Sharing pearls of practice on post adenoid /tonsillectomy bleeding

Many factors can lead to bleeding in patients post adenoid or tonsillectomy surgery especially in the pediatric group, and it falls upon the surgical team to ensure the risk is minimized.

Speaking at the recent ENT Summit 2025, held in Kuala Lumpur, a panel of speakers discussed the complexities of pediatric ENT surgeries, emphasizing the importance of considering patient weight for blood volume calculations and ensuring readiness for craniofacial and syndromic patient care. The panel was chaired by Associate Professor Dr Yap Yoke Yeow, consultant otorhinolaryngology-head and neck surgeon and populated by Clinical Associate Professor Dr Siow Jin Keat, Emeritus Consultant, Singapore; Dr Azida Zainal Anuar, consultant ENT surgeon, Johor Bahru; and Associate Professor Dr Jeyanthi Kulasegarah, consultant ENT surgeon, Petaling Jaya.

 Siow listed some best practices in managing medicolegal risks. These include:

1. Informed consent - Thoroughly explain treatment complications, benefits, and risks to patients - Ensure patients actively participate in treatment decisions - Document consent discussions comprehensively - Avoid rushed or coerced consent signatures

2. Professional conduct - Practice strictly within your professional competence - Prioritize patient protection over personal or institutional interests - Maintain high ethical standards - Avoid intentional departures from medical standards

3. Documentation - Keep meticulous, detailed medical records - Document all patient interactions, discussions, and consent processes - Be transparent about potential complications - Treat documentation as if you’re explaining the case to your own family member

4. Communication - Clearly communicate potential risks and treatment options - Be honest and transparent with patients - Explain medical procedures and potential outcomes thoroughly

5. Risk management - Understand legal standards - Know your professional guidelines - Seek guidance when dealing with complex medical scenarios - Continuously update your medical knowledge and skills

 

He stressed that the overarching principle is to always prioritize patient safety, maintain professional integrity, and document everything carefully.

Jeyanthi then presented a case study of a 6-year-old patient who experienced post-operative symptoms, and subsequently expelled a tonsil gauze, causing distress to the patient’s mother. The situation led the mother to file a lawsuit and root cause analysis discovered that the nurse had made an error in the total throat and ribbon gauze count, leading to a gauze being left in the postnasal space. Jeyanthi said the case was a reminder on the need for meticulous gauze counts and post-nasal space checks. Ideally, a surgeon should also perform their own count and do not rely solely on the nurse’s confirmation.

Next, Azida discussed managing expectations of patients before undergoing a tonsillectomy procedure. She said it was necessary to spend a significant amount of time on pre-operative counselling, even if the procedure seems routine. She also noted the importance of putting some accountability on the patient for their post-operative care in order to ensure they closely follow the instructions.

Azida also mentioned the importance of setting realistic expectations, discussing potential complications and the recovery process transparently. The patient should be very clear about factors that might impact surgical outcomes e.g., smoking, age and confounding medical conditions. Once the surgery is completed, they should always be provided with specific post-operative instructions.

Throughout the healing process, Azida stressed the importance of continuous communication. Here, patients and their relatives should be updated regularly as it displays a high degree of professionalism and demonstrates competence. Also, the surgical team should be prepared to answer questions about surgical technique and potential risks. Ultimately, she called for a personal approach when handling each patient, and stressed that the key to preventing misunderstandings and lawsuits is thorough, empathetic communication that empowers patients with knowledge and sets clear, realistic expectations.