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Kandemir S, Pamuk AE, Özel G, Şencan Z. Comparison of Three Tonsillectomy Techniques: Cold Dissection, Monopolar Electrocautery, and Coblation. Int Arch Otorhinolaryngol 2023; 27:e694-e698. [PMID: 37876704 PMCID: PMC10593530 DOI: 10.1055/s-0042-1758715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 08/24/2022] [Indexed: 03/31/2023] Open
Abstract
Introduction Tonsillectomy is among the most common otolaryngological surgeries. Objective To evaluate and compare three tonsillectomy techniques: cold steel dissection (CSD), monopolar electrocautery (MEC), and coblation. Methods The present study retrospectively reviewed the medical records of patients who underwent tonsillectomy between January 2014 and January 2016. Postoperative visual analog scale (VAS) pain scores, analgesic use, surgical duration, time to return to normal activity, and postoperative bleeding status were noted. Results The CSD group had less analgesic use and shorter return to normal activity than the MEC group ( p = 0.037 and p < 0.001, respectively). The coblation group had lower VAS pain scores than the MEC group only at 1 hour to 4 hours postsurgery ( p < 0.016). The postoperative bleeding rate was similar in all groups ( p = 0.096). Conclusion Cold steel dissection tonsillectomy is associated with less postoperative pain and shorter recovery than MEC. Coblation is better than MEC in terms of postoperative pain at 1 hour to 4 hours only, whereas CSD is associated with less postoperative pain than coblation at 2 days to 7 days.
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Affiliation(s)
- Süheyla Kandemir
- Department of Otorhinolaryngology, Kırıkkale Yüksek İhtisas Hospital, Kırıkkale, Turkey
| | - Ahmet Erim Pamuk
- Department of Otorhinolaryngology, Private Practice, Ankara, Turkey
| | - Gökçe Özel
- Department of Otorhinolaryngology, Private Practice, Ankara, Turkey
| | - Ziya Şencan
- Department of Otorhinolaryngology, Kırıkkale University, Faculty of Medicine, Kırıkkale Turkey
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Liu Q, Zhang Y, Liu Y. Preoperative thromboelastography in the prediction of post-tonsillectomy hemorrhage by coblation tonsillectomy: a post-hoc analysis. Ann Saudi Med 2022; 42:377-384. [PMID: 36444922 PMCID: PMC9706718 DOI: 10.5144/0256-4947.2022.377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Post-tonsillectomy hemorrhage (PTH) affects around 4% of patients after tonsillectomy. We hypothesized that preoperative thromboelastography (TEG) might identify patients at higher risk of PTH. OBJECTIVE Investigate whether evaluation of coagulation function by preoperative TEG might help to predict PTH after tonsillectomy by coblation tonsillectomy (TE). DESIGN Post-hoc analysis of randomized controlled study. SETTING Otolaryngology Department between January 2017 and August 2019. PATIENTS AND METHODS This post-hoc analysis included adults who underwent coblation TE for benign tonsillar disorders. Routine blood tests and TEG were performed preoperatively. The TEG parameters evaluated included coagulation reaction time (R) and maximum thrombus amplitude (MA). MAIN OUTCOME MEASURES The main outcome was PTH during the 4-week postoperative period. SAMPLE SIZE AND CHARACTERISTICS 284 RESULTS: The 19 patients (6.7%) that experienced PTH had a higher prevalence of diabetes mellitus, lower use of intraoperative suturing, fewer patients with grade I and II tonsillar enlargement, a higher white blood cell count, lower platelet count, lower fibrinogen level, lower R value, and a lower MA value than patients without PTH (all P<.05). Multivariate logistic regression revealed that diabetes mellitus (P<.053), fibrinogen level ≤2.735 g/L (P<.027), R≤6.55 min (P<.011) and MA≤59.15 mm (P<.012) were independently associated with PTH. A regression model incorporating these four factors predicted PTH with a sensitivity of 73.7% and specificity of 83.8%. CONCLUSION Preoperative evaluation of diabetes mellitus history, fibrinogen level, and TEG parameters might help to identify patients at higher risk of PTH after coblation TE. LIMITATIONS Single-center study with a small sample size; possibly underpowered statistically. TEG measurements might not accurately reflect coagulation function, and a validation cohort was unavailable. CONFLICT OF INTEREST None. CHINESE CLINICAL TRIAL REGISTRY NUMBER OF STUDY USED IN THIS ANALYSIS: ChiCTR2000032171. http://www.chictr.org.cn/showprojen.aspx?proj=52553.
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Affiliation(s)
- Qian Liu
- From the Department of Otolaryngology, Shenzhen People's Hospital, Shenzhen, China
| | - Yanping Zhang
- From the Department of Otolaryngology, 8th Medical Center, PLA General Hospital, Beijing, China
| | - Yanlu Liu
- From the Department of Otolaryngology, Shenzhen People's Hospital, Shenzhen, China
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Fushimi K, Gyo K, Okunaka M, Watanabe M, Sugihara A, Tsuzuki K. Analysis of risk factors for post-tonsillectomy hemorrhage in adults. Auris Nasus Larynx 2022; 50:389-394. [PMID: 36272864 DOI: 10.1016/j.anl.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 10/03/2022] [Accepted: 10/06/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVES To identify the risk factors for post-tonsillectomy hemorrhage (PTH) in adult patients (>19 years). METHODS 275 adult patients who underwent tonsillectomy between 2009 and 2019 were retrospectively analyzed. Possible risk factors associated with PTH were investigated by univariate and multivariate logistic regression analyses. RESULTS PTH occurred in 39 of 275 patients (14.2%). Regarding underlying diseases, PTH occurred more frequently in focal infection of IgA nephropathy. Furthermore, bipolar electrocautery was the other risk factor for PTH on multivariate analysis. CONCLUSION Focal infection of IgA nephropathy and bipolar electrocautery were identified as the risk factors for PTH.
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Feld K, Mellin W, Melzer B, Rothschild MA, Fries J. Fatal hemorrhage after tonsillectomy. Rechtsmedizin (Berl) 2021. [DOI: 10.1007/s00194-021-00502-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
AbstractThis is the first report of a segmental mediolysis occurring in arterioles, affecting the neck/tonsillar region and leading to a fatal hemorrhage after a tonsillectomy in a 20-year-old woman. Arteriolar mediolysis could be observed in tissue layers about 2 cm distant from the tonsillectomy region. Reparative changes were observed in the carotid and small neck arteries as well as in only one intramyocardial arteriole; however, no other vascular regions typically reported in segmental mediolysis arteriopathy were affected and aneurysm formation was not observed. No family history of vascular disease or hypertension was known. Pathophysiologically, previously reported reasons for post-tonsillectomy bleeding could be excluded. Segmental mediolysis may represent a wider spectrum of affected arteriolar vessels besides the reported small and medium sized arteries leading to aneurysms, which impedes radiographic diagnosis.
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Gross JH, Lindburg M, Kallogjeri D, Molter M, Molter D, Lieu JEC. Predictors of Occurrence and Timing of Post-Tonsillectomy Hemorrhage: A Case-Control Study. Ann Otol Rhinol Laryngol 2020; 130:825-832. [PMID: 33291963 DOI: 10.1177/0003489420978010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To describe cases and timing of pediatric post-tonsillectomy hemorrhage (PTH), to evaluate predictors of PTH, and to determine the optimal amount of postoperative care unit (PACU) monitoring time. STUDY DESIGN Using the Pediatric Health Information System (PHIS) database and electronic medical records, a matched case-control study from 2005 to 2015 was performed. SETTING A single, tertiary-care institution. SUBJECTS AND METHODS Each case of PTH was matched with 1 to 4 controls for the following factors: age, sex, surgeon, and time of year. A total of 124 cases of PTH and 479 tonsillectomy controls were included. The rate and timing of postoperative bleeding were assessed, and matched pair analysis was performed using conditional logistic regression. RESULTS Our institutional PTH rate of 1.9% (130 of 6949) included 124 patients; 15% (19) were primary (≤24 hours), with 50% (9) occurring within 5 hours. Twenty-one percent (4 of 19) of primary PTH patients received operative intervention. Eighty-five percent (105 of 124) of all cases were secondary PTH, and 47% (49) of those patients received operative intervention. Cold steel (OR 1.9, 95% CI 1.1-3.3) and Coblation (OR 1.9, 95% CI 1.2-3.1) techniques and tonsillectomy alone (OR 3.7, 95% CI 1.9-7.2) increased odds of PTH. Patients who developed PTH had 4 times the odds of having a preceding postoperative respiratory event than controls (OR 4.0, 95% CI 1.6-10.0). CONCLUSION We conducted a rigorous case-control study for PTH, finding that PTH was associated with use of cold steel and Coblation techniques and with tonsillectomy alone. Patients with a postoperative respiratory event may be more likely to develop a PTH and should be counseled accordingly. A PACU monitoring time of 4 hours is sufficient for outpatient tonsillectomy.
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Affiliation(s)
- Jennifer H Gross
- Department of Otolaryngology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Miranda Lindburg
- Department of Otolaryngology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Dorina Kallogjeri
- Department of Otolaryngology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Michelle Molter
- Department of Otolaryngology, Washington University School of Medicine, Saint Louis, MO, USA
| | - David Molter
- Department of Otolaryngology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Judith E C Lieu
- Department of Otolaryngology, Washington University School of Medicine, Saint Louis, MO, USA
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Gonçalves AI, Rato C, de Vilhena D, Duarte D, Lopes G, Trigueiros N. Evaluation of post-tonsillectomy hemorrhage and assessment of risk factors. Eur Arch Otorhinolaryngol 2020; 277:3095-3102. [PMID: 32451667 DOI: 10.1007/s00405-020-06060-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 05/13/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE Tonsillectomy is one of the most common surgical procedures in otorhinolaryngology. Hemorrhage in the postoperative period has an incidence of up to 20% and is a potentially fatal complication. We aim to assess the incidence of hemorrhage after tonsillectomy in our institution, and to evaluate and identify the possible associated risk factors. METHODS This retrospective study included 897 patients who underwent tonsillectomy between January 2015 and December 2018, 50.7% women and 49.3% men, aged between 2 and 83 years. No coagulopathies were identified. Comparison of age, gender, surgical indication, coagulation profile, concomitant adenoidectomy, surgical technique, surgeon's experience and hemostasis method between groups with and without post-operative bleeding was made. RESULTS Our incidence of post-tonsillectomy hemorrhage was 6%. Most patients (83.3%) had secondary bleeding (> 24 h after surgery). In 22.2% of the bleeding cases, it was necessary to revise the hemostasis in the operating room. Adulthood (age ≥ 18 years) (p < 0.001), INR values ≥ 1.2 (p = 0.014), aPTT values ≥ 35 s (p = 0.001), as well as concomitant adenoidectomy (p < 0.001) were the predictors of post-tonsillectomy bleeding. CONCLUSION Recognition of adult age, INR ≥ 1.2, aPTT ≥ 35 s and concomitant adenoidectomy as risk factors can be useful in identifying the patients at higher risk for bleeding complications.
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Affiliation(s)
- Ana Isabel Gonçalves
- Otolaryngology Department, Pedro Hispano Hospital, Matosinhos, Oporto, Portugal.
| | - Catarina Rato
- Otolaryngology Department, Pedro Hispano Hospital, Matosinhos, Oporto, Portugal
| | - Ditza de Vilhena
- Otolaryngology Department, Pedro Hispano Hospital, Matosinhos, Oporto, Portugal
| | - Delfim Duarte
- Otolaryngology Department, Pedro Hispano Hospital, Matosinhos, Oporto, Portugal
| | - Gustavo Lopes
- Otolaryngology Department, Pedro Hispano Hospital, Matosinhos, Oporto, Portugal
| | - Nuno Trigueiros
- Otolaryngology Department, Pedro Hispano Hospital, Matosinhos, Oporto, Portugal
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Seyhun N, Dizdar SK, Çoktur A, Bektaş ME, Albuz O, Erol ZN, Turgut S. Risk factors for post-tonsillectomy hemorrhage in adult population: Does smoking history have an impact? Am J Otolaryngol 2020; 41:102341. [PMID: 31732315 DOI: 10.1016/j.amjoto.2019.102341] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 11/03/2019] [Accepted: 11/06/2019] [Indexed: 12/11/2022]
Affiliation(s)
- Nurullah Seyhun
- Sisli Hamidiye Etfal Training and Research Hospital, ENT Clinic, Sisli, Istanbul, Turkey.
| | - Senem Kurt Dizdar
- Sisli Hamidiye Etfal Training and Research Hospital, ENT Clinic, Sisli, Istanbul, Turkey
| | - Alican Çoktur
- Sisli Hamidiye Etfal Training and Research Hospital, ENT Clinic, Sisli, Istanbul, Turkey
| | - Merve Ekici Bektaş
- Sisli Hamidiye Etfal Training and Research Hospital, ENT Clinic, Sisli, Istanbul, Turkey
| | - Onuralp Albuz
- Sisli Hamidiye Etfal Training and Research Hospital, ENT Clinic, Sisli, Istanbul, Turkey
| | - Zeynep Nur Erol
- Sisli Hamidiye Etfal Training and Research Hospital, ENT Clinic, Sisli, Istanbul, Turkey
| | - Suat Turgut
- Sisli Hamidiye Etfal Training and Research Hospital, ENT Clinic, Sisli, Istanbul, Turkey
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Bitar M, Dunya G, Khalifee E, Muwakkit S, Barazi R. Risk of post-operative hemorrhage after adenoidectomy and tonsillectomy: Value of the preoperative determination of partial thromboplastin time and prothrombin time. Int J Pediatr Otorhinolaryngol 2019; 116:62-64. [PMID: 30554709 DOI: 10.1016/j.ijporl.2018.10.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Revised: 10/16/2018] [Accepted: 10/16/2018] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Tonsillectomy and adenoidectomy (T& A) are the most common pediatric surgical procedures performed world-wide. Bleeding remains the most common complication of these procedures with 1-5.7% prevalence. METHODS We recruited 1269 patients who were scheduled for either tonsillectomy, adenoidectomy or both. All patients had preoperative CBC, PT, and aPTT ordered. According to the results, patients were labelled as either "abnormal group" or "normal group". RESULTS 35 patients had abnormal lab results 18 of these patients were diagnosed with coagulation disorders on further laboratory testing.9 of these patients had no pertinent history of bleeding. Even though an association is noted between abnormal lab tests and preoperative history of risk of bleeding, the correlation did not have high sensitivity (28.6%). CONCLUSION This study provides evidence that preoperative history can give some information on patients with abnormal coagulation profile but may underestimate the prevalence of such diseases. In addition, patients with abnormal coagulation profile have more risk of postoperative bleeding even after adequate medical treatment perioperative. Thus, identifying these patients will help the clinician in providing the best surgical management with the least morbidity and mortality.
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Affiliation(s)
- Mohamad Bitar
- Department of Otolaryngology Head and Neck Surgery, Al Jalila Children's Hospital, Dubai, United Arab Emirates
| | - Gabriel Dunya
- Department of Otolaryngology Head and Neck Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Elie Khalifee
- Department of Otolaryngology Head and Neck Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Samar Muwakkit
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Randa Barazi
- Department of Otolaryngology Head and Neck Surgery, American University of Beirut Medical Center, Beirut, Lebanon.
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Epithelial separation theory for post-tonsillectomy secondary hemorrhage: evidence in a mouse model and potential heparin-binding epidermal growth factor-like growth factor therapy. Eur Arch Otorhinolaryngol 2017; 275:569-578. [PMID: 29188436 DOI: 10.1007/s00405-017-4810-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Accepted: 11/09/2017] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To provide histological evidence to investigate a theory for post-tonsillectomy secondary hemorrhage (PTH) in a mouse model and to evaluate the potential for heparin-binding epidermal growth factor-like growth factor (HB-EGF) treatment on wound healing in this model. METHODS A prospective randomized single-blinded cohort study. A uniform tongue wound was created in 84 mice (day 0). Mice were randomized to HB-EGF (treatment, n = 42) or saline (control, n = 42). In treatment mice, HB-EGF 5 µg/ml was administered intramuscularly into the wound daily (days 0-14). In control mice, normal saline was administered daily. Three mice from each group were sacrificed daily through day 14 and the wounds evaluated histologically by blinded reviewers. RESULTS Key stages of wound healing, including keratinocyte proliferation and migration, wound contraction, epithelial separation, and neoangiogenesis, are defined with implications for post-tonsillectomy wound healing. Epithelial separation (59 vs. 100%, p = 0.003) and wound reopening (8 vs. 48%, p < 0.001) were reduced with HB-EGF. Epithelial thickness (220 vs. 30 µm, p = 0.04) was greater with HB-EGF. Wound closure (days 4-5 vs. day 6, p = 0.01) occurred earlier with HB-EGF. CONCLUSIONS In healing of oral keratinocytes on muscle epithelial separation secondary to muscle, contraction occurs concurrently with neoangiogenesis in the base of the wound, increasing the risk of hemorrhage. This potentially explains why post-tonsillectomy secondary hemorrhage occurs and its timing. HB-EGF-treated wounds showed greater epithelial thickness, less frequent epithelial separation and wound reopening, and earlier wound closure prior to neovascularization, suggesting that HB-EGF may be a potential preventative therapy for PTH. LEVEL OF EVIDENCE NA-animal studies or basic research.
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Patel PN, Arambula AM, Wheeler AP, Penn EB. Post-tonsillectomy hemorrhagic outcomes in children with bleeding disorders at a single institution. Int J Pediatr Otorhinolaryngol 2017; 100:216-222. [PMID: 28802375 DOI: 10.1016/j.ijporl.2017.07.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 07/12/2017] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To report on the post-tonsillectomy bleeding outcomes and factors associated with hemorrhage among children with pre- or post-operatively diagnosed bleeding disorders treated with an institutional protocol. METHODS Retrospective cohort study of patients with hematologic disorders who underwent tonsillectomy between 2003 and 2016 and were treated with perioperative desmopressin or factor replacement and/or aminocaproic acid. Postoperative outcomes were compared to controls matched for age, sex, and indication for surgery. Analysis of factors associated with hemorrhage was performed in patients with bleeding disorders using Mann-Whitney U or chi-squared tests. RESULTS 45 patients with hematologic disorders met inclusion criteria. Platelet dysfunction, including von Willebrand Disease (vWD), was the most common diagnosis (77.8%). Most patients had a preoperative diagnosis of a bleeding disorder and received perioperative hematologic medications (86.7%). Compared to matched controls, patients with hematologic disorders experienced more postoperative bleeding (15.5%; 12 bleeds, 7 patients vs. 1.7%; 1 bleed, 1 patient, p = 0.05) and had longer postoperative stays (1.3 days vs. 0.4 days, p < 0.001). Among the patients with hematologic disorders, patients who experienced a postoperative bleed were significantly more likely to have a factor deficiency (e.g. Hemophilia over vWD) and have a postoperative diagnosis (compared to preoperative diagnosis) for which they did not receive perioperative hematologic medication. Of patients with a postoperative bleed, all those diagnosed postoperatively required at least one surgical intervention to control bleeding compared to 33% of patients with a preoperative diagnosis. A history of post-surgical bleeding, male sex, age at surgery, and pharyngitis as surgical indication were not associated with higher hemorrhage rates in this group. CONCLUSIONS This study suggests a clinically important magnitude of increased bleeding risk in patients with hematologic disease. This risk appears to decrease with the use of an institutional protocol consisting of desmopressin or factor replacement and an antifibrinolytic agent extending through postoperative day 10.
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Affiliation(s)
- Priyesh N Patel
- Division of Pediatric Otolaryngology, Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, TN, USA.
| | | | - Allison P Wheeler
- Division of Hematology-Oncology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Edward B Penn
- Division of Pediatric Otolaryngology, Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, TN, USA
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Østvoll E, Sunnergren O, Stalfors J. Increasing Readmission Rates for Hemorrhage after Tonsil Surgery: A Longitudinal (26 Years) National Study. Otolaryngol Head Neck Surg 2017; 158:167-176. [PMID: 28828912 DOI: 10.1177/0194599817725680] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Objective To investigate the readmission rates due to postoperative hemorrhage in relation to tonsil surgery clinical practice in a national population. Study Design Retrospective longitudinal population-based cohort study. Setting Based on register data from the Swedish National Patient Register (NPR). Subjects and Methods All benign tonsil operations (256 053) performed in Sweden from 1987 to 2013 were identified through a search in the NPR. For all identified cases, data on gender, age, date of surgery, indication, type of surgery, level of care, length of stay (LOS) for inpatient surgery, readmission and reoperation because of postoperative bleeding (within 31 days) were collected. Results Overall frequency of readmission for hemorrhage was 2.61%, and the reoperation rate for hemostasis was 0.84%. The longitudinal analysis showed an increase from 1% (1987) to 5% (2013) in readmissions caused by hemorrhage. Tonsillectomies, surgery performed for infectious disease, and surgery on adult patients (age >18 years) showed readmission rates approaching 10% (2013). Male gender, increasing age, tonsillectomy, infectious indication, and recent year of surgery were identified as risk factors for readmission and reoperation due to hemorrhage. An increasing share of patients readmitted for hemorrhage underwent reoperation for hemostasis: 18% (1987) versus 43% (2013). Conclusion Readmissions for hemorrhage have increased by a factor of 5 in Sweden from 1987 to 2013. The design of the study and the data in NPR do not allow determination of the true reasons behind the alarming results.
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Affiliation(s)
- Eirik Østvoll
- 1 Department of Otorhinolaryngology, Head and Neck Surgery, Sahlgrenska University Hospital and Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Ola Sunnergren
- 2 Department of Otorhinolaryngology, Ryhov County Hospital, Jönköping, Sweden
| | - Joacim Stalfors
- 3 Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden and Sheikh Khalifa Medical City, Ajman, United Arab Emirates
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Bleeding following coblation tonsillectomy: a 10-year, single-surgeon audit and modified grading system. The Journal of Laryngology & Otology 2014; 129 Suppl 1:S32-7. [DOI: 10.1017/s0022215114002138] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
AbstractObjective:Coblation tonsillectomy can be controversial. This study assessed post-tonsillectomy haemorrhage outcomes for patients operated on by a single experienced coblation-trained ENT surgeon.Study design:A retrospective audit of coblation tonsillectomies was performed using the Flinders modification of Stammberger criteria for post-tonsillectomy haemorrhage.Method:Case note review, interview and database interrogation were utilised to obtain the dataset. Haemorrhage results were compared to reports in the current literature.Results:Of those who underwent coblation tonsillectomy, 3.4 per cent were readmitted to hospital with haemorrhage and 1.3 per cent returned to the operating theatre (0.4 per cent primary haemorrhage and 0.9 per cent secondary haemorrhage). Younger children had a lower risk of returning to the operating theatre than older children or adults (0.3 per cent under the age of 12 years vs 2.0 per cent aged 12 years or older).Conclusion:Coblation can be a safe method for tonsillectomy with low complication rates when performed by an experienced ENT surgeon. The Flinders modification of the Stammberger criteria for post-tonsillectomy haemorrhage provides a simple system for data comparison.
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Al-Mahbashi MY, Saeed SQ, Al-Attab AA, Raja’a YA. Comparison of three techniques for tonsillectomy during free medical camps in Yemen. THE EGYPTIAN JOURNAL OF OTOLARYNGOLOGY 2014. [DOI: 10.4103/1012-5574.138479] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Windfuhr JP. Malpractice claims and unintentional outcome of tonsil surgery and other standard procedures in otorhinolaryngology. GMS CURRENT TOPICS IN OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY 2013; 12:Doc08. [PMID: 24403976 PMCID: PMC3884543 DOI: 10.3205/cto000100] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Jochen P. Windfuhr
- Department of Otorhinolaryngology, Plastic Head and Neck Surgery, Kliniken Maria Hilf, Mönchengladbach, Germany
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Abstract
Adenotonsillectomy (AT) is one of the most common pediatric surgical procedures performed in the United States; more than 530,000 are performed annually in children younger than 15 years of age. AT was traditionally performed for recurrent tonsillitis and its sequelae but in recent times, sleep-disordered breathing/obstructive sleep apnea in children has emerged as the primary indication for surgical removal of adenoids and tonsils. The new guidelines used by clinicians to identify children who are appropriate candidates for AT address indications based primarily on obstructive and infectious causes.
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Affiliation(s)
- Sharon D Ramos
- Department of Otolaryngology, University of Texas-Medical Branch at Galveston, Galveston, TX 77555-0521, USA.
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Muratori E, Meccariello G, Deganello A, Mannelli G, Gallo O. Tonsillectomy and residents: a safe match? Clin Otolaryngol 2013; 38:279-80. [PMID: 23745541 DOI: 10.1111/coa.12122] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2013] [Indexed: 11/30/2022]
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Windfuhr JP. Serious Complications following Tonsillectomy: How Frequent Are They Really? ACTA ACUST UNITED AC 2013; 75:166-73. [DOI: 10.1159/000342317] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Walner DL, Miller SP, Villines D, Bussell GS. Coblation tonsillectomy in children: incidence of bleeding. Laryngoscope 2012; 122:2330-6. [PMID: 22833366 DOI: 10.1002/lary.23526] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2012] [Accepted: 05/22/2012] [Indexed: 12/18/2022]
Abstract
OBJECTIVES/HYPOTHESIS To evaluate the intraoperative and postoperative bleeding rate utilizing the Coblation device for total tonsillectomy in children. STUDY DESIGN Prospectively designed clinical study. METHODS Institutional review board approval was obtained to study patients undergoing Coblation tonsillectomy. Records of all children 1 to 18 years of age undergoing tonsillectomy or adenotonsillectomy from April 2003 to April 2010 were reviewed. All children underwent total tonsillectomy utilizing the Coblation device, and the intraoperative and postoperative bleeding complications were analyzed. The data were also analyzed to determine whether surgeon experience with the technique influenced the bleeding rate. RESULTS A total of 1,918 patients were evaluated. Intraoperative blood loss was <5 mL in >90% of the patients, with no patients experiencing >20 mL of blood loss. The postoperative bleeding rate was consistent with the literature (n = 87, 4.5%). Of the patients with bleeding following surgery, five (5.7%) experienced primary bleeding and 82 (94.3%) secondary bleeding. Postoperative bleeding that ceased spontaneously and did not require intervention was present in 56 (2.9%). The number of patients who actually required intervention to control postoperative bleeding was 31 (1.6%). The majority of bleeding occurred by postoperative day 7. There was no statistically significant difference in bleeding rates by age, and there was no evidence found to support a surgeon learning curve for performing Coblation tonsillectomy. CONCLUSIONS This study provides further support that Coblation total tonsillectomy in children is a reliable and safe procedure with a relatively low incidence of intraoperative and postoperative bleeding.
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Affiliation(s)
- David L Walner
- Department of Otolaryngology, Rush University Medical Center, Chicago, Illinois, USA.
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Kim JW, Mun SJ, Lee WH, Mo JH. Post-tonsillectomy hemorrhage in children: a single surgeon’s experience with coblation compared to diathermy. Eur Arch Otorhinolaryngol 2012; 270:339-44. [DOI: 10.1007/s00405-012-2098-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Accepted: 06/18/2012] [Indexed: 11/24/2022]
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Jones DT, Kenna MA, Guidi J, Huang L, Johnston PR, Licameli GR. Comparison of Postoperative Pain in Pediatric Patients Undergoing Coblation Tonsillectomy versus Cautery Tonsillectomy. Otolaryngol Head Neck Surg 2011; 144:972-7. [DOI: 10.1177/0194599811400369] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Objective. To compare postoperative pain scores between monopolar electrocautery and coblation subcapsular tonsillectomy. Study Design. Prospective double-blind randomized study. Setting. Tertiary care children’s hospital. Subjects and Methods. Between December 2004 and April 2008, 61 children, ages 4 to 20 years (mean age, 10 years; SD, 4 years), were randomized to have one tonsil removed by electrocautery and the other tonsil removed by coblation. Subjects used the FACES scale to rate pain on each side immediately postoperatively, 2 days postoperatively, and 2 weeks postoperatively. Postoperative hemorrhage was also tracked. Results. Coblation tonsillectomy resulted in statistically less pain than electrocautery immediately after surgery, but this difference was not clinically significant. Conclusions. Pediatric pain is similar following monopolar electrocautery or coblation subcapsular tonsillectomy.
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Affiliation(s)
- Dwight T. Jones
- Department of Otolaryngology and Communication Enhancement, Children’s Hospital Boston, Boston, Massachusetts, USA
- Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Margaret A. Kenna
- Department of Otolaryngology and Communication Enhancement, Children’s Hospital Boston, Boston, Massachusetts, USA
- Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Jessica Guidi
- Department of Otolaryngology and Communication Enhancement, Children’s Hospital Boston, Boston, Massachusetts, USA
| | - Lin Huang
- Clinical Research Program, Children’s Hospital Boston, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Patrick R. Johnston
- Clinical Research Program, Children’s Hospital Boston, Boston, Massachusetts, USA
| | - Greg R. Licameli
- Department of Otolaryngology and Communication Enhancement, Children’s Hospital Boston, Boston, Massachusetts, USA
- Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts, USA
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Hemorragia postamigdalectomía: ¿tienen las pruebas de coagulación y el historial de coagulopatía un valor predictivo? ACTA OTORRINOLARINGOLOGICA ESPANOLA 2010; 61:287-92. [DOI: 10.1016/j.otorri.2010.01.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2009] [Accepted: 01/14/2010] [Indexed: 12/29/2022]
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Kim DW, Koo JW, Ahn SH, Lee CH, Kim JW. Difference of delayed post-tonsillectomy bleeding between children and adults. Auris Nasus Larynx 2010; 37:456-60. [PMID: 20034752 DOI: 10.1016/j.anl.2009.11.011] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2009] [Revised: 11/27/2009] [Accepted: 11/27/2009] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To analyze the characteristics of post-tonsillectomy bleeding and its management comparing with adults. METHODS A retrospective chart review of 1489 patients who underwent tonsillectomy in our institution (June 2003-June 2006). RESULTS Post-tonsillectomy bleeding rate was 3.1%, 2.5% and 10.8% in younger children (age< or =11 years), older children (12< or =age< or =15 years) and adults (age>15 years), respectively. Although adults showed an unimodal peak time for onset of post-tonsillectomy bleeding, children showed a bimodal peak time. In the younger child group, all of the 28 bleeders had spontaneous hemostasis. However, in the older child group, there was no spontaneous hemostasis. Bleeding was controlled under local anesthesia in 3 patients and 2 patients required general anesthesia for bleeding control. In the adult group, spontaneous cessation of bleeding occurred in 25 patients (60.9%) and hemostasis under local or general anesthesia was performed in 16 (39.1%) patients. CONCLUSIONS Post-tonsillectomy bleeding occurred more frequently in adults than in children. Spontaneous hemostasis was more prevalent in children than in adults. Post-tonsillectomy bleeding in the younger child group was controlled with close observation alone.
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Affiliation(s)
- Dong Wook Kim
- Department of Otorhinolaryngology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 300 Goomi-dong, Bundang-gu, Seongnam 463-707, Republic of Korea
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Zagólski O. Post-tonsillectomy haemorrhage—Do coagulation tests and coagulopathy history have predictive value? ACTA OTORRINOLARINGOLOGICA ESPANOLA 2010. [DOI: 10.1016/s2173-5735(10)70051-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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