Post Tonsillectomy Hemorrhage - Primary, Reactionary and Secondary Hemorrhage

🩸 Post-Tonsillectomy Hemorrhage

📌 Classification of Post-Tonsillectomy Hemorrhage

Post-tonsillectomy hemorrhage is classified based on the time of occurrence into:

1. Primary hemorrhage
2. Reactionary hemorrhage
3. Secondary hemorrhage

🔴 Primary Hemorrhage

Definition of Primary Hemorrhage

Bleeding that occurs during the time of operation.

• More commonly seen in hot tonsillectomy

What is normal amount of blood loss during Tonsillectomy?

How much blood loss roughly is considered as Primary hemorrhage in Tonsillectomy?

What is Hot Tonsillectomy?

Causes of Primary Hemorrhage

• Improper ligation or cauterization of vessels

• Slippage of ligature

• Injury to:

  • Tonsillar branch of facial artery
  • Other nearby vessels

What is the blood supply of Tonsil?

Management of Primary Hemorrhage

1. Pack tonsillar fossa and apply pressure
2. Electrocautery of bleeding points
3. Ligation of identified bleeding vessel
4. Topical hemostatic agents (e.g. adrenaline)
5. Pillar to pillar suturing
6. External carotid artery ligation

What is Pillar to pillar suturing?

🟠 Reactionary Hemorrhage

Definition of Reactionary Hemorrhage

Bleeding occurring within 24 hours of surgery

What is the most common time when Reactionary hemorrhage is seen postoperatively?

What are the Causes of Reactionary Hemorrhage?

⚠️ Clinical Features of Reactionary Hemorrhage

🚩 Mnemonic: 3H

• Hypotensive
• Hypovolemic
• Hypoxic

What are the Signs to look for to suspect Reactionary hemorrhage in a postoperative case of Tonsillectomy?

Management of Reactionary Hemorrhage

1. Assess consciousness

   • Conscious → Sit upright, encourage spitting
   • Semi/unconscious → Recovery position, head low, suction

2. Resuscitation

   • IV crystalloids via wide-bore cannula

3. Shift to OT

   • No premedication
   • Intubate
   • Suction oropharynx
   • Remove clot
   • Ligate or cauterize bleeder

4. If bleeding persists

   • Gel foam in tonsillar fossa
   • Pillar-to-pillar suturing

5. Last resort

   • External carotid artery ligation

How will you identify External Carotid Artery for ligation?

🟡 Secondary Hemorrhage

Definition of Secondary Hemorrhage

Bleeding occurring after 24 hours, most commonly on:

• 5th–7th post-operative day

What are the causes of Secondary Hemorrhage?

Clinical Features

• Oropharyngeal pain

• Fever

• Diffuse bleeding

• Blood stained sputum

• Slough with bleeding points in tonsillar fossa

Management of Secondary Hemorrhage

1. Conservative Management

• Hospitalize patient

• IV fluids

• IV antibiotics

  • Preferably 2nd or 3rd generation cephalosporins

• Injectable analgesics

• Hydrogen peroxide gargles

• Blood transfusion if required

2. If Bleeding Persists

1. Shift to OT

2. Ligate or cauterize bleeder

3. Pillar to pillar suturing

4. External carotid artery ligation (last resort)

📝 Summary Table

📌 Exam Pearls

• Most common Post Tonsillectomy Hemorrhage: Reactionary hemorrhage
• Most dangerous Post Tonsillectomy Hemorrhage: Reactionary hemorrhage
• Most common cause of Secondary hemorrhage: Sepsis
• Final life saving step: External carotid artery ligation

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