CLINICAL PRACTICE GUIDELINE

CLINICAL PRACTICE GUIDELINE: Emergency Department

Post-Tonsillectomy Bleeding

Disclaimer: This Clinical Practice Guideline (‘CPG’) was written for use in The Royal Victorian Eye and Ear Hospital
Emergency Department. It should be used under the guidance of an Ophthalmology or ENT registrar. If clinical advice is
required, please contact the Eye and Ear Admitting Officer for assistance: EYE: +61 3 9929 8033; ENT: +61 3 9929
8032. Links to internal Eye and Ear documents cannot be accessed from the website CPG.

See also: Tonsillitis

Description:

Post-tonsillectomy bleeding is thought to occur in approximately 5% of cases following

tonsil surgery. A bleed in the first 24 hours is considered a PRIMARY bleed and those
occurring after 24 hours are a SECONDARY bleed (most frequently in days 5-9, up to 28
days).

The majority of post-tonsillectomy bleeds will be minor and self-limiting. However,

small bleeds (so-called “herald bleeds”) can precede a more severe haemorrhage in the
following 24 hours and consequently all reports of bleeding should be taken very
seriously. In its most serious form, post-tonsillectomy bleeding can cause haemorrhagic
shock and aspiration, requiring an urgent return to the operating theatre to control.

Red Flags:

• Young patients (less than 18 years old) compensate haemodynamically, and may
deteriorate rapidly
• Primary bleeds often require a return to theatre
• Consider coagulopathy if there is excessive and/or recurrent bleeding. Von
Willebrand Factor disease is the most common congenital coagulopathy.
• Airway compromise (especially pre-existing in patients with Obstructive Sleep
Apnea Syndrome)

How to Assess:

Phone Call Advice (ENT Admitting Officer):

If you are called by a patient/relative or a GP about bleeding, respond as follows:

1. If actively bleeding, advise going urgently to the nearest ED, preferably with
ENT cover.
2. If bleeding has stopped, it may be safe to advise close monitoring at home for
another 24 hours. Sucking ice can help if the bleeding has stopped or is
minimal. If bleeding increases or recurs, advise going urgently to the nearest
ED, preferably with ENT cover.

CPG28.0. Post Tonsillectomy Bleeding Clinical Practice Guideline. V.3.0. Date Approved 16/07/2018. This document is
uncontrolled when printed or downloaded. To ensure you have the latest version please check the website or intranet
Policy Centre. Page 1 of 5
History:

Bleeding

• Active, heavy or light, intermittent?

• Ask patient about the amount of blood and when it started. A patient may
present with active bleeding or with a history of recent bleeding, e.g. coughing
blood or seeing blood on their pillow.
o Try to estimate the blood loss (e.g. teaspoon, egg cup). This may be
difficult as blood may have been swallowed.
• In children, a higher degree of care is needed, as excessive or difficulty
swallowing may be the only clue to bleeding
• Some patients may vomit a small amount of dark, altered blood during the first
couple of days, which may in fact represent blood swallowed during surgery and
not a new bleed
• Find out who performed the operation, when and where it took place. Notify the
surgeon about bleed if possible.

Examination:

• Wear gloves/gown and protective eye wear as per standard precautions

• Check ABC: is patient haemodynamically stable or in shock?
• Remain calm and reassure the patient
• Look for a clot on the tonsillar bed, check meticulously for any slow bleeding
• A sloughy, white appearance is normal after tonsillectomy

Acute Management:

If bleeding actively:

• Notify ENT registrar

• Immediate and continuous haemodynamic monitoring
• Consider calling a CODE BLUE if patient is unstable – summon senior
anaesthetic/ENT assistance – this is a difficult airway situation
• May also need to call theatre to organise urgent theatre (including
anaesthetic/ENT consultant)
• High flow oxygen if tolerated
• Sit the patient in an upright position to facilitate the removal of blood
• Insert large bore intravenous access and take blood for full blood count, urea
and electrolytes and group and hold. If unstable, urgent cross-match. Patient
may need coagulation profile.
• Intravenous fluids (in children 20mls/kg as initial bolus), analgesia and anti-
emetics
o Analgesia: oral or IV paracetamol regularly. Avoid NSAIDs.
• Establish when the patient last ate and drank. Ensure the patient remains nil by
mouth.

CPG28.0. Post Tonsillectomy Bleeding Clinical Practice Guideline. V.3.0. Date Approved 16/07/2018. This document is
uncontrolled when printed or downloaded. To ensure you have the latest version please check the website or intranet
Policy Centre. Page 2 of 5
 • Tonsil procedure:
o If you can visualise the bleeding spot (i.e. right vs. left tonsillar
fossa/superior vs. inferior), firmly apply a large cotton swab stick soaked in
1:10,000 adrenaline
o Alternatively, silver nitrite cautery may be attempted on the bleeding spot
following application of topical Cophenylcaine® spray. This should be
performed with ENT assistance.
NOTE: Both methods may stimulate the gag reflex and should only be
attempted by an experienced operator. Both these measures should NOT delay
theatre if required.
o If blood clot is visible on tonsillar bed:
▪ Leave it if patient has only had one small bleed and is not actively
bleeding
▪ Remove/suction it out if there has been recurrent bleeding or if
actively bleeding in order to visualise the bleeding spot. However, this
can cause profuse bleeding, so only perform with ENT assistance and
prepare in advance necessary equipment (silver nitrate cautery,
bipolar cautery, suction, resuscitation equipment) and address
potential need for urgent theatre.

Self terminated bleeding:

• Examine the patient thoroughly

• Tonsil procedure
o If blood clot is visible on tonsillar bed, leave it if the patient has had a
single small bleed and is not actively bleeding
o Remove/suction the clot if there has been recurrent bleeding. This should
be performed with ENT assistance and with IV access in situ as per ‘If
bleeding actively’ section.

Further management:

• Patient usually should be admitted for 24hrs to observe for further bleeding
• Consider the use of 3% H2O2 dilute in 1-2x volume of water as four hourly
mouth washes if bleeding slowly or has stopped (the benefit of this has not been
established)
• The use of antibiotics is not necessarily indicated for the treatment of all post-
tonsillectomy secondary haemorrhage patients. Routine use of antibiotics in
patients who do not have clear features of infection (e.g. pyrexia, raised white
cell count or C reactive protein) remains uncertain.
• Tranexamic acid – there is no direct evidence for its use in post-tonsillectomy
bleeding but there is strong evidence that it reduces the need for transfusion in
surgical bleeding in general. Dosage: 1 gram tranexamic acid via IV infusion.

CPG28.0. Post Tonsillectomy Bleeding Clinical Practice Guideline. V.3.0. Date Approved 16/07/2018. This document is
uncontrolled when printed or downloaded. To ensure you have the latest version please check the website or intranet
Policy Centre. Page 3 of 5
Evidence Table
Level of Evidence
Author(s) Title Source
(Ι – VΙΙ)
Blakley BW Post tonsillectomy bleeding: How much is too Otolaryngol Head Neck Surg. 2009 vol. 140 no. 3 288- V
much? 290
Georgalas C, Tolley, Narula N Tonsillectomy. Cold Steel tonsillectomy compared BMJ Clinical Evidence June 2007 I
with diathermy tonsillectomy.
Lee MS, Montague MK, Post-tonsillectomy haemorrhage: cold vs. hot Otolaryngol Head Neck Surg. 2004 Dec; 131(6):833-6 III
Hussain SS dissection
Lowe D, van der Meulen J Tonsillectomy technique as a risk factor for post Lancet 2004; 364; 697-702 VI
operativehaemorrhage National Prospective
Tonsillectomy Audit
Ikoma R et al. Risk factors for post-tonsillectomy haemorrhage AurisNasus Larynx 2014 Aug 41(4): 376-9 VI
Sarny S, Habermann W, Significant post-tonsillectomy pain is associated Ann OtolRhinolLaryngol. 2012 Dec; 121(12):776-81 VI
Ossimitz G, Stammberger H. with increased risk of haemorrhage
Sarny S, Ossimitz G, Haemorrhage following tonsil surgery: a multicenter Laryngoscope. 2011 Dec; 121(12): 2553-60 III
Habermann W, Stammberger prospective study
H.
Pai I, Lo S, Brown S, Toma Does hydrogen peroxide mouthwash improve the Otolaryngol. Head and Neck Surgery. 2005. 133(2):202- VI
AG outcome of secondary post-tonsillectomy bleed? A 5
10 year review.
Ahsan F, Rashid H, Eng C, Is secondary haemorrhage after tonsillectomy in ClinOtolaryngol. 2007 Feb; 32(1): 24-7. IV
Bennett DM, Ah-See KW. adults an infective condition? Objective measure of
infection in a prospective cohort.
Chan CC, Chan YY, Tanweer F Systematic review and meta-analysis of the use of Eur Arch Otorhinolaryngol. 2013 Feb;270(2):735-48. I
tranexamic acid in tonsillectomy.
The Hierarchy of Evidence

The Hierarchy of evidence is based on summaries from the National Health and Medical Research Council (2009), the Oxford Centre for Evidence-based Medicine
Levels of Evidence (2011) and Melynk and Fineout-Overholt (2011).

I) Evidence obtained from a systematic review of all relevant randomised control trials.
II) Evidence obtained from at least one well designed randomised control trial.
III) Evidence obtained from well-designed controlled trials without randomisation.
IV) Evidence obtained from well-designed cohort studies, case control studies, interrupted time series with a control group, historically controlled studies,
interrupted time series without a control group or with case series.
V) Evidence obtained from systematic reviews of descriptive and qualitative studies.
VI) Evidence obtained from single descriptive and qualitative studies.
VII) Expert opinion from clinician, authorities and/or reports of expert committees or based on physiology

CPG28.0. Post Tonsillectomy Bleeding Clinical Practice Guideline. V.3.0. Date Approved 16/07/2018. This document is uncontrolled when printed
or downloaded. To ensure you have the latest version please check the website or intranet Policy Centre. Page 4 of 5
Version Details:
CPG No: CPG28.0
Responsible Executive: Executive Director, Medical Services
Review Officer: Director, Emergency Department
• Clinical Practice Guideline Working Group
• Director Emergency Department
Contributor(s):
• ENT Medical Officer
• Christian Longley
National Standard: Comprehensive Care
Version Number: 3.0
Approval Date: 16/07/2018
Next Review Due: 16/07/2023

CPG28.0. Post Tonsillectomy Bleeding Clinical Practice Guideline. V.3.0. Date Approved 16/07/2018. This document is
uncontrolled when printed or downloaded. To ensure you have the latest version please check the website or intranet
Policy Centre. Page 5 of 5