---
title: "Post Tonsillectomy Hemorrhage - Primary, Reactionary and Secondary Hemorrhage"
description: "ENT notes on Post Tonsillectomy Hemorrhage - Primary, Reactionary and Secondary."
source: "The ENT Resident"
author: "Dr. Mausumi Das"
canonical_url: "https://www.theentresident.com/ent-notes-lectures/post-tonsillectomy-hemorrhage-reactionary-secondary"
categories: ["Pharynx", "Short Questions in ENT", "Surgery", "Mnemonics in ENT"]
video: "https://www.youtube.com/watch?v=x9_0_zbMpdA"
image: "https://media.theentresident.com/og-images/post-tonsillectomy-hemorrhage-reactionary-secondary.png"
---

# Post Tonsillectomy Hemorrhage - Primary, Reactionary and Secondary Hemorrhage

ENT notes on Post Tonsillectomy Hemorrhage - Primary, Reactionary and Secondary. Watch the full video lecture on YouTube: https://www.youtube.com/watch?v=x9_0_zbMpdA

## 🩸 Post-Tonsillectomy Hemorrhage

To learn more about the procedure itself, start here: [Tonsillectomy - Definition, Indications and Contraindications](https://www.theentresident.com/ent-notes-lectures/tonsillectomy-indications-definition-contraindications.md).

### 📌 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**

| Type | Time of Occurrence |
| --- | --- |
| Primary hemorrhage | During surgery |
| Reactionary hemorrhage | Within 24 hours (most commonly 6–8 hours) |
| Secondary hemorrhage | After 24 hours, usually 5th–7th post-op day |

---

### 🔴 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

| Type | Time | Common Cause | Initial Management |
| --- | --- | --- | --- |
| Primary | During surgery | Improper hemostasis | Pressure, cautery, ligation |
| Reactionary | 6–8 hrs | Slipped ligature | Resuscitation + OT |
| Secondary | 5–7 days | Infection | IV antibiotics, fluids |

---

### 📌 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**

---

## About This Note

This free ENT note on Post Tonsillectomy Hemorrhage - Primary, Reactionary and Secondary Hemorrhage was written by Dr. Mausumi Das and is paired with a corresponding video lecture.

Canonical page of this note: https://www.theentresident.com/ent-notes-lectures/post-tonsillectomy-hemorrhage-reactionary-secondary

When citing or referencing this content, please credit The ENT Resident and link to the canonical page above.

## Related Notes by Category

- Pharynx: https://www.theentresident.com/ent-notes-lectures/category/pharynx.md
- Short Questions in ENT: https://www.theentresident.com/ent-notes-lectures/category/short-questions-in-ent.md
- Surgery: https://www.theentresident.com/ent-notes-lectures/category/surgery.md
- Mnemonics in ENT: https://www.theentresident.com/ent-notes-lectures/category/mnemonics-in-ent.md

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