Post-tonsillectomy hemorrhage: Underlying factors and prevention

Safety of Tonsillectomy and/or Adenoidectomy in Pediatric Patients with Prolonged Activated Partial Thromboplastin Time and Factor XII Deficiency

Objective

To evaluate the safety and feasibility of tonsillectomy and/or adenoidectomy (T&A) in pediatric patients with prolonged activated partial thromboplastin time (APTT) and coagulation factor deficiency.

Methods

A prospective study was admitted to the children undergoing T&A at our institution between October 2019 and January 2020, specifically focusing on preoperative coagulation function. Within this group, we identified 5 patients exhibiting prolonged APTT and coagulation factor deficiencies, constituting the experimental group, and 10 patients matched by gender and age with normal blood coagulation function were selected as the control group. Comparative analyses between the two groups were conducted, focusing on surgical duration, intraoperative bleeding volume, duration of hospital stay, and postoperative complications such as active bleeding across the groups. At the six-month postoperative mark, a reassessment of coagulation functions and factor assays was conducted within the experimental group.

Results

No statistically significant differences were discovered in terms of surgical duration or bleeding volume when comparing the experimental subgroups with their respective control counterparts. Furthermore, there were no incidences of postoperative active bleeding observed in any of the groups. Notably, postoperative APTT values (32.7 ± 1.7s) exhibited a significant disparity compared to preoperative levels (43.7 ± 1.8s, p < 0.01). Coagulation factors demonstrated normalization, evidenced by a significant difference in postoperative Factor XII levels (40.2 ± 5.4%) compared to preoperative levels (63.1 ± 5.9%, p < 0.01).

Conclusion

Prolonged APTT with FXII factor deficiency does not show a significant bleeding tendency and is not a contraindication for T&A surgery. Post T&A surgery, children with abnormal coagulation function and deficient clotting factors show significant improvement compared to pre-surgery. It is important to consider that chronic inflammation in adenoids and tonsils may contribute to the prolongation of APTT and the manifestation of Factor XII deficiency.

Associations Between Post-tonsillectomy Hemorrhage and Anatomical Subsites of the Tonsillar Fossa

OBJECTIVE

This study presents a novel classification of the anatomical subsites of the tonsillar fossa and discusses their associations with post-tonsillectomy hemorrhage (PTH) after extracapsular tonsillectomy.

MATERIALS AND METHODS

Coblation tonsillectomy was performed on three adult cadavers and the anatomical subsites of the tonsillar fossa based on the distribution of the tonsillar feeding artery: the upper pole (subsite A), most of the tonsil body (subsite B), the inferior tonsil body (subsite C), and components of the lower pole (subsites D and E). Extracapsular tonsillectomy was prospectively performed using various surgical techniques and PTH was evaluated.

RESULTS

A cadaveric study revealed that the intra- and extra-capsular vessel topographies were essentially identical. Although the demarcation lines varied either up or down by a few millimeters, the arterial vascular network was particularly dense at subsites D and E, and the vessel diameter at these subsites was significantly greater than at subsite C and also (especially) at subsite E. Of 680 patients who underwent tonsillectomy, PTH developed early in 13 (31.7%) and late in 28 (68.3%). Surgical interventions were required by 29/41 patients (70.7%). Subsites D and E were the most common subsites of late PTH and PTH that required intervention. Such intervention was rarely necessary when PTH developed at subsite A or B.

CONCLUSIONS

The new classification of the anatomical subsites of the tonsillar fossa aids inexperienced surgeons and provides an anatomical rationale for variation in surgical technique that minimizes vascular injury, thus improving safety.

Primary and secondary postoperative hemorrhage in pediatric tonsillectomy

BACKGROUND

Tonsillectomy is the most common procedure for treatment of pediatric recurrent acute tonsillitis and tonsillar enlargement that contributes to obstructive sleep apnea hypopnea syndrome. Postoperative hemorrhage of tonsillectomy is a life-threatening complication.

AIM

To identify the risk factors that may contribute to primary and secondary post-operative hemorrhage in pediatric tonsillectomy.

METHODS

The clinical data from 5015 children, 3443 males and 1572 females, aged 1.92-17.08 years, with recurrent tonsillitis and/or tonsil hypertrophy who underwent tonsillectomy in our hospital from January 2009 to December 2018 were retrospectively collected. The variables including sex, age, time of onset, diagnosis, method of tonsillectomy, experience of surgeon, time when the surgery started and monthly average air temperature were abstracted. The patients with postoperative hemorrhage were classified into two groups, the primary bleeding group and the secondary bleeding group, and their characteristics were compared with those of the nonbleeding group separately. Statistical analysis was performed by chi-square test with SPSS 20.

RESULTS

Ninety-two patients had post-tonsillectomy hemorrhage, and the incidence rate of post-tonsillectomy hemorrhage was 1.83%. The mean age was 5.75 years. Cases of primary hemorrhage accounted for approximately 33.70% (31/92), and cases of secondary hemorrhage occurred in 66.30% (61/92). The rate of reoperation for bleeding was 0.92%, and the rate of rehospitalization for bleeding was 0.88% in all patients. Multiple hemostasis surgery was performed in 6.52% (3/46) of patients. The method of tonsillectomy (coblation tonsillectomy) and experience of the surgeon (junior surgeon with less than 5 years of experience) were significantly associated with primary hemorrhage (χ² = 5.830, P = 0.016, χ²= 6.621, P = 0.010, respectively). Age (over 6 years old) and time of onset (more than a 1-year history) were significantly associated with secondary hemorrhage (χ²= 15.242, P = 0.000, χ²=4.293, P = 0.038, respectively). There was no significant difference in sex, diagnosis, time when the surgery started or monthly average air temperature. There was a significant difference in the intervention measures between the primary bleeding group and the secondary bleeding group (χ²= 10.947, P = 0.001). The lower pole and middle portion were the common bleeding sites, followed by the upper pole and palatoglossal arch.

CONCLUSION

The incidence rate of post-tonsillectomy hemorrhage is low. Coblation tonsillectomy and less than 5 years’ experience of surgeon contribute to the tendency for primary hemorrhage. Age and time of onset are responsible for secondary hemorrhage.

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.

Risk Factors for Multiple Hemorrhages Following Tonsil Surgery in Children

OBJECTIVES/HYPOTHESIS

Although much is known about the incidence and risk factors for hemorrhage after tonsil surgery, the incidence and factors related to multiple episodes of hemorrhage are not well examined. Our objective was to identify risk factors that may contribute to multiple hemorrhages following tonsil surgery in children.

STUDY DESIGN

Retrospective chart review.

METHODS

A retrospective review was conducted of pediatric patients who experienced one or more hemorrhages following tonsillectomy/tonsillotomy, with or without adenoidectomy, between 2010 and 2016 at a single, tertiary-care hospital. Risk factors for multiple hemorrhages were examined using a multivariable logistic regression model.

RESULTS

Among the 11,140 patients who underwent tonsil surgery, 452 patients experienced one or more hemorrhages; 32 of these had multiple episodes of hemorrhage (7.1% of all patients with bleeds/0.3% of all patients). Older age (≥12 years: adjusted odds ratio [OR]: 3.13; 95% confidence interval [CI]: 1.47-6.68) and high body mass index for age (≥85th percentile: adjusted OR: 2.26; 95% CI: 1.06-4.85) were significantly associated with an increased risk of multiple hemorrhages in the multivariable model. Medical comorbidities, indications for surgery, surgical technique, intraoperative blood loss, and perioperative medications were not associated with multiple episodes of bleeding.

CONCLUSIONS

Multiple hemorrhages after tonsillectomy/tonsillotomy are uncommon. The risk of a second PTH after an initial episode is 7.1%, almost double the risk of a bleed after the initial tonsil surgery. Age > 12 years and high BMI for age may be associated with increased risk of rebleeding. After an initial bleed, increased surveillance may be warranted, particularly for patients with risk factors.

LEVEL OF EVIDENCE

4 Laryngoscope, 129:2765-2770, 2019.

Risks and benefits of local anesthesia versus general anesthesia in tonsillectomy

PURPOSE

Tonsillectomy is one of the most common surgical procedures in otorhinolaryngology. Modern general anesthetic techniques have reduced surgical risks, but performing the procedure under local anesthesia may still offer significant benefit for both the patient and surgeon. This study analyzed the risks and benefits of performing tonsillectomies under local anesthesia.

METHODS

This is a retrospective longitudinal cohort study analyzing postoperative bleeding rates as a primary outcome measure. Secondary outcome measures were duration of surgery, consumption of analgesics and total surgery cost.

RESULTS

The study enrolled 1112 patients undergoing tonsillectomy, with 462 (41.5%) patients treated under general and 650 (58.5%) patients treated under local anesthesia. There were 12 postoperative bleeding incidents in in the local anesthesia group and 9 cases of postoperative bleeding in the general anesthesia group. No significant differences based on gender regarding quantity of intraoperative bleeding or patient age were observed between the patients undergoing local versus general anesthesia. However, significant differences were noted between the groups in analgesic consumption, (Mann-Whitney U test, p = 0.001), duration of operating room stay (Mann-Whitney U test, p = 0.001), duration of surgery (Mann-Whitney U test, p = 0.001) and cost of surgery (Mann-Whitney U test, p = 0.001).

CONCLUSIONS

The incidence of postoperative bleeding is not dependent on type of anesthesia. The results suggest that tonsillectomy performed under local anesthesia is a safe alternative to tonsillectomy under general anesthesia, with significant reduction of cost and duration of surgery.