Surgical technique and post-tonsillectomy hemorrhage: a single institution’s retrospective study

Readmission after OSA surgery in pediatric patients

OBJECTIVES

This study aimed to determine the readmission rate after adenotonsillectomy with the diagnosis of obstructive sleep apnea (OSA) and analyze the factors associated with readmission.

METHODS

It was planned as a retrospective study conducted in a single institution that included pediatric patients who underwent adenotonsillectomy with OSA diagnosis between December 2018 and March 2021. Patients who were readmitted for bleeding or pain/dehydration were compared with those who did not require readmission.

RESULTS

The mean postoperative admission time was 7.27 ± 3.49 days in patients with bleeding and 3.5 ± 2.27 days in patients with pain or dehydration. The mean length of stay in the hospital was 2.6 ± 1.6 days in patients with bleeding and 3.13 ± 2.03 days in patients with pain or dehydration. The postoperative admission time was 5.96 ± 3.57 days, and the hospital stay after readmission was 2.78 ± 1.73 days. No statistically significant correlation was found in terms of age, gender, surgeon's experience, use of electrocautery and seasonality factors, and readmission rates.

CONCLUSIONS

In children who underwent adenotonsillectomy for OSA, the hospitalization period of patients hospitalized due to pain/dehydration is much longer than patients admitted with bleeding. Therefore, measures to reduce pain or dehydration have the most significant potential to reduce the readmission rate and length of stay.

Investigation of Adult Post-Tonsillectomy Hemorrhage Rates and the Impact of NSAID Use

OBJECTIVES/HYPOTHESIS

Tonsillectomy is one of the most common ambulatory surgeries performed in the United States, yet the incidence of post-tonsillectomy hemorrhage (PTH) in adults remains unclear. In addition, any association between non-steroidal anti-inflammatory drugs (NSAIDs) and PTH in adults is currently unknown. The aim of this study is to examine the incidence and management of adult PTH at a single academic center and to assess for any association between NSAID use and PTH in adults.

STUDY DESIGN

Retrospective chart review.

METHODS

We conducted a retrospective chart review of adult tonsillectomies performed at our institution between January 1, 2012, and December 30, 2019. Demographics, past medical history, medications, NSAID use, surgical indication, bleeding events, and interventions were documented. The rate of PTH was calculated, logistic regression was performed to assess for any predictive factors, and odds ratios were calculated for NSAID use and PTH.

RESULTS

A total of 1,057 adult tonsillectomies were performed within the aforementioned time period. A total of 126 patients experienced 163 bleeding events for a postoperative hemorrhage rate of 11.9%. Most were controlled with bedside interventions, while 29 (23%) bled more than once. The hemorrhage rate for those who were not prescribed NSAIDs postoperatively (n = 625) was 11.7%, compared to 12.6% for those who did receive NSAIDs postoperatively (n = 432), which was not significantly different (adjusted odds ratio 1.01, 95% confidence interval 0.69-1.49; P = .95).

CONCLUSIONS

This retrospective cohort study of 1,057 adult patients found the incidence of PTH to be 11.9%. This study found no association between the use of NSAIDs and the rate of PTH, although a higher-powered study is needed.

LEVEL OF EVIDENCE

3 Laryngoscope, 132:949-953, 2022.

Intraoperative ketorolac for pediatric tonsillectomy: Effect on post-tonsillectomy hemorrhage and perioperative analgesia

OBJECTIVE

Determine the impact of ketorolac on post-tonsillectomy hemorrhage (PTH) and narcotic administration in children undergoing tonsillectomy.

METHODS

Retrospective case series from 2013 to 2017. Patients younger than 18 years undergoing tonsillectomy were included. PTH was the primary outcome measured. Secondary measures include percentage of patients requiring surgical intervention for PTH, average time to PTH, the number of post-operative opioid doses, and average post-operative opioid dose. Statistical methods include Chi-square, Wilcoxon rank sum, and binary logistic regression analyses.

RESULTS

During the study period, 669 patients received a single intraoperative dose of ketorolac (K+) and 653 patients did not receive ketorolac (K-). No differences were found in the rate of PTH (K- 6.5% vs. K+ 5.3%, RR = 0.82, 95% CI = 0.53 to 1.29, p = 0.40), surgical control of PTH (K- 4.0% vs. K+ 3.5%, RR = 0.87, CI = 0.51 to 1.51, p = 0.62), or average time [SD] to PTH (K- 6.0 [4.2] vs. K+ 5.2 [4.9] days; difference = 0.8 days; 95% CI, -1.3 to 2.9; p = 0.45). K+ patients had fewer post-operative opioid doses [SD] (K- 1.86 [1.14] vs. K+ 1.59 [1.23]; difference = -0.27; 95% CI, -0.053 to -0.49, Cohen d = 0.23) and a lower average opioid dose [SD] (K- 0.041 [0.032] vs. K+ 0.035 [0.030] mg/kg; difference = -0.006 mg/kg; 95% CI, -0.0003 to -0.012; Cohen d = 0.19).

CONCLUSION

Ketorolac did not increase risk of hemorrhage following tonsillectomy and decreased narcotic use.

[Subcutanious emphysema and pneunomediastinum - the rare complication of tonsillectomy]

Tonsillectomy is one of the most common surgical interventions in the practice of ENT hospitals. As a rule, complications of tonsillectomy are early and late postoperative bleeding. However, in extremely rare cases tonsillectomy can be complicated by subcutaneous emphysema and pneumomediastinum. The mechanism by which these complications develop are poorly understood. The article describes the case of a rare complication of tonsillectomy - the intraoperative development of subcutaneous emphysema and pneumomediastinum. Such complications are most likely caused by deep trauma of the pharyngobasilar fascia of the tonsillar fossa, which causes the penetration of the air into the parapharyngeal space and its subsequent spread to the mediastinum.

Frequency of post-tonsillectomy hemorrhage relative to time of day

OBJECTIVES

Postoperative hemorrhage is a serious complication of tonsillectomy, with secondary bleeding rates affecting up to 0.8% to 3% of patients. Although these bleeds are anecdotally perceived as occurring more frequently at night, the occurrence of hemorrhage relative to the time of day has not been investigated. We measured the frequency of post-tonsillectomy hemorrhage onset relative to the time of day.

METHODS

We reviewed electronic medical records of all patients who experienced postprocedural hemorrhage (International Classification of Disease, Ninth Edition [ICD-9] 998.11, ICD-10 J95.830 at two hospitals within a tertiary academic health system in a 10-year period). Patient demographics, time of bleed onset, emergency room [ED] arrival time, and management (operating room vs. observation) were abstracted. Patients without a recorded bleeding time were excluded. Time of bleed onset was categorized as morning (6:01 am-12 pm), afternoon (12:01 pm-6 pm), evening (6:01 pm-12 am), or overnight (12:01 am-6 am). Chi-square goodness of fit test was used to assess the distribution of hemorrhage timing (P ≤ 0.05).

RESULTS

A total of 7,396 patients underwent tonsillectomy May 2008 through May 2018, among whom 121 (2%) post-tonsillectomy hemorrhage patients were identified. Among the 104 patients with ED arrival times, 29 (28%) arrived in the morning; 15 (14%) arrived in the afternoon; 40 (38%) arrived in the evening; and 20 (19%) arrived overnight (P = 0.003). Sixty patients (mean age 17.1 years, standard deviation 16.6) had a recorded timing of bleed onset. Bleed onset occurred most commonly overnight (24, 40%), followed by evening (21, 35%), afternoon (11, 18%), and morning (4, 7%) (P = 0.0007).

CONCLUSION

In this cohort, post-tonsillectomy hemorrhage occurred most frequently between midnight and 6 am. Our findings confirm anecdotal experience and provide data in setting caregiver expectations.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:1823-1827, 2020.

Bipolar dissection technique in parotid gland surgery

BACKGROUND

Parotid gland surgery (PGS) has to manage the balancing act between sufficient radicality and preservation of functional structures. While many studies evaluate post-therapeutic complication due to different extent of surgery, the current study introduces bipolar dissection (BP) being a fast and safe preparation technique.

METHODS

Analysis of clinical parameters (age, sex, tumour entity, treatment modalities, facial nerve palsy, bleeding, saliva fistula and Frey's syndrome) of 319 consecutively included patients who underwent extracapsular dissection and superficial/total/radical parotidectomy. Subgroup analysis was done according to the preparation technique (cold vs BP).

RESULTS

Facial nerve palsy rate increased with the extent of PGS (p < .0001). There were no differences in the risk of post-operative bleeding, salivary fistula and Frey's syndrome. BP resulted in a significant reduction of operation time (p = .04), postoperative bleeding (p = .001) and salivary fistula (p = .045) when compared with cold preparation.

CONCLUSIONS

Ubiquitous available BP allows fast and safe PGS regardless its extent.