Definition & Overview

Control of oropharyngeal haemorrhage is a procedure that is commonly composed of several methods that are combined to stop and manage massive bleeding in the oral cavity and the pharynx. It typically occurs after surgery to the affected areas or following radiation therapy. If left unattended or if the cause is not properly identified, it could lead to serious complications and even death.

The oropharyngeal area is located in the middle part of the throat or pharynx, just behind the mouth. It is composed of the back part of the tongue, the soft palate, the tonsils, and the walls of the throat. The pharynx itself is a hollow tube that runs from behind the nose to the windpipe. It functions as a passageway for food and air on the way to the oesophagus or trachea.

Haemorrhage or excessive bleeding can be quite distressing to patients and their caregivers. It typically occurs without any warning and may be instant and profuse. In some cases, it can occur over time without the patient being aware of it until it is too late. It is therefore critical for physicians to identify those who are at significant risk of haemorrhaging or bleeding. Controlling oropharyngeal haemorrhage can be quite challenging because it is difficult to reach the affected areas. In addition, it can also involve respiratory distress since the airway could be blocked by blood or by swelling.

Who Should Undergo and Expected Results

Those who undergo tonsillectomy could undergo the procedure. This is because the removal of tonsils can sometimes lead to massive bleeding if the arteries located in or near the tonsils are damaged or injured. Primary haemorrhaging typically occurs within the first 24 hours following surgery. Secondary haemorrhaging, on the other hand, occurs within the first ten days postoperatively. Both conditions necessitate a visit to the emergency room to evaluate if the patient needs to undergo another surgery or not.

The procedure is also done on those who suffer from basal skull fractures. Injury to the base of the skull following trauma can cause a serious damage to ethmoidal blood vessels and other related structures. These could cause airway obstruction, gastric aspiration, and even haemorrhagic shock.

Neck and throat cancer patients undergoing radiotherapy also have a high risk of suffering from oropharyngeal haemorrhage. These patients typically have large tumours in the oropharyngeal region and are undergoing irradiation treatment. Some of these patients have already undergone surgery prior to radiation therapy. An episode of oropharyngeal haemorrhage is especially critical in these cases since it might be caused by a carotid blowout. This occurs when the artery is damaged or eroded by cancer treatments.

Patients may also need to undergo the procedure if the bleeding is due to the insertion of a tube into the pharynx and the trachea. The tube may injure some of the blood vessels in the oropharynx region, leading to excessive bleeding.

The success of controlling oropharyngeal haemorrhage depends on several factors. If the patient receives immediate care, there is a high chance that the bleeding can be stopped. Determining the origin and cause of the bleeding is also important so doctors can decide on the most appropriate steps for treating and preventing future episodes.

Once the initial episode of oropharyngeal bleeding has been controlled, the patient is placed under observation to make sure the condition does not recur. In most cases, patients are advised to rest and avoid strenuous activities. A blood transfusion may be needed if the patient has lost a significant amount of blood.

How is the Procedure Performed?

The process of controlling oropharyngeal haemorrhage could involve one or several techniques, depending on what is causing the condition.

The immediate concern is to make sure that the airway is not blocked with blood. To do this, the patient is asked to spit blood or to have a suction device ready.

One immediate treatment is the use of sucralfate suspension mixed with warm water. The patient is asked to use the solution as a mouthwash to control the bleeding. It provides a protective layer against gastric acid and other enzymes that might exacerbate wounds or lesions that cause the bleeding. Another solution that can be used is tranexamic mouthwash. This solution works as an antifibrinolytic agent, which can assist in the formation of blood clots to reduce bleeding.

Some patients are also administered with adrenaline either in nebulised or topical form. This is quite effective if bleeding is caused by tonsillectomy, where the bleeding site may be easily accessible. A dental roll or gauze is soaked with adrenaline. The patient’s head is kept tilted and the mouth is kept open. Using a pair of forceps, the physician holds the gauze firmly against the source of bleeding. In some cases, this method is suitable for controlling haemorrhage in patients diagnosed with cancer in the oropharynx area.

Interventional radiology may also be used to address uncontrolled bleeding. This involves arterial embolisation, in which an embolus is used to prevent further bleeding. A type of contrast agent is introduced into the bloodstream to visualise the affected area. The surgeon will use a catheter or a small tube to guide embolic agents inside a specific blood vessel and block the flow of blood. Cancer patients may also be suitable for this kind of treatment.

Some extreme cases of oropharyngeal haemorrhage might require surgical intervention. The surgeon will use video-assisted technology such as endoscopy to locate the source of bleeding. If it is an injury to an artery, the surgeon will attempt to stop the bleeding by repairing the leak.

Possible Risks and Complications

Patients who are given sucralfate may experience vomiting and nausea. Some patients also complain of dizziness and drowsiness after gargling with the solution. Stomach pain, constipation, and diarrhoea might also occur.

Those who are given tranexamic solution could also experience vomiting and nausea. There are also episodes of vision changes and eye problems.

Headaches, restlessness, chest pain, and troubled breathing are just some of the complications reported by patients who were administered with adrenaline.

Bacterial infection is also another possible complication, especially after surgery or arterial embolisation. There is also a possibility that a blood clot will form and travel to another area and reduce oxygen supply in the process.

References:

  • Epstein JB, Gorsky M, Cabay RJ, et al; Screening for and diagnosis of oral premalignant lesions and oropharyngeal squamous cell carcinoma: role of primary care physicians. Can Fam Physician. 2008 Jun;54(6):870-5.

  • Baujat B, Audry H, Bourhis J, et al; Chemotherapy as an adjunct to radiotherapy in locally advanced nasopharyngeal Cochrane Database Syst Rev. 2006 Oct 18;(4):CD004329.

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