in the vomitus the father had seen dark red blood clots and some pink areas. After the emesis, the patient had been having continued “pink spit” but was not having any bright red blood or clots. He had urinated 6 hours previously and had a total of 2 emesis since the procedure. The procedure was performed because of multiple infections and “really big tonsils” according to the father and he had been told that there were no problems with the actual procedure. The past medical history revealed no problems with his circumcision around birth. The family history was negative for any bleeding problems in the family or patient. The review of systems showed him to have no airway problems or fever.

The pertinent physical exam showed he was crying but consolable. He could talk appropriately and had normal mentation. Vital signs showed respiratory rate of 22/minute, pulse of 98/minute, blood pressure of 114/72. Weight was 50% and was not different from his pre-operative weight. HEENT showed eyes, nose and ears to be normal. The patient was spitting out very light pinkish saliva. Oral examination revealed a clot with some oozing in one area. There did not appear to be other oral lesions. His airway was patent and he had good air exchange in his lungs.

The diagnosis of post-operative oral bleeding was made. The patient was hemodynamically stable but was refusing to drink and his pain was not adequately controlled. The patient was given IV fluids and one dose of codeine. After this the patient was more comfortable and with re-inspection the oozing continued but was not getting worse. He was monitored for a few hours and during that time he took ibuprofen, was able to drink cold fluids and the oozing stopped. The patient was discharged, and the patient’s clinical course the next day with telephone followup found that he continued to have pain but the family was able to get him to drink. He had no more bleeding and no respiratory problems. They were instructed to be more aggressive with using over the counter pain medications to keep him comfortable.

Discussion
Tonsillectomy is one of the most commonly performed surgical procedures in the US with pressure equalizing tubes and circumcisions also being among the top procedures. About 500,000 are performed yearly in the US in children under 15 years. Primary indications are recurrent throat infections (e.g. “< 7 episodes in past year, < 5 episodes in the past 2 years, or < 3 episodes per year in the past 3 years.”) and obstructive sleep apnea.

Potential complications include:

  • *Pain – treated with ibuprofen or acetaminophen as the first choice and other medications as needed. Pain control also decreases the risk of dehydration from poor oral intake
  • *Structural edema – usually occurs in first few hours, dexamethasone is often given during surgery to help treat this and prevent nausea and emesis
  • Direct trauma to oral and head and neck structures
  • Airway and lung complications
  • Nausea, emesis, dehydration
  • Hemorrhage
  • Infection – is always a possibility, but usually is not treated presumptively
  • Delayed feeding
  • Speech disorders
  • Death

*=some occurs with almost all patients because of the type of procedure.

Hemorrhage or bleeding can range from mucous tinged secretions to severe bleeding. Most is minor but even with episodes that resolve or where a clot is seen, severe bleeding can still occur in the future.
History of number of episodes, estimated blood volume seen, bleeding duration, time since last bleeding episode along with detailed family history of potential bleeding disorders and NPO status are important to obtain. Location of the blood is also important as swallowed blood may be a cause for concern in parents but is not actual oral bleeding. On physical examination hemodynamic instability or airway compromise needs aggressive treatment. The oral cavity should be examined for presence of active bleeding, presence of clot or fibrin clot (see more in To Learn More below).

Minor bleeding (where patients are hemodynamically stable and patient has oozing/small clot formation) can be cauterized with electrocautery or silver nitrate if needed. More severe bleeding usually warrants assessment by an otolaryngologist and may need direct pressure, surgical packing and/or surgical treatment to manage the bleeding. Airway management at all times is important. Monitoring in the emergency room or through hospitalization is also an important consideration. Treatment includes assessment, home or inpatient monitoring, and more aggressive management such as direct pressure, surgical packing and surgical treatment along with airway management.

Learning Point
As the tonsillar bed lies close to major arteries, during and immediately after a tonsillectomy there is a risk of bleeding associated with the procedure. This is defined as primary hemorrhage. Within hours, the main complications are pain and edema of the surrounding structures. A fibrin clot forms in the first 24 hours after surgery which has a characteristic white/grey appearance. This fibrin clot helps to protect the area from complications. On days 5-7 this clot separates which leave a thin stroma covering the area. It is this time period when the area has relatively little protection that the peak incidence of more significant bleeding occurs. This is secondary hemorrhage. A thick epithelium layer then grows to cover by day 12-17 and during this time the risk of complications decreases.

A systemic review and meta-nalysis performed in 2017 found “post-tonsillectomy hemorrhage associated non-operative revisits/readmission or reoperation ranged from 0.2%-5.7% for total tonsillectomy and from 0.1%-3.7% for partial tonsillectomy.” Four deaths were reported among ~1.8 million children in a case series. Hemorrhage rates were different depending on the indication, technique used and total or partial tonsillectomy, and age (e.g. higher in teenagers).

Questions for Further Discussion
1. How common is bleeding after circumcision?
2. What are indications for pressure-equalizing tube placement?
3. What questions should you ask to obtain a potential bleeding history for the patient and family?
4. What are indications for evaluation for a potential bleeding disorder?
Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Bleeding and Tonsillitis.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Francis DO, Fonnesbeck C, Sathe N, McPheeters M, Krishnaswami S, Chinnadurai S. Postoperative Bleeding and Associated Utilization following Tonsillectomy in Children. Otolaryngol Head Neck Surg. 2017;156(3):442-455. doi:10.1177/0194599816683915

Tan GX, Tunkel DE. Control of Pain After Tonsillectomy in Children: A Review. JAMA Otolaryngol Head Neck Surg. 2017;143(9):937-942. doi:10.1001/jamaoto.2017.0845

Wall JJ, Tay K-Y. Postoperative Tonsillectomy Hemorrhage. Emerg Med Clin North Am. 2018;36(2):415-426. doi:10.1016/j.emc.2017.12.009

Mitchell RB, Archer SM, Ishman SL, et al. Clinical Practice Guideline: Tonsillectomy in Children (Update)-Executive Summary. Otolaryngol Head Neck Surg. 2019;160(2):187-205. doi:10.1177/0194599818807917

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa