A 6-year-old boy with Down syndrome is en route to your children’s hospital by ambulance with post-tonsillectomy bleeding.

He underwent adenotonsillectomy under general anesthesia 22 hours earlier. Despite being overweight at 37 kg and enlarged adenoids, he did not suffer from obstructive sleep apnea. Prior to his surgery, the child was uncooperative necessitating an inhalational induction with some struggling. Venous access was difficult even post-induction requiring several attempts, and finally being achieved in the left saphenous vein at the ankle. Because of possible atlanto-occipital instability associated with Down syndrome, cervical spine (C-spine) precautions were implemented during airway management. Bag-mask-ventilation with an oropharyngeal airway was easy. Direct laryngoscopy revealed a Grade 3 Cormack/Lehane (C-L) view of the larynx due to an enlarged tongue. Indirect laryngoscopy was then attempted using the GlideScope which revealed a Grade 1 view C-L. The trachea was intubated with an uncuffed 5.0-mm ID oral RAE tube. Adenotonsillectomy was performed uneventfully, and the child was discharged home after an overnight observation period.

While at home, the boy ate a hard tea biscuit, leading to onset of immediate sharp pain with intra-oral bleeding.

The child is in the emergency room sitting on a stretcher and spitting blood frequently into a kidney basin. The child is in moderate distress with the following vital signs: HR 152 bpm, BP 97/57 mm Hg. The child does not tolerate nasal prong oxygen and the pulse oximeter reading is 94% on room air. Auscultation of the chest is clear. Examination of the mouth reveals brisk bleeding in the right tonsillar bed. An attempt to start an intravenous line in the right saphenous vein was unsuccessful. However blood samples are obtained for a CBC, coagulation parameters, and a cross match. The child is then transferred to the operating room (OR) for further management.

What Is the Incidence, Morbidity, and Mortality of Pediatric Post-Tonsillectomy Bleeding?

Tonsillectomy is one of the most frequently performed surgical procedures in children, with approximately 580,000 outpatient pediatric adenotonsillectomies performed annually in the United States.¹ The most common post-tonsillectomy complications are postoperative nausea and vomiting (PONV) and pain. Dehydration may occur in children due to delayed poor oral intake, nausea, and fever. Delayed postoperative bleeding is the most significant complication and is not uncommon.^2,3 Many estimates of the incidence of post-tonsillectomy bleeding exist in the literature, varying widely from 0% to 11.5%.⁴ Typically, however, the rate ranges between 2.9% and 3.4%.^5,6 Mortality rates from severe bleeding are rarely reported in the literature.¹⁴ Two large studies reported an incidence of mortality of 0 out of 15,996 and 1 out of 16,381 tonsillectomies in 1979 and 1970, respectively.⁷ Sixty-seven percent of post-tonsillectomy bleeding originates in the tonsillar fossa and 27% in the nasopharynx. There are two major time frames for postoperative bleeding. Most often the bleeding occurs within the first 24 hours after surgery (primary bleeding).⁷ Primary bleeding is generally related to surgical technique, and the incidence is declining. Twenty-five percent of all post-tonsillectomy hemorrhage occurs after 24 hours. Secondary bleeding not related to surgical technique is rare, and of unchanged prevalence over the years.⁷ Although it may occur at any time, it is mainly observed between the 5th and the 10th postoperative day.⁸ Infection of the tonsillar bed with clot/eschar sloughing is believed to be the major cause of secondary bleeding. It occurs more commonly in older pediatric patients, because the indication in this age group is usually related to recurrent infections rather than airway obstruction, the most common indication for surgery in the younger pediatric age group.⁷

What Are the Initial Clinical Steps One Should Take in the Patient with Post-Tonsillectomy Bleeding?

The diagnosis of post-tonsillectomy bleeding is usually made by a focused history and physical examination, evidenced by a blunt or sharp trauma to the oropharynx. An intra-oral examination may reveal blood and blood clots. The differential diagnosis includes bleeding tumors of the oropharynx, like hemangiomas.

The child will present with fresh blood in the mouth and frequent swallowing of blood. It is important to emphasize that the amount of blood swallowed may be underestimated. Antiemetic medications may mask or suppress vomiting. It is not uncommon for children to have silent bleeding for prolonged periods with extensive blood loss. The child is often restless, diaphoretic, and pale. The vital signs may show an increased heart rate because of pain and hypovolemia. In awake children, hypotension following blood loss is a very late sign and then indicates significant hypovolemia. Intravenous access must be established as soon as possible followed by initial volume resuscitation with crystalloid or colloid solution. A blood sample for baseline hematocrit or hemoglobin is necessary as well as for blood type and cross match. Bleeding from the tonsillar bed may initially be controlled using pharyngeal packs and cautery. But children with post-tonsillectomy bleeding should be taken to the OR for exploration and surgical hemostasis. Repeated attempts to stop bleeding on the ward or in the emergency department should be avoided, except if exsanguination is imminent.

A questionnaire of children undergoing tonsillectomy with or without postoperative bleeding showed an increased incidence of posttraumatic stress disorder if the children were treated on the ward when compared to children treated in the OR.⁹

How Is the Airway Usually Managed in Post-Tonsillectomy Bleeding?

In addition to hypovolemia, patients with post-tonsillectomy bleeding present two major problems related to airway management:

• 
  

  Aspiration: These patients must be considered to have a full stomach and are at an increased risk of pulmonary aspiration.

  
  
• 
  

  Difficult airway: Blood and blood clots may impair visualization of the vocal cords. Additionally, edema of the oropharynx may have occurred because of surgery or infection. This may lead to altered oropharyngeal and/or laryngeal anatomy.

Because of the risk of aspiration, rapid sequence induction should be considered. The efficacy and use of cricoid pressure in children remains controversial. However, its use is typically employed in children with post-tonsillectomy bleeding.⁶ Of note, cricoid pressure can distort the laryngeal anatomy and potentially worsen the view of the larynx, and can induce vomiting in the partially anesthetized patient.¹⁰

The blood and blood clots in the oropharynx can impair visualization during laryngoscopy or cause obstruction of the placement of endotracheal tube and/or use of the suction apparatus. Therefore, two working suctions are essential. One should be a rigid, large-bore surgical suction and the other mounted with a flexible endotracheal suction catheter. If one becomes blocked with a blood clot, another is readily available. If large amounts of blood clot are present, it may be necessary during the initial laryngoscopy to manually remove them with a finger or gauze. Magill forceps should be available to retrieve clots deeper in the oropharynx. Different sized curved and straight blades as well as a flexible tip blade (McCoy laryngoscope) should be available. Different-sized cuffed styleted endotracheal tubes, with one size up and down of the calculated size must be prepared.

An Eschmann Tracheal Introducer may be helpful in the presence of a Grade 3 C-L view.¹⁰ If the epiglottis is visible, and if no laryngeal structure can be appreciated, a chest compression creating air bubbles through the larynx can help to locate the glottic opening.

The pediatric lightwand can be a useful technique for tracheal intubation when the glottic view is obscured by secretions or blood. The extremely bright light can shine easily through blood and blood clots.

Indirect laryngoscopy using this class of devices (e.g., GlideScope, Storz C-MAC, or Airtraq) may be difficult. Blood and secretions may obscure the optical lens, impairing the glottic view. However, this class of devices should be available when failed direct laryngoscopy is encountered.

Extraglottic devices (e.g., LMA) may be an alternative airway device in managing the difficult pediatric airway.¹⁰ It is often used to primarily manage the airway for adenotonsillectomies. Extraglottic devices are easy to place and may be used as a conduit for a flexible bronchoscope guided intubation if required.¹⁰ Use of a laryngeal mask may briefly tamponade the bleeding site, and possibly protects the airway and the optical lens of the bronchoscope. A case report recently described the successful use of a laryngeal mask for a failed intubation in a post-tonsillectomy bleed.¹¹

The use of a flexible bronchoscope alone is not recommended in cases of oropharyngeal bleeding. Experts recommend that the practitioner should rely on the alternative techniques with which they have the most experience and skill.¹⁰ An experienced otolaryngologist or other qualified rigid laryngoscopist/bronchoscopist should be available prior to anesthetic induction. If direct laryngoscopy fails, a rigid bronchoscope maybe useful. Equipment and preparation for a surgical airway is also essential (e.g., tracheotomy tray opened and ready).

What Are the Airway Management Options for This Patient?

This patient presents several issues regarding anesthesia induction and airway management:

• 
  

  Uncooperative nature of the child

  
  
• 
  

  Aspiration risk

  
  
• 
  

  Difficult intravenous access

  
  
• 
  

  Potential atlanto-occipital instability

  
  
• 
  

  History of difficult direct laryngoscopy (likely more difficult now due to blood and secretions)