73 A 5-year-old boy was evaluated for spitting up blood in the postanesthesia recovery unit 1 hour after a tonsillectomy and adenoidectomy. The procedure was done by means of electrocautery, and hemostasis was obtained using suction electrocautery. The child had just woken up and had not yet had anything to drink. He was immediately returned to the operating room, and bleeding was noted in the left tonsillar fossa. This was controlled with suction cautery, and the child was observed in hospital for 24 hours with no further bleeding. Five days later he was taken to the emergency department because of oral bleeding. The physical examination revealed an alert child with a pulse of 130 beats per minute and a blood pressure of 110/70. Examination of the oropharynx revealed no active bleeding. A clot was noted in the left tonsillar fossa. Complete blood count (CBC), prothrombin time (PT), activated partial thromboplastin time (PTT), and platelet function assay (PFA) were within normal limits. The clot was removed in the emergency department, and slight oozing was noted. Silver nitrate was used to control the bleeding. The child was admitted to the hospital for observation and discharged after 24 hours with no further bleeding. A clinic follow-up 3 weeks later revealed well-healed tonsillar fossae. 1. This patient presented initially with post-tonsillectomy bleeding within the first 24 hours after adenotonsillectomy. This is considered primary hemorrhage and is usually due to improper hemostasis during the primary surgery. Secondary posttonsillectomy hemorrhage is defined as any bleeding after the first 24 postoperative hours. Such bleeding usually occurs between postoperative day 5 and 10 and commonly is associated with premature separation of the granulation membrane that forms over the pharyngeal surface after tonsillectomy. The rate of primary hemorrhage generally ranges from 0.2 to 2.2% and of secondary hemorrhage from 0.1 to 3%. 2. Repeated postoperative bleeding should raise the possibility of a coagulation disorder. A thorough preoperative medical history regarding the patient and immediate family members should be obtained. Points that need to be addressed are history of easy bruising, epistaxis, oral bleeding, posttraumatic hemorrhage, excessive circumcision bleeding, postoperative or dental hemorrhage, hemarthrosis, perinatal bleeding, and recent use of any medication, especially nonsteroidal anti-inflammatory and anticoagulant medications. Systemic disorders that might result in excessive bleeding, such as liver disease, renal disease, or hemato-logic disease, should be addressed as well. The preoperative physical examination may help to detect possible coagulopathies and provides additional information. The presence of petechiae might suggest vascular or platelet disorders. Mucosal and gastrointestinal hemorrhage may be associated with vascular abnormalities such as bleeding into an elbow or knee joint, which is characteristic of hemophilia A (factor VIII deficiency) or factor IX deficiency. The presence of hepatosplenomegaly may indicate a liver disorder or hemolytic neoplasm. 3. In cases of recurrent bleeding with normal coagulation studies, vascular abnormalities should be suspected and evaluation by angiography should be done.
Posttonsillectomy Hemorrhage
History
Differential Diagnosis—Key Points
Test Interpretation
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