Gender-specific risk factors in post-tonsillectomy hemorrhage

Associations Between Social Vulnerability Indicators and Pediatric Tonsillectomy Outcomes

OBJECTIVE

To investigate the impact of neighborhood-level social vulnerability on pediatric tonsillectomy outcomes.

METHODS

This single-center retrospective cohort study included tonsillectomies performed on children aged 1 to 18 between August 2019 and August 2020. Geographic information systems were used to geocode addresses, and spatial overlays were used to assign census-tract level social vulnerability index (SVI) scores to each patient. For categorical variables, two-sided Pearson chi-square tests were used, whereas for continuous variables, paired t-tests, means, and standard deviations were calculated. SVI and its four subthemes were investigated using binomial logistic regressions to determine their impact on post-T&A complications and readmissions.

RESULTS

The study included 397 patients, with 52 having complications (13.1%) and 33 (8.3%) requiring readmissions due to their complications. Controlling for age, gender, race, insurance status, surgical indication, comorbidities, obesity, and obstructive sleep apnea, postoperative complications were associated with high overall SVI (odds ratio [OR] 5.086, 95% confidence interval [CI] 1.128-22.938), high socioeconomic vulnerability (SVI theme 1, OR 6.003, 95% CI 1.270-28.385), and high house composition vulnerability (SVI theme 2, OR 6.340, 95% CI 1.275-31.525). Readmissions were also associated with high overall SVI (10.149, 95% CI 1.293-79.647) and high housing/transportation vulnerability (SVI theme 4, OR 5.657, 95% CI 1.089-29.396).

CONCLUSION

Social vulnerability at the neighborhood level is linked to poorer surgical outcomes in otherwise healthy children, suggesting a target for community-based interventions. Because of the increased risk, it may have implications for preoperative decision-making, treatment plans, and clinic follow-ups.

LEVEL OF EVIDENCE: 3

Laryngoscope, 134:954-962, 2024.

Adult tonsillectomy-increased pain scores are correlated with risk of bleeding: a retrospective cohort study

PURPOSE

Tonsillectomy is among the most common surgical procedures performed worldwide, and post-tonsillectomy bleeding is a serious complication. This study aims to investigate the role of post-operative pain as a risk factor for bleeding in adults.

METHODS

A retrospective cohort study of adults who underwent tonsillectomy in a tertiary referral center between 2015-2021. Medical records were reviewed for demographics, diagnoses, surgical technique, treatments, pain scores (measured by visual analogue scale 0-10), readmissions, and bleeding events. The primary outcome was return to the operating room for hemostasis, and secondary outcomes were bleeding events and consumption of additional analgesic doses.

RESULTS

Of the 274 patients, 137 (50%) were males, the mean age was 30.3 ± 12 years (range 18-82), and 33 (12%) were smokers. Indications for tonsillectomy were recurrent throat infections in 213 (77.7%) patients and obstructive sleep apnea in 61 (22.3%). Surgical technique was cold dissection in 238 (86.9%) patients and electrocautery in 36 (13.1%). Primary post-tonsillectomy bleeding (< 24 h of surgery) occurred in 6 (2%) patients, and secondary bleeding (later than 24 h from tonsillectomy) in 43 (15.7%). A total of 19 (7%) patients necessitated surgical hemostasis. After controlling for technique and other confounders, high pain scores (VAS ≥ 5) on post-operative days 1 and 2 were associated with increased risk of bleeding that necessitated surgical hemostasis (adjusted odds ratio 6.9, 95% confidence interval 1.7-44.5). Other independent risk factors were male sex, age < 30 years, smoking, and recurrent throat infections.

CONCLUSIONS

Higher pain scores following tonsillectomy are correlated with bleeding episodes requiring surgical intervention in adults. Further studies may explore the role of different intensive pain regimens in minimizing the risk of bleeding.

Reducing post-tonsillectomy haemorrhage: a multicentre quality improvement programme incorporating video-based cold technique instruction

OBJECTIVE

Data from the Norwegian Tonsil Surgery Register (NTSR) showed large differences between the hospitals in Norway in the readmission rate due to post-tonsillectomy haemorrhage (rrPTH; range, 0%-25%; national average, 8%). Because of these large variations in the rrPTH, we conducted a quality improvement project involving hospitals with good and bad readmission rates.

METHODS

Seven hospitals with readmission rates greater than 10% and four with rates lower than 5% participated in this project. We recorded videos of ear, nose and throat surgeons from the hospitals with low readmission rates when they performed extracapsular tonsillectomy, and these videos of cold dissection tonsillectomy were used as teaching material for examples of good surgical skills for the other hospitals. After a 2-day workshop, all participants from the hospitals went back to their institutions and prepared local plans to improve their results. We used the Plan-Do-Study-Act model. The primary outcome variable was the patient-reported rrPTH in the NTSR. As secondary goal, we aimed to identify aspects of the tonsillectomy procedure that could help achieve a lower rrPTH.

RESULTS

The participating hospitals reduced their rrPTH from 18% at baseline (2017/2018) to 7% in 2020. Six of seven hospitals changed their dissection technique significantly to more use of cold dissection.

CONCLUSION

By learning cold dissection tonsillectomy from surgeons with low rrPTH, it seems possible to decrease the rates of bleeding complications after tonsillectomy. A combination of videos as a teaching tool, new treatment plans, and focus on quality and improvement may effectively improve surgical results. The videos can show details that are difficult to convey in the literature. Quality registers can be used to identify areas requiring improvement and evaluate the effects of changes in practice.

Reference rate for post-tonsillectomy haemorrhage in Australia—A 2000–2020 national hospital morbidity database analysis

This study aims to provide a national benchmark rate of post-tonsillectomy haemorrhage (PTH) in Australia. Using data from Australia’s National Hospital Morbidity Database (NHMD) from 1 July 2000 to 30 June 2020, we have conducted a nation-wide population-based study to estimate a reference rate of PTH. Outcomes of interest included the overall rate and time-trend of PTH, the relationship between PTH rates with age and gender as well as the epidemiology of tonsillectomy procedures. A total of 941,557 tonsillectomy procedures and 15,391 PTH episodes were recorded for the study period. Whilst the incidence of tonsillectomy procedures and the number of day-stay tonsillectomy procedures have increased substantially over time, the overall rate of PTH for all ages has remained relatively constant (1.6% [95% CI: 1.61 to 1.66]) with no significant association observed between the annual rates of PTH and time (year) (Spearman correlation coefficient, R_s = 0.24 (95% CI: -0.22 to 0.61), P = 0.3). However, the rate of PTH in adults (aged 15 years and over) experienced a statistically significant mild to moderate upward association with time (year) R_s = 0.64 (95% CI: 0.28 to 0.84), P = 0.003. Analysis of the odds of PTH using the risk factors of increasing age and male gender showed a unique age and gender risk pattern for PTH where males aged 20 to 24 years had the highest risk of PTH odds ratio 7.3 (95% CI: 6.7 to 7.8) compared to patients aged 1 to 4 years. Clinicians should be mindful of the greater risk of PTH in male adolescents and young adults. The NHMD datasets can be continually used to evaluate the benchmark PTH rate in Australia and to facilitate tonsillectomy surgical audit activities and quality improvement programs on a national basis.

Adult tonsillectomy: An evaluation of indications and complications

OBJECTIVE

This study aimed to evaluate current adult tonsillectomy indications along with risk factors associated with postoperative complications.

METHODS

In this retrospective chart review, demographic, clinical, and surgical data were collected from 2004 to 2020 of adult patients who underwent tonsillectomy. Indications for surgery were categorized as infectious etiology, biopsy, obstructive sleep apnea (OSA), and tonsillar stones. Data regarding postoperative hemorrhage, emergency department (ED) visits, and readmissions were collected. Multivariable logistic regression models were used to evaluate factors associated with postoperative complications.

RESULTS

574 adults (mean age 32 years, 69.9% F vs. 30.1% M) were included. The most common indication was infections (62.2%), followed by biopsy (26.5%), tonsillar stones (6.8%), and OSA (4.5%). The highest frequency of postoperative bleeds (17.9%) occurred in the tonsillar stones cohort; however, the indication for surgery was not a significant predictor on multivariate analysis. Male sex and younger age were independent predictors of postoperative bleeding, while younger age was a significant predictor of postoperative ED visits. There was a significant linear trend of an increasing proportion of tonsillectomies performed for tonsillar stones compared to other indications for 2011-2019.

CONCLUSION

Infectious etiology was the most common indication for tonsillectomy. Indication for surgery was not a significant predictor of postoperative bleeding; however, male sex and younger age had higher odds of postoperative bleeding. The proportion of tonsillectomies performed for tonsillar stones was steadily increasing.

Study of Patients’ Return to Surgery Post-Tonsillectomy and/or Adenoidectomy: A Relation Between Patient Age and Timing of Uncontrolled Bleeding

Background: Tonsillectomy and/or adenoidectomy (T/A) are common surgical procedures. Postoperative uncontrolled bleeding is a well-established complication; however, the relation between certain variables and uncontrolled bleeding are unclear. Methods: We explored the Pennsylvania Patient Safety Reporting System database for event reports that described a patient who had a T/A procedure and later returned to surgery to control bleeding. We analyzed the post-T/A bleeding events according to numerous variables, such as patient sex and age, timing of the bleed, procedure performed (i.e., tonsillectomy and/or adenoidectomy), and bleeding site. Results: We identified 219 event reports from 56 healthcare facilities over a four-year period. The study revealed that 78% of the patients were discharged and then returned to surgery to control bleeding. Patients ranged in age from 1–45 years and 53% were female. Among the 219 events, 41% were a primary bleed (0–1 postoperative days) and 59% were a secondary bleed (2–30 postoperative day). Additionally, 0–1 days and 6–7 days after operation were the periods when patients most frequently returned to surgery (range of 0–30 days). We expanded upon much of the previous research by exploring the relation between patient age and days postoperative return to surgery. We found that a majority of patients in age categories 1–10, 11–20, and 21–30 years had a secondary bleed; in contrast, a majority of patients age 31–45 had a primary bleed. Conclusion: Our findings indicate that the post-T/A timing of uncontrolled bleeding may vary systematically as a function of patient age; however, future research is needed to better understand this topic. We encourage readers to use our findings, along with findings from previous research, to inform their practice and strategies to mitigate risk of patient harm.

Post-Tonsillectomy Bleeding: A National Perspective

OBJECTIVES

Tonsillectomy is one of the most common otolaryngologic procedures. Hemorrhage after tonsillectomy is one of the most feared complications by surgeons and patients alike. The objective of this study was to analyze the risk factors associated with an increase in post-tonsillectomy hemorrhage in the pediatric population using a large national database.

METHODS

The Kids' Inpatient Database (KID) from 2000 to 2012 was queried for patients between the ages of 1 to 17 years with post-tonsillectomy hemorrhage. Univariate and multivariate analyses were performed to obtain trends in patient demographics, comorbidities, and hospital information.

RESULTS

Overall 45 940 pediatric cases of tonsillectomy were identified of which 5470 (11.9%) resulted in postoperative hemorrhage. Patients with postoperative hemorrhage were significantly older with mean age of 8.62 (±4.75) compared to all patients. Females were found to have higher rates of hemorrhage when compared to males 14.6% versus 11.5% (P < .001). The rate of white patients who had hemorrhage was 16.3% (P < .001). The most common comorbidities significantly associated with hemorrhage were fluid and electrolyte disorders (6.6% P < .001), deficiency anemia (3.8%; P < .001), and coagulopathy (2.7%; P < .001). Urban nonteaching hospitals had higher rates of hemorrhage (19.6%; P < .001) and the Northeast was the most common region (15.2%; P < .001). On multivariate analysis, older patients and white ethnicity showed a significantly increased risk of hemorrhage. Patients with pre-existing comorbidities such as coagulopathy, deficiency anemia, and fluid and electrolyte disorders circulation were also found to have higher odds ratios of bleeding.

CONCLUSION

Postoperative hemorrhage is a common complication following tonsillectomy with a rate of 11.9% in this study. A higher rate of hemorrhage was seen with increasing age, white race, and males overall, as well as patients with fluid and electrolyte disorders. Urban non-teaching hospitals and the Northeast region also saw increased rates of hemorrhage.

Risk factors of post-tonsillectomy hemorrhage in adults

OBJECTIVE

Tonsillectomy is an essential surgery and is conducted on both children and adults. However, the risk factors of post-tonsillectomy hemorrhage for adult patients remain unclear. In this study, we analyzed post-tonsillectomy hemorrhage in adult patients.

METHODS

We retrospectively analyzed 325 adult patients who underwent a tonsillectomy between 2014 and 2018 in our facilities.

RESULTS

The average age of this study's population was 31.7 ± 10.5 years (range: 19-70 years), and 250 (76.9%) patients were male. Overall, post-tonsillectomy hemorrhage occurred in 71 (21.8%) patients and 5 (1.5%) patients required a second surgery for hemostasis. Post-tonsillectomy hemorrhage often occurred on postoperative day zero or six. Using multiple logistic regression analysis, current smoking status (odds ratio 3.491; 95% confidence interval 1.813-6.723), male sex (odds ratio 3.924; 95% confidence interval 1.548-9.944), and perioperative non-steroidal anti-inflammatory drug administration (odds ratio 7.930; 95% confidence interval 1.004-62.64) were revealed as overall post-tonsillectomy hemorrhage risk factors. To analyze the hemorrhage period after tonsillectomy, we categorized the post-tonsillectomy hemorrhage patients into the primary (bleeding within postoperative day one) and secondary hemorrhage (bleeding on or after postoperative day two) groups. The current smoking status and older age were risk factors for primary hemorrhage and the current smoking status and sex (male) were risk factors for secondary hemorrhage.

CONCLUSIONS

In this study, smoking status, sex, and perioperative non-steroidal anti-inflammatory drug administration were the clinical risk factors for adult post-tonsillectomy hemorrhage. Thus, smoking cessation is, at least, mandatory for patients who receive tonsillectomy to avoid post-tonsillectomy hemorrhage.

LEVEL OF EVIDENCE

4.

Tonsillectomy plus steroid pulse therapy is the most effective treatment in adult patients with C-Grade I IgA nephropathy, and the weight of the extracted palatine tonsils and Yamamoto scale have no significant correlation with the effects of this treatment

OBJECTIVE

We studied patients who underwent tonsillectomy plus steroid pulse therapy (TSP) for immunoglobulin A nephropathy (IgAN), in order to investigate the clinical factors associated with a positive response to this treatment.

METHODS

We analyzed 118 IgAN patients who underwent TSP. We collected patients' data retrospectively, including age, sex, blood pressure, onset of IgAN, pathological findings of a renal biopsy, serum concentration of creatinine, estimated glomerular filtration rate, serum concentration of protein, urinary protein, hematuria, past history of tonsillitis, the Yamamoto scale, the weight and pathological findings of the extracted palatine tonsils, and the presence or absence of anti-platelet drugs and renin-angiotensin system inhibitors (RAS-I) usage. This study included participants who were over 18 years of age, had undergone tonsillectomy within three months of steroid pulse therapy administered thrice, in whom renal biopsy was performed within a year before treatment, and with follow-up period of over 3 years. Clinical remission (CR) of urinary abnormalities was defined as remission of both proteinuria and hematuria: three consecutive negative results over a 6-month period, with a urinary sediment red blood cell count of <5/HPF, and a proteinuria qualitative reaction of (-) to (±).

RESULTS

The CR rate of all cases was 56.8% and statistical significance was observed with respect to the C-Grade (P =  0.0003, P =  0.028) using both univariate and multivariate analysis. The CR rate of C-Grade І (73.4%) patients was significantly higher than that of C-Grade II patients (39.0%; P =  0.0004) and C-Grade III patients (30.8%; P =  0.003). We analyzed clinical factors in each C-Grade patient. No statistical significance was observed with respect to any of the factors using univariate analysis in C-Grade I patients. The weight of the extracted palatine tonsils and Yamamoto scale showed no statistical significance in every analysis. Fibrosis or hyalinization of the stroma of the palatine tonsils showed statistical significance (P =  0.026) only in the univariate analysis of C-Grade III patients. However, the patient number of C-Grade III was small.

CONCLUSION

Our results indicate that TSP is mostly effective in patients with of C-Grade I IgAN and that the C-Grade reflects the clinical indication for TSP. The weight of the extracted palatine tonsils and Yamamoto scale did not show obvious correlations with the clinical effect of TSP.

Peritonsillar infiltration of lidocaine with adrenaline is associated with increased risk of secondary post-tonsillectomy haemorrhage

OBJECTIVES

In order to evaluate the safety of tonsillectomy among children, we retrospectively studied the incidence of post-operative complications, adverse events and their association with peri-operative medication.

METHODS

Data were collected from the medical records of 691 patients aged 1-16 years, including details of post-operative complications (any unplanned contact with the hospital), analgesics, dexamethasone, 5-HT3 antagonists, local anaesthetic and haemostatic agents.

RESULTS

Recovery was complicated in 13.6 per cent of patients, of whom 8.4 per cent were re-admitted to the ward. The most common complication was post-tonsillectomy haemorrhage, experienced by 7.1 per cent of patients. Re-operation under general anaesthesia (for grade III post-tonsillectomy haemorrhage) was required by 4.2 per cent of patients. Peritonsillar infiltration of lidocaine with adrenaline increased the risk of post-tonsillectomy haemorrhage (odds ratio = 4.1; 95 per cent confidence interval = 2.1 to 8.3).

CONCLUSION

Every seventh paediatric patient experienced a complicated recovery after tonsillectomy, caused by post-tonsillectomy haemorrhage in most cases. Local peritonsillar infiltration of lidocaine with adrenaline was associated with an increased risk of post-tonsillectomy haemorrhage.