the entire tonsil with the fibromucosal capsule, leaving behind exposed muscle within the tonsil fossa The PTH rate for a total tonsillectomy is 3% to 5% More recently, the partial tonsillectomy, also known as tonsillotomy or intracapsular tonsillectomy, has been gaining popularity among surgeons, especially when operating on smaller children for obstructive sleep indications It involves removal of most of the tonsil tissue (up to 95%), while leaving a small rind of capsule and tonsil tissue behind in the fossa The remaining tissue behaves like a biologic dressing, and protects the underlying muscle and blood vessels As such, the secondary PTH rate can be as low as 1% Clinical Considerations Clinical Recognition Nearly all patients with PTH present with a history of blood-tinged sputum or discrete bleeding from the oral cavity after recent tonsil surgery, but some patients will present primarily with nausea and/or hematemesis Triage Considerations Active bleeding, expulsion of fresh clots from the mouth, or any patient with hemodynamic or airway instability secondary to bleeding must be promptly evaluated and otolaryngology consultation obtained emergently If the episode of bleeding was minor (isolated blood-tinged sputum, dried blood on patient’s pillow discovered in the morning, etc.), then the problem becomes less urgent, though no less important An initial minor bleed can be an initial event (a sentinel bleed) for a more severe subsequent bleeding incident: approximately 10% of sentinel bleeds result in another bleeding episode within 24 hours Initial Assessment Obtain routine vitals and procure IV access A careful and thorough examination of the oral cavity is performed, and both tonsil fossae must be completely examined Use of a headlamp and bimanual examination of the oral cavity with tongue depressors is important when available Alternatively, have an assistant hold an otoscope or light source, to allow the use of both hands If any active bleeding or fresh clot is identified in the fossa, no further intervention is required A clot should NOT be dislodged or irrigated, as this could cause further bleeding If no active bleeding is identified, then other sources of bleeding must be considered, including epistaxis and adenoid bed hemorrhage