Introduction

Adenotonsillectomy is a commonly performed procedure, with over 300,000 completed annually in the United States.1 Most adenotonsillectomies are not technically difficult and are performed by otolaryngologists at various levels of training and experience ( Fig. 12.1 ). Despite its commonality, adenotonsillectomy can be fraught with both minor and major complications.

Post-tonsillectomy Hemorrhage

Hemorrhage following adenotonsillectomy ( Fig. 12.2 ) occurs at a rate of 2 to 3%2 and can be defined as a primary bleed, which occurs within the first 24 hours, or a secondary hemorrhage, which occurs after 24 hours. Primary hemorrhage is thought to occur from inadequate hemostasis during the procedure. The incidence of primary hemorrhage has been reported to be ~ 0.2 to 1%.3

Inspecting the tonsillar fossa in a systematic fashion is paramount to avoid primary hemorrhage. Special attention should be paid to the inferior pole area because of the high concentration of blood vessels in that region ( Fig. 12.3 ). As a routine, release of the mouth gag or nasopharyngeal catheter to reduce tension on the fossae with reinspection will often reveal bleeding sites that were not obvious.

Secondary hemorrhage is more difficult to avoid. Use of electrocautery or radiofrequency creates an eschar in the tonsillar fossa and loss of this eschar, which occurs 5 to 7 days after tonsillectomy, is thought to contribute to the etiology ( Fig. 12.4 ). Maintaining the plane between pharyngeal constrictor muscle and tonsillar capsule without violation of the muscle may prevent exposure of larger caliber vessels. Maintaining the airway is the critical first step during a severe hemorrhage. Rapid sequence intubation is preferred as the patients have often swallowed a great deal of blood and are at aspiration risk. Bronchoscopy equipment should be available if blood is aspirated and ventilation becomes difficult. A ventilating bronchoscope with suction port and large caliber tracheal suction would be necessary should this scenario arise ( Fig. 12.5 ). Following control of the hemorrhage, it is important to pass an orogastric tube to evacuate the swallowed blood to prevent postoperative emesis ( Fig. 12.6 ).

Although bleeding is the most common complication of adenotonsillectomy, patients are typically not screened for a bleeding diathesis unless a family history for a bleeding disorder exists or a personal history of easy bleeding or bruising is present. Hemophilia A or B does not typically present in an insidious fashion and is usually diagnosed before presentation to an otolaryngologist. However, some bleeding disorders are discovered following a bleeding episode resulting from adenotonsillectomy. Von Willebrand disease may be present in up to 1.3% of the population and is often discovered in this manner.4 Type 1 and 2 are inherited in an autosomal dominant fashion and the first manifestation of the disease may be posttonsillectomy hemorrhage. Patients with von Willebrand disease have a higher risk of bleeding following surgery and their postoperative management should include consultation with hematologists. Use of intranasal desmopressin preoperatively and postoperatively and aminocaproic acid orally may help to prevent bleeding. Despite these measures, the rate of postoperative bleeding in patients with von Willebrand disease may be as high as 13 to 17%.5 No consensus exists as to the ideal technique for performing the surgery but the general principle is one of meticulous dissection and intraoperative hemostasis, which is used in all adenotonsillectomies. Counseling of patients with coagulopathies, and their parents, on these risks is imperative. Weighing the potential benefits of surgery against the rate of bleeding must be done in a clear manner.

Rarely, bleeding may not be controlled transorally. In these cases, ligation of the external carotid may be necessary. This has been reported in cases of massive hemorrhage or repeated hemorrhages following tonsillectomy.6 Aberrant vasculature in the posterior pharynx or medialized carotids may present a risk factor for catastrophic bleeding. Patients with velocardiofacial syndrome or 22q11 are at risk for medialized carotid arteries and special caution is needed. Aberrant arteries have been reported in the nasopharynx as well.7 Major vessel injury can be fatal and use of interventional radiology may be necessary. Entry into the parapharyngeal space during tonsillectomy may cause carotid pseudoaneurysm formation. Patients with repeated severe hemorrhage, or hemorrhage later than 14 days following surgery, may need thorough work-up including a pseudoaneurysm as part of the differential diagnosis. Diagnosis involves angiography, which could include embolization of the offending vessel.