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POSTOPERATIVE HEMATOMA

Overview
Postoperative hematoma, a collection of clotted or partially clotted blood within the operative bed, is among the most common postoperative complications in Otolaryngology. Most cases occur without an apparent underlying risk factor; however, several factors have been found to increase the probability of this complication including male sex, older age, smoking, diabetes, antiplatelet therapy, anticoagulation, underlying hepatorenal insufficiency, congenital or acquired thrombophilic conditions, and certain surgeries. Basic methods to reduce the risk of postoperative hematoma include meticulous operative hemostasis, judicious drain placement and postoperative drain management, and use of a compression dressing in some circumstances. Signs of hematoma formation chiefly include fluctuant or firm expansion of tissue surrounding the confines of the operative space with or without surrounding ecchymosis and with or without pain. To mitigate confusion by the floor nurse or overnight on-call resident, thoroughly communicate the appearance of the surgical site after complex tissue reconstruction, as a vascular pedicle (e.g., pectoralis major myocutaneous flap) or excess flap bulk (e.g., anterolateral thigh flap) may have a similar appearance and generate concern for hematoma formation. It is also important to consider other overlapping conditions that may present in a similar manner. For example, a seroma may develop in a delayed fashion (>1 week after surgery) in larger operative defects, abscess formation may develop de novo or within a pre-existing hematoma but usually occurs more than several weeks after surgery, and pseudomeningoceles may develop in any skull base procedure that communicates with the subarachnoid space at any time after surgery. Broadly, high risk hematomas that require emergent evaluation and management include:

 

  • Expanding neck hematomas, particularly after thyroidectomy; risk of airway compression.

  • Hematomas occurring after free-tissue transfer; risk of vascular pedicle compromise.

  • Hematomas within an operative bed communicating with the intracranial space; risk of life-threatening brain compression.

  • Hematomas in an extremity after free-tissue transfer harvest; risk of peripheral limb ischemia.

  • Hematomas in very large dead space (e.g., latissimus free flap or pectoralis muscle harvest sites); risk of significant blood loss.

  • Hematomas under significant tension; risk of overlying skin necrosis.

  • Septal or auricular hematomas; risk of cartilage ischemia and necrosis.

 

Key Supplies for Postoperative Hematoma Consultation

  • Appropriate PPE including mask, eye protection, gloves, and gown

  • Headlight

  • Normal saline bottles, piston syringe or other large syringe with Angiocath®, or red rubber catheter for wound irrigation

  • Iodine swabs

  • 18- and 27-gauge needles with 3 mL syringes for local anesthesia

  • Gauze, fluffs, and kidney basin for collecting evacuated blood

  • Laceration tray with forceps, needle driver, Kelly/tonsil clamp, and scissors

  • 15-blade scalpel

  • Suction

 

Management

  • First, globally examine the patient to evaluate for signs of respiratory distress or pain; evaluate the ABCs (Airway, Breathing, Circulation) in any case that may result in critical airway compression.

  • If the patient is hypotensive, diaphoretic, or concerningly tachycardic, or you suspect a large volume of blood loss based on the wound size, consider obtaining a CBC, type and cross, and coagulation panel.

  • Carefully examine the site of concern, looking for fluctuance (e.g., wave-like or boggy feeling upon palpation), tenseness (e.g., soft or firm), skin color changes (e.g., surrounding ecchymosis or blanching), or wound dehiscence.

  • After initial evaluation, the first decision to be made is whether the hematoma needs to be evacuated emergently at the bedside or whether transport to the OR is appropriate. In some cases, minor hematomas may be evacuated non-emergently at the bedside without transport to the OR.

  • High risk hematomas (as defined above) should always be ultimately addressed in the OR; however, they may require bedside evacuation to start if the benefits of doing so outweigh the risks of waiting for an OR to become available. Examples of this include impending airway compromise, signs of free flap compromise, or hematomas causing overlying skin ischemia or peripheral limb ischemia. If a neck hematoma is large enough or has been present long enough, it may lead to generalized upper airway edema due to compression of the microcirculation. This can lead to continued airway compromise due to edema after hematoma evacuation at the bedside and should be kept in mind as plans for transport to the OR are made.

  • For non-emergent hematomas, or hematomas that have been first evacuated at bedside, definitive treatment usually includes a “take back” to the OR for wound exploration, hemostasis, probable drain (re)placement, and reclosure; depending on the perceived risks of rebleed, adjuncts such as fibrin glue, Surgicel®, or other hemostatic products can be considered at the time of wound exploration; compression dressing or compression binders may also be used in some circumstances but are generally avoided around the neck or adjacent free flap vascular pedicle and anastomosis.

  • If applicable, determine whether associated drains are functioning appropriately and determine recent drain output.

    • If the drains are not holding suction, try to identify the source of the leak, which most typically occurs where the drain enters the skin; a strategically placed stich, adjustment of the drain as it enters the skin, or application of an occlusive ointment (such as petroleum-based ointment) or Tegaderm® on the drain hole or incision will often correct the problem.

    • If the drains are clogged with clot, attempt to carefully strip the tubing by sliding it tightly between your thumb and index finger from proximal to distal; oftentimes it is difficult to effectively evacuate blood from a surgical site hematoma through a drain or via needle aspiration because of clot formation; always check the drain stitch to make sure it is not too tight around the tubing as an underlying cause.

  • Hematoma formation after septoplasty or auricular surgery (e.g., microtia or otoplasty) is generally best managed by early clot evacuation and bolster placement, Penrose drain placement, or packing, depending on the size and location.

  • For very mild or low risk hematomas, observation with or without compression or attempted needle aspiration can be considered, understanding the risk of secondary hematoma infection; if choosing observation, it may be beneficial to mark a line around the perimeter of the hematoma to document any potential progression; may consider prophylactic antibiotics if observing a hematoma or if using a bolster or splint through cartilage.

  • Patients with a large volume of blood loss may require transfusion, particularly in the setting of free tissue transfer surgery; reversal or correction of any underlying coagulopathy should be considered based on clinical context.

 

References
1. Mydlarz, W.K., Eisele, D.W. (2020). Complications of Neck Surgery. In Flint, P.W., et al. (Eds.), Cummings Otolaryngology: Head and Neck Surgery 7e. (pp. 1831-1839). Philadelphia, PA: Elsevier.
2. Zhang, I., DeMauro-Jablonski, S., Ferris, R.L. (2013). Treatment of Thyroid Neoplasms. In Johnson, J.J., Rosen, C.A. (Eds.), Bailey’s Head and Neck Surgery-Otolaryngology 5e (pp. 2115-2130). Baltimore, MD: Lippincott Williams & Wilkins.