Post-Tonsillectomy Haemorrhage

Classification: Primary vs Secondary Haemorrhage

Primary haemorrhage occurs within 24 hours of tonsillectomy (typically in the immediate post-operative period). It is usually due to inadequate intraoperative haemostasis — a slipped ligature, diathermy eschar detachment, or a vessel that began bleeding when the vasoconstrictive effect of local anaesthetic wore off. Primary haemorrhage requires return to theatre in almost all cases.

Secondary haemorrhage occurs more than 24 hours after tonsillectomy — most commonly at 5 to 10 days post-operatively. It is the most common presentation seen on call, and is typically caused by infection of the tonsillar fossae causing sloughing of the healing eschar. The pattern is often one of a small initial bleed, followed by a more significant re-bleed. All cases must be taken seriously, even if the initial bleed appears minor and has stopped — subsequent bleeding can be sudden and torrential.

Assessment: Volume is Hard to Estimate

Estimating blood loss in post-tonsillectomy haemorrhage is notoriously difficult. Patients often swallow significant volumes of blood without recognising it — the first sign may be nausea, haematemesis (vomiting blood), or, in children, pallor and tachycardia. The visible haemorrhage in a bowl or on a pillow drastically underestimates the total volume lost. Therefore:

• Always assume blood loss is greater than it appears
• Treat haemodynamic signs (tachycardia, hypotension, pallor, prolonged capillary refill) as evidence of significant loss, even if bleeding appears minor
• Children compensate well until they suddenly decompensate — maintain a high index of suspicion

Initial Resuscitation (ABCDE)

All post-tonsillectomy bleeds require the following regardless of apparent severity:

• Airway: Ensure the airway is patent. If the patient is vomiting blood or has massive active bleeding, position them in the lateral recovery position (left lateral) to prevent aspiration. Call ENT and anaesthetics immediately if there is any airway compromise.
• Two large-bore IV cannulae (14 G): Insert in both antecubital fossae. Do not delay for a single cannula.
• Blood tests: FBC (haemoglobin, platelet count), coagulation screen (PT, APTT — particularly important to check in children with undiagnosed bleeding diatheses), U&Es, LFTs, and crucially group and save (cross-match if actively haemorrhaging).
• IV fluid replacement: Start a crystalloid bolus (normal saline or Hartmann's, 500 ml or 10 ml/kg in children) while awaiting blood products.
• Antibiotics: Start IV benzylpenicillin 1.2 g QDS and metronidazole 500 mg TDS — infection drives secondary haemorrhage and must be treated concurrently.
• Analgesia without NSAIDs: Prescribe paracetamol and/or codeine. Avoid NSAIDs (diclofenac, ibuprofen) — they impair platelet aggregation and may worsen haemostasis.
• Nil by mouth: Keep the patient NBM in anticipation of possible return to theatre.
• Hydrogen peroxide gargle: 20 ml of hydrogen peroxide diluted 1:6 with water, used as a gargle every 4 hours. The effervescent action helps to loosen and dissolve clot, promotes haemostasis via local haemolysis of the clot surface, and has mild antiseptic properties. It is appropriate only in cooperative adults and older children who can gargle safely without risk of aspiration.
• Inform the ENT registrar: All post-tonsillectomy bleeds require ENT involvement. Do not manage these patients independently.

Examination and Bedside Management

With equipment ready (Magill's forceps, gauze, 1:10,000 adrenaline, tongue depressor, and a headlight), examine the tonsillar fossae carefully. Three scenarios are possible:

Scenario 1: No Active Bleeding, Small Trace of Blood in Fossa

You see no active bleeding — only a small clot or trace of blood in one of the tonsillar fossae. The fossae will have a white-grey slough over them, which is normal healing tissue. You are looking specifically for a grey or dark area of clotted blood.

Management: follow the resuscitation plan above. Add hydrogen peroxide gargle. Admit to the ward, keep NBM, give IV fluids. Inform the ENT registrar — there may be an emergency operation that evening. Monitor closely for re-bleeding.

Scenario 2: No Active Bleeding, Large Clot Over Fossa

A large clot overlies one of the tonsillar beds. This clot may be concealing active bleeding beneath it and must be assessed.

Management: follow the resuscitation plan above. Contact the ENT registrar immediately and prepare the patient for theatre. Before the patient goes to theatre — and only with appropriate preparation — remove the clot with Magill's forceps and observe the underlying fossa. Use the technique described in Scenario 3 if active bleeding is revealed. If the fossa is not actively bleeding after clot removal, admit with IV antibiotics, IV fluids, and NBM. Monitor closely.

Scenario 3: Active Bleeding from Tonsillar Fossa

There is visible active haemorrhage from the tonsillar fossa. This requires immediate bedside haemostatic intervention while awaiting theatre and the ENT registrar:

1. Lean the patient forward (sitting up and leaning over a bowl) to allow blood to drain from the mouth rather than be swallowed. Give them a suction device or bowl.
2. Soak a gauze swab with 1:10,000 adrenaline (epinephrine). The vasoconstriction provided by adrenaline will help slow and stop haemorrhage from small vessels.
3. Grip the adrenaline-soaked gauze firmly with the tip of the Magill's forceps.
4. Press the gauze firmly and directly into the tonsillar fossa and hold it there for as long as the patient can tolerate — aim for at least 5 minutes. Apply pressure laterally (directly into the side wall of the fossa). Do not apply pressure posteriorly or inferiorly, as this causes gagging and may compromise the airway.
5. Continue this until bleeding stops or the ENT registrar/theatre team arrives.
6. If no equipment is available, use a gloved finger with firm gauze pressure on the fossa as a temporising measure.

Some clinicians use silver nitrate sticks to cauterise small visible secondary bleed points. This can be appropriate for very minor secondary bleeds from a clearly identified vessel in a cooperative adult, but requires caution and is not a substitute for the adrenaline gauze technique in active haemorrhage.

Return to Theatre

The following are indications for emergency return to theatre:

• Active haemorrhage not controlled by bedside measures after 10 to 15 minutes
• Large clot in the fossa requiring formal surgical removal
• Any primary haemorrhage
• Any child with post-tonsillectomy bleeding — children should have a lower threshold for theatre
• Haemodynamic instability (tachycardia, hypotension) despite resuscitation
• Clinical concern about re-bleeding risk even if bleeding has temporarily settled

In theatre, the bleeding vessel is identified and controlled under direct vision using bipolar diathermy, suture ligation, or haemostatic agents. Blood transfusion may be required if the haemoglobin is significantly reduced.

Special Considerations in Children

Post-tonsillectomy haemorrhage in children carries additional risks and requires a lower threshold for escalation and theatre:

• Children have a smaller circulating volume (approximately 70 to 80 ml/kg), meaning that blood loss causing haemodynamic compromise can occur rapidly
• Children compensate well initially due to higher sympathetic tone, then decompensate suddenly — a child who looks "reasonably well" can deteriorate within minutes
• Children may swallow large amounts of blood without complaining of nausea, presenting instead with tachycardia, pallor, or agitation
• Bedside examination and adrenaline gauze technique may not be possible in an uncooperative or distressed child — theatre may be the safest option even for apparently minor bleeds
• Fluid resuscitation in children: 10 ml/kg crystalloid bolus, titrated to response