Postoperative Tonsillectomy Hemorrhage

Nebulized tranexamic acid for treatment of post-tonsillectomy bleeding: a systematic review and meta-analysis

PURPOSE

Post-tonsillectomy bleeding (PTB) is a significant complication and common reason for emergency department (ED) visits. Limited literature has investigated the clinical efficacy of nebulized tranexamic acid (TXA) for treating PTB; however, the results were conflicting and not comprehensively summarized. This study aimed to provide the first-ever systematic review encompassing all literature exploring the efficacy and safety of nebulized TXA in treating PTB.

METHODS

We screened six databases until 01-July-2024, for relevant studies and assessed their quality using validated tools. We provided a qualitative summary of baseline characteristics and clinical data. The primary endpoint was the reoperation rate to manage PTB, and its effect size was aggregated as a proportion or risk ratio (RR) with a 95% confidence interval (CI) using a random-effects model.

RESULTS

We analyzed nine studies (2 case reports, 4 case series, and 3 retrospective comparative studies), all of which demonstrated good quality and low risk-of-bias. In studies using nebulized TXA for treating PTB (n = 9 studies), the pooled proportion of reoperation to control bleeding was 0.27 (95% CI: 0.08-0.5). The rate of reoperation to control bleeding was significantly lower in the nebulized TXA arm compared to the no-TXA arm (n = 3 studies, RR = 0.55, 95% CI [0.39-0.77], p < 0.001).

CONCLUSION

Nebulized TXA is safe and promising for treating PTB. This is evidenced by its high efficacy in achieving hemostasis in acute settings during ED visits and reducing the rate of reoperations needed to control PTB. Further high-quality investigations are warranted to corroborate these findings.

Postoperative Complications in Lingual Versus Palatine Tonsillectomies

OBJECTIVE

The aim of this study was to investigate the risks of lingual tonsillectomy (LT) in a large cohort and compare these risks to those of palatine tonsillectomy (PT).

METHODS

A retrospective cohort study was conducted using data from the United States collaborative network within TriNetX. The LT group was defined using Current Procedural Terminology (CPT) code 42870 and PT group using CPT codes 42820, 42821, 42825, or 42826. Groups were further subdivided into pediatric and adult populations and matched based on propensity scores within the cohorts. Complications occurring within 14 days of procedure were compared within each cohort.

RESULTS

There were 1,357 adult patients (mean age, 42.9 years) and 863 pediatric patients (mean age, 8.1 years). Adults who had LT were more likely to experience postoperative dysphagia (OR = 2.6, p < 0.001) and require admission to the hospital (OR = 4.3, p < 0.001) or intensive care unit (OR = 6.1, p < 0.001). There was no significant difference in bleeding between adult PT and LT groups, occurring at rates of 3.8% and 4.4%, respectively (p = 0.50). Pediatric patients who had LT were also more likely to experience postoperative dysphagia (OR = 2.4, p = 0.017) and require admission to the hospital (OR = 8.2, p < 0.001) or intensive care unit (OR = 2.7, p = 0.012). The postoperative bleed rate was 3.2% in the pediatric PT cohort, which was 2.4 times higher compared to those who underwent LT (1.5%, p = 0.016).

CONCLUSION

Postoperative complications after lingual tonsillectomy are more common than after palatine tonsillectomy in both adults and children.

LEVEL OF EVIDENCE

3 Laryngoscope, 135:1054-1059, 2025.

Dose-Related Effects and Bleeding Risk of Ketorolac in Pediatric Tonsillectomy

OBJECTIVE

To investigate the safety and effectiveness of dose-related ketorolac administration in children who underwent tonsillectomy.

DATA SOURCES

Data sourced from PubMed, SCOPUS, Embase, Web of Science, and Cochrane databases, encompassing literature from their inception until June 2024.

REVIEW METHODS

The perioperative administration of ketorolac in comparison with a control group was included in this analysis. The outcomes assessed were postoperative pain levels; utilization patterns of analgesic medication in terms of quantity and frequency; and the incidence rates of postoperative nausea, vomiting, and bleeding.

RESULTS

Eighteen studies with 11,729 patients that investigated. The ketorolac treatment group with postoperative bleeding had a higher incidence of primary bleeding (significant bleeding and operative bleeding control) compared to the control group. However, ketorolac treatment did not affect the risk of secondary bleeding. Subgroup analysis showed that 0.9 to 1 mg/kg of ketorolac significantly increases primary operative control (odds ratio [OR] = 4.0700 [1.6352; 10.1302]; I2 = 0.0%) and primary significant bleeding (OR = 2.3200 [1.1322; 4.7538]; I2 = 0.0%). On the other hand, 0.5 mg/kg ketorolac did not show any influence on primary operative control. The administration of ketorolac (both 0.9-1 and 0.5 mg/kg) led to a significant decrease in postoperative pain (2-24 hours), nausea, and vomiting compared to the control group.

CONCLUSION

Low-dose (0.5 mg/kg) ketorolac administration to children could significantly reduce the risk of primary significant bleeding and surgical hemostasis compared to high-dose administration (0.9-1.0 mg/kg). In addition, low-dose ketorolac administration could provide sufficient pain control and reduce postoperative nausea and vomiting.

Predictors of Posttransplant Lymphoproliferative Disease in Pediatric Patients

OBJECTIVE

Posttransplant lymphoproliferative disorder (PTLD) is a complication of pediatric solid organ transplantation. Benign adenotonsillar lymphoid hyperplasia confounds the ability to diagnose PTLD. Our aim was to identify factors that predict the presence of PTLD to inform decision-making regarding adenotonsillectomy.

METHODS

The electronic medical records at a quaternary children's hospital were queried over a 23-year period (2000-2023) for solid organ transplant patients that underwent tonsillectomy and/or adenoidectomy. Demographics, clinical presentation, and EBV serologies were analyzed to determine factors associated with presence of PTLD on final pathology.

RESULTS

A total of 114 patients met inclusion criteria for analysis. Thirty-two of the 114 patients (28.1%) who underwent tonsillectomy and/or adenoidectomy had PTLD. Age at transplant, age at biopsy, sex, race, and type of organ transplanted were not found to be associated with development of PTLD. Patients with PTLD were more likely to have smaller tonsils, sore throat, fever, and tonsillar exudate; they were less likely to experience sleep disordered breathing. The immunosuppression agent used for induction and the number of maintenance immunosuppressive medications were not associated with the development of PTLD. Increased Epstein-Barr Virus (EBV) PCR copy number correlated to increased risk of developing PTLD (p < 0.003).

CONCLUSION

Tonsillar hypertrophy and sleep disordered breathing are not necessarily indicative of the presence of PTLD. Suspicion for adenotonsillar PTLD should be based on symptomatology, clinical exam, EBV serologies, and degree of EBV PCR positivity. Sore throat, fever, tonsillar exudates, and significant elevation in EBV PCR copy number are particularly concerning for PTLD.

LEVEL OF EVIDENCE

3 Laryngoscope, 2025.

Effect and safety of perioperative ibuprofen administration in pediatric tonsillectomy: A systematic review and meta-analysis

OBJECTIVES

This study aimed to evaluate the safety and efficacy of perioperative ibuprofen administration by conducting a meta-analysis of pertinent literature.

METHODS

We conducted a comprehensive review of studies sourced from PubMed, SCOPUS, Embase, Web of Science, and Cochrane databases. The studies covered the period from database inception to June 2024. A perioperative ibuprofen administration group was compared to a control group administered either saline, acetaminophen, paracetamol, or opioids. The primary outcome was post-tonsillectomy bleeding that was categorized into overall bleeding and further classified as type 1 (observed at home or evaluated in the emergency department without additional intervention), type 2 (necessitating readmission for observation), and type 3 (requiring a return to the operating room for hemorrhage control). Morbidity incidence rates for postoperative nausea and vomiting were also assessed. The secondary outcomes assessed were postoperative pain management and the frequency of analgesic drug usage. Postoperative pain management was assessed from the incidence of emergency department visits or nurses' calls for pain independent of the presence or absence of dehydration.

RESULTS

Twenty-two studies with 27,149 patients were included and reviewed for this meta-analysis. Post-tonsillectomy bleeding (OR = 0.9954, 95 % CI [0.8800; 1.1260], I2 = 0.0 %) was not significantly higher in the ibuprofen administration group compared to the control group. In subgroup analysis of post-tonsillectomy bleeding severity, ibuprofen caused clinically insignificant type 1 post-tonsillectomy bleeding that did not require intervention (OR = 1.1310 [0.7398; 1.7289]). Clinically significant bleeding requiring hospital admission (type 2) or surgical control (type 3) was not observed. Administration of ibuprofen has demonstrated efficacy in reducing the need for analgesic drugs (OR = 0.4734, 95 % CI [0.2840; 0.7893]; I2 = 19.8 %) and is associated with a significant decrease in the incidence of postoperative nausea and vomiting (OR = 0.4886, 95 % CI [0.3156; 0.7562], I2 = 34.3 %).

CONCLUSION

This study demonstrated that administration of ibuprofen for pediatric tonsillectomy did not increase the incidence of clinically significant postoperative bleeding. Ibuprofen administration decreased the incidence and severity of postoperative pain, nausea, and vomiting.

Efficacy and safety of perioperative ibuprofen for pain control after pediatric tonsillectomy: A systemic review and meta-analysis

OBJECTIVES

To assess the safety and effectiveness of perioperative ibuprofen in pediatric tonsillectomy through a meta-analysis of relevant randomized controlled trials.

METHODS

We conducted a comprehensive review of studies available in PubMed, SCOPUS, Embase, Web of Science, and Cochrane databases up to June 2024. This analysis compared perioperative ibuprofen administration to control groups (saline, acetaminophen, or opioids). Outcomes assessed were postoperative pain management, as indicated by the frequency of analgesic use, and morbidity rates, which included the incidence of postoperative nausea and vomiting and post-tonsillectomy hemorrhage (PTH). PTH was further categorized as primary (occurring on the day of operation) or secondary (occurring after the day of operation), and classified as type 1 (observed at home or evaluated in the emergency department without further intervention), type 2 (requiring readmission for observation), or type 3 (necessitating a return to the operating room for hemorrhage control).

RESULTS

This analysis included nine studies involving a total of 1545 patients. Incidences of primary PTH (OR = 1.0949, 95 % CI [0.4169; 2.8755], I2 = 0.0 %), secondary PTH (OR = 1.6433 95 % CI [0.7783; 3.4695], I2 = 0.1 %), and overall PTH (OR = 1.4296 95 % CI [0.8383; 2.4378], I2 = 0.0 %) were not significantly higher in the ibuprofen group than the control groups. Administration of ibuprofen led to a significant decrease in postoperative nausea and vomiting (OR = 0.4228 95 % CI [0.2500; 0.7150], I2 = 40.0 %) and frequency of postoperative analgesic uptake (OR = 0.4734 95 % CI [0.2840; 0.7893]; I2 = 19.8 %). There was no difference in bleeding by type between the ibuprofen and control groups.

CONCLUSIONS

Our meta-analysis demonstrated that administration of ibuprofen for pediatric tonsillectomy did not significantly increase the incidence of postoperative bleeding but did decrease postoperative emesis and improve pain control.

Treatment of Post-Tonsillectomy Hemorrhage With Nebulized Tranexamic Acid: Initial Investigation of a Novel Therapeutic Modality

OBJECTIVES

The use of nebulized tranexamic acid (TXA) in massive pulmonary hemorrhage is well-described. Published utilization in post-tonsillectomy bleeding (PTB) is limited to a single case. This study examines whether TXA resulted in change of operative intervention necessity and narcotic utilization.

METHODS

This was a retrospective cohort study at a single, urban academic medical center in the United States. Chart review was conducted of all patients who presented to the hospital for post-tonsillectomy bleed (PTB) between 3/1/2018 and 7/1/2020. Demographic data, intervention modality, need for control under general anesthesia, and opioid use were collected and analyzed.

RESULTS

Twenty-one patients underwent a total of 23 visits for PTB over the study period. Control of hemorrhage without need for operating room intervention for PTB was 100% (6/6) for patients receiving TXA nebulizer and 53% (9/17) for those receiving other treatment modalities. Opioid usage in hospital and on discharge was also lower in patients receiving TXA nebulizers. All results were statistically significant.

CONCLUSIONS

Our study supports nebulized TXA as an effective, non-invasive mode of hemostasis in patients presenting to the emergency department for post-tonsillectomy hemorrhage. Nebulized TXA may prevent the need for general anesthesia and operative intervention. Otolaryngologists should consider addition of this novel treatment appropriation of TXA to their management options for postoperative tonsillar hemorrhage.

Posttonsillectomy Pain Relief and Wound Healing by Applying Bismuth Iodoform Paraffin Paste (BIPP) to Dissected Tonsillar Beds

Introduction  Tonsillectomy is one of the most common operations performed by otorhinolaryngology surgeons worldwide; however, the insufficient quality of the postoperative pain management and effective posttonsillectomy pain relief remain a clinical dilemma. Objective  To evaluate the efficacy of applying bismuth iodine paraffin paste (BIPP) to the dissected fossa as an adjuvant therapy for a better outcome in terms of posttonsillectomy pain management and due to its wound healing properties. Methods  The present is a prospective randomized control pilot study with 44 patients aged > 7 years who underwent tonsillectomy. The patients were divided into two groups: the control group and the group that had BIPP applied to the dissected tonsillar fossa. The visual analogue scale score and the post-onsillectomy percentage of tonsillar fossa epithelization were recorded and evaluated. Results  Both subjectively and objectively, there a was statistically significant pain-relieving effect in the BIPP group within the first 5 postoperative days ( p  < 0.05). From postoperative day 3 onward, the dissected area of the tonsillar fossa healed significantly faster in the BIPP group compared with the control group, and it became stable on day 14. Conclusion  The topical application of BIPP showed a better pain-relieving effect, it was safe, and hastened wound healing after tonsillectomy.

Effect of perioperative ketorolac on postoperative bleeding after pediatric tonsillectomy

INTRODUCTION

Ketorolac is a frequently used anesthetic pain agent which is traditionally avoided during tonsillectomy due to concern for postoperative hemorrhage. Our goal was to assess the degree of risk associated with the use of Ketorolac following pediatric tonsillectomy.

METHODS

The TriNetX electronic health records research database was queried in January 2024 for patients undergoing tonsillectomy with or without adenoidectomy under the age of 18 years and without a diagnosed bleeding disorder. Patients were separated into two cohorts either having received or not having received ketorolac the same day as surgery. Propensity score matching was performed for age at the time of surgery, sex, race, ethnicity, and preoperative diagnoses. The outcomes assessed were postoperative hemorrhage requiring operative control within the first day (primary hemorrhage) and within the first month after surgery (secondary hemorrhage).

RESULTS

17,434 patients were identified who had undergone pediatric tonsillectomy with or without adenoidectomy and had received ketorolac the same day as surgery. 290,373 patients were identified who had undergone pediatric tonsillectomy with or without adenoidectomy and had not received ketorolac the same day as surgery. 1:1 propensity score matching resulted in 17,434 patients within each cohort. Receipt of ketorolac the same day as surgery resulted in an increased risk of primary hemorrhage OR 2.158 (95 % CI 1.354, 3.437) and secondary hemorrhage OR 1.374 (95 % CI 1.057, 1.787) requiring operative control.

CONCLUSION

Ketorolac use during pediatric tonsillectomy with or without adenoidectomy was associated with an increased risk of postoperative primary and secondary bleeding requiring surgery.

Incidence and predictors of readmission following tonsillectomy in pediatric population

BACKGROUND

Tonsillectomy is one of the most common surgical procedures performed in the pediatric population. This study aims to estimate the incidence rate of readmission post tonsillectomy in pediatrics and identify the causes and predictors contributing to the readmission post-surgery.

METHODS

A retrospective cohort study included 1280 pediatric patients (18 years or younger) who underwent tonsillectomy at a tertiary hospital in 2019 and 2020. The study sample was divided into two groups based on readmission and were compared using the appropriate statistical tests. Significant variables (p-value≤0.05) were included in the logistic regression model to determine the predictors of readmission following tonsillectomy in these patients.

RESULTS

The readmission rate following tonsillectomy was 6.3 % (95 % confidence interval 5.1-7.9). The causes of readmission included poor oral intake followed by bleeding and vomiting, 55.6 %,49.4 %, and 13.6 %, respectively. In the multivariable logistic regression model, the only significant predictor of post-tonsillectomy readmission was the use of a single postoperative analgesia (OR: 57.27, P = 0.000).

CONCLUSION

The readmission rate following tonsillectomy in this study was relatively high. The most common causes contributing to readmission post tonsillectomy were poor oral intake and hemorrhage. The study also revealed a significant association between the utilization of single postoperative analgesia and an increased likelihood of readmission.

Postoperative Outcomes of Intracapsular Tonsillectomy With Coblation: A Systematic Review and Meta-Analysis

OBJECTIVE

Following tonsillectomy, postoperative pain and hemorrhage from the tonsillar bed are causes of significant morbidity. Intracapsular tonsillectomy with Coblation is suggested to minimize such morbidity while remaining efficacious in long-term outcomes. This systematic review and meta-analysis assessed short-term morbidity and long-term outcomes from intracapsular tonsillectomy with Coblation, focusing primarily on posttonsillectomy hemorrhage.

DATA SOURCES

Medline, Embase, and the Cochrane Library.

REVIEW METHODS

Guided by PRISMA guidelines, studies on intracapsular tonsillectomy with Coblation published between December 2002 and July 2022 evaluating frequency of posttonsillectomy hemorrhage were screened. Studies without primary data were excluded. Meta-analysis was conducted using the random-effect model. The primary outcome was the proportion of patients who experienced posttonsillectomy hemorrhage. The secondary outcomes were posttonsillectomy pain, the proportion requiring revision tonsillectomy, and severity of sleep-disordered breathing measured by polysomnography outcomes.

RESULTS

From 14 studies there were 9821 patients. The proportion of total posttonsillectomy hemorrhage was 1.0% (95% confidence interval [CI] 0.5%-1.6%, n = 9821). The proportion experiencing primary hemorrhage, secondary hemorrhage, and those requiring further tonsil surgery were 0.1% (95% CI 0.0%-0.1%; study n = 7), 0.8% (95% CI 0.2%-1.4%; study n = 7), and 1.4% (95% CI 0.6%-2.2%; study n = 6), respectively. Mean reduction in apnea-hypopnea index was -16.0 events per hour (95% CI -8.8 to -23.3, study n = 3) and mean increase in oxygen nadir was 5.9% (95% CI 2.6%-9.1%, study n = 3).

CONCLUSION

Intracapsular tonsillectomy with Coblation has been demonstrated to have a low rate of posttonsillectomy hemorrhage. Data regarding long-term tonsil regrowth and need for reoperation were encouraging of the efficacy of this technique.

Reducing Unnecessary Instruments in Tonsil Hemorrhage Trays at a Canadian Tertiary Care Center: A Quality Improvement Project

BACKGROUND

In the emergency department (ED), there are pre-assembled tonsillar hemorrhage trays for management of post-tonsillectomy hemorrhage and peritonsillar abscess. After use, the tray is sent to the medical device reprocessing (MDR) department for decontamination, sterilization, and re-organization, all at a significant cost to the hospital and environment.

OBJECTIVE

The goal of this project was to reduce unnecessary instruments on the tonsil hemorrhage tray by 30% by 1 year and report on the associated cost and carbon dioxide (CO2) emissions savings.

METHODS

This quality improvement project was framed according to the Institute for Healthcare Improvement's Model for Improvement. ED and Otolaryngology-Head & Neck Surgery staff and residents were surveyed to determine which instruments on the tonsil hemorrhage trays were used regularly. Based on results, a new tray was developed and compared to the old tray using MDR data and existing CO2 emissions calculations.

RESULTS

Tray optimization resulted in a total cost reduction from $1092.63 to $330.21 per tray per year, decreased processing time from 12 to 6-8 minutes per tray, and decreased CO2 emissions from 6.11 to 2.85 kg per year for the old versus new tray, respectively. Overall, the new tray contains half the number of instruments, takes half the time to assemble, produces 50% less CO2 emissions, and will save the hospital approximately $100,000 over 10 years.

CONCLUSION

Healthcare costs and environmental sustainability are collective responsibilities. Surgical and procedure tray optimization is a simple, effective, and scalable form of eco-action.

Assessing the Relationship Between Infection Frequency and Risk of Post-Tonsillectomy Hemorrhage

OBJECTIVE

To determine the relationship between frequency of tonsillitis and the risk of post-tonsillectomy hemorrhage (PTH) in pediatric patients undergoing tonsillectomy for recurrent tonsillitis.

METHODS

After obtaining IRB approval from Nationwide Children's Hospital, charts for all patients who underwent a total tonsillectomy in 2017 for recurrent or chronic tonsillitis were retrospectively reviewed (n = 424). Patients were divided into 2 cohorts based on the frequency of tonsillitis prior to surgery: those meeting the 1-year criteria with 7 or more infections in the past year (n = 100), and those who did not meet criteria defined as those with fewer than 7 infections in the past year (n = 324). The primary outcome of interest was PTH. Comparison of cohorts and frequency of PTH were assessed using bivariate analyses. Kaplan-Meier curves were used to compare time to onset of hemorrhage between primary vs. secondary PTH. Generalized mixed and logistic regression models were used to evaluate risk of hemorrhage following tonsillectomy.

RESULTS

Among a total cohort of 424 patients undergoing tonsillectomy, 23.58% (n = 100) met criteria while 76.42% (n = 324) did not. A total of 8.73% (n = 37) patients experienced PTH. Compared to those who did not meet criteria, those who met criteria had a higher odds of developing PTH; however, this was not significant (OR: 1.42 [95% CI: 0.67, 2.98], P = .3582). Estimated probability of developing PTH for those who met criteria was 11% [95% CI: 6.19, 18.81] compared to 8.03% [95% CI: 5.52, 11.54] for those who did not meet criteria. Among all PTH cases, 5.41% (n = 2) were primary hemorrhage while 94.59% (n = 35) were secondary hemorrhage with 50% of those with secondary PTH having experienced hemorrhage within 6 days [95% CI: 5, 7] of tonsillectomy. Patients with neuromuscular conditions had significantly higher odds of PTH (OR: 4.75 [95% CI: 1.19, 18.97], P = .0276).

CONCLUSION

Patients who met the 1-year criteria for tonsillectomy did not have a significantly higher odds of PTH. Further research is needed to better evaluate the relationship between infection frequency and risk of PTH.

Management of a Large Post-tonsillectomy Thrombus Obstructing the Laryngeal View: A Case Report

Anesthetic management of children with a post-tonsillectomy hemorrhage can be challenging. The patients may be anemic and hypovolemic and are at increased risk of having a difficult airway due to active bleeding, vomiting, and anatomical issues. A clot may also interfere with viewing the larynx, further exacerbating the difficulty of intubation. We describe a pediatric post-tonsillectomy hemorrhage case complicated by a large obstructing clot that was removed with Magill forceps after the airway was successfully secured with an endotracheal tube during rapid sequence induction.

Effect of gold laser energy delivery on postoperative adenotonsillectomy complications

BACKGROUND

This study aimed to determine if the energy delivered by the Gold laser impacted postoperative complication rates after adenoidectomy, tonsillectomy, or adenotonsillectomy.

METHODS

A retrospective chart review identified 420 patients who met the criteria within the last five years. Indications for the surgeries included recurrent tonsillitis, obstructive sleep apnea, sleep-disordered breathing, adenoiditis, peritonsillar abscess, and other indications. The relationship between the energy delivered (kJ) and various complications such as bleeding, pain, dehydration, readmission, emergency center visits, and clinic calls was evaluated.

RESULTS

There was a significant correlation between higher kJ delivered and the incidence of major bleeding requiring cauterization in the operating room (p = 0.0311). In addition, emergency center visits (p = 0.0131) and readmission (p = 0.0210) showed a significant correlation with the amount of energy (kJ) delivered. Furthermore, higher energy correlated to higher maximum post-operative pain scores (p = 0.0302). Attendings displayed a different pattern of energy delivery compared to residents (p < 0.0001), which also differed by PGY (p < 0.0001).

CONCLUSION

There are significant correlations between higher energy delivered in kJ using the Gold laser and less desirable post-operative results. In addition, residents tend to utilize higher energy levels than attendings, but this trend tapers off in the 4th and 5th years. Clinicians utilizing the Gold laser during these procedures should be mindful of the amount of kJ they use.

Treatment of post-tonsillectomy hemorrhage with nebulized tranexamic acid: A retrospective study

OBJECTIVE

To evaluate the association of treatment with nebulized tranexamic acid (TXA) with rates of operative intervention in post-tonsillectomy hemorrhage (PTH).

METHODS

Single tertiary-referral center and satellite hospitals, retrospective cohort of adult and pediatric patients who were diagnosed with PTH in 2015-2022 and treated with nebulized TXA and standard care, compared with an age- and gender-matched control cohort treated with standard care. Patients were typically treated in the emergency department with a single dose of 500mg/5 mL TXA delivered via nebulizer.

RESULTS

1110 total cases of PTH were observed, and 83 were treated with nebulized TXA. Compared to 249 age- and gender-matched PTH controls, TXA-treated patients had a rate of operating room (OR) intervention of 36.1% versus 60.2% (p < 0.0001) and a rate of repeat bleeding of 4.9% versus 14.2% (p < 0.02). The odds ratio for OR intervention with TXA treatment was 0.37 (95% CI 0.22, 0.63). There were no adverse effects identified with an average follow-up time of 586 days.

CONCLUSION

Treatment of PTH with nebulized TXA is associated with lower rates of operative intervention and lower rates of repeat bleeding events. Prospective studies are needed to further characterize efficacy and optimal treatment protocols.

LEVEL OF EVIDENCE: 3

Implication of American Society of Anesthesiologists Physical Status (ASA-PS) on tonsillectomy with or without adenoidectomy outcomes

BACKGROUND

The American Society of Anesthesiologists Physical status classification (ASA-PS) is a simple categorization of a patient's physiological status during the perioperative period. The role of ASA-PS in predicting operative risk and complications following tonsillectomy with or without adenoidectomy (T ± A) has not been studied. The objective of the study was to identify the association of the pre-operative ASA-PS with 30-day complication rates and adverse events following T ± A.

STUDY DESIGN

A retrospective analysis was performed using data from the American College of Surgeons' National Surgical Quality Improvement Program database (ACS NSQIP) of patients aged 16 years or older who underwent T ± A between 2005 and 2016. Patients were stratified into ASA-PS Classes I/II and III/IV. Patient demographics, preoperative comorbidities, pre-operative laboratory values, operation-specific variables, and postoperative outcomes in the 30-day period following surgery were compared between the two subsets of ASA-PS groups.

RESULTS

On multivariate analysis, patients with ASA class III and IV were more likely to experience an unplanned readmission (OR 1.39, 95 % CI 1.09-1.76; p = 0.007), overall complications (OR 1.49, 95 % CI 1.28-1.72; p < 0.001), major complications (OR 1.52, 95 % CI 1.31-1.77, p ≤ 0.001), reoperation (OR 1.33, 95 % CI 1.04-1.69; p = 0.022), and extended length of stay >1 day (OR 1.78, 95 % CI 1.41-2.25; p < 0.001) following a T ± A.

CONCLUSION

Higher ASA-PS classification is an independent predictor of complications following T ± A. Surgeons should aim to optimize the systemic medical conditions of ASA-PS classes III and IV patients prior to T ± A and implement post-operative management protocols specific to these patients to decrease morbidity, complications, and overall health care cost.

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.

Perioperative management in chronically anticoagulated children undergoing tonsillectomy

BACKGROUND

When undergoing tonsillectomy, patients at high risk of thrombosis who require chronic anticoagulation therapy pose a special challenge as bleeding may occur up to 2 weeks after surgery. Because of a lack of evidence-based data, there is no consensus on the best management for such patients. The objective of our study was to review perioperative anticoagulation bridging strategies in children undergoing tonsillectomy.

METHODS

The study group were a retrospective series of patients on chronic anticoagulation therapy at high risk of a thromboembolic event, who underwent tonsillectomy from 2010 to 2021. Patients whose anticoagulation treatment was discontinued because of a low risk of thromboembolic events were excluded.

RESULTS

Four patients met the inclusion criteria (age range, 1.5-16.1 years). All patients were admitted prior to surgery for bridging therapy with intravenous unfractionated heparin (UFH), drip-titrated to a therapeutic dose until 4-6 h prior to surgery. The estimated blood loss during surgery was minimal in all surgeries. Unfractionated heparin was readministered according to the hospital protocol on the night of surgery and titrated to a therapeutic dose. Warfarin was restarted within 2 days postsurgery for all patients. High-risk patients were kept in hospital until postoperative day 6-8 because of concern for delayed bleeding. One patient was noticed to have blood-tinged sputum requiring no intervention; none of the patients developed early or delayed hematemesis.

CONCLUSIONS

Our data show that bridging therapy with UFH has been successful in chronically anticoagulated patients undergoing tonsillectomy. These patients require multidisciplinary care for the management of their pre- and postoperative course.

A novel classification and grading scale of palatine tonsil anatomy in children

PURPOSE

The influence of tonsil anatomical differences on post-tonsillectomy hemorrhage and pain has not been studied yet. This study aimed to establish a classification and grading scale of palatine tonsil anatomy, not size, for personalized post-tonsillectomy care.

METHODS

Between August 2020 and August 2021, 337 children who underwent extracapsular tonsillectomy were recruited. The images of tonsil anatomy during the surgery were recorded and then classified and graded. Postoperative hemorrhage was recorded, and the degree of pain was measured using a visual analog scale (VAS). The primary outcomes were the associations between postoperative hemorrhage, pain, and the classification and grade of tonsil anatomy, analyzed by univariable and multivariable analyses.

RESULTS

186 of the 337 patients (55.2%) were male and 151 (44.8%) were female; the mean age was 5.59 years. The overall postoperative hemorrhage rate was 4.1%. The mean postoperative VAS score was 4.96. By univariable analysis with logistic regression model, significant associations were found between postoperative hemorrhage and the grade 2 and grade 3 tonsillar lower pole, and grade 3 tonsillar bed. Multivariable analysis with binary logistic regression model also revealed significant associations between postoperative hemorrhage and the grade 2 and grade 3 lower pole (OR: 8.23, 95% CI 1.01-67.37, P = 0.049; OR: 23.86, 95% CI 2.22-56.47, P = 0.009, respectively) and grade 3 tonsillar bed (OR: 14.25, 95% CI 1.46-18.75, P = 0.022). Linear regression analysis showed the associations between postoperative pain and grade 2 and grade 3 lower pole (β: 0.88, 95% CI 0.31-1.32, P = 0.002; β: 1.56, 95% CI 1.29-3.29, P = 0.001, respectively) and grade 3 anterior surface (β: 0.85, 95% CI 0.30-3.07, P = 0.004). Age and upper pole were not associated with the postoperative hemorrhage and pain neither.

CONCLUSION

In the present study, we established a novel classification and 3-grade scale of palatine tonsil anatomy, based on upper pole, anterior surface, lower pole, and tonsillar bed. Furthermore, we revealed for the first time that some anatomical characteristics of tonsils were associated with post-tonsillectomy complications.

Tonsillectomy and Adenoidectomy - Pediatric Clinics of North America

Tonsillectomy and adenoidectomy are among the most commonly performed major pediatric operations in the United States, with more than 500,000 procedures performed annually. This procedure can be performed with or without adenoidectomy. These procedures were traditionally performed for recurrent tonsillitis; however, the vast majority of tonsillectomies are currently performed for obstructive symptoms. When performed for appropriate indications, tonsillectomy and adenoidectomy can greatly improve a child's quality of life and general health. Given the prevalence of these conditions and subsequent surgical procedures, evidence-based recommendations are regularly evaluated and updated. As such, familiarity with these guidelines is necessary for pediatric practitioners. This review summarizes the indications, complications, and outcomes for tonsillectomy and adenoidectomy, as well as provides a brief overview of operative techniques.

Pediatric Anesthesia Management for Post-Tonsillectomy Bleed: Current Status and Future Directions

After medical stabilization, several techniques are considered for anesthesia in the surgical intervention of post-tonsillectomy bleeding in children. Hypoxia during induction of general anesthesia occurs more frequently than aspiration for this population. While classical (apneic) rapid sequence induction and intubation with cricoid pressure still has a role, controlled rapid sequence induction and intubation that incorporates mask ventilation at low pressure (<12 cm H₂O) before direct laryngoscopy under a deep plane of anesthesia is a viable alternative for cases of slow venous bleeding. Supplemental oxygen delivery during laryngoscopy to permit apneic oxygenation is a future trend in management. While the routine administration of tranexamic acid during tonsillectomy has not been shown to be of benefit, it may have a role in post-tonsillectomy hemorrhage with further study.

Post-tonsillectomy Hemorrhage: A Seven-year Retrospective Study

Introduction:

Post-tonsillectomy hemorrhage (PTH) is a serious complication that sometimes requires immediate surgical interventions. The present study aimed to assess the association between patients’ age, the time of onset of PTH, and the need for surgery to control bleeding.

Materials and Methods:

All patients with PTH were retrospectively admitted to two tertiary hospitals in Mashhad, during 2012-2019. Hospital records were investigated to select eligible cases and retrieve their characteristics such as demographics, source and time of bleeding, and type of intervention. Chi-square, independent samples T-test, and binary logistic regression were used as research tools.

Results:

A total of 227 patients with PTH and a mean age of 14.99±10.34 years were studied, of whom 128 (56.4%) were male and 63 (27.8%) required surgery to control PTH. The mean onset of PTH was 8.14±3.47 days after the surgery and in 59 cases (26.5%) was the seventh day. Those patients aged 6 years or older in whom PTH occurred during the first postoperative week were significantly more likely to need surgery to control it (P= 0.034). Adult (OR= 4.032, 95%CI= 1.932-8.414, P<0.001), bleeding from both tonsils (OR= 2.380, 95%CI= 1.032-5.487, P= 0.042), and receiving blood transfusion (OR= 7.934, 95%CI= 2.003-31.422, P= 0.002) were independent predictors of the need for surgical treatment to control PTH.

Conclusion:

PTH within the first postoperative week in patients older than 6 years, adults, bleeding from both tonsils, and receiving a blood transfusion is recommended to be considered as a potential predictor of the need for surgery.

Detecting coagulopathy in pediatric patients with post-tonsillectomy hemorrhage

INTRODUCTION

Post-tonsillectomy hemorrhage (PTH) is a serious complication after a tonsillectomy. Utility of lab work at presentation for PTH was low. This study aims to determine the frequency and type of labs drawn at emergency department (ED) presentation and assess the incidence of uncovering a previously unidentified coagulopathy.

METHODS

A retrospective chart review was performed on pediatric patients who were seen in the ED after tonsillectomy at a tertiary care children's hospital from 2017 to 2019. Exclusion criteria were the following: no tonsillar bleed, history of known coagulopathy, treated by outside provider, ≥18 years old. Lab work included complete blood count (CBC), prothrombin time (PT), partial thromboplastin time (PTT), and von Willebrand factor (VWF).

RESULTS

364/723 (50.3%) patients met inclusion criteria. 179/364 (49.2%) patients were male and 309/364 (84.9%) patients were Caucasian. Average age at surgery was 8.12 years (SD = 4.0) and average post-operative day at presentation was 6 days (SD = 2.1). Operative control of bleed was performed in 68/364 (18.7%) patients. 334/364 (91.8%) patients had labs drawn in the ED. 64/334 (19.1%) patients were anemic (hemoglobin (Hgb) < 11), 46/334 (13.8%) patients had thrombocytosis (platelets>450,000), 10/334 (3.0%) had elevated PTT and 8/334 (2.4%) had elevated PT. Hematology was consulted in 14/364 (3.8%) patients of whom 6/14 were diagnosed with von Willebrand disease and 1/14 with factor VII deficiency. Aminocaproic acid was used in 8/364 (2.2%) patients due to elevated PTT in 3/8 and multiple episodes of bleeding in 5/8.3/364 (0.8%) patients needed a blood transfusion. No difference was found in incidence of abnormal lab work in patients who did and did not need operative control of bleed (p = .125). Of the 334 patients who had ED labs drawn, 7 (2.1%) had an uncovered coagulopathy.

CONCLUSION

Uncovering incidental coagulopathies is rare in patients who present with PTH. Though anemia was the most common abnormality noted, only a small percentage required transfusion, with all having abnormal vital signs. Thrombocytosis was the next common abnormality, and this can be seen in an inflammatory state. Developing algorithms is necessary to better guide appropriate lab work in patients who present with PTH and to provide optimal value of care to patients.

Post-tonsillectomy hemorrhage control with nebulized tranexamic acid: A retrospective cohort study

OBJECTIVE

Evaluate nebulized tranexamic acid (TXA) as a treatment to reduce the need for an operation to control a post-tonsillectomy hemorrhage (PTH).

METHODS

Based on a successful case report of a child treated with nebulized TXA for PTH in 2018, our institution began to treat PTH patients with three doses of nebulized TXA. To evaluate the outcomes of this non-invasive management, we conducted a three-year retrospective cohort study of children presenting with PTH from 2016 to 2019. Demographics, insurance, and laboratory information were collected from all pediatric tonsillectomies with and without adenoidectomy performed during the study period. Tonsillar fossae observations of bleeding and clot were documented before and after receiving TXA.

RESULTS

The incidence of pediatric PTH at our institution during the study period was 5.4%. Fourteen out of 58 PTH patients received nebulized TXA. Receiving nebulized TXA had no adverse events and over 60% showed resolution of bleeding on exam. Receiving nebulized TXA compared to routine care decreased the need for an operation to restore hemostasis by 44%, p < 0.005. There was no significant difference in age, gender, body mass index, hemoglobin, platelet count, trainee presence, or Medicaid status between the children that received TXA and those that did not.

CONCLUSION

Treatment of PTH with nebulized TXA may be a safe first-line therapy to decrease the need for operative control of bleeding. This data suggests that a large clinical trial is needed to determine the efficacy of nebulized TXA to mitigate this common and potentially fatal post-operative complication.

LEVEL OF EVIDENCE

4.

Predictive clinical exam findings in post-tonsillectomy hemorrhage

OBJECTIVES

Post tonsillectomy hemorrhage (PTH) is a common complication of tonsillectomy. Our objectives were to: 1) Examine the postoperative course of patients presenting to St. Christopher's Hospital for Children (SCHC) with PTH; 2) Compare patients with and without a blood clot visualized in the tonsillar fossa at time of presentation to determine if outcomes regarding return to the operating room (OR) differ.

METHODS

This was a retrospective chart review conducted at an academic, tertiary, pediatric hospital in an urban setting. Pediatric patients who underwent a tonsillectomy with concurrent adenoidectomy and were admitted for observation following secondary post tonsillectomy hemorrhage were reviewed. The effects of age, gender, indication, and clinical exam findings on admission on the rate of eventual return to the OR for control of hemorrhage were also analyzed. Chi-square analysis and Fisher's exact test were used to compare the significance of categorical frequencies.

RESULTS

The rate of blood clot presence in our cohort was 50.9% (28/55). Return to OR rates were defined as patients who began actively hemorrhaging following admission for observation, further stratified by presence or absence of clot on admission physical exam. There was a statistically significant higher rate of return to OR in patients who presented with a clot (46.6%) on clinical exam versus no clot (18.5%) after resolved post tonsillectomy hemorrhage (p < .027). Furthermore, patients with a blood clot present were significantly more likely to require OR sooner (21.31 h from admission) than those without a clot (100.75 h from admission) (p < .012). There was no statistically significant higher rate of blood clot presence or rate of return to OR in groups based on age, gender, or indication.

DISCUSSION

Pediatric patients presenting after resolved secondary PTH with a blood clot visualized in the tonsillar fossa are more likely to require return to the OR for hemostasis and cautery than are those without a blood clot, and this is more likely to occur within 24 h of admission. Thus, patients with a blood clot on initial presentation may benefit from admission for a 24-h observation period, while a similar observation period may be unproductive for patients without a blood clot.

CONCLUSIONS

Patients who present with a resolved secondary PTH and a blood clot present on clinical exam require return to the OR more often than patients presenting without a blood clot. While previously controversial, we feel that this demonstrates that a 24-h observation of a patient with a clot on exam is reasonable.

Delayed Hemorrhage Following Laser Frenotomy Leading to Hypovolemic Shock

Ankyloglossia is a failure of the tongue to release from the oral floor with reported consequences that include breastfeeding difficulties and speech impediments. Frenotomy is a commonly performed procedure for the treatment of ankyloglossia. Laser (light amplification by stimulated emission of radiation) is one of several mediums used to perform frenotomies. Although most frenotomies are uncomplicated, there remains a small possibility of complication, such as infection, pain, ductal injury, and hemorrhage, even in expert hands. Because frenotomies are most often performed in infants, postoperative hemorrhage is an important complication to look for as even small amount of bleed may prove fatal, due to low blood volume reserve. We report a case of delayed hemorrhage after laser frenotomy in a 6-week old infant displaying shock symptoms and required fluid resuscitation.

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.

Is Postextracapsular Tonsillectomy Bleeding More Common on the Side of the Surgeon's Nondominant Hand?

OBJECTIVES

To determine the difference in bleeding when extracapsular tonsillectomy with electrocautery is performed on the dominant and nondominant side of the surgeon's hands.

STUDY DESIGN

Retrospective cohort study.

SETTING

Academic university hospital.

METHODS

Medical record data of patients who were admitted with posttonsillectomy bleeding from January 1, 2000, to July 31, 2017, were reviewed. Included were age, sex, surgical indication, side of posttonsillectomy bleeding, and time of bleeding. Information on the surgeon's dominant hand was also collected. All patients underwent total extracapsular resection with electrocautery.

RESULTS

Of 280 patients, 186 met the inclusion criteria, 116 (62.3%) males and 70 (37.7%) females. Ages ranged from 2 to 74 years (mean ± SD, 17 ± 13 years; median, 13 years). In 136 cases (73.1%), bleeding was on the side of the surgeon's nondominant hand (P < .0001). In 50 (26.9%) cases, bleeding was on the side of the surgeon's dominant hand. The odds ratio of bleeding on the side of the surgeon's nondominant hand compared to the dominant hand was 8.99.

CONCLUSION

The risk of bleeding following extracapsular tonsillectomy with electrocautery on the side of the surgeon's nondominant hand is significantly higher than on the side of the dominant hand. Thus, additional caution is required when operating on the nondominant side of the oral cavity in extracapsular tonsillectomy using electrocautery. These findings raise questions regarding dexterity as a risk factor for posttonsillectomy bleeding.

Post-Tonsillectomy Hemorrhage and the Diagnosis of Occult Pediatric Coagulopathies

OBJECTIVES/HYPOTHESIS

The primary objective of this investigation was to determine rates of abnormal coagulation panels and diagnoses of coagulopathies in children with post-tonsillectomy hemorrhage (PTH). Secondary objectives identified patient demographics and hemorrhage event characteristics that correlated with a coagulopathy diagnosis.

STUDY DESIGN

Case series with chart review.

METHODS

Patients requiring operative control of PTH at a tertiary children's hospital between 2015 and 2019 were included. Details of tonsillectomy procedures and hemorrhage events were reviewed along with screening labs for coagulopathy, referrals to hematology and bleeding disorder diagnoses.

RESULTS

There were 250 children included. Mean age was 8.8 years (95% CI: 8.2-9.4) and 53.6% were males. PTH events occurred at a median of postoperative day six (mean: 5.9, 95% CI: 5.4-6.3), and 14.8% occurred within 24 hours of surgery. In this series, 23 patients (9.2%) had a second PTH, and three (1.2%) had a third PTH. Single and multiple PTH patients were similar with respect to age, gender, postoperative day, and technique (P > .05). Screening coagulation panels were obtained on presentation in 67.8% of children with one PTH and abnormally elevated in 38.3%. All children with multiple PTHs had labs drawn with 34.8% having elevated levels. No child with a single PTH was diagnosed with a bleeding disorder. Conversely, 87.0% of children with multiple PTHs saw hematology and three (13.0%) were diagnosed with a bleeding disorder (P < .001).

CONCLUSIONS

Obtaining coagulation panels in pediatric patients presenting with PTH is rarely useful and diagnosing a coagulopathy is uncommon. However, among children with a second PTH, referral to hematology is reasonable as this group has a significantly higher, albeit small, incidence of undiagnosed bleeding disorders.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E2069-E2073, 2021.

Improved cancer detection in Waldeyer's tonsillar ring by 68Ga-FAPI PET/CT imaging

Purpose

In cancer of unknown primary (CUP), positron emission tomography/computed tomography (PET/CT) with the glucose analog [¹⁸F]FDG represents the standard imaging approach for localization of the malignant primary. Frequently, however, [¹⁸F]FDG PET/CT cannot precisely distinguish between small occult tumors and chronic inflammation, especially in Waldeyer’s tonsillar ring. To improve the accuracy for detecting primary tumors in the Waldeyer’s tonsillar ring, the novel PET tracer [⁶⁸Ga]Ga-FAPI-4 for specific imaging of fibroblast activation protein (FAP) expression was used as a more specific target for cancer imaging.

Methods

Eight patients with suspicion of a malignant tumor in Waldeyer’s tonsillar ring or a CUP syndrome were examined. PET/CT scans with [¹⁸F]-FDG and [⁶⁸Ga]Ga-FAPI-4 were performed for pre-operative tumor localization. After surgical resection, histopathological and immunohistochemical results were compared to PET/CT findings.

Results

Histopathology revealed a palatine or lingual tonsil carcinoma in all patients. In case of lymph node metastases smaller than 7 mm in size, the [¹⁸F]FDG PET/CT detection rate of cervical lymph node metastases was higher than that of [⁶⁸Ga]FAPI PET/CT, while both tracers identified the primary tumors in all eight cases. The size of the primary and the lymph node metastases was directly correlated to the respective FAP expression, as detected by immunohistochemistry. The mean SUV_max for the primary tumors was 21.29 ± 7.97 for ¹⁸F-FDG and 16.06 ± 6.29 for ⁶⁸Ga-FAPI, respectively (p = 0.2). The mean SUV_max for the healthy contralateral tonsils was 8.38 ± 2.45 for [¹⁸F]FDG and 3.55 ± 0.47 for [⁶⁸Ga]FAPI (p < 0.001). The SUV_max ratio of [⁶⁸Ga]FAPI was significantly different from [¹⁸F] FDG (p = 0.03). Mean TBR_max for the [⁶⁸Ga]Ga-FAPI-4 tracer was markedly higher in comparison to [¹⁸F]FDG (10.90 vs. 4.11).

Conclusion

Non-invasive imaging of FAP expression by [⁶⁸Ga]FAPI PET/CT resulted in a better visual detection of the malignant primary in CUP, as compared to [¹⁸F]FDG imaging. However, the detection rate of lymph node metastases was inferior, presumably due to low FAP expression in small metastases. Nevertheless, by offering a detection method for primary tumors with the potential of lower false positive rates and thus avoiding biopsies, patients with CUP syndrome may benefit from [⁶⁸Ga]FAPI PET/CT imaging.

Application of Coblation Tonsillectomy with Inferior Pole Capsule Preservation in Pediatric Patients

OBJECTIVES/HYPOTHESIS

To evaluate the application and advantages of coblation tonsillectomy with inferior pole capsule preservation in pediatric patients with tonsillar hypertrophy and recurrent tonsillitis.

STUDY DESIGN

Retrospective chart review.

METHODS

A total of 726 children who were diagnosed with either tonsillar hypertrophy or recurrent tonsillitis were included. Children were divided into two groups according to the surgical technique: conventional coblation tonsillectomy and coblation tonsillectomy with inferior pole capsule preservation. The duration of surgery, intraoperative hemorrhage volume, and postoperative pain, as well as postoperative hemorrhage data in the format of time, location, and degree were compared between the two groups.

RESULTS

Of the 726 children included, conventional coblation tonsillectomy was performed in 320 children, coblation tonsillectomy with inferior pole capsule preservation was performed in 406 children. There were no significant differences in duration of surgery or intraoperative hemorrhage volume between the two groups. Children who underwent coblation tonsillectomy with inferior pole capsule preservation showed a remarkable improvement in postoperative pain on days 3 and 5 postoperatively. Additionally, the coblation tonsillectomy with inferior pole capsule preservation group exhibited a significantly lower total postoperative hemorrhage rate, secondary hemorrhage rate, and hemorrhage rate in the inferior pole compared with that in the conventional coblation tonsillectomy group. During the 1-year follow-up period, no cases of tonsillar re-hypertrophy or recurrent tonsillitis were observed in either group.

CONCLUSION

For pediatric tonsillar hypertrophy and recurrent tonsillitis, coblation tonsillectomy with inferior pole capsule preservation is a safe and effective technique, capable of reducing postoperative pain and hemorrhage, especially secondary hemorrhage at the inferior pole.

LEVEL OF EVIDENCE

3b Laryngoscope, 131:1157-1162, 2021.

A Case Report of Nebulized Tranexamic Acid for Post-tonsillectomy Hemorrhage in an Adult

Introduction

Post-tonsillectomy hemorrhage is a potentially life-threatening, postoperative complication that is commonly encountered in the emergency department (ED).

Case Report

Herein, we describe the case of a 22-year-old male who presented to the ED with an active post-tonsillectomy hemorrhage. He rapidly became hypotensive and experienced an episode of syncope. Immediate interventions included intravenous fluids, emergency release blood and nebulized tranexamic acid (TXA). After completion of the nebulized TXA, the patient’s bleeding was controlled.

Conclusion

To our knowledge, this is the first case in the emergency medicine literature that describes the use of nebulized TXA in an adult to achieve hemostasis in post-tonsillectomy hemorrhage.

Patient Safety in Anesthesia

Anesthesiologists and otolaryngologists share the airway in an elegant ballet that requires communication, collaboration, and mutual respect. This article addresses principles to prevent or manage challenging conditions such as airway fires, anatomically difficult airways, and post-tonsillectomy hemorrhage. Discussion includes rationales for the use of simulation and resilience engineering principles to achieve the safest patient care.

Topical biomaterials to prevent post-tonsillectomy hemorrhage

Despite advances in surgical technique, postoperative hemorrhage remains a common cause of mortality and morbidity for patients following tonsillectomy. Application of biomaterials at the time of tonsillectomy can potentially accelerate mucosal wound healing and eliminate the risk of post-tonsillectomy hemorrhage (PTH). To understand the current state and identify possible routes for the development of the ideal biomaterials to prevent PTH, topical biomaterials for eliminating the risk of PTH were reviewed. Alternative topical biomaterials that hold the potential to reduce the risk of PTH were also summarized.

Risk factors of post-tonsillectomy dysgeusia

OBJECTIVE

To investigate risk factors for dysgeusia after tonsillectomy.

METHODS

A retrospective survey of medical records identified 318 patients (163 male and 155 female subjects aged 12-75 years, average 41.7±16.1 years) who underwent tonsillectomy.

RESULTS

Thirty three patients (10.4%) and seven patients (2.2%) reported suffering from dysgeusia three and six months after tonsillectomy, respectively. Average age, serum level of Zn and operation time were not significantly different between positive and negative findings of dysgeusia. Women with positive findings of dysgeusia (72.7%) was significantly higher than men (27.3%) (Odds ratio: 3.276, 95% CI: 1.441-7.450, p<0.005). A chi-square test of independence was calculated comparing the frequency of dysgeusia in under 60 years old group (13-59 years-old) and 60 years old and over group (60-75 years-old). A significant interaction was found (χ2 (1)=5.238. p<0.05).

CONCLUSIONS

Women and under 60 years old patients had a significantly higher rate of dysgeusia after tonsillectomy. It is recommended that patients are informed of the potential postoperative complication of dysgeusia.

Massive recurrent post-tonsillectomy bleedings revealing a transient factor XIII deficiency in a 10-year-old boy. A case report

A previously healthy 10-year-old boy was hospitalized for a left cervical abscess associated with massive tonsillar hypertrophy. He underwent abscess drainage and bilateral tonsillectomy. At H36 post-surgery, he presented with tonsillar hemorrhage requiring surgical revision. Hemorrhage relapsed 2 days later, with a total of 7 episodes, 5 of which required surgical revisions. Laboratory investigations were normal except for a markedly low factor XIII (FXIII) activity at 7%. After administration of a single dose of 40 IU/kg plasma-derived FXIII (Fibrogammin^®) I.V., the bleeding stopped with no further recurrence. FXIII activity gradually normalized (75%) at 6 weeks, confirming the transient character of factor XIII deficiency. Severe congenital FXIII deficiency (FXIIID) (<1%) is very rare (1:2,000,000 births), whereas partial congenital deficiency and/or acquired deficiency may be more frequent but likely underreported. Acquired FXIIID may result from impaired synthesis (liver failure) or increased consumption (surgery, sepsis, leukemia, Henoch-Schönlein, inflammatory bowel disease, stroke, disseminated intravascular coagulation). FXIII replacement in form of fresh frozen plasma (FFP) or plasma-derived FXIII may be necessary for the presence of bleeding.

Patient injuries in pediatric otorhinolaryngology

OBJECTIVES

Patient injuries in children can have lifelong effects on the patient and a marked impact on the whole family. The aim of this study was to identify the errors and incidents leading to patient injuries in pediatric otorhinolaryngology (ORL) by evaluating accepted patient injury claims.

METHODS

The records of all accepted patient injury claims in ORL between 2001 and 2011 were searched from the nationwide Patient Insurance Centre registry. Pediatric injuries were reviewed and evaluated in detail, and factors contributing to injury were identified.

RESULTS

In the 10-year study period, 17 (7.6%) of the 223 patient injuries occurred in children, and of these, 15 (88%) were considered operative care. The median age of the patients was 8 years (range 3-16 years). All operations were performed as daytime elective surgery and by a fully trained specialist in 93% of the cases. One-half of the cases were routine surgeries for common ORL diseases. The most common incidences were incomplete surgery, retained gauze or foreign body, injury to adjacent anatomic structure, and insufficient charts or instructions (each occurred in 3 cases). The most frequent consequence was burn (n = 4). One child died because of post-tonsillectomy hemorrhage.

CONCLUSIONS

Patient injuries in pediatric ORL are strongly related to surgery. Most injuries occurred after routine operations by a fully trained specialist. Clinicians should be aware of the most likely scenarios resulting in claims.

Paediatric Posttonsillectomy Haemorrhage Rates in Auckland: A Retrospective Case Series

Background

Tonsillectomy is one of the most commonly performed surgical procedures in children. It is performed for sleep-disordered breathing and infective symptoms. Despite advances in instrumentation and perioperative care, posttonsillectomy haemorrhage (PTH) remains a significant complication, which should be audited regularly.

Methods

A retrospective case series of all tonsillectomies performed in patients <15 years old in the Auckland region during 2017 was performed. Demographic, clinical, and surgical data were extracted and analysed. Univariate analysis was performed to compare patients with and without PTH.

Results

A total of 2177 tonsillectomies were performed during the study period, 64% in a public hospital and 36% in a private hospital. The overall PTH rate was 3.6% (0.23% occurring within the first 24 hours (primary) and 3.4% after 24 hours (secondary)). Mean time to PTH was 6.6 ± 3 days (range: 1-16 days). 90% of PTH occurred within the first 10 days and 99% by 14 days. Return to theatre was required in 28% of these cases, representing 1% of all tonsillectomies. There were no deaths or major complications in this cohort. The only differences observed between patients with PTH and those without were that children with PTH had smaller tonsils (p=0.004) and were less likely to have associated OME (p<0.001).

Conclusion

It is important to report institutional tonsillectomy outcomes and associated complications. These results show that PTH rates in Auckland remain within acceptable limits according to the literature.