Intervention
The main author adopted the common techniques that are utilised in other otolaryngology and head and neck surgery procedures to develop the following multi-step approach to the haemostatic check at the final stage of a tonsillectomy:
  1. Pack wound with swab, relax gag, and neutralise neck position for one minute.
  2. Re-extend the Boyle–Davis mouth gag (BDG), remove swabs and wash the site with a saline-soaked swab.
  3. Valsalva manoeuvre if allowed by airway device.
  4. Trendelenburg position.
To ensure patient safety was not compromised during the second cycle, we carried out a researched, evidence-based approach to the implementation of a change in practice for achieving and checking haemostasis in our tonsillectomy cases. Recent studies have shown that the Trendelenburg position can detect a significantly higher number of bleeding vessels in head and neck surgery compared to the Valsalva manoeuvre alone, with one study reporting additional bleeding points identified in 68% of patients with the use of the Trendelenburg tilt following Valsalva[4]. In this same study, it is also important to note that in five cases, there was significant bleeding that required suturing which were not identified using the Valsalva manoeuvre alone.