The relevant curriculum item is knowing "The principles of the recognition and appropriate management of acute ENT emergencies, including bleeding tonsils..."
Anaesthesia for elective tonsillectomy is covered in a separate page.
Haemorrhage is the most serious surgical complication of tonsillectomy and accounts for around a third of tonsillectomy-related deaths
Post-tonsillectomy bleeding can be classified as either:
Primary: within 24hrs of surgery, usually due to surgical technique; most occur within the first 4 - 6hrs
Secondary: from 24hrs to 28 days post-operatively, due to wound healing and sloughing of the eschar; peaks at days 5 - 7
In the UK National Prospective Tonsillectomy Audit, the overall haemorrhage rate was 3.5%, with 0.9% returning to theatre
Primary haemorrhage occurred in 0.6%; the majority of bleeds were therefore secondary
Primary bleeds are typically seen in the hospital recovery or ward setting, while secondary bleeds usually re-present via the emergency department
Post-tonsillectomy bleeding is typically a venous or capillary ooze from the tonsillar bed
Arterial supply
Venous drainage
Ascending pharyngeal artery
Tonsillar capsule venous plexus
Lesser & ascending palatine arteries
Lingual vein
Tonsillar artery
Pharyngeal venous plexus
Dorsal lingual artery
Facial artery
Surgical risk factors
Hot techniques (e.g. diathermy) reduce intra-operative bleeding but increase secondary bleeding from thermal injury, compared with cold dissection
The Cochrane bods found no robust evidence that a coblation technique increases risk of primary bleeding, although it may slightly increase secondary bleeding
Bleeding is more common after tonsillectomy than tonsillotomy (4.2% vs 1.5%), with higher re-operation rates (2.2% vs 0.64%)
An inexperienced surgeon during the initial surgery increases risk of bleeding
Patient risk factors
Adults bleed more than children; age >6yrs increases the rate of secondary bleeding
Indication: highest rates with quinsy and recurrent tonsillitis, lowest with obstructive symptoms
Perhaps counter-intuitively, presence of abnormal coagulation doesn't appear to increase risk
Obesity does not increase risk
Drugs
Meta-analyses have not shown an increased risk of bleeding with NSAIDs; ketorolac is the exception and should be avoided
Dexamethasone was once implicated, but this has not been substantiated
Airway
Anticipate a difficult airway on account of:
Blood loss obscuring laryngoscopic view
Risk of aspiration of swallowed blood or post-operative oral intake (full stomach)
Airway oedema from recent airway instrumentation/surgery
Hypovolaemia
Blood loss is difficult to quantify, as it occurs over several hours and is largely swallowed
A child spitting blood is likely to be significantly hypovolaemic and anaemic
Early signs: tachycardia, tachypnoea, prolonged capillary refill, reduced urine output
Late signs: hypotension and altered conscious level indicate advanced volume depletion
Other considerations
Patient has recently had a GA; possible residual anaesthetic drugs and opioids in a primary bleed
Potential for undiagnosed coagulation disorder
Patient and parental anxiety/distress
Post-tonsillectomy bleeds are an emergency and I would seek senior anaesthetic and ENT support as well as making a rapid but thorough assessment of the patient
Perioperative management of the patient with a post-tonsillectomy bleed
Resuscitation
An ABCDE approach and 100% oxygen first-off; sit the patient up or lean forwards to allow blood to drain
The patient should be managed à la major haemorrhage:
Wide-bore IV access; intraosseous access if required
Urgent bloods: group & cross-match, clotting profile, FBC, U&E, venous gas, point-of-care Hb and visco-elastic haemostatic assay
Prompt resuscitation with crystalloid or blood, guided by trends in monitoring
Consider TXA
Ensure normothermia
Induction in a hypovolaemic child can precipitate cardiovascular collapse; resuscitate and induce once haemodynamically stable
Planning
Review the previous anaesthetic chart: ETT size, grade of intubation, drugs given
Have smaller-than-expected ETTs and a selection of laryngoscope blades available
Two working suction devices, ideally with a dedicated assistant
Videolaryngoscope, extra light source and difficult airway trolley
Blood and blood products available in theatre
ENT surgeon scrubbed and present at induction
Induction
Two techniques are described, each with their own (de)merits:
RSI with slight head-down tilt (most common)
Inhalational induction in the left lateral, head-down position
Reported incidence of difficult intubation is ∽3%
Transient hypoxia is the most common complication during induction (up to 10%); gentle bagging post-induction as part of a modified RSI technique can reduce this
Rapid sequence induction
Advantages
Disadvantages
Rapid control of the airway
Pre-oxygenation difficult, especially in an anxious child
Reduces risk of aspiration
Apnoea increases risk of hypoxaemia
NMBA optimises intubating conditions
Bag-mask ventilation may inflate the stomach
Familiar technique; less stressful for the child
Risk of CV collapse if under-resuscitated
Inhalational induction (lateral, head-down)
Advantages
Disadvantages
Blood drains from the airway via gravity
May be difficult in an anxious child
Spontaneous ventilation maintained
Deep volatile anaesthesia risks CV instability in hypovolaemia
Allows ongoing oxygenation during induction
Risk of aspiration and laryngospasm
Unfamiliar technique; intubation in the lateral position
Use reduced doses of induction agent and consider suxamethonium
Maintenance
Controlled ventilation provides good conditions for haemostasis
Continue fluid resuscitation and transfusion of blood products as necessary
Once haemostasis is achieved, pass a large-bore orogastric tube under direct vision and empty the stomach of blood and clots
Extubation
Thorough suctioning of the upper airway
Fully reverse neuromuscular blockade
Extubate wide awake, in the left lateral, head-down position
Close monitoring for recurrence of bleeding; at least 24hrs admission is required
Check Hb and coagulation post-operatively, particularly after transfusion
HDU care may be required after massive haemorrhage or a difficult airway
Consider investigation for an underlying bleeding disorder if there is no obvious surgical cause