Postoperative hemorrhage following tonsillectomy in adults: Analysis of population-based inpatient cohort in Taiwan

The Effect of Tranexamic Acid Local Injection on Bleeding during and after Tonsillectomy: A Double-Blind Randomized Placebo-Controlled Trial

Background

Tonsillectomy-related bleeding is one of the most prevalent and potentially fatal complications of this common surgical procedure. We aimed to assess the effect of tranexamic acid (TXA) local injection on bleeding during and after tonsillectomy.

Methods

This double-blind, randomized placebo-controlled trial included 20 candidates for tonsillectomy referred to Al-Zahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran, in 2022. The subjects were randomized into two groups. Ten patients received TXA on their left side and the other ten on their right side 10 min before surgery. Placebo was administered to the contralateral side. The primary outcome was the volume of blood loss during tonsillectomy and up to 24 hours post-tonsillectomy. The secondary outcomes were surgeon satisfaction (rated 0-10), hemodynamic complications (patients' heart rate (HR) and mean arterial pressure (MAP) were recorded every 10 min), and rebleeding. The duration of surgery was also noted.

Results

The mean age of the patients was 21.35 ± 3.16 years, of whom 8 (30%) were male and 12 (60%) were female. there was no significant difference between groups in terms of HR and MAP at any time point. The median of surgery duration did not differ significantly between the two groups; however, the surgeon satisfaction with the procedure was significantly higher with TXA compared to placebo. None of the patients developed hemodynamic complications, and rebleeding did not occur in any of the subjects.

Conclusions

TXA local injection was not superior to placebo in terms of bleeding control during and after tonsillectomy, hemodynamic complications, rebleeding, and surgery duration.

Analysis of risk factors for post-tonsillectomy hemorrhage in adults

OBJECTIVES

To identify the risk factors for post-tonsillectomy hemorrhage (PTH) in adult patients (>19 years).

METHODS

275 adult patients who underwent tonsillectomy between 2009 and 2019 were retrospectively analyzed. Possible risk factors associated with PTH were investigated by univariate and multivariate logistic regression analyses.

RESULTS

PTH occurred in 39 of 275 patients (14.2%). Regarding underlying diseases, PTH occurred more frequently in focal infection of IgA nephropathy. Furthermore, bipolar electrocautery was the other risk factor for PTH on multivariate analysis.

CONCLUSION

Focal infection of IgA nephropathy and bipolar electrocautery were identified as the risk factors for PTH.

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.

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.

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.

Epidemiology of pediatric tracheotomy: A population-based study using National Health Insurance Research Database in Taiwan

OBJECTIVE

Tracheostomy in children is a surgical procedure with considerable morbidity and mortality. However, there is still a lack of population-based survey in pediatric tracheostomy. This study analyses population-based data in pediatric tracheostomy among different ages in Taiwan.

METHODS

This study used National Health Insurance Research Database in Taiwan. All children (aged <18 years) who underwent tracheostomy during 1997-2016 were identified. We retrieved data regarding baseline characteristics, perioperative care, and mortality associated with pediatric tracheostomy, and compared differences in variables between different age groups.

RESULTS

We observed that 2300 children received tracheostomy (mean age, 8.7 years; 64% boys). Regarding the age group distribution of the patients, 585 (25.4%) were infants (<1 year), 227 (9.9%) were toddlers (1-3 years), 175 (7.6%) were preschool-aged children (3-6 years), 317 (13.8%) were school-aged children (6-12 years), and 996 (43.3%) were adolescents (12-18 years). Surgical indications included pulmonary disorders (64.9%), neurological disorders (38.4%), trauma (32.3%), head injury (25.2%), and congenital anomalies (21.5%). Of these patients, 94.9% required intensive care unit (ICU) care, with the mean length of ICU stay being 63.8 days. The mean length of hospital stay was 74.5 days. The overall mortality at the last follow-up was 43.96% (1011/2300), and the tracheostomy related mortality at the last follow-up was 1.43% (33/2300). Compared with adolescents, infants more commonly underwent tracheostomy in the northern area (66.7% vs 37.2%, P < .001), more commonly received tracheostomy indicated by congenital anomalies (53.7 vs 4.6%, P < .001), had longer ICU stays, had longer hospital stays (100.7 vs 57.5 days, P < .001), and had a higher 5-year mortality rate (42.4 vs 29.6%, P < .001). Multivariable logistic and Cox regression models revealed that young age was associated with an increased risk of prolonged hospital stay and long-term mortality, respectively.

CONCLUSIONS

This study elaborates the epidemiology of pediatric tracheostomy in different age groups.

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.

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.

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.

Adverse Outcomes Associated With Inpatient Administration of Beers List Medications Following Total Knee Replacement

PURPOSE

Beers List drugs are potentially harmful in older adults and are grouped by level of risk. Over 9000 total knee arthroplasties (TKAs) are performed each year Veterans Affairs (VA) hospitals, primarily on older adults. Minimal data on the administration of Beers List drugs following arthroplasty currently exists in the literature. Our goal was to quantify the risks of these drugs following TKA. We hypothesized that increasing doses of Beers List drugs would be associated with increased risks for readmission, reoperation, emergency department (ED) visits, and mortality.

METHODS

In this retrospective cohort study, data from TKAs performed in VA hospitals from 2010 to 2014 were examined, with complicated or bilateral procedures excluded. The data were obtained from the VA Corporate Data Warehouse. The outcomes examined were readmission, postoperative ED visits, reoperation on ipsilateral knee, and mortality. Beers List drugs were divided into 3 categories: medications to use with caution (Beers 0); medications to avoid in older adults (Beers 1); and medications to avoid in certain disease states (Beers 2). Beers 2 was not included in the final analysis due to an inability to verify appropriate diagnostic criteria without manual chart review. Logistic regression was performed looking at the total number of doses in the first 48 h after surgery compared to the above-mentioned outcomes.

FINDINGS

Data from 12,639 TKAs were analyzed; the mean age of the patients was 65.06 years, and 77.8% of patients received Beers List drugs while admitted. The most frequently administered Beers List drugs were proton pump inhibitors, NSAIDs, insulin, α-blockers, benzodiazepines, antihistamines, muscle relaxants, and antipsychotics. There was a dose-dependent increase in readmission and ED visits in the Beers 1 group. The odds ratios were 1.03 for 30-day readmission and 1.02 at 90 days. The odds ratios for ED visits were 1.05 for 72-h ED visits and 1.04 for ED visits within 7 and 30 days. The odds ratios were set at 1-unit dose intervals. All results were found after control for VA facility, sex, age, American Society of Anesthesiologists class, Charlson score, case length, and body mass index.

IMPLICATIONS

The group of medications to avoid (Beers 1) from the 2015 Beers List showed associations with increased frequency of readmission and postoperative ED visits. Reinforcement of the need to avoid those drugs during surgical care will hopefully reduce such complications. Limitations included not controlling for overall discharge drug count and reliance on the outpatient problem list for outpatient diagnoses. Additional subgroup analysis will be performed to see whether specific drugs pose a higher than risk others.

Trends in the management of peritonsillar abscess in children: A nationwide population-based study in Taiwan

OBJECTIVE

Population-based studies analyzing peritonsillar abscess in children are lacking. In this study, a population-based survey of the epidemiology of pediatric peritonsillar abscess in Taiwan was conducted.

METHODS

This cross-sectional study was conducted using the Taiwan National Health Insurance Research Database. All cases of inpatient pediatric peritonsillar abscess (age < 18 years) in Taiwan between 2000 and 2012 were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification. Incidence rates of inpatient peritonsillar abscess in children were calculated. Characteristics such as age, gender, hospital level, treatment modalities, imaging studies, drug administration, and length of hospital stays during the study period were analyzed.

RESULTS

A total of 12,965 children with peritonsillar abscess were included (mean age, 6.6 years [standard deviation, 4.8 years]; 56.5% boys). The overall incidence was 18 per 100,000 children. Incidence rates decreased from 2000 to 2012 (19.1/100,000 to 8.3/100,000 children) (p_trend < 0.001). During the study period, the proportion of peritonsillar abscess treatments at medical centers increased from 4.6% to 15.0%. The proportion of treatments involving incision and drainage or needle aspiration increased significantly (1.3%-4.1% and 49.4%-65.6%, respectively), whereas treatments with antibiotics only decreased significantly (48.9%-29.0%). The use of computed tomography (CT) increased (1.4%-12%, p_trend < 0.001). The use of nonsteroidal anti-inflammatory drugs, steroids, and penicillin increased during the study period. The mean length of hospital stays increased from 3.78 to 4.67 days.

CONCLUSIONS

The incidence of peritonsillar abscess in children decreased between 2000 and 2012 in Taiwan. Moreover, increasing trends were observed in the use of CT, the rates of incision and drainage and needle aspiration procedures, and the length of hospital stay in this study cohort.

Pathogenic role of palatine tonsils in palmoplantar pustulosis: A review

Palmoplantar pustulosis (PPP) is characterized by symmetrical, erythematous, scaly plaques, with numerous, sterile, non-bacterial, pinpoint pustules, which are restricted to the palms and soles. Because several reports have described the efficacy of tonsillectomy for improvement in PPP skin lesions, we consider that PPP is tonsil-induced autoimmune/inflammatory syndrome (TIAS) while other factors are also involved in the pathogenesis of PPP. Here, the association between PPP pathogenesis and TIAS was examined, with a focus on results of previous studies. PPP patients show a hyperimmune response to indigenous bacteria such as α-streptococci, due to impaired immunological tolerance towards such organisms. Such a novel immune response leads to T-cell activation through the abnormal expression of secondary stimulation molecules, including cytotoxic T-lymphocyte-associated antigen 4, inducible T-cell co-stimulator and Smad7, in the tonsils of PPP patients. Activated tonsillar T cells express cutaneous lymphocyte antigen (CLA), CCR6 and β1-integrin, enter the blood circulation and are recruited to PPP skin lesions. Within lesions, T cells roll onto endothelial cells through the interaction between CLA and E-selectin, migrate into the extravascular area through β1-integrin-vascular cell adhesion molecule 1 binding, and assemble in the skin through CCL20-CCR6 binding. Hyperimmune responses to autoantigens such as keratin and heat shock proteins could also be involved in PPP pathogenesis, through the stimulation of the T-helper 17 reaction.

Incidence of Multilevel Surgical Procedures and Readmissions in Uvulopalatopharyngoplasty in Taiwan

Importance

Multilevel surgical procedures with uvulopalatopharyngoplasty (UPPP) appear to be associated with more complications than UPPP alone, but general and bleeding-related hospital readmissions have not been specifically investigated to date.

Objective

To compare the risk of 30-day general and bleeding-related readmissions in adult patients who underwent UPPP alone and those who received a multilevel surgical procedure.

Design, Setting, and Participants

This cross-sectional study retrospectively analyzed all cases of UPPP among adults (aged >20 years) in Taiwan from January 1, 2000, to December 31, 2012. Claims data in the Taiwan National Health Insurance Research Database were used. Participants were patients who underwent inpatient UPPP (n = 35 029), and their basic information was acquired from the database. Data analyses were conducted from June 22, 2018, to August 22, 2018.

Main Outcomes and Measures

The risks of major complications in patients who underwent UPPP alone, UPPP with nasal operation, and UPPP with tongue or hypopharyngeal operation were compared using a generalized linear mixed model.

Results

In total, 35 029 adults were identified (mean [SD] age of 39.2 [12.2] years, and 25 923 men [74.0%]). The proportion of UPPP concurrent with nasal operation increased from 2000 to 2012 (19.9% to 42.9%), as did that of UPPP with concurrent tongue or hypopharyngeal operation (2.7% to 5.2%). The rate of readmission for any reason after UPPP with nasal operation was higher than that for UPPP alone (4.7% vs 3.7%; adjusted odds ratio [aOR], 1.22; 95% CI, 1.09-1.37). The rate of readmission for any reason and readmission for bleeding for UPPP with tongue or hypopharyngeal operation (aOR, 1.68; 95% CI, 1.34-2.11) was also higher than that for UPPP alone (aOR, 2.34; 95% CI, 1.72-3.17). However, a multilevel surgical procedure was not associated with an increased risk of bleeding-related reoperation, regardless of the concurrent procedure.

Conclusions and Relevance

The incidence of multilevel UPPP in Taiwan increased from 2000 to 2012, and these surgeries appeared to be associated with a higher risk of complications; results of this study suggest that these findings should be considered during surgical decision-making.

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.

Do changing trends in tonsil surgery affect hemorrhage rates? A longitudinal study covering 1,452,637 procedures

PURPOSE

To evaluate whether changing trends in tonsil surgery between 2005 and 2017 in Germany were associated with different age- and gender-specific hemorrhage rates.

METHODS

A longitudinal population-based inpatient cohort study was performed including all patients who had undergone tonsillectomy (with or without adenoidectomy), tonsillotomy, abscess-tonsillectomy, removal of tonsillar remnants and surgical treatment to achieve hemostasis following tonsil surgery. The population was stratified by age (groups of 5 years) and gender. Operation rates were calculated in relation to the end-year population number according to the German Federal Office of Statistics.

RESULTS

The surgical rates per 100,000 had significantly decreased from 170.39 to 90.95 (46.62%) in female patients and from 147.33 to 88.19 (40.14%) in male patients within the study period (p < 0.001). A total of 42.352 female patients had required surgical treatment to achieve hemostasis following 783,005 procedures (5.41%). In contrast, only 669,632 operations were performed in male patients but were complicated by hemorrhage in 51.185 cases (7.64%) which was significantly different (p < 0.001). The male-to-female ratio of the surgical rates had increased from 0.86:1 to 0.93:1. Hemorrhage rates differed significantly between age groups (p < 0.001). Male gender is a significant risk factor for bleeding at all ages < 85 years with greatest differences in 20- to 25-year-old patients (12.19% male vs. 6.26% female).

CONCLUSIONS

Changing trends in tonsil surgery are not associated with increased rates of bleeding complications. Hemorrhage following tonsil surgery is significantly related to age and gender and this should be noted when reported hemorrhage rates in the literature are appraised by the reader.