Most oropharyngeal bleeds are secondary to trauma or dental procedures such as tooth extractions (1). Post-operative bleeding can occur up to 6 days after a procedure (2). Due to the risk of thromboembolism, many patients on anticoagulation remain on their medications and can pose an increased risk of bleeding (2).

Examination (1)

General assessment

1. Volume status – assess for signs of shock.

Assessment of airway patency is important with an oropharyngeal bleed. This includes:

1. Phonation.
2. Swallowing ability.
3. Ability to clear secretions or blood.
4. Stridor.
5. Subjective foreign body sensation in the throat or airway.

An intraoral assessment includes:

1. Inspection for dental fractures.
2. Palpation of teeth for instability or tenderness.
3. Intraoral tissue inspection for lacerations, abrasions, ecchymoses, foreign bodies, tooth fragments, edema, masses, or signs of infection) and palpation (gingiva, buccal mucosa, tongue, frenulum, tonsils, uvula).

Most oropharyngeal bleeds are self-limited.

First-line therapy

1. Fluid resuscitation or administration of blood products if patient has signs of shock secondary to blood loss.
2. Constant direct pressure for a minimum of 20 minute.
3. Gelfoam or Surgicel packing into the site.

Second-line therapy

1. Topical tranexamic acid 500 mg (5 ml) as a soaked pledget – hold pressure on the site of bleeding or ask patient to bite on the gauze or cotton pledget.
2. Local injection of lidocaine with epinephrine to vasoconstrict the site, followed by direct pressure.

Third-line therapy

1. Suture of extraction site with nylon or prolene in figure 8 fashion to achieve hemostasis.
2. Reversal of any anticoagulation.
3. Inherent coagulopathy and/or an antiplatelet agent should be considered if there is ongoing bleeding.
4. If the above measures are unsuccessful, consult an oral surgeon and/or interventional radiology for possible surgical management or embolization as there may be an injury to a blood vessel.

1. Hammel JM, Fischel J. Dental emergencies. Emerg Med Clin N Am. 2019; 37(1): 81-93.

   
   

2. Poznanski SL. Dental emergencies in the ED. Emerg Med Rep. 2015; 26(21).

   
   

3. Benko KR. Chapter 64 – Emergency Dental Procedures. In: Roberts JR, Custalow CB, editors. Roberts and Hedges’ Clinical Procedures in Emergency Medicine and Acute Care. 7^th ed. Philadelphia: Elsevier; 2019: 1384-1404. Accessed January 5, 2022. https://www.clinicalkey.com/#!/content/book/3-s2.0-B9780323354783000646?scrollTo=%23hl0000668

   
   

4. Engelen, Eveline T, Schutgens, EG Roger, Mauser-Bunschoten, Evelien P, van Es, JJ Robert, van Galen, PM Karin. Antifibrinolytic therapy for preventing oral bleeding in people on anticoagulants undergoing minor oral surgery or dental extractions. Cochrane Database of Systematic Reviews. 2018;(7). Available from EBM Reviews – Cochrane Database of Systematic Reviews at http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=coch&NEWS=N&AN=00075320-100000000-10704. Accessed January 16, 2022.

   
   

5. Kanaa MD, Whitworth JM, Corbett IP, Meechan JG. Articaine buccal infiltration enhances the effectiveness of lidocaine inferior alveolar nerve block. Int Endod J. 2009;42(3):238-246

   
   

6. Laino L, Cicciu M, Fiorillo L, Crimi S, Bianchi A, Amoroso G, Monte IP, Herford AS, Cervino G. Surgical risk on patients with coagulopathies: guidelines on hemophiliac patients for oromaxillofacial surgery. Int J Environ Res Public Health. 2019; 16(8): 1386. Accessed Jan 17, 2022. doi: 10.3390/ijerph16081386.

   
   

7. Hsieh JT, Klein K, Batstone, M. Ten-year study of postoperative complications following dental extractions in patients with inherited bleeding disorders. Int J Oral Maxillofac. 2017; 46(9): 1147-1150. Accessed Jan 17, 2022. https://doi.org/10.1016/j.ijom.2017.04.016.