Clinical Assessment and Risk Stratification


When assessing a patient with suspected post-tonsillectomy bleed, ask about the following signs:

  • Haematemesis/haemoptysis
  • Bleeding from the nose
  • Patient reporting tasting blood/metallic taste
  • Excessive swallowing in young children
  • Parents of younger children may describe finding blood on the child’s pillowcase
  • Estimated amount of blood loss

In addition, ask about the surgical and medical history:

  • Time of operation
  • Post-operative analgesia – specifically ibuprofen or aspirin
  • Past medical history – specifically inherited or acquired bleeding disorders
  • Inter-current illnesses – especially upper respiratory tract infections or other febrile illnesses

A full set of observations should be recorded. Be aware that young patients can compensate for large amounts of blood loss before registering a tachycardia or a drop in blood pressure.

Perform an ABCDE assessment specifically looking for:

  • Airway compromise
  • Haemodynamic instability
  • Evidence of bleeding

To examine the tonsils, use a headlamp (if available). Otherwise, examine the patient in a well-lit environment:

  • It is normal for the operative site to look yellow-white and sloughy after the operation. This does not mean there is infection.
  • Examine the tonsillar fossae and the patient’s throat for fresh bleeding. Excess blood may need to be removed with suction under direct supervision. Do not disturb a formed clot.  If active bleeding is present, try to localise the source as left or right, and inferior or superior pole.
  • If the patient is not actively bleeding, look for an old bleeding point or a blood clot in the tonsillar fossae.

Be aware that a small, self-limiting bleed (a ‘herald bleed’) may be a prelude to a larger bleed.

Learning bites

  • It is easy to underestimate blood loss, especially in children who are unable to give a full history and can compensate well haemodynamically.
  • Small bleeds may be a prelude to a larger bleed.