Tonsilar haemorrhage and re-admission: a questionnaire based study

Very-Low Energy Monopolar Reduces Post-Tonsillectomy Hemorrhage Versus Standard Energy Techniques

OBJECTIVES/HYPOTHESIS

To compare rates of post-tonsillectomy hemorrhage (PTH) between a very-low energy transfer monopolar technique (VLET) and standard energy techniques.

STUDY DESIGN

Retrospective controlled cohort study.

METHODS

All tonsillectomies performed by practice physicians during the period January 1, 2010 to August 31, 2019 were identified. Three groups were created based on surgeon technique utilization: the study group (VLET) and two control groups (exclusive standard energy monopolar [Standard]; exclusive "hot" technique without exclusive monopolar use [Mixed "Hot"]). Each group's PTH occurrences requiring surgical intervention (PTHRSI) were identified and rates compared.

RESULTS

During the study period 11,348 tonsillectomies were performed (4,427 Standard, 1,374 VLET, 5,547 Mixed "Hot"), and 167 (1.47%) PTHRSI events identified (14 primary (<24 hours), 153 secondary (>24 hours), 12 repeat (>1PTHRSI/patient). Compared to the Standard group secondary and total PTHRSI rates (1.47%, 1.60%), the Mixed "Hot" group experienced similar rates (1.57%, P = .54; 1.68%, P = .64), but the VLET group experienced significantly lower rates (0.15%, P = .0026, adjusted odds ratio [OR] 0.114 [0.028-0.469]; 0.22%, P = .0016, adjusted OR 0.155 [0.048-0.494]). Age was a significant risk factor for both secondary and total PTHRSI (P = .0025, P = .0024, adjusted OR 1.02/year [1.01-1.03]). No significant difference in rate of primary PTHRSI was seen collectively or in any age group. The <12VLET Group experienced 0 episodes of secondary PTHRSI and a total PTHRSI rate of 0.09% in 1060 tonsillectomies.

CONCLUSIONS

Standard energy techniques had an adjusted odds ratio over 8-fold higher for secondary PTHRSI and over 6-fold higher for total PTHRSI compared to the minimized energy transfer VLET technique.

LEVEL OF EVIDENCE

3 Laryngoscope, 2021.

Grasl M, Grasl S, Arnoldner C, Steyrer J, Erovic BM. Post-tonsillectomy hemorrhage: cost-benefit analysis of prolonged hospitalization

Background: Prolonged hospitalization after tonsillectomy up to three nights was implemented to decrease mortality due to post-tonsillectomy hemorrhage.Aims: To assess if extension of postoperative inpatient observation time from one to three nights results in potential benefits following tonsillectomy.Subjects and methods: Patients who stayed only one night post-tonsillectomy between 1994 and 2006 (Group A) were compared to 1570 patients who stayed three nights postoperatively between 2008 and 2016 (Group B). Complication rate and expense of hospitalization were compared.Results: Published data show that 114 (1.78%) out of 6400 patients in group A had post-tonsillectomy hemorrhage. In this patient group 75.4% (n = 86) of all bleedings occurred after discharge from hospital. However, in group B post-tonsillectomy hemorrhage occurred in 70 (4.5%) and of those only 0.38% (n = 6) developed bleeding episodes on the second or third postoperative day (POD). As observed in group A, the majority of hemorrhage (n = 57; 81.4%) was observed after discharge. Cost analysis reveals a difference of approximately 6 million €for all 32 ENT departments per year in Austria.Conclusions and significance: Extending postoperative hospitalization from one to three nights reveals no benefit after tonsillectomy. Comparison reveals substantial increase of costs for an extended 3 nights inpatient stay.

Tonsillectomy versus tonsillotomy for obstructive sleep-disordered breathing in children

BACKGROUND

Obstructive sleep-disordered breathing (oSDB) is a condition encompassing breathing problems when asleep due to upper airway obstruction. In children, hypertrophy of the tonsils and/or adenoids is thought to be the commonest cause. As such, (adeno)tonsillectomy has long been the treatment of choice. A rise in partial removal of the tonsils over the last decade is due to the hypothesis that tonsillotomy is associated with lower postoperative morbidity and fewer complications.

OBJECTIVES

To assess whether partial removal of the tonsils (intracapsular tonsillotomy) is as effective as total removal of the tonsils (extracapsular tonsillectomy) in relieving signs and symptoms of oSDB in children, and has lower postoperative morbidity and fewer complications.

SEARCH METHODS

We searched the Cochrane ENT Trials Register; Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The search date was 22 July 2019.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing the effectiveness of (adeno)tonsillectomy with (adeno)tonsillotomy in children aged 2 to 16 years with oSDB.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods and assessed the certainty of the evidence for our pre-defined outcomes using GRADE. Our primary outcomes were disease-specific quality of life, peri-operative blood loss and the proportion of children requiring postoperative medical intervention (with or without hospitalisation). Secondary outcomes included postoperative pain, return to normal activity, recurrence of oSDB symptoms as a result of tonsil regrowth and reoperation rates.

MAIN RESULTS

We included 22 studies (1984 children), with predominantly unclear or high risk of bias. Three studies used polysomnography as part of their inclusion criteria. Follow-up duration ranged from six days to six years. Although 19 studies reported on some of our outcomes, we could only pool the results from a few due both to the variety of outcomes and the measurement instruments used, and an absence of combinable data. Disease-specific quality of life Four studies (540 children; 484 (90%) analysed) reported this outcome; data could not be pooled due to the different outcome measurement instruments used. It is very uncertain whether there is any difference in disease-specific quality of life between the two surgical procedures in the short (0 to 6 months; 3 studies, 410 children), medium (7 to 13 months; 2 studies, 117 children) and long term (13 to 24 months; 1 study, 67 children) (very low-certainty evidence). Peri-operative blood loss We are uncertain whether tonsillotomy reduces peri-operative blood loss by a clinically meaningful amount (mean difference (MD) 14.06 mL, 95% CI 1.91 to 26.21 mL; 8 studies, 610 children; very low-certainty evidence). In sensitivity analysis (restricted to three studies with low risk of bias) there was no evidence of a difference between the groups. Postoperative complications requiring medical intervention (with or without hospitalisation) The risk of postoperative complications in the first week after surgery was probably lower in children who underwent tonsillotomy (4.9% versus 2.6%, risk ratio (RR) 1.75, 95% CI 1.06 to 2.91; 16 studies, 1416 children; moderate-certainty evidence). Postoperative pain Eleven studies (1017 children) reported this outcome. Pain was measured using various scales and scored by either children, parents, clinicians or study personnel. When considering postoperative pain there was little or no difference between tonsillectomy and tonsillotomy at 24 hours (10-point scale) (MD 1.09, 95% CI 0.88 to 1.29; 4 studies, 368 children); at two to three days (MD 0.93, 95% CI -0.14 to 2.00; 3 studies, 301 children); or at four to seven days (MD 1.07, 95% CI -0.40 to 2.53; 4 studies, 370 children) (all very low-certainty evidence). In sensitivity analysis (restricted to studies with low risk of bias), we found no evidence of a difference in mean pain scores between groups. Return to normal activity Tonsillotomy probably results in a faster return to normal activity. Children who underwent tonsillotomy were able to return to normal activity four days earlier (MD 3.84 days, 95% CI 0.23 to 7.44; 3 studies, 248 children; moderate-certainty evidence). Recurrence of oSDB and reoperation rates We are uncertain whether there is a difference between the groups in the short (RR 0.26, 95% CI 0.03 to 2.22; 3 studies, 186 children), medium (RR 0.35, 95% CI 0.04 to 3.23; 4 studies, 206 children) or long term (RR 0.21 95% CI 0.01 to 4.13; 1 study, 65 children) (all very low-certainty evidence).

AUTHORS' CONCLUSIONS

For children with oSDB selected for tonsil surgery, tonsillotomy probably results in a faster return to normal activity (four days) and in a slight reduction in postoperative complications requiring medical intervention in the first week after surgery. This should be balanced against the clinical effectiveness of one operation over the other. However, this is not possible to determine in this review as data on the long-term effects of the two operations on oSDB symptoms, quality of life, oSDB recurrence and need for reoperation are limited and the evidence is of very low quality leading to a high degree of uncertainty about the results. More robust data from high-quality cohort studies, which may be more appropriate for detecting differences in less common events in the long term, are required to inform guidance on which tonsil surgery technique is best for children with oSDB requiring surgery.

Self-Reported Complications after Tonsillectomy: Comparison of Responders and Nonresponders to a Mailed Questionnaire

Some studies of tonsillectomy outcomes have low response rates to mailed quality control questionnaires. This study evaluated the effect of nonresponders to mailed questionnaires about posttonsillectomy complications by determining whether mail responders and nonresponders differ. Questionnaires were mailed to patients 3-6 weeks after tonsillectomy to assess postoperative complications, defined as contact with a private practitioner and/or hospital readmission related to postsurgical bleeding, pain, or infection. Nonresponders to the mailed questionnaire were interviewed by telephone 7-11 weeks postoperatively, and responses of mail and telephone responders were compared. Of 818 patients undergoing tonsillectomy during the study period, 66.3% responded by mail, and 29.5% were interviewed by telephone, for a total response rate of 95.7%. The mail response rate was significantly higher among parents of pediatric patients than among adult patients (71.4% versus 58.7%, p < 0.001). In the pediatric group, overall complication rates were 65% higher among mail responders than telephone responders (20.9% versus 12.7%, p=0.049), likely due to their higher rates of both visits to private practitioners and infection, as there were no differences in rates of pediatric readmission, bleeding, or pain between the responder groups. Among adult patients, mail and telephone responders did not differ with respect to their overall complication rate (40.9% versus 34.1%, p=0.226) or their rates of readmission or bleeding. However, similar to the pediatric group, visits to a private practitioner were slightly more common among adult mail responders than telephone responders (30.6% versus 21.1%, p=0.065), as were reports of pain (p=0.001) and infection (p=0.006). Studies relying on mailed questionnaires with low response rates likely overestimate the rate of minor complications handled outside the hospital, but rates of major complications involving readmission are unlikely to be seriously biased by low response rates. Supplementing mailed questionnaires with telephone interviews may increase the validity of surgical outcome studies.

Paediatric Posttonsillectomy Haemorrhage Rates in Auckland: A Retrospective Case Series

Background

Tonsillectomy is one of the most commonly performed surgical procedures in children. It is performed for sleep-disordered breathing and infective symptoms. Despite advances in instrumentation and perioperative care, posttonsillectomy haemorrhage (PTH) remains a significant complication, which should be audited regularly.

Methods

A retrospective case series of all tonsillectomies performed in patients <15 years old in the Auckland region during 2017 was performed. Demographic, clinical, and surgical data were extracted and analysed. Univariate analysis was performed to compare patients with and without PTH.

Results

A total of 2177 tonsillectomies were performed during the study period, 64% in a public hospital and 36% in a private hospital. The overall PTH rate was 3.6% (0.23% occurring within the first 24 hours (primary) and 3.4% after 24 hours (secondary)). Mean time to PTH was 6.6 ± 3 days (range: 1-16 days). 90% of PTH occurred within the first 10 days and 99% by 14 days. Return to theatre was required in 28% of these cases, representing 1% of all tonsillectomies. There were no deaths or major complications in this cohort. The only differences observed between patients with PTH and those without were that children with PTH had smaller tonsils (p=0.004) and were less likely to have associated OME (p<0.001).

Conclusion

It is important to report institutional tonsillectomy outcomes and associated complications. These results show that PTH rates in Auckland remain within acceptable limits according to the literature.

Effect of paracetamol/prednisolone versus paracetamol/ibuprofen on post-operative recovery after adult tonsillectomy

OBJECTIVE

To compare the effect of Paracetamol/Prednisolone versus Paracetamol/Ibuprofen on post-operative recovery after adult tonsillectomy.

BACKGROUND

Various analgesic protocols have been proposed for the control of post-tonsillectomy morbidity with need for better control in adult population for having higher severity of post-operative pain and risk of secondary post-tonsillectomy bleeding.

METHODS

This is a prospective cohort study conducted on 248 patients with age of 12 years or older distributed as two equal groups; the first one receiving Paracetamol/Prednisolone and the second one receiving Paracetamol/Ibuprofen. Both groups were compared at 7 days post-operative regarding pain at rest, tiredness of speech, dietary intake, and decrease in sleep duration. Both groups were compared regarding incidence of nausea and vomiting at 2 days post-operative. The incidence and severity of secondary post-tonsillectomy hemorrhage was compared between the two groups.

RESULTS

Pain at rest (no swallowing - no talking) was less in group I but not reaching statistical significance (p = 0.36). In addition, dietary intake was better in group I but not reaching statistical significance (P = 0.17). However, talking ability was better with statistically significant difference (P = 0.03) in group I. Impairment of sleep was less with group II but not reaching statistical significance (p = 0.31). The incidence of vomiting at second post-operative day was less in group I with statistical significance (p = 0.049). The incidence of secondary post-tonsillectomy bleeding was significantly higher in group II with statistical significance (p = 0.046). The severity of bleeding episodes was also significantly higher in group II (p = 0.045).

CONCLUSION

Both ibuprofen and prednisolone were effective as a part of post-operative medication regimen after adult tonsillectomy. However, prednisolone was superior to ibuprofen regarding improvement of pain at rest, dietary intake, tiredness of speech and post-operative nausea and vomiting. However, ibuprofen had a better impact on sleep. The incidence and severity of secondary post-tonsillectomy hemorrhage were significantly higher with ibuprofen favoring the selection of prednisolone to be combined with paracetamol in the post-operative medication protocol following tonsillectomy.

Reducing post-tonsillectomy haemorrhage rates through a quality improvement project using a Swedish National quality register: a case study

Purpose

Tonsillectomy (TE) is one of the most frequently performed ENT surgical procedures. Post-tonsillectomy haemorrhage (PTH) is a potentially life-threatening complication of TE. The National Tonsil Surgery Register in Sweden (NTSRS) has revealed wide variations in PTH rates among Swedish ENT centres. In 2013, the steering committee of the NTSRS, therefore, initiated a quality improvement project (QIP) to decrease the PTH incidence. The aim of the present study was to describe and evaluate the multicentre QIP initiated to decrease PTH rates.

Methods

Six ENT centres, all with PTH rates above the Swedish average, participated in the 7-month quality improvement project. Each centre developed improvement plans describing the intended changes in clinical practice. The project’s primary outcome variable was the PTH rate. Process indicators, such as surgical technique, were also documented. Data from the QIP centres were compared with a control group of 15 surgical centres in Sweden with similarly high PTH rates. Data from both groups for the 12 months prior to the start of the QIP were compared with data for the 12 months after the QIP.

Results

The QIP centres reduced the PTH rate from 12.7 to 7.1% from pre-QIP to follow-up; in the control group, the PTH rate remained unchanged. The QIP centres also exhibited positive changes in related key process indicators, i.e., increasing the use of cold techniques for dissection and haemostasis.

Conclusions

The rates of PTH can be reduced with a QIP. A national quality register can be used not only to identify areas for improvement but also to evaluate the impact of subsequent improvement efforts and thereby guide professional development and enhance patient outcomes.

Tonsil surgery in Sweden 2013-2015. Indications, surgical methods and patient-reported outcomes from the National Tonsil Surgery Register

AIM

To describes how tonsil surgery was performed in Sweden from 2013 to 2015 with data from the National Tonsil Surgery Registry in Sweden (NTSRS).

METHOD

The registry collects data from both professionals and patients through questionnaires. A total of 33,870 tonsil surgeries were analysed, comprising approximately 80% of all tonsil surgeries in Sweden from 2013 to 2015.

RESULTS

The two most common procedures were tonsillectomy (41%) and tonsillotomy with adenoidectomy (38%). Tonsillectomy was most commonly performed to treat frequent tonsillitis, while the main indication for tonsil surgery with combined adenoidectomy and for tonsillotomy alone was upper airway obstruction. The most commonly used techniques were cold steel (70%) for tonsillectomy/adenotonsillectomy and radiofrequency (79%) for tonsillotomy/adenotonsillotomy. Ninety-five percent of patients reported symptom relief after 180 d. Day surgery was utilised in 70% of the surgeries. The rate of readmission due to post-tonsillectomy haemorrhage was 5.1%. Male patients more often underwent tonsil surgery at preschool ages due to upper airway obstruction; in comparison, female patients to a larger extent underwent surgery in their early teens because of previous infections.

CONCLUSIONS

The NTSRS provides an opportunity to survey tonsil surgery in Sweden and to launch and follow up improvement programmes as desired.

Increasing Readmission Rates for Hemorrhage after Tonsil Surgery: A Longitudinal (26 Years) National Study

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.

Gabapentin in the Management of Pain following Tonsillectomy: A Randomized Double-Blind Placebo-Controlled Trial

Objective To determine if a single dose of oral gabapentin given prior to tonsillectomy decreases postoperative morbidity. Study Design Prospective randomized double-blind placebo-controlled trial. Setting Southern District Health Board University Hospitals, New Zealand, over a 10-month period. Subjects and Methods Seventy-three adults undergoing tonsillectomy were randomized to receive either a single preoperative dose of oral gabapentin (600 mg) or placebo. A standard analgesic protocol was prescribed for 14 postoperative days. The primary outcome was a patient-assigned visual analog scale pain score during rest and swallow; secondary outcomes were analgesic consumption, nausea, vomiting, and return to normal diet and activities. Complications and adverse effects were also recorded. Results Thirty-seven participants were allocated to the placebo group and 36 to the gabapentin group. After withdrawals, data were analyzed from 31 in the placebo group and 27 in the gabapentin group. Pain scores between groups were not significantly different within the first 6 hours. The gabapentin group recorded significantly higher pain scores between days 5 and 10 (maximal difference, day 8: 17.6 mm; effect size, -8.87; P = .03; 95% CI, -16.883 to -0.865). There was no significant difference in swallow pain scores or early postoperative fentanyl consumption. Consumption of paracetamol ( P = .01 at day 13 and P = .004 at day 14) and codeine ( P < .05 at days 3-5, 7, 8, 10, 14) was higher in the gabapentin group. No significant difference between groups was found for the other outcomes. Conclusions Preemptive gabapentin (600 mg) was associated with greater postoperative pain scores and analgesic consumption following adult tonsillectomy when compared with placebo.

Effect of Body Mass Index on Posttonsillectomy Hemorrhage

OBJECTIVE

Obesity affects adverse outcomes in patients undergoing various surgeries. Tonsillectomy is one of the most common surgical procedures and posttonsillectomy hemorrhage (PTH) is the major complication in patients with tonsillectomy. However, the effect of body mass index (BMI) on posttonsillectomy bleeding episodes is not well known. This study aimed to assess the clinical association between obesity and PTH.

METHODS

A total of 98 tonsillectomies were retrospectively reviewed. Patient charts were analyzed regarding demographic data and the indication for surgery. Patients with PTH were compared with uneventful cases. Patients were divided into three groups based on BMI: normal weight (BMI < 25 kg/m²), overweight (BMI ≥ 25 and <30 kg/m²), and obese (≥30 kg/m²).

RESULTS

PTH occurred in 13% of patients with normal weight, in 23.5% of patients with overweight, and in 50% patients with obesity. The occurrence of PTH was significantly higher in patients with obesity than in those with normal weight and overweight (p = 0.008). Multivariate analysis showed that obesity was a significant factor affecting the incidence of PTH after adjusting for confounding factors.

CONCLUSIONS

Our findings suggest that the obese condition is independently associated with the incidence of PTH.

Is celecoxib a useful adjunct in the treatment of post-tonsillectomy pain in the adult population? A randomised, double-blind, placebo-controlled study

OBJECTIVE

To evaluate the efficacy and safety of celecoxib for pain management in post-tonsillectomy adult patients.

DESIGN

A randomised, double-blind, placebo-controlled, phase 3 clinical trial was conducted in an adult population (aged 18-55 years), with a parallel group design using an allocation ratio of 1:1.

METHODS

Eighty patients underwent elective tonsillectomy or adenotonsillectomy, operated on by one surgeon. They were discharged home with randomly assigned celecoxib or placebo, together with regular post-tonsillectomy medications (paracetamol and Endone). Pain scores were measured from post-operative days 1 to 10. All patients were assessed on post-operative days 5, 12 and 28.

RESULTS

There were no statistically significant differences in the daily or overall pain scores, the total intake of Endone, or the time taken to achieve freedom from pain after tonsillectomy between the study arms (n = 40 each arm). The celecoxib-treated group experienced significantly more vomiting (celecoxib vs placebo p < 0.001 (Mann-Whitney test), confidence interval = 0.57 to 0.76).

CONCLUSION

Celecoxib usage was associated with significantly more vomiting and did not reduce narcotic analgesia requirement post-tonsillectomy.

Developing a Registry for Complications in Otorhinolaryngologic Surgery: Tonsil Surgery as a Pilot Cohort

OBJECTIVE

To find a suitable method to prospectively register all tonsil surgery-related complications.

STUDY DESIGN

Prospective cohort study.

SETTING

Tertiary care center.

SUBJECTS AND METHODS

From September 2011 to February 2012, patients undergoing tonsillectomy or tonsillotomy were enrolled. A wide range of demographic and clinical data including incidents of postoperative complications was recorded prospectively, and patient records were reviewed 9 months after the end of study period. We evaluated the coverage of prospective data recording, analyzed the complication rates, and assessed the process of registration.

RESULTS

A total of 573 patients were recruited. The study registry including 57 variables required the completion of missing data before analysis. Of all 79 patients with a complication, 69.6% were captured prospectively at the emergency department, and the rest were found when reviewing the patient records. The proportion of prospectively captured complications was highest for the most common complications (eg, 81.1% for secondary hemorrhage). The overall complication rate was 13.8%. Secondary hemorrhage was the most common complication, with the incidence of 9.6%.

CONCLUSION

We have demonstrated the initial feasibility of a prospective complication registry for otorhinolaryngology procedures, and the results can be applied accordingly. We also present 5 practical recommendations when initiating a functional registry. Particular attention should be paid to recognition and registration of both rare and serious events. Regular analysis of the results is required in order to respond to possible changes in the incidence or nature of complications.

Microdebrider-assisted intracapsular tonsillectomy in adults with chronic or recurrent tonsillitis

OBJECTIVES/HYPOTHESIS

We compared the effectiveness and morbidity of microdebrider-assisted total intracapsular tonsillectomy (ICTE) with conventional extracapsular tonsillectomy (ECTE) in adults with chronic or recurrent tonsillitis.

STUDY DESIGN

Prospective randomized surgical trial.

METHODS

Adult patients with recurrent or chronic tonsillitis who underwent tonsillectomy between July 2010 and July 2012 in the Department of Otorhinolaryngology-Head and Neck Surgery, Medical University Innsbruck, Innsbruck, Austria, were consecutively included. Patients were randomized to receive either ICTE or ECTE. Patients and examiners were blinded to the surgical procedure. Effectiveness was assessed with the Tonsil and Adenoid Health Status Instrument (TAHSI). Various parameters of perioperative morbidity and the occurrence of tonsillar remnants were recorded.

RESULTS

In the 104 randomized patients, the average TAHSI score was 34.6 ± 11.7 before and 2.2 ± 5.7 after 6 months following tonsillectomy (P < 0.001). TAHSI scores improved equally in patients receiving conventional ECTE (33.6 points; 95% confidence interval (CI), 29.5 to 37.6) and in patients with ICTE (31.8 points; 95% CI, 27.7 to 35.9; between groups P = 0.6). Posttonsillectomy hemorrhage was more frequent following conventional ECTE (P = 0.03). Following ECTE, patients required more pain medication then following ICTE (P < 0.05). Tonsillar remnants were significantly more frequent after ICTE (P < 0,001). However, presence of tonsillar remnants had no influence on postoperative THASI scores (P > 0.5).

CONCLUSION

Tonsillectomy reduced symptoms of chronic or recurrent tonsillitis in adults with remarkable effectiveness. Microdebrider-assisted ICTE reduced symptoms as effectively as conventional ECTE. ICTE was associated with lower morbidity, but residual tonsils occurred in almost half of patients, costs were higher, and the intracapsular approach was more intricate and time-consuming.

LEVEL OF EVIDENCE

1b.

A population-based study of acute care revisits following tonsillectomy

OBJECTIVES

To describe the clinical spectrum and frequency of acute care revisits after tonsillectomy in a population-based sample from a single state in the US.

STUDY DESIGN

We used California state discharge databases from 2009 to 2011 to retrospectively identify retrospectively routine tonsillectomy discharges in residents <25 years of age and to establish record linkage to revisits within 30 days at ambulatory surgery, inpatient, and emergency department facilities statewide. Percentages and descriptive statistics were sample-weighted, and revisit rates were adjusted for demographic factors, expected payer, chronic conditions, surgical indication, facility type, and clustering.

RESULTS

Records were available for 35 085 index tonsillectomies, most of which were performed at hospital-owned ambulatory and inpatient facilities. There were 4944 associated revisits: 3761 (75.9%) treat-and-release emergency room visits, 816 (17.1%) inpatient admissions, and 367 (7.0%) ambulatory surgery visits. Most revisits (3225 [67.7%]) were unrelated to bleeding; these typically occurred early (mode, day 2) and were commonly associated with diagnosis codes indicating pain, nausea/vomiting, or dehydration. Crude all-cause revisit and readmission rates were 10.5% and 2.1%, respectively. Adjusted all-cause revisit rates (range, 8.6%-24.5%) were lowest in young children, increased in adolescents, and peaked in young adults. Adjusted bleeding-related revisit rates increased abruptly in adolescents and reached 13.9% in males (6.8% in females, P < .001) ages 20-24 years.

CONCLUSIONS

Acute care revisits after tonsillectomy performed at predominantly hospital-owned facilities in California are common and strongly age-related. Most revisits are early treat-and-release outpatient encounters, and these are usually associated with potentially preventable problems such as pain, nausea and vomiting, and dehydration.

Tonsillitis and sore throat in children

Surgery of the tonsils is still one of the most frequent procedures during childhood. Due to a series of fatal outcomes after hemorrhage in children in Austria in 2006, the standards and indications for tonsillectomy have slowly changed in Germany. However, no national guidelines exist and the frequency of tonsil surgery varies across the country. In some districts eight times more children were tonsillectomized than in others. A tonsillectomy in children under six years should only be done if the child suffers from recurrent acute bacterially tonsillitis. In all other cases (i.e. hyperplasia of the tonsils) the low risk partial tonsillectomy should be the first line therapy. Postoperative pain and the risk of hemorrhage are much lower in partial tonsillectomy (=tonsillotomy). No matter whether the tonsillotomy is done by laser, radiofrequency, shaver, coblation, bipolar scissor or Colorado needle, as long as the crypts are kept open and some tonsil tissue is left behind. Total extracapsular tonsillectomy is still indicated in severely affected children with recurrent infections of the tonsils, allergy to antibiotics, PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis) and peritonsillar abscess. With regard to the frequency and seriousness of the recurrent tonsillitis the indication for tonsillectomy in children is justified if 7 or more well-documented, clinically important, adequately treated episodes of throat infection occur in the preceding year, or 5 or more of such episodes occur in each of the 2 preceding years (according to the paradise criteria). Diagnosis of acute tonsillitis is clinical, but sometimes it is hard to distinguish viral from bacterial infections. Rapid antigen testing has a very low sensitivity in the diagnosis of bacterial tonsillitis and swabs are highly sensitive but take a long time. In all microbiological tests the treating physician has to keep in mind, that most of the bacterials, viruses and fungi belong to the healthy flora and do no harm. Ten percent of healthy children even bear strepptococcus pyogenes all the time in the tonsils with no clinical signs. In these children decolonization is not necessary. Therefore, microbiological screening tests in children without symptoms are senseless and do not justify an antibiotic treatment (which is sometimes postulated by the kindergartens). The acute tonsillitis should be treated with steroids (e.g. dexamethasone), NSAIDs (e.g. ibuprofene) and betalactam antibiotics (e.g. penicillin or cefuroxime). With respect to the symptom reduction and primary healing the short-term late-generation antibiotic therapy (azithromycin, clarithromycin or cephalosporine for three to five days) is comparable to the long-term penicilline therapy. There is no difference in the course of healing, recurrence or microbiological resistance between the short-term penicilline therapy and the standard ten days therapy. On the other hand, only the ten days antibiotic therapy has proven to be effective in the prevention of rheumatic fever and glomerulonephritic diseases. The incidence of rheumatic heart disease is currently 0.5 per 100,000 children of school age. The main morbidity after tonsillectomy is pain and the late haemorrhage. Posttonsillectomy bleeding can occur till the whole wound is completely healed, which is normally after three weeks. Life-threatening haemorrhages occur often after smaller bleedings, which can spontaneously cease. That is why every haemorrhage, even the smallest, has to be treated properly and in ward. Patients and parents have to be informed about the correct behaviour in case of haemorrhage with a written consent before the surgery. The handout should contain important addresses, phone numbers and contact persons. Almost all cases of fatal outcome after tonsillectomy were due to false management of haemorrhage. Haemorrhage in small children can be especially life-threatening because of the lower blood volume and the danger of aspiration with asphyxia. A massive haemorrhage is an extreme challenge for every paramedic or emergency doctor because of the difficult airway management. Intubation is only possible with appropriate inflexible suction tubes. All different surgical techniques have the risk of haemorrhage and even the best surgeon will experience a postoperative haemorrhage. The lowest risk of haemorrhage is after cold dissection with ligature or suturing. All "hot" techniques with laser, radiofrequency, coblation, mono- or bipolar forceps have a higher risk of late haemorrhage. Children with a hereditary coagulopathy have a higher risk of haemorrhage. It is possible, that these children were not identified before surgery. Therefore it is recommended by the Society of paediatrics, anaesthesia and ENT, that a standardised questionnaire should be answered by the parents before tonsillectomy and adenoidectomy. This 17-point-checklist questionnaire is more sensitive and easier to perform than a screening with blood tests (e.g. INR and PTT). Unfortunately, a lot of surgeons still screen the children preoperatively by coagulative blood tests, although these tests are inappropriate and incapable of detecting the von Willebrand disease, which is the most frequent coagulopathy in Europe. The preoperative information about the surgery should be done with the child and the parents in a calm and objective atmosphere with a written consent. A copy of the consent with the signature of the surgeon and both custodial parents has to be handed out to the parents.

No association between obesity and post-tonsillectomy haemorrhage

Background:

The prevalence of overweight and obesity is increasing worldwide. The impact of overweight on post-tonsillectomy haemorrhage rates in children and adults is unclear.

Methods:

Body mass index and post-tonsillectomy haemorrhage were evaluated in all patients treated with tonsillectomy within one year in a tertiary referral centre. Bleeding episodes were categorised according to the Austrian Tonsil Study.

Results:

Between June 2011 and June 2012, 300 adults and children underwent tonsillectomy. Post-tonsillectomy haemorrhage occurred in 55 patients. Of those, 29 were type A (history of blood in saliva only, no active bleeding), 15 were type B (active bleeding, treatment under local anaesthesia) and 11 were type C (active bleeding, treatment under general anaesthesia). The return to operating theatre rate was 3.7 per cent. Post-tonsillectomy haemorrhage was more frequent in adolescents and adults than in children. Overweight or obesity was positively correlated with age. Post-tonsillectomy bleeding was recorded in 11.1 per cent of underweight patients, 18.9 per cent of normal weight patients and 18.7 per cent of overweight patients (p = 0.7). Data stratification (according to age and weight) did not alter the post-tonsillectomy bleeding risk (p = 0.8).

Conclusion:

Overweight or obesity did not increase the risk of post-tonsillectomy haemorrhage in either children or adults.

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.