A Face Full of Blood: ENT Tips and Tricks

ENT bleeding emergencies are airway and hemorrhage problems first: post-tonsillectomy hemorrhage can escalate fast, auricular hematoma can destroy cartilage within 24 hours, and most tongue lacerations heal without sutures. Epistaxis, peritonsillar abscess, and dental bleeding all reward a few precise bedside moves.

Tongue lacerations and oral bleeding

• Selective tongue closure: Tongue lacerations under 2 cm that are non-gaping at rest and spare the tip usually heal well by secondary intention, with no functional or cosmetic advantage from routine suturing.
• High-yield wound exam: Look for tooth fragments, other intraoral injuries, and signs of hemorrhage or airway compromise before focusing on closure; those associated injuries matter more than the tongue itself.
• Primary repair triggers: Persistent bleeding, bisecting wounds, large flaps, tip involvement, and larger gaping lacerations are the main reasons to close rather than observe. We get into the bedside judgment calls in the episode.
• Sedation-aware repair: When closure is needed, a larger absorbable suture such as 2-0 or 3-0 is preferred, and many children need referral for procedural sedation rather than a rushed repair.
• Dental socket hemostasis: Post-dental bleeding often stops with 20 minutes of direct pressure on gauze, with lidocaine-epinephrine, TXA, or thrombin as useful topical adjuncts, especially in anticoagulated patients.

Post-tonsillectomy hemorrhage

• Delayed bleed window: Secondary post-tonsillectomy hemorrhage classically appears around days 7 to 10 when the fibrin eschar separates, and even a minor bleed can evolve into major hemorrhage.
• Lateral pressure technique: Apply pressure laterally against the tonsillar fossa vessels rather than pushing straight posteriorly; that simple directional change can improve control while help is mobilized.
• Airway-first setup: Keep the patient leaning forward with suction ready, and call ENT plus anesthesia early because these cases can deteriorate into difficult airway management without much warning.
• Adjunct hemostatic options: Ice water, TXA, racemic epinephrine, and in selected children DDAVP are reasonable temporizing therapies for ongoing bleeding, with route and sequencing nuances we walk through in the episode.
• Intubation red flags: Severe active hemorrhage and any sign of airway compromise should push the team toward definitive airway planning early rather than repeated bedside attempts at local control.

Peritonsillar abscess, epistaxis, and ear hematoma

• PTA imaging choice: CT with IV contrast is highly sensitive for peritonsillar abscess and especially useful with severe trismus, while ultrasound can confirm the collection and define nearby anatomy.
• PTA drainage target: Needle aspiration is aimed at the superior pole with careful controlled passes under direct visualization, followed by antibiotics and ENT follow-up within 48 hours.
• Anterior packing basics: For epistaxis that persists after pressure, have the patient clear clots before placing an anterior pack such as a Rhino Rocket, but avoid it with nasal fracture or septal perforation.
• Timed epistaxis reassessment: A formal recheck after 15 to 20 minutes matters because apparent hemostasis can be misleading once the pack is partially deflated. We cover the practical reassessment sequence in the chapter.
• Auricular hematoma urgency: Auricular hematoma is a perichondrial separation injury that can progress to cartilage necrosis and cauliflower ear within 24 hours, so drainage should not wait.
• Compression after drainage: Evacuation alone is not enough; a dental-roll bolster or compression dressing must eliminate dead space, with anti-staphylococcal coverage and ENT follow-up to prevent reaccumulation.

References:

1. Fox SM. Tongue Laceration. Pediatric EM Morsels. Published August 7, 2015. Link
2. Seiler M, et al. Tongue lacerations in children: to suture or not? Swiss Medical Weekly. Published online October 28, 2018. Link
3. Ballew JD. Unlocking Common ED Procedures - Peritonsillar Abscess Drainage. emDOCs.net - Emergency Medicine Education. Published April 4, 2019. Link
4. Coneybeare D. Peritonsillar Abscess. Core EM. Published June 9, 2015. Link
5. Guthrie K. A Case of Epistaxis • LITFL • ENT Equivocation. Life in the Fast Lane • LITFL • Medical Blog. Published September 12, 2011. Link
6. SGEM#210: (Don’t) Let it Bleed – TXA for Epistaxis in Patients on Anti-Platelet Drugs. The Skeptics Guide to Emergency Medicine. Published March 10, 2018. Link
7. Berg A. Simple Steps To Auricular Hematoma Drainage. NUEM Blog. Published July 25, 2016. Link
8. Krogmann RJ, et al. Auricular Hematoma. Nih.gov. Published December 16, 2018. Link
9. Fox SM. Post-Tonsillectomy Hemorrhage. emDOCs.net - Emergency Medicine Education. Published April 3, 2015. Link
10. Morgenstern J. Massive Hemorrhage Post-Tonsillectomy. First10EM. Published August 6, 2018. Link
11. Tonsillectomy bleed (hemorrhage) management (post-tonsillectomy hemorrhage) | Iowa Head and Neck Protocols. medicine.uiowa.edu. Link
12. Dermendjieva M, et al. Nebulized Tranexamic Acid in Secondary Post-Tonsillectomy Hemorrhage: Case Series and Review of the Literature. Clin Pract Cases Emerg Med. 2021;5(3):1-7. PMID: 34437029