Instilled Epinephrine into the Oropharynx for Life Threatening Post-Tonsillectomy Hemorrhage

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Instilled Epinephrine into the Oropharynx for Life Threatening Post-Tonsillectomy Hemorrhage

Journal Title: Biomedical Journal of Scientific & Technical Research (BJSTR) - Year 2019, Vol 13, Issue 4

Abstract

Post-Tonsillectomy Hemorrhage (PTH) is one of the more lethal complications after a tonsillectomy and if one survives there is significant neurologic morbidity due to hypoxia. A 7-year-old female patient with PTH presented to an Emergency Department requiring intubation and cardiac resuscitation. In this case the use of instilled liquid epinephrine administered down the oropharynx allowed intubation and full recovery of the patient.Post-Tonsillectomy Hemorrhage (PTH) is one of the more lethal complications after a tonsillectomy. It occurs in up to 3% of all patients [1]. The mortality is low, reported as <1 % [2,3] however, morbidity has been reported as 20% [4]. PTH is classified as primary or secondary hemorrhage. Primary hemorrhage after a tonsillectomy is bleeding that occurs in the first 24 hours and is attributed to the surgical procedure itself. A secondary hemorrhage is bleeding that starts more than 24 hours after tonsillectomy and is associated with clot sloughing from the tonsillar fossa and often unrelated to surgical technique. Secondary bleeding occurs an average of 7 days after tonsillectomy and is far more common than primary bleeding [5,6]. There is little evidence available on the management of PTH. Among recent studies, some investigators have suggested admission to the hospital of all patients with a history of PTH and recommended electrocautery or suture ligature in the operating room for any clot or active bleeding noted [7,8]. Others have described several methods of initial management that range from observation to bedside intervention with silver nitrate, topical or injected vasoconstrictors or bipolar cautery [8-13]. In a survey by the American Society of Pediatric Otolaryngologists in 2017, the majority (82%) of otolaryngologists agreed that control of the hemorrhage should occur in the operating room after topical treatment [14]. Most otolaryngologists agree that for massive hemorrhage, ligation of the ipsilateral external carotid artery is recommended in the operating room [15]. Since intubation is difficult due to arterial bleeding in massive PTH, failed intubation is a possibility. Recommendations are that immediate surgical airway such as a cricothyrotomy should be performed if one cannot intubate by traditional direct laryngoscopy (DL) or alternative airways such as laryngeal mask airway (LMA), flexible scope intubation (FI) or video laryngoscopy (VL) [16].

Authors and Affiliations

Donna Mendez

Keywords

Donna Mendez Hypoxia Hypoxia Oropharynx Tonsillectomy Tonsillar Fossa Vasoconstrictors Bipolar Cautery Hemorrhage Pediatric Otolaryngologists Arterial Bleeding

EP ID EP585784
DOI 10.26717/BJSTR.2019.13.002438
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