Post-tonsillectomy hemorrhage in children: a single surgeon’s experience with coblation compared to diathermy

Postoperative Morbidity of Different Tonsillectomy Techniques: A Systematic Review and Network Meta-Analysis

OBJECTIVE

To compare different tonsillectomy techniques in terms of postoperative bleeding incidence and postoperative pain.

METHODS

An arm-based network analysis was conducted using a Bayesian hierarchical model. The primary and secondary outcomes were postoperative bleeding incidence and mean postoperative pain score.

RESULTS

A total of 6464 patients were included for five different interventions (cold dissection tonsillectomy; extracapsular coblation tonsillectomy; intracapsular coblation tonsillectomy [ICT]; bipolar diathermy tonsillectomy [BDT]; monopolar diathermy tonsillectomy). ICT showed the lowest absolute risk (4.44%) of postoperative bleeding incidence (73.31% chance of ranking first) and the lowest mean postoperative pain score (1.74 ± 0.68) with a 94.0% chance of ranking first, whereas BDT showed both the highest absolute risk of bleeding incidence (10.75%) and the highest mean postoperative pain score (5.67 ± 1.43).

CONCLUSIONS

ICT seems to offer better postoperative outcomes, in terms of reduced risk of bleeding and reduced pain. Further prospective studies are advised to confirm these findings.

LEVEL OF EVIDENCE

NA Laryngoscope, 134:1696-1704, 2024.

The Impact of Surgical Indication on Posttonsillectomy Hemorrhage: A Systematic Review and Meta-Analysis

OBJECTIVE

To investigate the impact of the surgical indication on posttonsillectomy bleed rates.

DATA SOURCES

PubMed, Scopus, CINAHL.

REVIEW METHODS

A systematic review was performed searching for articles published from the date of inception to July 6, 2022. English language articles describing posttonsillectomy hemorrhage rates in pediatric patients (age ≤ 18) stratified by indication were selected for inclusion. A meta-analysis of proportions with comparison (Δ) of weighted proportions was conducted. All studies were assessed for risk of bias.

RESULTS

A total of 72 articles with 173,970 patients were selected for inclusion. The most common indications were chronic/recurrent tonsillitis (CT/RT), obstructive sleep apnea/sleep-disordered breathing (OSA/SDB), and adenotonsillar hypertrophy (ATH). Posttonsillectomy hemorrhage rates for CT/RT, OSA/SDB, and ATH were 3.57%, 3.69%, and 2.72%, respectively. Patients operated on for a combination of CT/RT and OSA/SDB had a bleed rate of 5.99% which was significantly higher than those operated on for CT/RT alone (Δ2.42%, p = .0006), OSA/SDB alone (Δ2.30%, p = .0016), and ATH alone (Δ3.27%, p < .0001). Additionally, those operated on for a combination of ATH and CT/RT had a hemorrhage rate of 6.93%, significantly higher than those operated on for CT/RT alone (Δ3.36%, p = .0003), OSA/SDB alone (Δ3.01%, p = .0014), and ATH alone (Δ3.98%, p < .0001).

CONCLUSION

Patients operated on for multiple indications had significantly higher rates of posttonsillectomy hemorrhage than those operated on for a single surgical indication. Better documentation of patients with multiple indications would help further characterize the magnitude of the compounding effect described here.

A comparison of coblation and modified monopolar tonsillectomy in adults

OBJECTIVE

To compare the intraoperative records and postoperative clinical outcomes of adults who underwent coblation and modified monopolar tonsillectomy tonsillectomies.

MATERIALS AND METHODS

Adult patients with tonsillectomy were randomly divided into the coblation and modified monopolar tonsillectomy groups. The estimated blood loss, postoperative pain score, operation time, post-tonsillectomy hemorrhage (PTH), and cost of disposable equipment were compared.

RESULTS

Pain intensity in the coblation and monopolar groups was similar on postoperative days 3 and 7. However, the mean maximum pain score in the monopolar group was significantly higher compared to the coblation group on postoperative days 1 (P < 0.01) and 2 (P < 0.05).Secondary PTH occurred in 7.1% (23/326) of patients in the coblation group and 2.8% (9/327) of patients in the monopolar group (P < 0.05).

CONCLUSION

Although pain was significantly increased on postoperative days 1 and 2 in the modified monopolar tonsillectomy group, the operation time, secondary PTH, and medical costs were significantly decreased compared to the coblation technique group.

Preoperative thromboelastography in the prediction of post-tonsillectomy hemorrhage by coblation tonsillectomy: a post-hoc analysis

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.

A prospective, randomized, single-blind study comparing coblation and monopolar extracapsular tonsillectomy

Objective

The aim of this study was to compare intraoperative blood loss, postoperative pain, post-tonsillectomy hemorrhage (PTH), and medical costs associated with extracapsular tonsillectomy between coblation and monopolar electrocautery in children.

Materials and methods

This study included 293 patients aged 6-15 years planned to undergo extracapsular tonsillectomy. Data on estimated blood loss, postoperative pain score, operation time, PTH, and the cost of disposable equipment were collected.

Results

Coblation extracapsular tonsillectomy was associated with significantly lower mean pain scores than monopolar technique on postoperative days 1 (p <.001) and 2 (p = 0.02). However, the pain score was similar between the groups at all other time points. The monopolar group had a significantly shorter operation time compared to the coblation group (11.09 ± 7.53 vs. 17.12 ± 4.29 min, p <.001). Intraoperative estimated blood loss was not significantly different between the groups (p = .43).The cost of extracapsular tonsillectomy was significantly lower in the monopolar compared to the coblation group (US$ 28.18 vs. US$ 430.48, p <.001). PTH occurred in 17 patients (5.80%) and required a second surgery. Secondary PTH occurred in 6.16% (9/146) and 0.68% (1/147) of patients in the coblation and monopolar groups, respectively (p <.001). The PTH was significantly higher in the tonsillitis compared to in the tonsillar hypertrophy (12.37% vs. 2.55%, p = .002), However, the difference of PTH was not significant among mean pain scores subgroups. Of the 17 patients with PTH, the lower pole, middle portion, and upper pole were involved in 15 (88.24%), 2 (11.76%), and 0 cases, respectively.

Conclusions

Coblation and novel monopolar electrocautery extracapsular tonsillectomy are associated with similar postoperative pain scores except on postoperative days 1 and 2. However, monopolar technique offers significant advantages over coblation method with less operative time, decreased secondary PTH, and cost.Level of Evidence: NA.

Postoperative hemorrhage following coblation tonsillectomy with and without suture: A randomized study in Chinese adults

PURPOSE

Coblation tonsillectomy (TE) increases gradually in China. Hemorrhage is the main complication after tonsillectomy. The conclusions of the studies about suture after tonsillectomy are conflicting. To compare the post-tonsillectomy hemorrhage (PTH) rates in patients who underwent coblation with vs. without suture.

MATERIALS AND METHODS

This was a randomized controlled study of adult patients who underwent coblation TE at our hospital between 01/2017 and 08/2019. The patients were randomized to TE with or without suture. The primary endpoint was the secondary PTH. The secondary endpoints included the primary PTH, grade of PTH, and incidence of PTH within 4 weeks post-TE.

RESULTS

There were no differences between the two groups regarding sex, age, disease course, and BMI (all P > 0.05). The occurrence of secondary PTH was lower in the suture group compared with the non-suture group (2.8% vs. 7.7%, P = 0.016). Compared with non-suture group, the incidence of PTH within 4 weeks (2.8% vs. 10.6%, P = 0.009) and the PTH degree (P = 0.02) were all significantly lower in the suture group.

CONCLUSION

Intraoperative suture reduces the secondary PTH in adult patients who underwent coblation tonsillectomy. The incidence of PTH within 4 weeks, PTH degree and pain might all improved for intraoperative suture.

Paediatric patient bleeding and pain outcomes following subtotal (tonsillotomy) and total tonsillectomy: a 10-year consecutive, single surgeon series

BACKGROUND

Subtotal tonsil surgery (tonsillotomy) remains a controversial procedure. We aimed to document bleeding rates and return to normal activity for total versus subtotal tonsil surgery in the paediatric population.

METHODS

A 10-year cohort of 608 children from a single-surgeon series was analysed. Bleeding events were classified using the Flinders modification of the Stammberger criteria. Return to normal activity was defined as normal diet and return to childcare/school.

RESULTS

A total of 8.3% of tonsil procedures and a subtotal of 1.8% of procedures had some kind of bleeding episode (P < 0.01; odds ratio 3.2; 95% confidence interval (CI) 1.3-7.6). When blood-stained sputum (type A bleed) was excluded, this dropped to 2.5% versus 0.3%, respectively (P < 0.05; odds ratio 8.5; 95% CI 1.2-96.0). Return to normal activities occurred at a mean of 11.1 (95% CI 9.7-12.5) versus 4.6 (95% CI 4.0-5.3) days, respectively (P < 0.0001).

CONCLUSION

In this 10-year single surgeon series, subtotal tonsillectomy or 'tonsillotomy' was associated with a significant reduction in both prevalence and severity of bleeding, in addition to a more rapid return to normal activities when compared to total tonsillectomy.

Coblation tonsillectomy versus coblation tonsillectomy with ties in adults

Objective

This study was performed to compare the intraoperative and postoperative courses of coblation tonsillectomy and coblation tonsillectomy with ties in adults.

Methods

All patients who underwent tonsillectomy from July 2012 to September 2016 were retrospectively reviewed. Intraoperative and postoperative bleeding, pain, and return to normal food intake were compared between patients who underwent coblation tonsillectomy and those who underwent coblation tonsillectomy with ties.

Results

Of 515 patients, 300 (58.3%) underwent coblation tonsillectomy and 215 (41.7%) underwent coblation tonsillectomy with ties. Twenty-five (4.9%) patients developed postoperative hemorrhage, 22 (88.0%) of whom had undergone coblation tonsillectomy and 3 (12.0%) of whom had undergone coblation tonsillectomy with ties. Patients who underwent coblation tonsillectomy reported less pain than those who underwent coblation tonsillectomy with ties. Patients who underwent coblation tonsillectomy with ties resumed a normal diet significantly later than those who underwent coblation tonsillectomy (10.0 ± 3.2 vs. 8.2 ± 1.9 days, respectively).

Conclusion

Coblation tonsillectomy is associated with less intraoperative bleeding, a shorter surgery time, less postoperative pain, and fewer days to recovery of a normal diet than is coblation tonsillectomy with ties. However, coblation tonsillectomy with ties is associated with remarkably reduced postoperative hemorrhage.

Post-tonsillectomy hemorrhage rates in children compared by surgical technique

Despite the sheer number of pediatric tonsillectomies performed in the United States annually, there is no clear consensus as to which surgical technique is superior. One way to compare surgical techniques is to study the morbidity associated with each. We report postoperative hemorrhage rates, one of the frequently encountered major adverse events, as part of a retrospective chart review across four different surgical techniques. These surgeries involved either (1) Coblation, (2) Co-blation with partial suture closure of the tonsillar fossa, (3) diathermy, or (4) partial intracapsular tonsillectomy (PIT). Of the 7,024 children we evaluated, 99 (1.4%) experienced a postoperative hemorrhage that required a second surgery; hemorrhage occurred after 33 of the 3,177 Coblation-alone procedures (1.04%), 28 of the 1,633 Coblation with partial suture closure procedures (1.71%), 29 of the 1,850 diathermies (1.57%), and 9 of the 364 PIT procedures (2.47%). Statistical analysis of hemorrhage rates with each surgical technique yielded p values >0.05 in each case (Coblation alone and Coblation with partial suture closure: p = 0.29; diathermy: p = 0.47; PIT, p = 0.20). Based on these data, we conclude that none of these techniques is significantly superior in terms of decreasing the risk of post-tonsillectomy hemorrhage in children. Therefore, surgeons should continue to use the surgical procedure they are most familiar with to optimize recovery in the postoperative period.

Time between First and Second Posttonsillectomy Bleeds

Objective

To determine the time between first and recurrent posttonsillectomy hemorrhages (PTHs) and find factors related to multiple PTHs.

Methods

Retrospective chart review.

Results

Of 112 patients, 91 had one PTH, while 21 had recurrent PTHs. Patients with recurrent bleeds had significant differences (P < 0.05) in indication for tonsillectomy (47.6% had recurrent tonsillitis), prior cardiac conditions (28.6%), transfusions (9.5%), and hematology consults during the initial PTH visit (19%). Bleeding occurred at a mean of 6.1 (range 1–13) days for the first episode and 10 (range 9–18) days for the second episode as compared to 6.65 (range 1–18) days for those who bled once. Recurrent PTH patients were less likely to have had surgical control of the initial bleed (P < 0.05). Patients who bled at 7 days or later were more likely to bleed again within one day (OR 23.0, RR 12). Regression analysis showed that age, failure to have operative control of PTH, and surgical indication were most important in predicting recurrent PTH.

Conclusions

Operative control of PTH is associated with a better outcome than monitoring alone. Patients with PTH within 7 days of tonsillectomy are likely safe to discharge soon after treatment; those who bleed after 7 days should be monitored longer.

Coblation tonsillectomy under surgical microscopy: A retrospective study

Objective

A retrospective study to compare surgical parameters and postoperative pain in patients undergoing coblation tonsillectomy with or without microscopic guidance.

Methods

Data regarding duration of surgery and hospital stay, intraoperative blood loss, incidence of haemorrhage and postoperative pain scores were retrieved from the medical records of adult patients undergoing coblation tonsillectomy under direct vision or with microscopic guidance.

Results

The incidence of secondary haemorrhage (>24 h postoperatively) was significantly lower and the duration of hospital stay was significantly shorter in the microscope group (n = 92) than the direct vision group (n = 76). Pain scores both at rest and while swallowing reached ≤3 (no significant impact on quality-of-life) significantly faster in the microscope group than the direct vision group.

Conclusions

Microscope-assisted coblation tonsillectomy decreases the duration of hospital stay and the incidence of postoperative secondary haemorrhage, and results in an early improvement in postoperative pain scores.

Routine tonsillar bed oversew after diathermy tonsillectomy: does it reduce secondary tonsillar haemorrhage?

Tonsillectomy is a common otolaryngological procedure and is associated with a small risk of postoperative pharyngeal haemorrhage. This study compares secondary post tonsillectomy haemorrhage rates between two operative techniques: diathermy tonsillectomy and diathermy tonsillectomy with tonsillar bed oversew. A total of 424 patients underwent tonsillectomies with or without other procedures such as adenoidectomy and grommet insertion by two ears, nose and throat surgeons at three hospitals from May 2012 to July 2013. A diathermy tonsillectomy was performed in 266 patients, while a diathermy tonsillectomy with tonsillar bed oversew was performed in 158 patients. All patients were followed up within 2-4 weeks of surgery. Primary haemorrhage did not occur in either surgical technique groups. Secondary haemorrhage occurred in 20 patients (7.52 %) in the diathermy tonsillectomy group and in 9 patients (5.70 %) in the diathermy with tonsillar bed oversew group. This result was not significantly different (OR = 0.74, 95 % CI 0.33-1.67, p = 0.47). Sex, age, indication for surgery and whether or not a tonsillectomy was performed alone or with other procedures were not significant factors for secondary haemorrhage. In summary, routine tonsillar bed oversew after diathermy tonsillectomy does not reduce the risk of secondary tonsillar haemorrhage.