Does primary indication for tonsillectomy influence post-tonsillectomy haemorrhage rates in children?

Adenotonsillectomy for Obstructive Sleep Apnea in Children

Obstructed breathing is the most common indication for tonsillectomy in children. Although tonsillectomy is performed frequently worldwide, the surgery is associated with a number of significant complications such as bleeding and respiratory failure. Complication risk depends on a number of complex factors, including indications for surgery, demographics, patient comorbidities, and variations in perioperative techniques. While polysomnography is currently accepted as the gold standard diagnostic tool for obstructive sleep apnea, studies evaluating outcomes following surgery suggest that more research is needed on the identification of more readily available and accurate tools for the diagnosis and follow-up of children with obstructed breathing.

The Impact of Surgical Indication on Posttonsillectomy Hemorrhage: A Systematic Review and Meta-Analysis

OBJECTIVE

To investigate the impact of the surgical indication on posttonsillectomy bleed rates.

DATA SOURCES

PubMed, Scopus, CINAHL.

REVIEW METHODS

A systematic review was performed searching for articles published from the date of inception to July 6, 2022. English language articles describing posttonsillectomy hemorrhage rates in pediatric patients (age ≤ 18) stratified by indication were selected for inclusion. A meta-analysis of proportions with comparison (Δ) of weighted proportions was conducted. All studies were assessed for risk of bias.

RESULTS

A total of 72 articles with 173,970 patients were selected for inclusion. The most common indications were chronic/recurrent tonsillitis (CT/RT), obstructive sleep apnea/sleep-disordered breathing (OSA/SDB), and adenotonsillar hypertrophy (ATH). Posttonsillectomy hemorrhage rates for CT/RT, OSA/SDB, and ATH were 3.57%, 3.69%, and 2.72%, respectively. Patients operated on for a combination of CT/RT and OSA/SDB had a bleed rate of 5.99% which was significantly higher than those operated on for CT/RT alone (Δ2.42%, p = .0006), OSA/SDB alone (Δ2.30%, p = .0016), and ATH alone (Δ3.27%, p < .0001). Additionally, those operated on for a combination of ATH and CT/RT had a hemorrhage rate of 6.93%, significantly higher than those operated on for CT/RT alone (Δ3.36%, p = .0003), OSA/SDB alone (Δ3.01%, p = .0014), and ATH alone (Δ3.98%, p < .0001).

CONCLUSION

Patients operated on for multiple indications had significantly higher rates of posttonsillectomy hemorrhage than those operated on for a single surgical indication. Better documentation of patients with multiple indications would help further characterize the magnitude of the compounding effect described here.

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.

Hemorrhage after adenotonsillectomy in children: tertiary center experiences

BACKGROUND

Adenotonsillectomy is the most commonly performed surgery in the pediatric population. Hemorrhage after adenotonsillectomy, which can occur at any time postoperatively, is one of the most serious complications.

OBJECTIVE

To determine the frequency of hemorrhage in children after adenotonsillectomy and to compare postoperative hemorrhage with regard to age and sex.

METHODS

A cross-sectional longitudinal study was conducted at the Ear, Nose, and Throat Clinic, University Clinical Center Tuzla, and included all children of both sexes, aged 3 to 15 years, who underwent adenotonsillectomy during a 1.5-year period.

RESULTS

A total of 201 children aged 3-15 years underwent adenotonsillectomy, 113 males and 88 females, which corresponds to a ratio of 1.28: 1. Adenotonsillectomy was performed in 147 (73.1%) patients and adenoidectomy in 54 (27%). In the overall sample, there were 19 (9.5%) subjects with postoperative hemorrhage. Primary hemorrhage occurred in 9 subjects (47%) and secondary hemorrhage in 10 subjects (53%). Significantly more female subjects had postoperative hemorrhage. In the group of subjects with hemorrhage, the mean age (standard deviation) was 8.45 (3.3) years. Tonsillar lodges are common sites of hemorrhage.

CONCLUSION

The frequency and causes of hemorrhage after adenotonsillectomy in our study are partially comparable to the world data.

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

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

Post-tonsillectomy 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.

Tonsillotomy versus Tonsillectomy for Chronic Recurrent Tonsillitis in Children

Objective

This study was conducted to compare two different surgical methods; partial tonsil resection using the bipolar technique, tonsillotomy (TT), and total tonsillectomy (TE) (blunt dissection) for recurrent tonsillitis in children. The frequency of recurrent throat infections was determined during postoperative follow-up.

Methods

A total of 393 patients were included in this study. TT was performed on 174 patients (100 males, 74 females) and TE on 219 patients (112 males, 107 females). Following surgery, an analysis was made of treatment outcomes of patients with upper respiratory tract infections. The patients were followed up for 12-48 months. Their parents were also contacted by telephone to determine the frequency of reinfection and their satisfaction with the surgery. Also, parents of the patients completed a questionnaire pertaining to postoperative satisfaction (scale of 1-10).

Results

In the TT group, 14 (8.1%) patients had recurrent tonsillitis postoperatively. In the TE group, 12 (5.4%) patients required antibiotherapy due to recurrent pharyngitis after the surgery. There was no significant difference between the two groups in terms of the one-year infection recurrence rate after surgery (p=0.281). Three patients (1.6%) in the TT group and 12 (5.4%) in the TE group complained of bleeding within the first 24 hours. The rate of bleeding was significantly lower in the TT group than the TE group (p=0.001). There were no fatalities in either group.

Conclusion

In both groups, the rate of reinfection accorded with the requirement for postoperative antibiotics. For recurrent tonsillitis, TT was as effective as TE. However, TT was superior in terms of the risk of bleeding.

Association of Blood Type With Postsurgical Mucosal Bleeding in Pediatric Patients Undergoing Tonsillectomy With or Without Adenoidectomy

IMPORTANCE

Blood type (BT) O has been identified as a risk factor for bleeding complications, while non-O BTs may increase risk for thromboembolic events. Limited data are available in children undergoing tonsillectomy with or without adenoidectomy.

OBJECTIVE

To determine whether BT O is associated with hemorrhage after tonsillectomy with or without adenoidectomy.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study of patients younger than 22 years who underwent tonsillectomy with or without adenoidectomy at a single institution between January 1, 2008, and August 7, 2017. Statistical analysis was performed from November 2017 to January 2019.

MAIN OUTCOMES AND MEASURES

Prevalence of hemorrhage following surgery was defined as any bleeding requiring cauterization up to 1 month after the procedure. Data on sex, age, von Willebrand disease (VWD) status, BT, white blood cell counts, and platelet counts closest to date of surgery were collected from an electronic medical record system, and the association of these factors with hemorrhage following surgery was investigated.

RESULTS

A total of 14 951 pediatric patients (median [range] age, 5.6 [0.8-21.9] years; 6956 [46.5%] female) underwent tonsillectomy with or without adenoidectomy. Prevalence of hemorrhage following the procedure was 3.9% (578 patients) for the full cohort and 2.8% (362 of 13 065) for patients with no BT identified or preprocedure VWD panel results at baseline. Children who had a BT identified and/or a VWD panel before surgery had higher bleeding rates (BT only, 14.9% [172 of 1156]; preprocedure VWD panel only, 4.6% [28 of 607]; and BT and preprocedure VWD panel, 13.0% [16 of 123]), all of which were significantly different from the baseline bleeding rate (P < .001). While the bleeding rates in children with BT O were not statistically different from those with non-O BT (14.8% and 14.6%, respectively; P > .99), mean von Willebrand factor values were statistically different (mean [SD] von Willebrand factor antigen level in O group, 86.9 [42.4] IU/dL in the O group vs 118.0 [53.8] IU/dL in the non-O group; P = .002; and mean [SD] von Willebrand factor ristocetin-cofactor in the O group, 72.2 [44.3] IU/dL vs 112.6 [68.0] IU/dL in the non-O group; P = .001). In addition, children older than 12 years had increased bleeding rates in the full cohort (8.3% vs 3.2%), in the testing-naive cohort (6.5% vs 2.3%), and in those with a preprocedure VWD panel only (13.5% vs 3.1%) compared with children aged 12 years or younger.

CONCLUSIONS AND RELEVANCE

Type O blood was not a risk factor associated with hemorrhage after tonsillectomy with or without adenoidectomy despite lower baseline von Willebrand factor antigen and von Willebrand factor ristocetin-cofactor values in children with BT O vs those with non-O BT in our study cohort. No association was found between VWD status and bleeding, and there was no difference in VWD panel values in those who experienced hemorrhage vs those who did not within BT groups. Further studies elucidating the utility of von Willebrand factor values for children undergoing tonsillectomy with or without adenoidectomy are needed.

Association Between Age and Weight as Risk Factors for Complication After Tonsillectomy in Healthy Children

Importance

The 1996 Tonsillectomy and Adenoidectomy Inpatient Guidelines of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) Pediatric Otolaryngology Committee recommended that children younger than 3 years be admitted following tonsillectomy. Recommendations for hospital observation were not included as a key action statement in the 2011 AAO-HNS Clinical Practice Guidelines for Tonsillectomy in Children.

Objective

To examine the association between posttonsillectomy complication rate and the age and weight of the child at the time of surgery.

Design, Setting, and Participants

This was a multicenter case series study with medical record review of 2139 consecutive children ages 3 to 6 years who underwent tonsillectomy at 1 tertiary care academic center and 5 acute care centers in New Orleans, Louisiana, between 2005 and 2015. Children with moderate to severe developmental delay, bleeding disorders, and other major medical comorbidities were excluded.

Main Outcomes and Measures

Complications examined included respiratory distress, dehydration requiring intravenous fluids, and bleeding.

Results

Of the 2139 patients, 1817 met inclusion criteria. A total of 1011 (55.6%) were male. The mean (SD) age at the time of the procedure was 46 (14) months (range, 12-72 months). The mean weight at the time of the procedure was 17 (5) kg (range, 9-43 kg). A total of 95 patients (5.2%) had a postoperative complication. Of the 455 children younger than 3 years in the study, 32 (7.0%) had complications compared with 63 (4.6%) of the 1362 patients 3 years or older. The odds of having a complication in children younger than 3 years was 1.5 times greater than it was in children 3 years or older (odds ratio [OR], 1.56; 95% CI, 1.00-2.42). When examining total complications, children younger than 3 years were more likely to experience a complication within the first 24 hours after surgery than children 3 years or older (25% vs 9.5%; OR, 3.17; 95% CI, 1.00-10.11). The children admitted to the hospital had a greater risk of complication than those treated as an outpatient, independent of age (6.9% vs 93.0%; OR, 3.49; 95% CI, 2.0.18-6.05). No association between weight and complications was found on logistic regression (area under the curve = 0.5268; P = .66).

Conclusions and Relevance

Healthy children younger than 3 years may be at an increased risk for complication following tonsillectomy. Those children may also be at increased risk for complications within the first 24 hours after surgery compared with children 3 years or older. Our data suggest that complications are independent of weight in these patients. In our cohort, those patients selected for overnight observation were associated with an increased number of adverse events following tonsillectomy, suggesting that clinician judgment is crucial in determining which patients are safe for outpatient tonsillectomy.

Predictors for hemorrhage following pediatric adenotonsillectomy

OBJECTIVE

To determine risk factors and trends for posttonsillectomy hemorrhage (PTH) following adenotonsillectomy (T&A) at a single children's tertiary referral hospital.

METHODS

Charts from all patients 2-12 years old undergoing T&A alone at a single children's hospital from January 1, 2010 through December 31, 2015 were reviewed. Data was collected on patient demographics, indication for procedure, time of year, academic affiliation of surgeon, surgical technique and method, post-operative pain medication prescribed,and readmission for PTH. Univariate chi-square analyses and logistic regression along with multivariable stepwise logistic regression were used to identify predictors of PTH. SPSS version 24 was used for statistical analyses with p < .05 indicating statistical significance.

RESULTS

There were 2565 children undergoing T&A during the study period. One hundred seventy-three (6.7%) patients were readmitted, of which 53 (30.6%) were due to PTH. Univariate analyses identified children at the highest age quartile of the study, 7.72-12.97 years old (odds ratio [OR] = 5.775, 95% confidence interval [CI] = 2.248-14.837, p < .001) and children with a BMI z-score of 2 or greater (OR = 3.391, 95% CI = 1.497-7.680, p = .003) were at increased risk for PTH. Multivariable analyses also identified both the highest age quartile and BMI z-score of 2 or greater to be a risk factor for PTH.

CONCLUSION

In children undergoing T&A, age greater than 7.72 years old and BMI z-score of 2 or greater are significant risk factors for PTH. Replication of these findings in a more highly powered trial is needed.

Is weight a predictive risk factor of postoperative tonsillectomy bleed?

Objective

To determine if a correlation exists between weight-for-age percentile and post-tonsillectomy hemorrhage in the pediatric population.

Study Design

Retrospective study.

Methods

1418 patients under the age of 15 who underwent tonsillectomy with or without adenoidectomy at a tertiary children's hospital between June 2012 and March 2015 were included in this retrospective study. Patient demographic information, operative and postoperative variables, as well as category and day of postoperative tonsillectomy bleed, if one occurred, were recorded. Fisher's exact and ordinal logistic regression analyses were performed on the full cohort.

Results

The overall post-tonsillectomy hemorrhage prevalence was found to be 2.2%, with primary and secondary rates of 0.78% and 1.34%, respectively. Weight-for-age percentile, sex, indication for or method of tonsillectomy, or postoperative use of NSAIDs, antibiotics or narcotics were not significantly associated with post-tonsillectomy hemorrhage. There was a significant relationship between postoperative use of dexamethasone and higher rate of Category 3 post-tonsillectomy hemorrhage (P = .028).

Conclusion

The post-tonsillectomy hemorrhage rate in our study is consistent with that cited in the literature. No correlation was demonstrated between weight-for-age percentile and occurrence of post-tonsillectomy hemorrhage. Postoperative administration of dexamethasone was associated with a significant increased rate of post-tonsillectomy hemorrhage requiring surgical intervention, a novel finding.

Level of Evidence

4.

Association Between Ibuprofen Use and Severity of Surgically Managed Posttonsillectomy Hemorrhage

Importance

Ibuprofen used in postoperative management of pain after tonsillectomy has not been shown to increase the overall risk for posttonsillectomy hemorrhage (PTH). The severity of bleeding is difficult to quantify but may be a more important outcome to measure.

Objective

To evaluate the association between ibuprofen use and severity of PTH using transfusion events as a marker of severity.

Design, Setting, and Participants

This retrospective cohort study identified 8868 patients who underwent tonsillectomy from January 20, 2011, through June 30, 2014, at the tertiary academic Children's Hospital of Philadelphia. Of these patients, 6710 met the inclusion criteria. Data were collected using electronic database acquisition and query.

Main Outcomes and Measures

Multivariate analysis was performed to identify independent prognostic factors for PTH and receipt of transfusion.

Results

Of the 6710 patients who met criteria for analysis (3454 male [51.5%] and 3256 female [48.5%]; median age, 5.4 years [interquartile range, 3.7-8.2 years]), 222 (3.3%) presented with PTH that required surgical control (sPTH). A total of 15 of the 8868 patients required transfusion for an overall risk for transfusion after tonsillectomy of 0.2%. Fifteen of 222 patients undergoing sPTH (6.8%) received transfusions. No significant independent increased risk for sPTH was associated with use of ibuprofen (adjusted odds ratio [OR], 0.90; 95% CI, 0.68-1.19). A significant independent association was found in the risk for sPTH in patients 12 years or older (adjusted OR, 2.74; 95% CI, 1.99-3.76) and in patients with a history of recurrent tonsillitis (adjusted OR, 1.52; 95% CI, 1.12-2.06). When using transfusion rates as a surrogate for severity of sPTH, transfusion increased by more than 3-fold among ibuprofen users compared with nonusers (adjusted OR, 3.16; 95% CI, 1.01-9.91), and the upper limit of the 95% CI suggests the difference could be nearly 10 times greater.

Conclusions and Relevance

The risk for sPTH is not increased with use of postoperative ibuprofen but is increased in patients 12 years or older and patients undergoing tonsillectomy with a history of recurrent tonsillitis. Hemorrhage severity is significantly increased with ibuprofen use when using transfusion rate as a surrogate marker for severity.

The effect of perioperative dexamethasone dosing on post-tonsillectomy hemorrhage risk

OBJECTIVES

Dexamethasone is currently recommended for routine prophylaxis against postoperative nausea and vomiting after tonsillectomy procedures. However, some studies have raised concern that dexamethasone use may lead to higher rates of post-tonsillectomy hemorrhage. Our objective was to determine whether higher doses of dexamethasone administered perioperatively during tonsillectomy procedures are associated with an increased risk of secondary post-tonsillectomy hemorrhage.

METHODS

We conducted a retrospective review of 9843 patients who underwent tonsillectomy and received dexamethasone at our institution from January 2010 to October 2014. We compared the dose of dexamethasone administered to patients who did and did not develop secondary post-tonsillectomy hemorrhage using Mann Whitney U tests. Multivariable logistic regression models were used to evaluate the association between dexamethasone dose and post-tonsillectomy hemorrhage after adjustment for demographic and clinical characteristics.

RESULTS

A total of 280 (2.8%) patients developed secondary post-tonsillectomy hemorrhage. Patients who developed hemorrhage tended to be older (median (interquartile range) 7 (4-11) vs. 5 (3-8) years), p < 0.001) and had undergone tonsillectomy more often for chronic tonsillitis but less often for tonsillar or adenotonsillar hypertrophy or sleep disturbances. Dexamethasone dose was significantly lower on average in patients who experienced secondary post-tonsillectomy hemorrhage (median (interquartile range) 0.19 (0.14, 0.23) mg/kg vs. 0.21 (0.17, 0.30), p < 0.001). Multivariable modeling demonstrated that the dose of dexamethasone was not significantly associated with post-tonsillectomy hemorrhage after adjustment for age.

CONCLUSIONS

There does not appear to be a dose-related increase in the risk of post-tonsillectomy hemorrhage for patients receiving dexamethasone during tonsillectomy procedures.

Hemostasis in Tonsillectomy

Tonsillectomy is a commonly performed procedure with an accepted risk of posttonsillectomy hemorrhage (PTH) approaching 5%, but catastrophic effects of hemorrhage are exceedingly rare. A variety of surgical techniques and hemostatic agents have been used to reduce the rate of hemorrhage, although none eliminate the risk. Numerous patient, surgical, and postoperative care factors have been studied for an association with PTH. The most consistent risk factors for PTH seem to be patient age and coagulopathies. Surgeon skill and surgical technique are most consistently associated with primary PTH.

Postoperative Bleeding and Associated Utilization following Tonsillectomy in Children

Objective To assess posttonsillectomy hemorrhage (PTH), associated nonoperative readmissions/revisits, and reoperations in children. Data Sources MEDLINE, EMBASE, and the Cochrane Library. Review Methods Two investigators independently screened studies against predetermined criteria and extracted key data. Investigators independently assessed study risk of bias and the strength of the evidence of the body of literature. We calculated unadjusted pooled estimates of PTH frequency and conducted a Bayesian meta-analysis to estimate frequency of primary and secondary PTH and PTH-associated reoperation and revisits/readmissions by partial and total tonsillectomy and surgical approach. Results In meta-analysis, the frequency of primary and secondary PTH associated with total and partial tonsillectomy was <4% for any technique and with overlapping confidence bounds. Pooled frequencies of PTH were also <5% overall (4.2% for total tonsillectomy, 1.5% for partial tonsillectomy) in comparative studies. Fewer PTH episodes occurred with tonsillectomy for obstructive sleep-disordered breathing than for throat infection. In meta-analysis, frequency of PTH-associated nonoperative revisits/readmission or reoperation ranged from 0.2% to 5.7% for total tonsillectomy and from 0.1% to 3.7% for partial tonsillectomy. At least 4 deaths were reported in case series including 1,778,342 children. Conclusions PTH occurred in roughly 4% of tonsillectomies in studies included in this review. Although studies typically did not report bleeding severity or amount, relatively few episodes of PTH necessitated reoperation for hemostasis. Nonetheless, tonsillectomy is not without risk of harm. Frequency of PTH across techniques was similar; thus, we cannot conclude that a given technique is superior.

Risk factors for secondary post-tonsillectomy haemorrhage following tonsillectomy with bipolar scissors: four-year retrospective cohort study

Objective:

To analyse risk factors associated with secondary post-operative bleeding when only one technique, namely bipolar scissors, is used.

Methods:

The medical records of all consecutive patients aged six years or older who underwent tonsillectomy or adenotonsillectomy between 1 December 2010 and 30 November 2014 were retrospectively analysed.

Results:

A total of 1734 patients were included in the study. A secondary haemorrhage occurred in 208 patients (12 per cent). Patients aged 15 years or older were 4.5 times (95 per cent confidence interval = 2.6–7.9;p< 0.001) more likely to experience secondary haemorrhage. In cases of acute quinsy, patients aged 15 years or older had an 8.1-fold (95 per cent confidence interval = 1.1–59.6;p= 0.02) increased likelihood of experiencing secondary haemorrhage.

Conclusion:

Patients aged 15 years or older have a higher risk for bleeding regardless of the primary indication for the tonsillectomy. The risk for secondary haemorrhage does not seem to depend on the primary indication itself.

Tonsillectomy or adenotonsillectomy versus non-surgical management for obstructive sleep-disordered breathing in children

BACKGROUND

Obstructive sleep-disordered breathing (oSDB) is a condition that encompasses breathing problems when asleep, due to an obstruction of the upper airways, ranging in severity from simple snoring to obstructive sleep apnoea syndrome (OSAS). It affects both children and adults. In children, hypertrophy of the tonsils and adenoid tissue is thought to be the commonest cause of oSDB. As such, tonsillectomy - with or without adenoidectomy - is considered an appropriate first-line treatment for most cases of paediatric oSDB.

OBJECTIVES

To assess the benefits and harms of tonsillectomy with or without adenoidectomy compared with non-surgical management of children with oSDB.

SEARCH METHODS

We searched the Cochrane Register of Studies Online, PubMed, EMBASE, CINAHL, Web of Science, Clinicaltrials.gov, ICTRP and additional sources for published and unpublished trials. The date of the search was 5 March 2015.

SELECTION CRITERIA

Randomised controlled trials comparing the effectiveness and safety of (adeno)tonsillectomy with non-surgical management in children with oSDB aged 2 to 16 years.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

Three trials (562 children) met our inclusion criteria. Two were at moderate to high risk of bias and one at low risk of bias. We did not pool the results because of substantial clinical heterogeneity. They evaluated three different groups of children: those diagnosed with mild to moderate OSAS by polysomnography (PSG) (453 children aged five to nine years; low risk of bias; CHAT trial), those with a clinical diagnosis of oSDB but with negative PSG recordings (29 children aged two to 14 years; moderate to high risk of bias; Goldstein) and children with Down syndrome or mucopolysaccharidosis (MPS) diagnosed with mild to moderate OSAS by PSG (80 children aged six to 12 years; moderate to high risk of bias; Sudarsan). Moreover, the trials included two different comparisons: adenotonsillectomy versus no surgery (CHAT trial and Goldstein) or versus continuous positive airway pressure (CPAP) (Sudarsan). Disease-specific quality of life and/or symptom score (using a validated instrument): first primary outcomeIn the largest trial with lowest risk of bias (CHAT trial), at seven months, mean scores for those instruments measuring disease-specific quality of life and/or symptoms were lower (that is, better quality of life or fewer symptoms) in children receiving adenotonsillectomy than in those managed by watchful waiting:- OSA-18 questionnaire (scale 18 to 126): 31.8 versus 49.5 (mean difference (MD) -17.7, 95% confidence interval (CI) -21.2 to -14.2);- PSQ-SRBD questionnaire (scale 0 to 1): 0.2 versus 0.5 (MD -0.3, 95% CI -0.31 to -0.26);- Modified Epworth Sleepiness Scale (scale 0 to 24): 5.1 versus 7.1 (MD -2.0, 95% CI -2.9 to -1.1).No data on this primary outcome were reported in the Goldstein trial.In the Sudarsan trial, the mean OSA-18 score at 12 months did not significantly differ between the adenotonsillectomy and CPAP groups. The mean modified Epworth Sleepiness Scale scores did not differ at six months, but were lower in the surgery group at 12 months: 5.5 versus 7.9 (MD -2.4, 95% CI -3.1 to -1.7). Adverse events: second primary outcomeIn the CHAT trial, 15 children experienced a serious adverse event: 6/194 (3%) in the adenotonsillectomy group and 9/203 (4%) in the control group (RD -1%, 95% CI -5% to 2%).No major complications were reported in the Goldstein trial.In the Sudarsan trial, 2/37 (5%) developed a secondary haemorrhage after adenotonsillectomy, while 1/36 (3%) developed a rash on the nasal dorsum secondary to the CPAP mask (RD -3%, 95% CI -6% to 12%). Secondary outcomesIn the CHAT trial, at seven months, mean scores for generic caregiver-rated quality of life were higher in children receiving adenotonsillectomy than in those managed by watchful waiting. No data on this outcome were reported by Sudarsan and Goldstein.In the CHAT trial, at seven months, more children in the surgery group had normalisation of respiratory events during sleep as measured by PSG than those allocated to watchful waiting: 153/194 (79%) versus 93/203 (46%) (RD 33%, 95% CI 24% to 42%). In the Goldstein trial, at six months, PSG recordings were similar between groups and in the Sudarsan trial resolution of OSAS (Apnoea/Hypopnoea Index score below 1) did not significantly differ between the adenotonsillectomy and CPAP groups.In the CHAT trial, at seven months, neurocognitive performance and attention and executive function had not improved with surgery: scores were similar in both groups. In the CHAT trial, at seven months, mean scores for caregiver-reported ratings of behaviour were lower (that is, better behaviour) in children receiving adenotonsillectomy than in those managed by watchful waiting, however, teacher-reported ratings of behaviour did not significantly differ.No data on these outcomes were reported by Goldstein and Sudarsan.

AUTHORS' CONCLUSIONS

In otherwise healthy children, without a syndrome, of older age (five to nine years), and diagnosed with mild to moderate OSAS by PSG, there is moderate quality evidence that adenotonsillectomy provides benefit in terms of quality of life, symptoms and behaviour as rated by caregivers and high quality evidence that this procedure is beneficial in terms of PSG parameters. At the same time, high quality evidence indicates no benefit in terms of objective measures of attention and neurocognitive performance compared with watchful waiting. Furthermore, PSG recordings of almost half of the children managed non-surgically had normalised by seven months, indicating that physicians and parents should carefully weigh the benefits and risks of adenotonsillectomy against watchful waiting in these children. This is a condition that may recover spontaneously over time.For non-syndromic children classified as having oSDB on purely clinical grounds but with negative PSG recordings, the evidence on the effects of adenotonsillectomy is of very low quality and is inconclusive.Low-quality evidence suggests that adenotonsillectomy and CPAP may be equally effective in children with Down syndrome or MPS diagnosed with mild to moderate OSAS by PSG.We are unable to present data on the benefits of adenotonsillectomy in children with oSDB aged under five, despite this being a population in whom this procedure is often performed for this purpose.

Adenotonsillectomy Complications: A Meta-analysis

BACKGROUND AND OBJECTIVE

Complications after adenotonsillectomy (AT) in children have been extensively studied, but differences between children with and without obstructive sleep apnea (OSA) have not been systematically reported. Our objective was to identify the most frequent complications after AT, and evaluate if differences between children with and without OSA exist.

METHODS

Several electronic databases were searched. A partial gray literature search was undertaken by using Google Scholar. Experts were consulted to identify any missing publications. Studies assessing complications after AT in otherwise healthy children were included. One author collected the required information from the selected articles. A second author crosschecked the collected information and confirmed its accuracy. Most of the selected studies collected information from medical charts.

RESULTS

A total of 1254 studies were initially identified. Only 23 articles remained after a 2-step selection process. The most frequent complication was respiratory compromise (9.4%), followed by secondary hemorrhage (2.6%). Four studies compared postoperative complications in children with and without OSA, and revealed that children with OSA have nearly 5 times more respiratory complications after AT than children without OSA (odds ratio = 4.90; 95% confidence interval: 2.38-10.10). In contrast, children with OSA are less likely to have postoperative bleeding when compared with children without OSA (odds ratio = 0.41; 95% confidence interval: 0.23-0.74).

CONCLUSIONS

The most frequent early complications after AT are respiratory compromise and secondary hemorrhage. Based on the current limited evidence, children with OSA appear to have more respiratory complications. Conversely, hemorrhage appears to be more frequent in children without OSA.