Posttonsillectomy Hemorrhage/Pain
Kei U. Wong
Benjamin Tweel
THE CLINICAL CHALLENGE
One of the most commonly performed surgical procedures in the United States is tonsillectomy, with or without adenoidectomy, the two most common indications being recurrent tonsillitis and sleep-related breathing disorders (eg, obstructive sleep apnea).1,2 Complications associated with tonsillectomy include bleeding, pain, infection, adverse effects of anesthesia, dehydration, and postoperative respiratory complications (especially in patients with obstructive sleep apnea).2,3
Recent database studies demonstrate that approximately 6% to 7% of pediatric patients return to the emergency department (ED) or unscheduled outpatient ambulatory settings following tonsillectomy, of whom approximately 16% require inpatient readmission.1,4 The most common reasons for return visits were bleeding (2%), throat pain (1.2%-1.4%), nausea and vomiting (1%), and dehydration (2.3%-28.2%).1,4 In a retrospective analysis of 36 210 adult patients who underwent tonsillectomy, 1.5% were readmitted within 14 days postsurgery, 10% of patients had postoperative ED revisits, 6% of whom were treated for hemorrhage, and 11% for pain management.3
Posttonsillectomy Hemorrhage
Postoperative hemorrhage is a potentially life-threatening complication associated with tonsillectomy, with an incidence of up to 6% of cases following tonsillectomy.3 Estimated rates of postoperative bleeding may vary depending on how hemorrhage is defined, and more inclusive criteria have approximated posttonsillectomy hemorrhage in up to 21.8%.5 In a prospective, multicenter cohort study with 9405 adult and pediatric patients, patients over age 15 years were more than twice as likely to experience hemorrhage after tonsillectomy compared with those under age 6 years.6 The challenge comes in managing two life-threatening processes simultaneously: hemorrhage and possible subsequent hemodynamic instability as well as maintenance of an intact airway.
Posttonsillectomy Pain
Although postoperative throat pain is an expected outcome rather than a complication, it is also an important cause of morbidity after tonsillectomy. Throat pain can lead to dysphagia, reduced oral intake of liquids, dehydration, weight loss, and, potentially, admission to the hospital.2 Referred otalgia, throat swelling, excess phlegm, and difficulty swallowing are also common postoperative complaints, which can compound the challenges of appropriate pain control.2
PATHOPHYSIOLOGY
The palatine tonsils are highly vascular structures, receiving blood through both the internal (ophthalmic) and external (lingual, ascending pharyngeal, facial arteries) carotid systems. A venous plexus drains the tonsils to the internal jugular vein via the lingual and pharyngeal veins.
Sensation from the tonsil is mediated through the glossopharyngeal nerve (CN IX) and through the lesser palatine nerve, a branch of the maxillary division of the trigeminal nerve (CN V2). Because the glossopharyngeal nerve runs just deep to the tonsillar fossa, tonsillar pain is frequently referred to the ear through the tympanic division of CN IX (Jacobson nerve).
Posttonsillectomy, a fibrinous eschar forms within the first day, then sloughs off around postoperative day 5 to 7. At that time, patients typically note an increase in pain, because loss of the protective eschar causes exposure of the underlying tissue once again. Notably, the first day and days 5 to 7 are also the most common times for postoperative bleeding.7
APPROACH/THE FOCUSED EXAM
Posttonsillectomy Hemorrhage
Posttonsillectomy hemorrhage is a common reason for presentation to the ED, but uncommonly life threatening. A cross-sectional data analysis on tonsillectomies in 2010 found a mortality rate of 0.006 percent (two deaths among 36 221 pediatric tonsillectomies).1
The management of significant posttonsillectomy bleeding is challenging owing to limited evidence-based practice guidelines and wide variation of practice patterns. Furthermore, management strategies in the adult population have not been extensively studied.
A focused ED assessment is crucial to identify patients at higher risk of severe posttonsillectomy hemorrhage. More importantly, in many community EDs without ENT physicians on call or surgical capabilities, these cases present a greater challenge. The initial ED assessment should focus on active bleeding control and hemodynamic stability. The presence of active bleeding, oozing, or fibrin clot in the oropharynx requires surgical management, and the ED provider should alert the otolaryngologist and anesthesiologist as soon as possible.7,8
History
A focused history should include date of surgery, duration, frequency, amount of bleeding, and time of last oral intake. The patient’s medical history, difficulties in surgery, and family or personal history of bleeding are also helpful.7
Examination
The initial assessment should focus on the airway and hemodynamic stability. In particular, tachycardia is often the first sign of hemodynamic instability.7 Most patients presenting in the ED will be alert, with intact airway reflexes. A complete visualization of the tonsillar fossa may be challenging owing to patient age, cooperation, and level of discomfort. Careful inspection with adequate light is warranted and the patient positioned upright to avoid airway obstruction.7 A headlamp is an ideal source of lighting, because it allows both hands of the clinician to be free.
The fibrin clot appearance is dependent on the technique and time following surgery. This will begin to form within the first day, and by day 5 the fibrin clot propagates into a thick cake with a characteristic gray-white appearance (Figure 18.1).8 The separation of protective eschar from underlying granulation tissues coincides with the high-risk period for delayed hemorrhage.7,8
Posttonsillectomy Pain
The biggest source of posttonsillectomy morbidity is oropharyngeal pain, which can cause dysphagia, decreased oral hydration intake, dehydration, and weight loss.2,8 The emergency provider should assess for clinical signs of dehydration (ie, decreased urine output, tachycardia, dry mucous membranes, decreased skin turgor) and address this as indicated. The provider should also inquire about the pain-control regimen at home and if reasonable augment it.7
Postoperative nausea and vomiting is another major source of morbidity and can enhance overall pain perception.2 A single dose of intraoperative dexamethasone during tonsillectomy has been shown to decrease nausea and vomiting and improve postoperative throat pain and swelling.2,7
For those who fail outpatient pain control with oral analgesics or who are unable to maintain adequate oral hydration, hospital admission for parenteral pain medication and fluid rehydration should be considered.
For those who fail outpatient pain control with oral analgesics or who are unable to maintain adequate oral hydration, hospital admission for parenteral pain medication and fluid rehydration should be considered.
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