1. Tonsillectomy, and Adenoidectomy
T & A is the most common surgical procedure in children in the US today with annual expenditure of $500 million.
Trends are toward selective performance of T & A, with 259,000 surgeries in 1987, 1/4 the 1970 figure.
Recurrent infection has always been the #1 indication, recently an increasing % are performed for OSA (approx 19% 1986 study at Mt Sinai).

2. History Celsus 50 A.D. Caque of Rheims Philip Syng Wilhelm Meyer 1867
Samuel Crowe
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3. Embryology
8 weeks: Tonsillar fossa and palatine tonsils develop from the dorsal wing of the 1st pharyngeal pouch and the ventral wing of the 2nd pouch; tonsillar pillars originate from 2nd/3rd arches
Crypts 3-6 months; capsule 5th month; germinal centers after birth
16 weeks: Adenoids develop as a subepithelial infiltration of lymphocytes
The first 8 weeks constitutes the period of greatest embryonic development of the head and neck.
There are 5 arches (pharyngeal or branchial). Btw these arches are the clefts externally and the pouches internally.
Each pouch has a ventral or dorsal wing.
The derivatives of arches are usually mesoderm origin.
The cleft is lined by ectoderm, the pouch is lined by endoderm
The adenoids are colonized with bacteria soon after birth, enlarge early and middle childhood form antigenic challenges and should regress by early adulthood. Hypertrophic tonsils are rare in adults and suggest chronic infection or lymphoma.
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4. Anatomy Tonsils Adenoids Plica triangularis Gerlach’s tonsil
Fossa of Rosenmüller
Passavant’s ridge
The tonsil is nestled in a fossa formed by the muscular anterior and posterior tonsillar pillars (palatoglossus and palatopharyngeus) and lying superficial to the superior constrictor muscle; preservation of these muscular condensations and the overlying mucosa is critical to maintaining physiologic function of the palate postoperatively.
The tonsil is contiguous inferiorly with the lingual tonsil. The point of attachment (plica triangularis) must be transected during tonsillectomy. In pts with marked hypertrophy, this extension is freq quite large and can result in troublesome bleeding at the pt of transection at the base of the tongue.
The adenoid is positioned in the midline of the posterior wall of the NP immediately inferior to the rostrum of the sphenoid and extending laterally to but not onto the lateral wall of the NP. It makes up the most rostral portion of the pharyngeal lymphoid tissue termed Waldeyer’s ring. The space created lateral to the adenoid and posteromedial to the ET orifice is termed the FOSSA of Rosenmuller.
Gerlach’s tonsil is lymphoid tissue within lip of the fossa of Rosenmuller; goes into ET.
Inferiorly, the adenoid extends nearly to the superior margin of the superior constrictor…Passavant’s ridge.
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5. Blood Supply Tonsils Adenoids
Ascending and descending palatine arteries
Tonsillar artery
1% aberrant ICA just deep to superior constrictor
Adenoids
Ascending pharyngeal, sphenopalatine arteries
Tonsillar branch of the facial artery is the main supply of the entire tonsil.
Facial artery:
Tonsillar art
Ascending palatine art
Lingual art
dorsal lingual branch
IMA
Desceding palatine
Greater palatine
Ascending pharyngeal (ECA)
Venous drainage of the tonsil is thru lingual and pharyngeal veins which empty into the IJ.
In most people the ICA lies 2cm posterolateral to the deep surface of the tonsil; however in 1% of the population, it is found just deep to the superior constrictor.
Adenoids: Ascending palatine, ascending phayrngeal, pharyngeal br of IMA, ascending cervical branch of thyrocervical trunk
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6. Common Diseases of the Tonsils and Adenoids
Acute adenoiditis/tonsillitis
Recurrent/chronic adenoiditis/tonsillitis
Obstructive hyperplasia
Malignancy
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7. Acute Adenotonsillitis
Etiology
5-30% bacterial; of these 39% are beta-lactamase-producing (BLPO)
Anaerobic BLPO
GABHS most important pathogen because of potential sequelae
Throat culture
Treatment
1. MC bacteria:
Beta streptoccoci, staphylococci, streptoccocus pneumoniae, hemophilus
2. Prevalence of beta-lactamase producing organisms is rising:
from 2 % in 1980 to 44% in (FIND STUDY)
3. Prevalence of anaerobic org is also rising
Asymptomatic streptococcal pharyngitis responsible for at least 1/3 of ARF in 3rd world. Gold std is throat culture.
Blood agar plate with septra more sensitive than plain agar plate.
Culture both tonsils; if only one, may miss 25%.
Rapid streptococcal antigen test, 12 min.; highly specific but variable sensitivity; must confirm negative result with a throat cx.
Newer solid-phase enzyme immunoassay
Older latex agglutination test
Treat with 10 day course of PCN if high clinical suspicion (augmentin, clinda, pcn + rifampin for recurrence)
Post treatment culture: high risk RF, remain symptomatic, recurring symptoms; if asymptomatic but positive cx, treat if h/o RF or if FH of RF
Suspect infectious mononucleosis if sore throat and malaise persist despite abx treatment; order WBC and Paul-Bunnell. Characterized by white membrane covering one or both tonsils and hypersensitivity to ampicillin. Look for atypical mononuclear cells and positive Paul-Bunnell blood test.
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8. Microbiology of Adenotonsillitis
Most common organisms cultured from patients with chronic tonsillar disease (recurrent/chronic infection, hyperplasia):
Streptococcus pyogenes (Group A beta-hemolytic streptococcus)
H.influenza
S. aureus
Streptococcus pneumoniae
Tonsil weight is directly proportional to bacterial load.
Study by Brodsky et al (1988) taking cultures from core specimens (not surface).
Core species do not always correlate with surface bacteria. 90% correlation with H.influenza, 73% strept pyogenes
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9. Acute Adenotonsillitis
Differential diagnosis
Infectious mononucleosis Malignancy: lymphoma, leukemia, carcinoma Diptheria Scarlet fever Agranulocytosis
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10. Medical Management
PCN is first line, even if throat culture is negative for GABHS
For acute UAO: NP airway, steroids, IV abx, and immediate tonsillectomy for poor response
Recurrent tonsillitis: PCN injection if concerned about noncompliance or antibiotics aimed against BLPO and anaerobes
For chronic tonsillitis or obstruction, antibiotics directed against BLPO and anaerobes for 3-6 weeks will eliminate need for surgery in 17%
Co-amoxiclav or clindamycin or PCN+Rifampin
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11. Obstructive Hyperplasia
Adenotonsillar hypertrophy most common cause of SDB in children
Diagnosis:snoring, restless sleep, FTT, daytime symptoms… poor mentation, decreased attn span, poor scholastic performance, dysphagia, nocturnal enuresis, chronic mouth breathing
Indications for polysomnography
Interpretation of polysomnography
Perioperative considerations
Diagnosis of OSA is based on H & P (snoring, restless sleep, FTT, daytime symptoms… poor mentation, decreased attn span, poor scholastic performance, dysphagia, nocturnal enuresis, chronic mouth breathing; predisposing conditions craniofacial abnormalities, NM disorders, FTT, cor pulmonale, Downs syndrome) MC symptom in kids is snoring (adults is daytime somnolence).
Obtain sleep study when PE does not correlate with history ($1600), or when suspect central component.
Apnea (10s breathing pause)from complete obstruction is uncommon in children. Children tend to have a continuous partial obstructive hypoventilation that is characterized by decreased oxygen saturation, hypercapnia, labored paradoxical resp efforts, and snoring.
Controversy over how to interpret sleep study in kids… few normative data. Marcus et al.(1992) studied normal resp patterns in children during sleep.
Abnormal values: >1 obstructive apnea of any duration per hour
central apnea assoc with desat <90%
Pco2>53 or Pco2>45 for more than 60% test time
fall of o2 sat < 92%
No consensus on indications for surgery for those without severe obstruction/apnea.
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12. Interpretation of polysomnography:
Indications for surgical intervention
>1 apnea in 1 hour
Central apnea + o2sat<90%
O2sat<92%
CO2>53
CO2>45 in more than 60% of test time
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13. Unilateral Tonsillar Enlargement
Apparent enlargement vs true enlargement
Non-neoplastic:
Acute infective
Chronic infective
Hypertrophy
Congenital
Neoplastic
Apparent: tonsil sits in more medial position, displacement medially by PTA or parapharyngeal space mass.
Chronic infections: tubercular tonsillitis, actinomycosis, and congenital syphilis
Congenital include teratoma, hemangioma, lymphangioma, and cystic hygroma.
Neoplastic:
Benign papillomas
Lymphoma (usually non-Hodgkins B-cell) and squamous cell
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14. Peritonsillar Abscess
Displacement of tonsil and uvula medially, trismus, dysphagia, pain referred to the ear, malaise, fever, cervical adenopathy.
Initial mgmt is needle aspiration, IM penicillin, oral penicillin.
Quinsy tonsillectomy for uncooperative, toxic patient, bleeding.
Peritonsillar Abscess
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15. ICA Aneurysm 4/16/2017 rhinoplastyman@yahoo.com
This patient came to the ER for sore throat
ICA Aneurysm
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16. Pleomorphic Adenoma 4/16/2017 rhinoplastyman@yahoo.com
Consider masses in the parapharyngeal space for apparent UTE including tumors of the deep lobe of the parotid gland (ie pleomorphic adenoma), chemodectomas, neurofibromata, and enlargement of the parapharyngeal lymph nodes.
Pleomorphic Adenoma
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17. Other Tonsillar Pathology
Hyperkeratosis, mycosis leptothrica
Tonsilloliths
Yellow spicules due to hyperkearatineized areas of epithelium are sometimes extensive over the tonsil. It is important to probe the tonsil to be certain these areas are not exudate. No treatment is required unless assoc with tonsillitis.
Tonsilloliths are yellow gritty particles in crypts, more commonly seen in adults with a h/o recurrent tonsillitis.
Elongated styloid process causes pain exacerbated during maximal deglutition and deep breathing…. 2nd branchial arch derivitative, approx 2.5 cm long, located btw internal and ECA just lateral to tonsillar fossa.
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18. Candidiasis 4/16/2017 rhinoplastyman@yahoo.com
A fungal infection of the pharynx and one of the most common upper respiratory tract manifestation of AIDS. Also seen in neonates and may complicate treatment with broad spectrum antibiotics.
Characterized by extensive white areas (either continuous or punctate) covering the entire oropharynx and not limited to the tonsil.
Swab shows candida albicans.
Candidiasis
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19. Retention Cysts 4/16/2017 rhinoplastyman@yahoo.com
These are common on the tonsil and appear as sessile yellow swellings. If small, they can be ignored. Also seen after tonsillectomy in region of the fauces.
Retention Cysts
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20. Supratonsillar Cleft 4/16/2017 rhinoplastyman@yahoo.com
This recess near the superior pole of the tonsil tends if large to collect debris. A mass of yellow fetid tissue can be extruded from the tonsil with pressure, and discomfort, halitosis are symptoms. Tonsillectomy may be necessary.
Supratonsillar Cleft
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21. Indications for Tonsillectomy; Historical Evolution
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22. Indications for Tonsillectomy
Paradise study
Frequency criteria: 7 episodes in 1 year or 5 episodes/year for 2 years or 3 episodes/year for 3 years
Clinical features (one or more): T 38.3, cervical LAD (>2cm) or tender LAD; tonsillar/pharyngeal exudate; positive culture for GABHS; antibiotic treatment
From the Children’s Hospital of Pittsburgh conducted parallel randomized and nonrandomized clinical trials to determine
1. efficacy of tonsillectomy in reducing the frequency and severity of episodes of pharyngitis,
2. the efficacy of adenoidectomy in reducing the freq/severity of OM, and
3. the effect of adenoidectomy of the course of nasal obstruction due to large adenoids
Findings:
1. Histories of recurrent throat infections that are undocumented do not validly predict recurrence; need documentation by physician before performing tonsillectomy
2. Using the selection criteria, the incidence of throat infection during the first 2 years of f/u was significantly lower in the surgical groups
3. Many pts in the nonsurgical group had fewer than 3 episodes of infx, and most cases were mild… therefore, treatment should be individualized, taking into consideration pt/parental preference, anxieties, tolerance of illness, tolerance of antimicrobial drugs, child’s school performance in relation to illness-related absence, accessability of health-care services, out-of-pocket costs, nature of available anesthetic and surgical services/facilities
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23. Indications for Tonsillectomy
AAO-HNS:
3 or more episodes/year
Hypertrophy causing malocclusion, UAO
PTA unresponsive to nonsurgical mgmt
Halitosis, not responsive to medical therapy
UTE, suspicious for malignancy
Individual considerations
Contraindications:
Tonsillectomy
Acute infection
Anemia
Disorders of hemostasis
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24. Recurrent tonsillitis in patient with heart valve dis
Also:
Recurrent tonsillitis in patient with heart valve dis
In patient with febrile convulsion
Unresponsive carrier
Obstructive IMN unresponsive to medical therapy
Carrier of diphtheria
Chronic tonsillitis with never-ending sore throat
OSAS
FTT
Disphagia
phonation disorders
Malocclusion
Craniofacial growth abnormalities
Corpulmonale
Suspicious malignancy
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25. Pathophysiology of corpulmonale in OSA: URT obstruction
Alveolar hypovantilation
Chronic hypoxia and hypercapnea
Respiratory acidosis
Vasoconstriction of alveolar capillaries
Right atrial dilatation
Pulmonary hypertension
Corpulmonale and CHF
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26. Pathophysiology of enuresis: SDB REM abnormalities
Irregularities in ADH secretion
Pathophysiology of FTT:
SDB
REM abnormalities
Irregularities in GH secretion, may sometimes stop totally
Both return to normal following A&T
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27. ADHD (Attention Deficit Hyperactivity Disorder) is the most
Common psychiatric diagnosis in children.
In direct correlation with Sleep Disordered Breathing(SDB)
Pathophysiology uncertain, Maybe due to abnormal sleep pattern
Neurocognitive development delays:
Healthy sleeping pattern: important component of brain growth
Frontal cortex growth continues up to puberty
Most critical age: 3-7
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28. Indications for Adenoidectomy
Paradise study
28-35% fewer acute episodes of OM with adenoidectomy in kids with previous tube placement
Adenoidectomy or T & A not indicated in children with recurrent OM who had not undergone previous tube placement
Gates et al
Recommend adenoidectomy with M & T as the initial surgical treatment for children with MEE > 90 days and CHL > 20 dB
Paradise:
Parallel randomized and nonrandomized clinical trials of
213 children who developed recurrence of OM after extrusion of t-tubes;
In both trials, over a period of 2 years, 28-35% fewer episodes than controls.
Gates: 578 children with chronic middle ear effusion. Adenoidectomy combined with myringotomy or with t tube placement proved to be more effective thatn myringotomy or tube placement alone in preventing recurrences of OM over a 2 year period
* differences were small (31 vs 36 weeks as mean cumulative times with effusion in 2 treatment groups over 2 yr f/u).
TT surgery alone is assoc with higher rate of repeat surgeries, increased rate of otorrhea, greater expense and human cost of illness than initial adenoidectomy and myringotomy
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29. Indications for Adenoidectomy
Obstruction:
Chronic nasal obstruction or obligate mouth breathing
SDB with FTT, cor pulmonale
Dysphagia
Speech problems
Severe orofacial/dental abnormalities
Infection:
Recurrent/chronic adenoiditis (3 or more episodes/year)
Recurrent/chronic OME (+/- previous BMT)
Contraindications:
Adenoidectomy
Overt or submucous CP
Neurologic or neuromuscular abnormalities with impaired palatal function
Anemia
Disorders of hemostasis
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30. Chronic sinusitis: first step
Also:
Chronic sinusitis: first step
biofilm in 95% adenoid specimen vs. 2% in SDB
Chronic recurrent AOM
COM
Chronic otorrhea
VT and persistent discharge
Suspecious malignancy
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31. PreOp Evaluation of Adenoid Disease
Triad of hyponasality, snoring, and mouth breathing
Rhinorrhea, nocturnal cough, post nasal drip
“Adenoid facies”
“Milkman” & “Micky Mouse”
Overbite, long face, crowded incisors
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32. PreOp Evaluation of Adenoid Disease
Differential diagnoses
Allergic rhinitis
Sinusitis
GERD
For concomitant sinus disease, treat adenoids first
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33. PreOp Evaluation of Adenoid Disease
Evaluate palate
Symptoms/FH of CP or VPI
Midline diastasis of muscles, bifid uvula
CNS or neuromuscular disease
Preexisting speech disorder?
Speech path consult for speech disorder.
Submucous cp 1 in 1200
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34. PreOp Evaluation of Adenoid Disease
Lateral neck films are useful only when history and physical exam are not in agreement.
Accuracy of lateral neck films is dependent on proper positioning and patient cooperation.
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35. PreOp Evaluation of Adenoid Disease
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36. PreOp Evaluation of Tonsillar Disease
History
Documentation of episodes by physician
FTT
Cor pulmonale
Poststreptococcal GN
Rheumatic fever
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37. PreOp Evaluation of Tonsillar Disease
TONSIL SIZE
0 in fossa
+1 <25% occupation of oropharynx % %
+4 >75%
Avoid gagging the patient
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38. PreOp Evaluation of Tonsillar Disease
Down syndrome
10% have AtlantoAxial laxity
Obtain lateral cervical films (flexion/extension) when positive findings on history, PE
If unstable, need neurosurgical evaluation preoperatively
Large tongue and small mandible… difficult intubation
Prone to cardiac arrhythmias/hypotension during induction
Instability is caused by laxity of transverse ligament.
Neck pain, muscular problems.
Hyperactive DTR, clonus
atlas-dens interval > 4.5mm
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39. PreOp Evaluation for Adenotonsillar Disease
Coagulation disorders
Historical screening
CBC, PT/PTT, BT, vWF activity
Hematology consult
von Willebrand’s disease
ITP
Sickle cell anemia
Von Willebrand’s disease is the most common inherited coagulopathy (AD with variable expression) (1% population) and is caused by a deficiency in Factor VIII:VW complex necessary in platelet activation. 3 types… type 1 is the most common (80-90%) with subnormal levels of qualitatively normal vWF and most will respond to desmopressin. Type 2 is a defect in the factor, type 3 is complete absence of the factor.
DX elevated PTT, BT, decreased vWF antigen, factor VIII procoagulant activity, ristocetin cofactor activity; measure response of levels to desmopressin (0.3microg/kg IV)
RX give IV over 30 min preop (peak levels min), 12 hr postop, then q am until eschar completely sloughed and fossae completely healed; also give aminocaproic acid or tranexamic acid preop and postop to decrease fibrinolysis (oral cavity high conc of fibrinolytic enzymes); not useful type 2/3
adverse effects… Na <132 or tachyphylaxis, d/c desmopressin, give cryoprepipitate or vWF-containing antihemophilic factor
ITP:
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40. Principles of Surgical Management
Numerous techniques:
Guillotine
Tonsillotome
Beck’s snare
Dissection with snare (Scissor dissection, Fisher’s knife dissection, Finger dissection
Electrodissection
Laser dissection (CO2, KTP)
Coblation
RadioFrequency
… Surgeon’s preference
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41. Post Operative Managment
Criteria for Overnight Observation
Poor oral intake, vomiting, hemorrhage
Age < 3
Home > 45 minutes away
Poor socioeconomic condition
Comorbid medical problems
Surgery for OSA or PTA
Abnormal coagulation values (+/- identified disorder) in patient or family member
MC reasons for inpt stays… emesis, dehydration, hemorrhage, obstruction, pulm edema
< 3years: 7% airway complications (2.3 times other kids), 4% dehydration, 1.5 % hemorrhage; less likely to cooperate with oral intake and more likely to have surgery for airway obstruction
Conditions associated with a complicated postop course (resp compromise):
CP, seizures, age <3, congenital heart disease, prematurity, chromosomal abnormalities, loud snoring with apnea, difficulty breathing during sleep
Excessive adenotonsillar tissue obstructs airway and increases resistance to inspiration/expiration… maintains PEEP with increased intrathoracic venous and hydrostatic pressure. Sudden relief of excess PEEP by intubation or T & A results in transudation of fluid into interstitial and alveolar spaces….pulm edema. Treatment… intubation and reestablishment of PEEP.
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42. Complications #1 Postoperative bleeding Other:
Sore throat, otalgia, uvular swelling
Respiratory compromise
Dehydration
Burns and iatrogenic trauma
Dental problems and trauma
Mortality 1 in 16,000 to 35,000 (anesthetic and hemorrhage); Hemorrhage %; 76% occur within first 6 hrs; 0.04% require transfusion; 0.002% mortality (mc for primary); Etiology: retained adenoid tissue, damage to post pharyngeal wall muscle; Increased incidence winter, age > 20
Anesthetic: kinking, extubation, fire, laryngospasm
Resp compromise: sudden loss of PEEP… pulmonary edema; avoid sedating analgesics
Assess for loose teeth… post op CXR to r/o aspiration if loss of tooth
Draping to avoid burns… avoid towel clips (penetration); avoid tape (accidental extubation when take drapes off)
Sore throat: increased with increased age, electrocautery, KTP/ less with CO2 lasere and periop/postop antibiotics (4.4 to 3.3 days)
Otalgia: referred from IX, r/o otitis, ET tube injury or edema
Fever: normal in 1st 36 hr… watch for dehydration
Dehydration: n/v 2nd to anesth, swallowed blood; decreased po intake with pain, esp younger kids less cooperative and smaller volume reserve; single intraoperative steroid earlier return to nl diet
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43. Rare Complications Velopharyngeal Insufficiency
Nasopharyngeal stenosis
Atlantoaxial subluxation/ Grisel’s syndrome
Regrowth
Eustachian tube injury
Depression
Laceration of ICA/ pseudoaneursym of ICA
VPI: usu transient; sig in 1 in ; only 1/3 identified preop as increased risk; > 2mo speech therapy; > 6-12mo pharyngeal flap
NP stenosis: circumferential contracture of pharynx Waldeyer’s ring, T AND A; syphilis; increased risk with excessive mucosal excision; difficult to rx
AA subluxation.. Grisel’s syndrome vertebral body decalcification and laxity of anterior transverse ligament secondary to infection in the nasopharynx… may cause spontaneous subluxation 1 week postoperatively…pain and torticollis (traumatic adenoidectomy or injection of local anesthestic into prevertebral space)
15-28% tonsil tags; 6% recurrent pharyngitis
adenoids may grow from adjacent lymphoid tissue… incomplete removal?
Laceration of ICA usu occurs medially and near the skull base.
Pseudoanerusym of ICA requires embolization and proximal ligation.
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44. Management of Hemorrhage
Ice water gargle, afrin
Overnight observation and IV fluids
Dangerous induction
ECA ligation
Arteriography
Anesthetic induction is hazardous…. Hypovolemic, underestimated blood loss (T &C). Risk of aspiration, stomach full of swallowed blood… tracheotomy if active hemorrhage prevents intubation.
ECA ligation via lateral neck incision, retraction of SCM posteriorly if unable to stop bleeding.
Angiography if ECA ligation fails…
ICA and ECA communicate via opthalmic/angular nasal arteries and via middle meningeal artery
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47. Case study
13 year old female referred by PCP for frequent throat infections
“She’s always sick. She’s been on four different antibiotics this year.”
You call her pediatrician… he is out of town and his nurse can’t find the chart
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48. Case study No known medical problems, no prior surgical procedures
Takes motrin for menustrual cramps
No personal history of bleeding other than occasional nose bleeds and extremely heavy periods.
Family history unknown. Patient is adopted.
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49. Case study Physical exam is unremarkable.
Mom breaks down in tears when you tell her you do not have enough documentation of illness to warrant T & A. “I had to go on welfare because I’ve missed so much work from her being out sick.”
You hesitate. She adds, “Her grades have dropped from all A’s to all F’s. If she misses any more school, she’ll be held back.”
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50. Case study
You confirm with her pediatrician that she has had 4 episodes of tonsillitis this year and agree to T & A.
Because of her history of epistaxis and menorrhagia, you order a PT, PTT, CBC, BT.
She has a mild microcytic anemia and prolonged bleeding time.
You order vWF activity level and consult hematology
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51. Case study
She has a subnormal level of vWF, which responds to a DDAVP challenge (rise in vWF and Factor VII greater than 100%).
You advise her to stop taking motrin.
Before surgery, she receives desmopressin 0.3 microg/kg IV over 30 min and amicar 200mg/kg.
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52. Case study
She receives the same dose of DDVAP 12 hours postoperatively and every morning.
Amicar is given 100mg/kg PO q 6 hr.
Before each dose of DDAVP, serum sodium is drawn. Sodium levels drop to 130.
Desmopressin is discontinued and substituted with cryoprecipitate.
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53. Case study
Patient presents to the ER on POD # 7 complaining of intermittent bleeding from her mouth.
You order cryoprecipitate, draw a Factor VII level and CBC, and call her hematologist.
Hemoglobin has dropped from 11.9 to 9.6.
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54. Case study PE reveals no active bleeding; an old clot is present
You establish IV access, admit the patient for overnight observation, have her gargle with ice water, and administer crypoprecipitate
No further bleeding occurs, patient is discharged the next day
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