UMEM Educational Pearls

  • Large vascular supply to the tonsil and the surrounding tissues that do not compress on themselves which can lead to hemorrhage
  • 2 types of hemorrhage - primary and secondary
    • primary - within 24 hours
    • secondary - after 24 hours
      • most commonly POD 5-10
      • median time to bleed is POD 7
  • Bleeding occurs as the fibrin clot sloughs off from the tonsillar pillar (which occurs on day 5-10)
  • Surgery in older children and acute peritonsillar abscess are at increased risk for bleeding
  • Due to the proximity to arteries and the possibility of pseudoaneurysm formation, bleeding post-procedure can result in significant, life-threatening hemorrhage.
  • When assessing these patients, start with the ABCs
    • Assess the airway for compromise, some patients have heavy bleeding that requires intubation to secure the airway
    • Obtain access if needed due to the concern for exsanguination from these areas
  • Patients that have active bleeding or a clot should be referred to surgery (ENT) for cautery of bleeding area
  • Most patients are not bleeding when they reach the ED. If a patient presents with a history of bleeding, they should be observed (no standardized time frame)
  • If the patient has severe bleeding and awaiting the OR, can place gauze soaked with lidocaine with epinephrine on the bleeding area with Magill forceps
  • Topical hemostatic agents may help with bleeding, however, more severe bleeding requires surgery



1) Fox, S. (2012, August 17). Post-Tonsillectomy Hemorrhage. Retrieved April 8, 2015, from

2) Isaacson G. Tonsillectomy Care for the Pediatrician. Pediatrics. 2012; 130(2): pp. 324-334.

3) Perterson J, Losek JD. Post-tonsillectomy hemorrhage and pediatric emergency care. Clin. Pediatr. Jun 2004; 43(5): pp. 445-448.