Background

RPA is more common in children than adults, particularly in children under 5 years of age. Although RPA is uncommon in general, it can lead to serious complications, such as airway obstruction, mediastinitis, and vascular compromise. RPA likely results from extension of nasopharyngeal infections to the retropharyngeal lymph nodes. These lymph nodes regress by puberty, which is why it is an uncommon diagnosis in adolescents and adults. RPA is associated with antecedent upper respiratory tract infection in approximately half of cases. ^, The infection commonly is found to be polymicrobial, including bacteria, such as group A beta-hemolytic streptococcus and Staphylococcus aureus . Local trauma from sharp foods like fish bones, endoscopy, dental procedures, and intubation also may result in RPA. This is the more likely cause in adolescents and adults.

Anatomy

The retropharyngeal space refers to a potential space between the base of the skull to the posterior mediastinum. The anterior boundary is the middle layer of the deep cervical fascia. The retropharyngeal space contains 2 chains of lymph nodes that are prominent in the young child but atrophy before puberty. These lymph nodes drain the nasopharynx, adenoids, posterior paranasal sinuses, middle ear, and eustachian tube.

Evaluation

Symptoms concerning for a diagnosis of RPA include

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  Fever

  
  
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  Neck pain or swelling

  
  
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  Nuchal rigidity or torticollis

  
  
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  Sore throat

  
  
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  Cervical lymphadenopathy

  
  
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  Drooling

  
  
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  Respiratory distress or stridor

Diagnosis of RPA should be considered in a nonverbal child with fever, with or without torticollis, and decreased oral intake without another likely cause.

Laboratory Testing and Imaging

Initial blood work should include a complete blood cell count (CBC) and blood culture. Blood cultures rarely are positive but may help in identifying the pathogen. CBC usually shows an increased white blood cell count with predominantly neutrophils and bands. ^,

Obtaining a lateral soft tissue neck radiograph is the first study to evaluate for RPA, especially when suspicion is low. If possible, patients should have their neck in normal extension and image taken during inspiration. Widening of the prevertebral space is suspicious for a diagnosis of RPA. Falsely thickened space may be due to poor positioning (neck in flexion), image taken during expiration, or crying, especially in an infant. Widening is measured at C2 and C6, with values over 7 mm and 14 mm, respectively. An alternative way to evaluate the retropharyngeal space for RPA is if the space measures greater than a full vertebral body at C2 or C3. If the radiograph is concerning or clinical suspicion is high, CT with contrast should be obtained to further distinguish RPA from other entities, such as cellulitis or a suppurative node ( Figs. 1 and 2 ). It also helps identify loculations and the position of the abscess to surrounding vessels, such as the carotid artery and internal jugular vein. This information is helpful to the ENT specialist when planning the surgical approach.

Sagittal view on CT of RPA.

(Courtesy of J. Rios, MD, Morristown, NJ)

Axial view on CT of RPA.

(Courtesy of J. Rios, MD, Morristown, NJ)

Although computed tomography (CT) is the test of choice, it is not a perfect test, and clinical judgment must be the ultimate determinant of management. Surgical exploration still is the gold standard. The sensitivity and specificity of CT in predicting purulent material at surgery vary from study to study and data are difficult to interpret given surgery not always is performed on the day of imaging. There have been clear reports, however, of apparent abscesses seen on CT that were not verified at the time of surgery.

If a child with suspected RPA is in acute distress, consultation of anesthesia and otolaryngology should not be delayed, given that the airway may need to be secured and urgent surgical drainage could be necessary. ENT consult should be made in any patient with the diagnosis of RPA regardless of severity of symptoms.

Differential Diagnosis

Many different conditions can present similarly to RPA. History, examination, and imaging studies should help distinguish the various possible etiologies for a patient’s presentation ( Table 1 ).

Management

If there are any signs of significant respiratory distress, there must be immediate consideration of the airway. ENT should be consulted in the event that a surgical airway and operative drainage are needed. Regardless of whether the airway is compromised, the patient should be started immediately on intravenous (IV) antibiotics followed by surgical drainage if there is no improvement within 24 hours to 48 hours. Antibiotics chosen should provide coverage of gram-positive and anaerobic bacteria. Surgical drainage usually depends on the clinical picture of the patient, size of the abscess on CT, and whether there is improvement on IV antibiotics. Mature abscesses that are larger than 2.5 cm should be considered for drainage. If there is no clinical improvement in 24 hours to 48 hours, then a repeat CT may be indicated or surgical drainage performed without further imaging. Airway compromise or signs of sepsis also should prompt surgical intervention ( Fig. 3 ).

Management of RPA.

All children with suspected RPA should be admitted with ENT consultation. Management of RPA is controversial; some sources encourage immediate drainage and IV antibiotics for every child whereas others favor the trial of IV antibiotics alone first. Those that advocate for early surgical drainage believe it shortens the length of stay and, therefore, reduces total cost. The data available, however, do not necessarily support this. An observational study of 111 children with RPAs showed that surgical drainage actually was associated with higher cost and similar lengths of stay compared with children treated with IV antibiotics alone. ^, The success rates of patients treated with IV antibiotics alone also is quite variable. Possible reasons for treatment failure may be infection with resistant or unusual organisms, underlying problems, or development of complications. ^, Thus, the plan for surgical drainage is dictated by close and frequent discussions with the ENT consultant as well as a patient’s presentation, imaging results, and hospital course. Other considerations for patients admitted for RPA include pain control and hydration.

Complications

The most emergent complication of delayed diagnosis and therefore treatment can include airway compromise or obstruction. Other complications of the disease process include mediastinitis, sepsis, necrotizing fasciitis, aspiration pneumonia, internal jugular venous thrombosis, Lemierre syndrome, and carotid artery aneurysm/rupture. These complications occur rarely but can be life threatening.

Background

PTA is the most common deep infection of the neck. It most often is diagnosed in the adolescent and young adult populations. The usual course of developing a PTA is initial tonsillitis or pharyngitis, which progresses to cellulitis and then to abscess formation. Infrequently, infection does not initiate this process; rather, obstruction of soft palate salivary glands is in the inciting factor.

Anatomy

The palatine tonsils are surrounded by a capsule. A PTA usually develops in the superior pole of the tonsil. The collection of pus is noted between the tonsillar capsule, superior constrictor muscle, and the palatopharyngeus muscle. ^, The abscess develops due to oral flora invading the peritonsillar space, leading to an abscess between the palatine tonsil and its capsule. The infection often is polymicrobial, including aerobes and anaerobes, most often including group A streptococcus and Staphylococcus aureus .

Evaluation

Symptoms concerning for a diagnosis of PTA include

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  Sore throat

  
  
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  Fever

  
  
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  Muffled voice

  
  
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  Drooling

  
  
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  Pharyngeal erythema

  
  
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  Asymmetric peritonsillar swelling, especially with uvular deviation away from the affected side

  
  
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  Trismus

Laboratory Testing and Imaging

Initial blood work may include a CBC and electrolyte panel to assess for signs of infection and state of hydration, respectively. CBC usually shows an increased white blood cell count, but this is nonspecific.

To confirm a diagnosis, needle aspiration, ultrasound, or CT needs to be used to confirm fluid collection in the peritonsillar space ( Figs. 4 and 5 ). Patients who have symptoms suspicious for PTA with nondiagnostic ultrasound imaging but who are without airway compromise can be admitted for 24 hours of observation with pain control, hydration, and antibiotics. CT is recommended only if there is concern for an alternate diagnosis or lack of improvement.

Axial view on CT of PTA.

(Courtesy of J. Rios, MD, Morristown, NJ)

Sagittal view on CT of PTA.

(Courtesy of J. Rios, MD, Morristown, NJ)

Management

The primary interventions for the treatment of PTA include drainage, antibiotics, pain control, and hydration. Admission is more likely in children, but adolescents and young adults may be managed outpatient if they can tolerate drainage and demonstrate ability to take medications and tolerate liquids afterward. These patients then should have follow-up in 24 hours. Return precautions include, dyspnea, worsening pain, fever, bleeding, and trismus.

Needle aspiration is the most common primary management of PTA. It is less invasive, less painful, and leads to less bleeding. Ultrasound use during aspiration is the current recommendation. When assisted with intraoral ultrasound, needle aspiration was found 100% successful in 1 study of 18 patients with confirmed PTA. This same study showed that aspiration with just the traditional anatomic landmark technique was only 50% successful.

Needle aspiration has been shown equally successful as incision and drainage in multiple studies. There have been some studies that suggest a lower recurrence rate with incision and drainage, but the data are inconsistent. ^, Thus, the choice typically depends on the age of the patient and their ability to cooperate. Patients unable to tolerate the procedure should go to the operating room (OR) and be sedated.

Injury to the internal carotid artery from needle aspiration or incision and drainage is a feared complication. That said, injury to the carotid artery during PTA drainage never has been reported in the medical literature. The use of ultrasound during these procedures allows visualization of important neighboring structures, such as the internal carotid artery ICA, which assists in avoiding this adverse event. Other potential complications include hemorrhage and aspiration of pus and blood into the airway.

Antibiotics alone may treat PTA adequately if the abscess is small and the patient is able to tolerate liquids and only endorses mild pain. This decision can be made with consultation with ENT. Antibiotic choice should cover for Staphylococcus aureus , group A streptococcus, and respiratory anaerobes. Typical antibiotics used are amoxicillin/clavulanate or clindamycin. If the patient does not improve, worsens, or presents with more severe disease, the addition of vancomycin may be considered. Tonsillectomy or incision and drainage by ENT should be considered if there is lack of improvement within 24 hours of the medical management.

Controversies

The use of steroids in the treatment of PTA is controversial. Data are similar to studies conducted evaluating its utility in the treatment of pharyngitis. Results have been inconsistent, but some studies have shown improvement in pain in 24 hours. Given the lack of profound data, their use in the treatment of PTA should be on a case-by-case basis and decided on in conjunction with the specialist involved in the patient’s care.

Procedural Approach

Clinical Outcomes and Complications

Once patients are afebrile and show clinical improvement, they may be discharged with oral antibiotics to complete a 14-day course. The most emergent complication of PTA is airway obstruction. Complications are similar to RPA and therefore include mediastinitis, aspiration pneumonia, necrotizing fasciitis, sepsis, internal jugular vein thrombosis, Lemierre syndrome, carotid artery aneurysm or rupture, and hemorrhage. These complications are rare but potentially fatal. An estimated 10% to 15% of PTAs recur.

Background

Epiglottitis was a diagnosis seen primarily in children until vaccination against Haemophilus influenzae type B (Hib) was developed and instituted. It since has decreased in incidence but also has evolved into an adult disease. The more common causative bacteria since the Hib vaccine are nontypeable H influenza , Staphylococcus aureus , Streptococcus pneumonia , Pseudomonas , Moraxella , and Neisseria . There are, however, Hib vaccine failures as well. Therefore, vaccinated and unvaccinated individuals may be diagnosed with this disease.

Epiglottitis primarily results from bacteria from the posterior nasopharynx directly extending into the epithelial layer covering the epiglottal cartilage or may result from bacteremia. This leads to cellulitis of the epiglottis and periepiglottic tissues, which results in epiglottitis. The swelling associated with this process is what leads to narrowing of the upper airway, resulting in stridor, distress, and potentially fatal airway obstruction. The signs of severe obstruction can present late in the disease process and lead to delayed airway management.

Evaluation

Symptoms concerning for a diagnosis of epiglottitis include

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  Rapid breathing

  
  
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  Fever

  
  
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  Toxic appearance

  
  
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  Tripod or sniffing position

  
  
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  Drooling

  
  
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  Dysphagia, pharyngitis, or voice change

  
  
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  Tachycardia

  
  
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  Respiratory distress

  
  
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  Stridor

The gold standard for diagnosis is visualization of an inflamed epiglottis and surrounding structures, such as the aryepiglottic folds and arytenoid cartilages. Visualization can be via direct pharyngoscopy with a tongue blade, bronchoscopy, or direct laryngoscopy with appropriate equipment and staff in cases of need for further airway management. ^, The aforementioned techniques are appropriate, however, only in patients without stridor, signs of significant distress, or increased distress with agitation. The goal is to make the diagnosis and start treatment before and without leading to full airway obstruction.

Imaging

Typical initial evaluation in the emergency department (ED) of stable patients with lower suspicion for epiglottitis includes a lateral soft tissue neck radiograph, which may reveal a thumbprint sign, due to thickening of the epiglottis. It also helps rule out foreign body or croup as the cause of symptoms given, the overlap in many of them. Radiographs should be deferred if it leads to increased agitation and therefore increased respiratory distress.

Work-up of patients with suspected epiglottitis also includes obtaining laboratory test results, such as CBC, blood culture, and a culture from the epiglottis after establishing a secure airway. Tests such as these also may agitate patients and thereby worsen their respiratory status. Therefore, they should be done only in patients without distress or stridor. Otherwise, laboratory assessments should wait until a patient is stabilized with an established airway.

Management

The priority of the management of epiglottitis is to evaluate the airway and anticipate for airway obstruction. Allow patients to remain in a position of comfort with their caretaker to reduce any anxiety.

If any compromise of the airway is suspected, anesthesia and a surgeon should be notified immediately. A difficul airway should be prepared for with potential need for a needle or surgical cricothyrotomy. If the patient is toxic-appearing or under 6 years old with confirmed epiglottitis, then plans for immediate intubation in the OR should be made in consultation with the ENT specialist.

Patients with suspected or confirmed epiglottitis should be started immediately on antibiotics and fluids, and steps should be taken to admit the patient to the intensive care unit. Antibiotic choice should include coverage for the bacteria, discussed previously, regardless of vaccination history, given potential for vaccination failure. Typical antibiotic choices are ampicillin/sulbactam, cefotaxime, and ceftriaxone. Consider additional coverage for methicillin-resistant Staphylococcus aureus based on local prevalence of the bacteria.

Data on the benefits of steroid use are limited and thus its utility are debatable, although steroids often are incorporated in the management of epiglottitis with the hopes of reducing the inflammation.

Clinical Outcomes

Rates of intubation and tracheotomy are low in patients with epiglottitis. One study in 2009, found that 11% (40 children) of pediatric patients studied required intubation or tracheotomy. Regardless of these studies, the concern and preparation for complete airway obstruction are necessary in patients where epiglottitis is suspected.

Background

Bacterial tracheitis is characterized by thick purulent exudates and tracheal pseudomembranes, which can lead to airway narrowing and obstruction and result in respiratory arrest. The mean age at diagnosis is 5 years old and its incidence is highest in the fall and winter. Bacterial tracheitis affects children with their own native airway or with an endotracheal tube or tracheotomy tube. It is a rare disease but with a high mortality rate. Historically, patients were typically noted to look toxic and critically ill, but some children now present with less severe forms. ^,

Nature of the Problem

Bacterial tracheitis often is thought to be due to a superinfection of viral tracheobronchitis due to influenza, parainfluenza, or respiratory syncytial virus. These viral infections cause mucosal damage to the airway, which then predisposes the trachea to bacterial infections. The most common bacteria leading to this entity include Staphylococcus aureus , Moraxella catarrhalis , Streptococcus pyogenes, Streptococcus pneumonias , Streptococcus viridans , and Haemophilus influenzae . Gram-negative bacteria also rarely may cause bacterial tracheitis.

Patients with tracheotomy develop bacterial tracheitis due to the artificial airway providing easy entry of bacteria and due to the tube potentially causing ulceration and disrupting mucosal immunity. Strict tracheotomy care is important to the prevention of infection.

The airway, in either the native or artificial group, inflicted with bacterial tracheitis, leads to tracheal mucosal inflammation and edema, thick mucopurulent secretions, ulceration, and sloughing, which then can lead to subglottic narrowing.

Evaluation

History and physical examination often are all that is needed to diagnose bacterial tracheitis.

Symptoms concerning for a diagnosis of bacterial tracheitis in those with a native airway include

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  Prodrome of upper respiratory infection

  
  
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  Sudden high fevers

  
  
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  Toxic appearance

  
  
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  Hoarseness

  
  
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  Productive cough

  
  
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  Stridor

  
  
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  Respiratory distress or cyanosis

  
  
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  No drooling or tripod positioning (more consistent with epiglottitis)

Symptoms concerning for a diagnosis of bacterial tracheitis in those with an artificial airway are less acute and include

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  Increasing purulent secretions requiring more suctioning

  
  
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  Changes in color or thickness of secretions

  
  
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  Need for changes in mechanical ventilation settings

Laboratory Testing and Imaging

The steps taken in diagnosis of bacterial tracheitis depend on determining the stability of the patient’s airway. In patients without distress or airway compromise, obtaining lateral and anteroposterior radiographs typically is the first step. Steeple sign of croup may be noted. Radiographs less often may be notable for haziness or irregularity of the tracheal column, which indicate detachment of the pseudomembrane. The epiglottis should look normal. Reports have shown that in those who also underwent a chest radiograph, 50% also had findings consistent with pneumonia. This increases the severity of disease course and likely intubation.

Definitive diagnosis is via direct visualization by performing laryngoscopy or bronchoscopy, but diagnosis can be made if there is strong clinical suspicion. Flexible laryngoscopy also may be performed to evaluate for mucopurulent secretions of the glottis and supraglottic area and edema of the trachea. If a patient’s airway status worsens or if cases are more severe, a direct rigid bronchoscopy under anesthesia by an ENT specialist is recommended after the airway is secured. With bronchoscopy, therapeutic clearing of exudates can help with the degree of airway narrowing due to these secretions or pseudomembranes. Gram stain and bacterial and viral cultures should be sent from tracheal secretions. When intubating a patient with suspected or confirmed bacterial tracheitis, the airway likely os narrower than normal due to inflammation and thus a smaller diameter endotracheal tube should be anticipated.

Work-up also may include a CBC, erythrocyte semination rate, C-reactive protein, and blood culture if there is concern for sepsis. These tests are nonspecific and blood cultures rarely are positive.

Management

The airway is the priority in managing patients with bacterial tracheitis. If there is significant respiratory distress, the airway should be secured via intubation. Given that intubation can be difficult, it is performed best in the OR, with readiness for a surgical airway if it becomes necessary.

Treatment with IV broad-spectrum antibiotics also should be initiated immediately. Coverage should include MRSA. Typical choices include clindamycin or vancomycin and ceftriaxone or cefotaxime. Fluoroquinolones may be used in cases of penicillin allergy.

The use of steroids and racemic epinephrine is controversial. There have been no studies that have shown any benefit in improving airway compromise; thus, a trial of them likely shows no improvement in the patient. ^,

Definitive treatment involves débridement via suctioning in the OR. Postprocedure, the patient is admitted to the pediatric intensive care unit (PICU). Admission to the PICU is recommended even in those patients who are not intubated, given the potential for worsening of condition and therefore need for close monitoring.

Clinical Outcomes and Complications

Aside from the concern for impending airway obstruction, complications include septic shock and acute respiratory distress syndrome. Mortality rates have been documented as high as 20%. Approximately 80% of children with bacterial tracheitis end up intubated; however, most make a full recovery without any permanent damage to the tracheal mucosa. This clearly makes it a serious, although rare, disease that requires consideration in patients presenting with consistent signs or symptoms.

Background

Tonsillectomy is one of the most common surgeries in children. The procedure is performed most often in the outpatient setting, unless there is a concerning past medical history, such as sickle cell disease or blood disorder, or the child is under 3 years old. Pain control is a common issue postprocedure, lasting up to 2 weeks. Typically pain is treated with acetaminophen or ibuprofen. The risk of hemorrhage has not been shown to increase with the use of nonsteroidal anti-inflammatory drugs. Codeine, however, should not be prescribed for pain in children post-tonsillectomy. In 2013, the Food and Drug Administration added a black box warning to the drug’s label stating that it is contraindicated for this use due to receipt of several reports of respiratory depression and death among children prescribed codeine after undergoing a tonsillectomy. In 2016, the American Academy of Pediatrics reinforced the warning and also called for the elimination of codeine use more broadly in pediatrics.

Revisits for dehydration and bleeding are common after a tonsillectomy. Post-tonsillectomy bleeding is referred to as early or primary if it occurs within 24 hours of surgery. It is considered late or secondary once more than 24 hours have elapsed from the time of surgery. Secondary bleeding is caused by premature separation of the eschar from the healing tissue, food trauma, or infection and usually occurs between day 5 and day 10 from the procedure. There is an increased risk of bleeding post-tonsillectomy in adolescents and those who had the procedure for chronic tonsillitis. ^,

Hemorrhage can lead to shock, airway obstruction, and death. A recent meta-analysis found a mortality rate of 1 in 500,000.

Evaluation

On arrival to the ED, the patient should be sitting upright and, if actively bleeding, leaning forward with suction available. The patient’s airway, breathing, and circulation should be immediately evaluated. Next, the surgical area should be assessed for bleeding or clot formation.

Laboratory Testing

Initial management of post-tonsillectomy bleeding also may involve obtaining a CBC and providing fluid resuscitation, depending on the level of bleeding and if actively bleeding. Consider the need for a type and cross.

Management

Patients often stop bleeding without intervention. Otherwise, removal of as much blood and clot from the oropharynx and direct pressure pushed laterally should be attempted to stop the bleeding. The use of Magill forceps with gauze wrapped around the end can help with this. Other options include applying epinephrine (1:10,000) to the gauze. If a patient is not tolerating the direct pressure, consider sedation, typically ketamine. With sedation, be prepared to potentially need to intubate the patient and ensure the ENT specialist and operating room are prepared for the patient. An alternative approach is to nebulize the epinephrine rather than direct application.

Another option, not yet studied in a randomized controlled trial but showing some potential use in case studies, is tranexamic acid (TXA). TXA for post-tonsillectomy hemorrhage has been studied but only as a preventive measure. It was not found to reduce the number of post-tonsillectomy hemorrhages when given preoperatively or intraoperatively. Given there is strong evidence that TXA reduces the need for transfusion in surgical bleeding in general, however, topical application of TXA onto the gauze used to apply pressure to the bleeding site or TXA given via nebulization may be trialed in patients presenting to the ED for post-tonsillectomy bleeding. ^, A case study of a 3-year-old presenting with post-tonsillectomy bleeding that did not respond to other measures, as discussed previously, found that bleeding ceased within 7 minutes of nebulized TXA. Nebulized TXA has been used in pediatric diffuse alveolar hemorrhage, with dosing of 250 mg for children under 25 kg and 500 mg for those over 25 kg. No adverse effects have been reported in cases of nebulized TXA use in these pediatric patients. Systemic TXA, on the other hand, does have potential side effects to consider, including hypotension in fast administration and seizures in higher than recommended dosing.

Thus, given the nebulized and topical use, TXA appears safe and tolerable. In cases where direct pressure, fluids, and epinephrine do not work to stop post-tonsillectomy bleeding and the OR is not yet ready, the use of TXA should be considered while prepping for airway management and awaiting surgical intervention. ^,

Infrequently, patients with post-tonsillectomy hemorrhage require another trip to the OR. Thus, notifying the ENT surgeon early on, regardless of level of bleeding, is important. Patients with post-tonsillectomy bleeding should be observed overnight, because the bleeding rarely can become life threatening. In 1 study, patients with minor bleeding had a 41% rate of severe bleeding within 24 hours. ^,