Tonsillektomie mit Koagulationsschere oder Raspatorium

Malpractice claims and unintentional outcome of tonsil surgery and other standard procedures in otorhinolaryngology

BACKGROUND

Septoplasty, tonsillectomy (with and without adenoidectomy) and cervical lymph node excision are amongst the most common 50 inpatient operations in Germany. Intracapsular tonsillectomies (i.e. tonsillotomies) are increasingly performed. The aim of this study was to evaluate technical traps and pitfalls as well as alleged medical malpractice associated with tonsillectomy (TE), adenoidectomy (AE), tonsillotomy (TT), septoplasty (SP) and cervical lymph node excision (LN).

METHODS

A questionnaire was sent to the Regional Medical Conciliation Boards, Medical Services of the Health Insurance Companies (MDK) and Regional Institutes of Forensic Medicine in Germany to collect anonymized cases of complications following TE, TT, AE, LN and SP. The results were discussed in the light of the contemporary medical literature and published trials and verdicts in Germany.

RESULTS

The response rate of our survey was 55.9%. The Institutes of Forensic Medicine contributed nine cases, 49 cases were submitted by the Regional Conciliation Boards and none by MDK. All forensic cases were associated with exsanguinations following tonsillectomy including two children (5 and 8 years of age) and seven adults (aged 20 to 69 years). The fatal post-tonsillectomy hemorrhage (PTH) had occurred 8.7 days on average; four patients experienced the bleeding episode at home (day 5, 8, 9 and 17, respectively). Repeated episodes of bleeding requiring surgical intervention had occurred in 6 patients. Three Conciliation Boards submitted decicions associated with TT (1), AE (4), LN (3), SP (16) and TE (25). Cases with lethal outcome were not registered. Only three of the 49 cases were assessed as surgical malpractice (6.1%) including lesion of the spinal accessory nerve, wrong indication for TE and dental lesion after insertion of the mouth gag. The review of the medico legal literature yielded 71 published verdicts after AE and TE (29), LN (28) and SP (14) of which 37 resulted in compensation of malpractice after LN (16; 57%), TE (10; 37%), SP (8; 57%) and AE (2; 100%). There were 16 cases of PTH amongst 27 trials after TE resulting either in death (5) or apallic syndrome (5). Bleeding complications had occurred on the day of surgery in only 2 patients. 16 trials were based on malpractice claims following SP encompassing lack of informed consent (6), anosmia (4), septal perforation (2), frontobasal injury (2) and dry nose (2). Trials after LN procedures were associated exclusively with a lesion of the spinal accessory nerve (28), including lack of informed consent in 19 cases. 49 cases (69%) were decided for the defendant, 22 (31%) were decided for the plaintiff with monetary compensation in 7 of 29 AE/TE-trials, 9 of 28 LN-trials and 6 of 14 SP-trials. Lack of informed consent was not registered for AE/TE but LN (11) and SP (2).

CONCLUSION

Complicated cases following TE, TT, ATE, SP and LN are not systematically collected in Germany. It can be assumed, that not every complicated case is published in the medical literature or law journals and therefore not obtainable for scientific research. Alleged medical malpracice is proven for less than 6% before trial stage. Approximately half of all cases result in a plaintiff verdict or settlement at court. Proper documentation of a thourough counselling, examination, indication, informed consent and follow-up assists the surgeon in litigation. An adequate complication management of PTH is essential, including instructions for the patients/parents, instructions for the medical staff and readily available surgical instruments. Successful outcome of life-threatening PTH is widely based on a proper airway management in an interdisciplinary approach. Electrosurgical tonsillectomy techniques were repeatedly labeled as a risk factor for bleeding complications following TE. Institutions should analyse the individual PTH rate on a yearly basis. Contradictory expert opinions and verdicts of the courts concerning spinal accesory nerve lesions following LN are due to a lack of a surgical standard.

Hemorrhage after tonsillectomy: does the surgical technique really matter?

A thorough review of the publications on surgical techniques used for tonsillectomy is provided, emphasizing randomized studies and meta-analysis. In the assessment of the data it is important to clearly define and categorize the types of posttonsillectomy bleeding (PTB), as well as the various factors that have been associated with increased PTB. In recent audits of a large number of tonsillectomies, the PTB rates seem to concur: 1% early and 2.5% delayed PTB; 10% anamnestic, 2% objective, and 2% re-operation PTB. Objective PTB rates beyond 10% should require an audit. The bipolar technique seems associated with the least early PTB, while the cold technique is associated with the least delayed PTB. Because of the lack of large well-conducted randomized trials, it is difficult to conclude which technique is the best. With electrocautery techniques, the current power should be adjusted to the minimal level providing hemostasis. Surgical techniques for tonsillectomy that should probably be abandoned include monopolar electrocautery, Coblation, various lasers, and the harmonic scalpel. Vessel-sealing systems might hold promise and deserve further evaluation. Tonsillotomy might be associated with less postoperative pain, but the hemorrhagic advantage in randomized studies is not obvious. Tonsil regrowth rates and efficacy to treat obstruction need also further evaluation.

[Bleeding and coagulation disorders in tonsillectomies]

BACKGROUND

The aim of our prospective analysis was to show the incidence of bleeding disorders among a tonsillectomy patient population and in case of bleeding disorders.

PATIENTS AND METHODS

This study comprised 92 consecutive patients who underwent tonsillectomies from 1 January 2007 to 31 December 2007 at the Department of Otorhinolaryngology, University Medical Center Mainz. In addition to gender, age, date of bleeding, Quick, aPTT and platelet count, the following blood values were determined: vWF:AG, vWF:RCo, vWF:RCo/vWF:AG, factor XIII, factor VIII:C, PFA 100™ ADP and PFA 100™ epinephrine (special coagulation analysis).

RESULTS

Twelve of 92 patients (13%) showed evidence of coagulopathy. Four of these 12 patients had a postoperative hemorrhage. In eight patients a factor XIII deficiency was diagnosed, with two of them suffering a hemorrhage. In four patients, von Willebrand disease was diagnosed; two of them bled. No correlation between the presence of a coagulopathy and the bleeding rate could be determined.

CONCLUSION

Routine preoperative performance of special coagulation analysis in all patients does not significantly contribute to the detection of increased postoperative hemorrhage risk.

Comparison of post-tonsillectomy pain with two different types of bipolar forceps: low temperature quantum molecular resonance device versus high temperature conventional electrocautery

CONCLUSION

The low temperature device did not show any advantages over the conventional high temperature electrocautery in terms of the postoperative pain, operation time, and complications in pediatric tonsillectomy.

OBJECTIVE

To compare post-tonsillectomy pain following the use of two different instruments with the same bipolar forceps techniques: low temperature quantum molecular resonance (QMR) device versus conventional high temperature electrocautery.

METHODS

Pediatric patients admitted from July 2008 through January 2009 were included. The participants underwent bilateral tonsillectomy; one side by the QMR device and the other by the bipolar electrocautery. The sides for each instrument were counterbalanced by the order of presentation. The postoperative pain was measured using the faces pain rating scale.

RESULTS

In all, 33 patients with a mean age of 7.6 years were enrolled. The postoperative pain, operation time, and complications in 33 sides dissected by the electrocautery and 33 sides by the QMR device were compared. The average operation times with each device were not statistically different. The mean ratings of the perception of pain related to each instrument were not different on operation day and postoperative day 1, day 4, and day 7 (p = 0.133, 0.057, 0.625, and 1.0, respectively). There was no postoperative complication in any of the patients.