Hemostasis in Tonsillectomy

Postoperative Bleeding in Children With Tonsillectomy: A Retrospective Cohort

BACKGROUND

It is necessary to evaluate the risk factors of secondary bleeding after tonsillectomy in children, to provide reference for clinical children management and care.

METHODS

Children who underwent tonsillectomy from January 1, 2018, to December 31, 2022, in our hospital were retrospectively included. The characteristics of children with and without secondary bleeding were analyzed.

RESULTS

A total of 1068 children undergoing tonsillectomy were included, and the incidence of secondary bleeding children undergoing tonsillectomy was 4.87%. Age ≥ 9 years old (odds ratio [OR] = 2.609, 95% confidence interval [CI] = 2.112-3.437), type of surgery (OR = 1.764, 95% CI = 1.148-2.291), and degree of tonsil embedding (OR = 2.116, 95% CI = 1.805-2.644) were the risk factors of secondary bleeding after tonsillectomy in children (all P < .05).

CONCLUSION

Medical staff should proactively monitor and address the identified risk factors by implementing timely warning systems and preventive strategies to reduce the postoperative bleeding following tonsillectomy.

Impact of Ketorolac on Reoperation for Hemorrhage After Pediatric Tonsillectomy: A Single-Center Retrospective Propensity-Matched Study

OBJECTIVE

To determine if perioperative ketorolac is associated with an increased rate of reoperation for hemorrhage after pediatric tonsillectomy at 30 days and 48 hours.

STUDY DESIGN

Single-center retrospective propensity-matched study.

SETTING

Quaternary pediatric hospital and ambulatory surgery center.

METHODS

Patients less than 18 years old undergoing tonsillectomy or adenotonsillectomy between January 1, 2015 and October 1, 2020 were included. Hemorrhage rates between exposed (K+) and unexposed (K-) patients were calculated for the total cohort and a 1:1 propensity-matched cohort. Additional analyses included: multivariable logistic regression, subgroup analysis of ASA 1 and 2 patients, subgroup analysis comparing children with teenagers.

RESULTS

There were 5873 patients (42.1% K+) in the full cohort and 4694 patients in the propensity-matched cohort. Reoperation for hemorrhage within 30 days occurred in 1.9% of K+ patients and 1.6% of K- patients (P = 0.455) in the full cohort and 1.9% of K+ patients and 1.7% of K- patients (odds ratio [OR] 1.10, 95% confidence interval [CI] 0.72-1.69, P = 0.662) in the propensity-matched cohort. Reoperation within 48 hours occurred in 0.65% of K+ patients and 0.53% of K- patients (P = 0.679) in the full cohort and 0.68% of K+ patients and 0.51% of K- patients (OR 1.33, 95% CI 0.63-2.81, P = 0.451) in the propensity-matched cohort. There was no association between perioperative ketorolac administration and reoperation for hemorrhage in any of the other analyses.

CONCLUSION

Ketorolac at end of surgery should be considered as part of the nonopioid analgesic regimen for pediatric tonsillectomy.

Management of massive cerebral infarction as a complication of post-tonsillectomy and analysis of the risk factors: a case report

BACKGROUND

The majority of postoperative complications of tonsillectomy are bleeding. However, massive cerebral infarction following haemostasis is a very rare and serious complication and has rarely been reported clinically.

CASE PRESENTATION

We performed a left tonsillectomy on a patient with chronic tonsillitis. After that, active bleeding was found under the tonsillar fossa, so an exploratory hypopharyngeal haemostasis was performed. However, the bleeding worsened intraoperatively, so the patient was converted to a cervical angiographic embolization. The interventional procedure was completed successfully without an ectopic embolic event. After the procedure, the patient was transferred to the intensive care unit (ICU) and was diagnosed with acute massive cerebral infarction in the left cerebral hemisphere after awakening symptoms combined with cranial computed tomography angiography (CTA) results. Symptomatic treatment such as sedation and analgesia, dehydration to lower intracranial pressure, and maintenance of respiratory and circulatory stability was then administered. After treatment, the patient's condition stabilized and he was transferred to the rehabilitation physiotherapy unit for rehabilitation.

CONCLUSION

Post-tonsillectomy haemorrhage can be augmented with a carotid arteriogram to clarify whether the tonsillar fossa is at a safe distance from the posterior internal carotid artery. Furthermore, interventional haemostasis can also be performed as early as possible to reduce the incidence of complications in cases of persistent post-tonsillectomy bleeding.

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.

Pediatric Obstructive Sleep Apnea and Neurocognition

Pediatric obstructive sleep apnea affects a large number of children and has multiple end-organ sequelae. Although many of these have been demonstrated to be reversible, the effects on some of the organ systems, including the brain, have not shown easy reversibility. Progress in this area has been hampered by lack of a preclinical model to study the disease. Therefore, perioperative and sleep physicians are tasked with making a number of difficult decisions, including optimal surgical timing to prevent disease evolution, but also to keep the perioperative morbidity in a safe range for these patients.

Screening for undiagnosed bleeding disorders in post-tonsillectomy bleed patients: Retrospective review and systematic review of the literature

OBJECTIVES

There is currently no standard for screening children with post-tonsillectomy bleeds (PTB) for coagulopathy disorders. This study aims to identify children with occult coagulopathy diagnosed at PTB and to identify factors associated with diagnosis. A systematic review of the literature further identified trends in this topic.

METHODS

A retrospective chart review of patients returning to the operating room for PTB at a tertiary children's hospital was undertaken from 2012 to 2016. A systematic review using Medline OVID was subsequently performed.

RESULTS

Of 12,503 tonsillectomies, 311 children (52% male, mean age 8 years) required surgery for PTB (2.5% rate). Twenty-one patients (7%) had multiple episodes. Only two patients (0.6%) (both with known coagulopathy) underwent pre-tonsillectomy labs and 260 (84%) had labs at PTB. Six patients (2%) were diagnosed with a new coagulopathy, most commonly von Willebrand's Disease (vWD) in five (2%). Three patients (1%) were diagnosed at first PTB and three (1%) at second PTB. Of the three diagnosed at second PTB, two had normal partial thromboplastin time (PTT). In systematic review, 1243 manuscripts were reviewed and 8 papers discussing this topic are presented.

CONCLUSION

Occult coagulopathy was rarely diagnosed at PTB, but this may be limited by inconsistent screening. PT and PTT are not sensitive tests for vWD, and normal coagulation labs may lead to delayed diagnosis. The literature reveals occult coagulopathy is rare but often diagnosed after severe or recurrent hemorrhage. In order to provide efficient care and medical management, a standardized algorithm and sensitive labs for screening PTB patients are needed.

Surgeons’ preferences and anxiety levels in paediatric adenotonsillectomy: European perspective

Objective

This study assessed the preferences of surgeons regarding surgical modalities used for adenotonsillectomy, and determined anxiety levels related to the adenotonsillectomy procedure.

Methods

A 10-question survey created by the authors was administered to 413 ENT specialists attending the 4th Congress of Otorhinolaryngology Head and Neck Surgery, held in October 2017 in Barcelona, Spain.

Results

Cold knife dissection was the preferred surgical modality for both adenoidectomy and tonsillectomy. Most participants reported encountering one to five patients with post-tonsillectomy bleeding throughout their entire career. The mean anxiety levels during surgery and the 10-day post-operative period were 3.39 ± 2.14 and 4.18 ± 2.63, respectively (p < 0.05). There was a significant negative correlation between anxiety level and surgeon's experience (p < 0.05).

Conclusion

Cold dissection is still the preferred surgical modality for adenotonsillectomy, while both suture ligation and electrocautery are used for haemostasis. Paediatric adenotonsillectomy is likely to generate anxiety in ENT surgeons, and the possibility of secondary post-tonsillectomy bleeding increases the anxiety levels of surgeons in the post-operative period.

To transfuse or not to transfuse? Jehovah's Witnesses and postoperative hemorrhage in pediatric otolaryngology

OBJECTIVES

Discuss the ethical issues in the management of postoperative hemorrhage in pediatric patients whose parents are Jehovah's Witnesses (JW) and 2) Describe a framework for shared decision making in this population.

METHODS

A recall review of pediatric otolaryngology patients with parents of the JW faith and postoperative hemorrhage was performed over a year long period at a single institution. The literature on transfusions for JW minors was reviewed.

RESULTS

Two patients were identified. The first patient had a severe post-tonsillectomy hemorrhage requiring multiple emergency operative interventions. The child developed a hemoglobin of 5.2 g/dl and received an emergent transfusion against parents' wishes. The child subsequently did not require further intervention. The second patient hemorrhaged after a supraglottoplasty and was administered erythropoietin and iron infusion but did not require transfusion (hemoglobin nadir 7.9 g/dl). In both cases hematology was consulted, and extensive discussion with the families and the JW Hospital Liaison Committee occurred.

CONCLUSIONS

The risks of hemorrhage should be discussed with JW parents of patients undergoing even routine otolaryngologic surgery. In these cases, early shared decision making with family, the JW Hospital Liaison committee, and hematology was pursued regarding mutually acceptable interventions. Aggressive non-transfusion based resuscitation was carried out to minimize the likelihood of transfusion. In the first case, danger to the patient's life eventually necessitated transfusion in accordance with the patient's best interest and previous case law. A defined framework involving all stake-holders, including Pastoral Care, in the event of postoperative hemorrhage is critical.

Recurrent post tonsillectomy bleeds: Presentation and characteristics in the paediatric population

OBJECTIVE

To evaluate the incidence of, features and risk factors for recurrent post tonsillectomy bleeding.

METHODS

Audit of all patients 0-15 years of age undergoing tonsillectomy between 01/2004-12/2014 with selection of those with recurrent bleeding post tonsillectomy for subanalysis.

RESULTS

Of 5400 single centre tonsillectomies, 234 (4.8%) presented with bleeding and 9 (0.17%) presented with recurrent bleeding. 13 patients in total were treated, 10 surgically. Average patient age: 8.5 years with median time to presentation of the first bleed: 5 days and second bleed: 11 days. There was no association with abnormal coagulation, NSAID usage, severity of the first bleed or surgical technique. The risk of developing a second bleed following treatment for one post tonsillectomy bleeding incident is approximately 1 in 25.

CONCLUSION

Recurrent post tonsillectomy bleeds are rare, and cannot be predicted preoperatively. The mainstay of management is surgical cautery, but other interventions are occasionally needed.

Pediatric post-tonsillectomy hemorrhage in the setting of post-transplantation immunosuppression

INTRODUCTION

Long-term immunosuppressants form an integral part of therapy for post-transplantation patients. Immunosuppressants may also have an anticoagulant effect, and little is known about their effects on bleeding risk after adenotonsillectomy. Our objective was to investigate whether there is an increased observed rate of post-tonsillectomy hemorrhage in a population of pediatric patients on long-term immunosuppressants after solid organ transplantation, compared to healthy controls.

METHODS

This was a retrospective chart review of pediatric patients with a history of renal or heart transplant undergoing adenotonsillectomy at our institution between 2000 and 2014. All patients underwent tonsillectomy with monopolar electrocautery. Retrieved data included perioperative medications, occurrence of post-operative bleeding and associated treatment. For comparison, we obtained a population of age-matched controls with no history of immunosuppression who underwent the same procedure.

RESULTS

A total of 34 patients meeting criteria were identified, of which 3 (8.82%) suffered a postoperative bleed. Forty-seven controls were obtained, with a total of 2 (4.26%) postoperative hemorrhages (p = 0.65). Two of the post-transplantation patients who bled postoperatively required cauterization in the operating room. None of the controls required surgical treatment. The incidences of postoperative bleeding requiring surgical treatment were 5.88% and 0%, respectively (p = 0.17).

CONCLUSION

We failed to demonstrate an increased risk of bleeding after undergoing adenotonsillectomy in our cohort of post-transplantation pediatric patients on chronic immunosuppression. Future research, likely requiring a multi-institutional effort, could stratify by immunosuppressive agent to elucidate bleeding risk with specific medications.

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.