1
|
Kim DH, Stybayeva G, Hwang SH. Efficacy and safety of perioperative ibuprofen for pain control after pediatric tonsillectomy: A systemic review and meta-analysis. Int J Pediatr Otorhinolaryngol 2024; 184:112078. [PMID: 39178604 DOI: 10.1016/j.ijporl.2024.112078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2024] [Revised: 08/04/2024] [Accepted: 08/19/2024] [Indexed: 08/26/2024]
Abstract
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.
Collapse
Affiliation(s)
- Do Hyun Kim
- Department of Otolaryngology-Head and Neck Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Gulnaz Stybayeva
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, USA
| | - Se Hwan Hwang
- Department of Otolaryngology-Head and Neck Surgery, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea.
| |
Collapse
|
2
|
So V, Radhakrishnan D, MacCormick J, Webster RJ, Tsampalieros A, Zitikyte G, Ripley A, Murto K. Does Celecoxib Prescription for Pain Management Affect Post-tonsillectomy Hemorrhage Requiring Surgery? A Retrospective Observational Cohort Study. Anesthesiology 2024; 141:313-325. [PMID: 38684054 DOI: 10.1097/aln.0000000000005032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
BACKGROUND Adenotonsillectomy and tonsillectomy (referred to as tonsillectomy hereafter) are common pediatric surgeries. Postoperative complications include hemorrhage requiring surgery (2 to 3% of cases) and pain. Although nonsteroidal anti-inflammatory drugs are commonly administered for postsurgical pain, controversy exists regarding bleeding risk with cyclooxygenase-1 inhibition and associated platelet dysfunction. Preliminary evidence suggests selective cyclooxygenase-2 inhibitors, for example celecoxib, effectively manage pain without adverse events including bleeding. Given the paucity of data for routine celecoxib use after tonsillectomy, this study was designed to investigate the association between postoperative celecoxib prescription and post-tonsillectomy hemorrhage requiring surgery using chart-review data from the Children's Hospital of Eastern Ontario. METHODS After ethics approval, a retrospective single-center observational cohort study was performed in children less than 18 yr of age undergoing tonsillectomy from January 2007 to December 2017. Cases of adenoidectomy alone were excluded due to low bleed rates. The primary outcome was the proportion of patients with post-tonsillectomy hemorrhage requiring surgery. The association between a celecoxib prescription and post-tonsillectomy hemorrhage requiring surgery was estimated using inverse probability of treatment weighting based on propensity scores and using generalized estimating equations to accommodate clustering by surgeon. RESULTS An initial patient cohort of 6,468 was identified, and 5,846 children with complete data were included in analyses. Median (interquartile range) age was 6.10 (4.40, 9.00) yr, and 46% were female. In the cohort, 28.1% (n = 1,644) were prescribed celecoxib. Among the 4,996 tonsillectomy patients, 1.7% (n = 86) experienced post-tonsillectomy hemorrhage requiring surgery. The proportion with post-tonsillectomy hemorrhage requiring surgery among patients who had a tonsillectomy and were or were not prescribed celecoxib was 1.94% (30 of 1,548; 95% CI, 1.36 to 2.75) and 1.62% (56 of 3,448; 95% CI, 1.25 to 2.10), respectively. Modeling did not identify an association between celecoxib prescription and increased odds of post-tonsillectomy hemorrhage requiring surgery (odds ratio = 1.4; 95% CI, 0.85 to 2.31; P = 0.20). CONCLUSIONS Celecoxib does not significantly increase the odds of post-tonsillectomy hemorrhage requiring surgery, after adjusting for covariates. This large pediatric cohort study of celecoxib administered after tonsillectomy provides compelling evidence for safety but requires confirmation with a multisite randomized controlled trial. EDITOR’S PERSPECTIVE
Collapse
Affiliation(s)
- Vincent So
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Dhenuka Radhakrishnan
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada; Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Johnna MacCormick
- Department of Otolaryngology Head and Neck Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Richard J Webster
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Anne Tsampalieros
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Gabriele Zitikyte
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Allyson Ripley
- University of Western Ontario, Faculty of Medicine, London, Ontario, Canada
| | - Kimmo Murto
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, Ontario, Canada; Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| |
Collapse
|
3
|
Hakanen O, Torkki P, Luukkainen V, Sakki A, Haaramo A, Aaltonen LM, Tolvi M. A prospective cohort study: The effects of preoperative E-health on the postoperative course of tonsillectomy patients. Am J Otolaryngol 2024; 45:104304. [PMID: 38643537 DOI: 10.1016/j.amjoto.2024.104304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Accepted: 04/14/2024] [Indexed: 04/23/2024]
Abstract
PURPOSE At our clinic, a significant portion of tonsillectomy (TE) preoperative assessments are conducted remotely. The aim of our study was to examine the variation in TE complications, contact rates, and reasons for patient contact between those evaluated preoperatively at the outpatient clinic (OPC), or remotely through virtual visits (VV), or via a digital care pathway (DCP). This investigation is critical for optimizing patient flow through the volume-intensive process of TE. METHODS We conducted a prospective cohort study involving 422 patients who underwent TE at Helsinki University Hospital ENT clinic to investigate their 30-day postoperative course. We extracted information on postoperative contacts, complications, and demographic data. Postoperative contact rate was the primary outcome measure to evaluate whether telehealth patients suffered fewer postoperative issues. RESULTS Patients from the OPC were least likely to seek medical assistance in the 30-day postoperative period. However, no significant difference was discovered compared to the remotely assessed DCP patients, and over entire TE episodes, the DCP patients had the fewest unplanned contacts compared to the VV and OPC cohorts. Furthermore, the care paths shared similar complication and contact method profiles with comparable post-tonsillectomy hemorrhage incidence. CONCLUSION A preoperative DCP for TE appeared to carry similar postoperative contact and complication rates, as well as comparable contact method profiles compared to the OPC model. Given the high patient satisfaction and cost-consciousness associated with the DCP, our findings encourage a broader implementation of highly developed DCPs in preoperative assessment for TE.
Collapse
Affiliation(s)
- Oskari Hakanen
- Faculty of Medicine, University of Helsinki, Haartmaninkatu 8, 00290 Helsinki, Finland.
| | - Paulus Torkki
- Department of Public Health, Faculty of Medicine, University of Helsinki, Yliopistonkatu 4, 00100 Helsinki, Finland
| | - Veera Luukkainen
- Department of Otorhinolaryngology - Head and Neck Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Anniina Sakki
- Department of Otorhinolaryngology - Head and Neck Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Anu Haaramo
- Department of Otorhinolaryngology - Head and Neck Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Leena-Maija Aaltonen
- Department of Otorhinolaryngology - Head and Neck Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Morag Tolvi
- Department of Otorhinolaryngology - Head and Neck Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| |
Collapse
|
4
|
Falz H, von Lücken HJ, Münscher A, Möckelmann N. A comparative study of BiZact™ tonsillectomy versus cold steel dissection technique in adults: Analysis of operating time, intraoperative blood loss, postoperative bleeding rate and pain. Clin Otolaryngol 2024; 49:299-305. [PMID: 38169104 DOI: 10.1111/coa.14140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 10/18/2023] [Accepted: 11/25/2023] [Indexed: 01/05/2024]
Abstract
OBJECTIVES To analyse operating time, intraoperative blood loss, postoperative bleeding rate and pain when using the relatively new BiZact™ tonsillectomy device compared to the commonly used cold steel dissection technique with bipolar cautery in adults. DESIGN Retrospective case control study. Parameters analysed for significant association with technique were operating time, intraoperative blood loss, wound pain on postoperative days 1-4 and rate of post-tonsillectomy bleeding (PTB). SETTING Monocentric study at a department of otolaryngology and head and neck surgery at a tertiary centre in Germany. PARTICIPANTS A total of 183 patients who underwent a bilateral tonsillectomy with either the BiZact™ tonsillectomy device or the cold dissection technique with bipolar cautery for haemostasis. MAIN OUTCOME MEASURES Operating time, intraoperative blood loss, postoperative pain on the first to fourth postoperative day (numeric rating scale: 0-10) (PTB, primary bleeding ≤24 h, secondary bleeding >24 h postoperative; Stammberger scale). RESULTS AND CONCLUSION The BiZact™ tonsillectomy device leads to a significant shorter operating time with less intraoperative blood loss compared to cold steel dissection with bipolar haemostasis. No benefits with regards to PTB or postoperative pain could be observed. The use of the BiZact™ device provides major benefits in clinical routine and stands up to conventional tonsillectomy techniques.
Collapse
Affiliation(s)
- Hendrik Falz
- Department of Otorhinolaryngology, Head and Neck Surgery, Katholisches Marienkrankenhaus gGmbH, Hamburg, Germany
| | - Hans-Jürgen von Lücken
- Department of Otorhinolaryngology, Head and Neck Surgery, Katholisches Marienkrankenhaus gGmbH, Hamburg, Germany
| | - Adrian Münscher
- Department of Otorhinolaryngology, Head and Neck Surgery, Katholisches Marienkrankenhaus gGmbH, Hamburg, Germany
| | - Nikolaus Möckelmann
- Department of Otorhinolaryngology, Head and Neck Surgery, Katholisches Marienkrankenhaus gGmbH, Hamburg, Germany
| |
Collapse
|
5
|
Mughal Z, Gupta KK, Yeo JJY, Metcalfe C, Weller M. Blood, Sweat, and Tonsils: Bleeding After Abscess Tonsillectomy for Quinsy-A Meta-Analysis. Laryngoscope 2024. [PMID: 38613457 DOI: 10.1002/lary.31449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Revised: 03/06/2024] [Accepted: 04/01/2024] [Indexed: 04/15/2024]
Abstract
OBJECTIVE Abscess tonsillectomy is performed during an active episode of quinsy. Apprehensions regarding an elevated bleeding risk have hindered its widespread acceptance. This study aims to assess the prevalence of post-tonsillectomy bleeding (PTB) associated with abscess tonsillectomy. DATA SOURCES A search was performed on August 27, 2023 in Medline, Embase, PubMed, Cochrane CENTRAL, and Web of Science databases. REVIEW METHODS The systematic review was conducted in adherence to the PRISMA guidelines. Pooled PTB rate was determined using a meta-analysis of proportions. The JBI tool was used to assess the quality of the included studies. RESULTS Of the 525 search records, 18 studies met the eligibility criteria for final analysis. These comprised of retrospective single-center analyses. The pooled prevalence of PTB was 6.65% (95% C.I. 4.01-9.81), and the return-to-theatre rate was 2.35% (95% C.I. 1.48-3.37). There was no difference in PTB rate between unilateral and bilateral tonsillectomy. However, the bipolar technique was associated with a higher PTB rate compared to cold steel dissection. The overall quality of the body of evidence was moderate. CONCLUSION Our study highlights the complications associated with abscess tonsillectomy. These findings contribute valuable insights into this potential treatment option for quinsy. LEVEL OF EVIDENCE N/A Laryngoscope, 2024.
Collapse
Affiliation(s)
- Zahir Mughal
- Department of Otolaryngology, Russells Hall Hospital, Dudley, UK
| | | | | | | | - Matthew Weller
- Department of Otolaryngology, Russells Hall Hospital, Dudley, UK
| |
Collapse
|
6
|
Matsui H, Mukaigawa T, Goto S, Okada S, Hiiragi Y, Wada K. Risk factors for late postoperative bleeding after partial glossectomy for tongue cancer. Acta Otolaryngol 2024; 144:76-81. [PMID: 38343347 DOI: 10.1080/00016489.2024.2310695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 01/18/2024] [Indexed: 03/16/2024]
Abstract
BACKGROUND Partial glossectomy is the most common procedure for early-stage tongue cancer. Although late postoperative bleeding occasionally occurs, the associated risk factors have not been adequately identified. AIMS/OBJECTIVES We aimed to investigate the rate and risk factors for late postoperative bleeding after transoral partial glossectomy with or without neck dissection for tongue cancer at our institution. MATERIAL AND METHODS We analysed 211 patients who had undergone transoral partial glossectomy between January 2016 and January 2023. The potential risk factors associated with late postoperative bleeding were investigated using univariate and multivariate logistic regression analyses. RESULTS Of the 211 patients, 40 (19%) showed late postoperative bleeding, with 19 (9%) classified as grade IIIa (Clavien-Dindo classification). Regarding all grades, late postoperative bleeding was significantly higher in patients aged <70 years and in those with polyglycolic acid (PGA) sheets (p = .046 and .030, respectively). For grade ≥ IIIa, late postoperative bleeding was significantly higher in patients with a history of anticoagulant/platelet administration, a mucosal defect covered with fibrin glue and a PGA sheet (p = .045 and .026, respectively). CONCLUSIONS AND SIGNIFICANCE The findings of this study suggest that primary closure decreases the frequency of late postoperative bleeding.
Collapse
Affiliation(s)
- Hidehito Matsui
- Division of Head and Neck Surgery, Shizuoka Cancer Center, Shizuoka, Japan
- Department of Otolaryngology, Toho University Omori Medical Center, Tokyo, Japan
| | - Takashi Mukaigawa
- Division of Head and Neck Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Seiya Goto
- Division of Head and Neck Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Shinichi Okada
- Division of Head and Neck Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Yohei Hiiragi
- Division of Head and Neck Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Kota Wada
- Department of Otolaryngology, Toho University Omori Medical Center, Tokyo, Japan
| |
Collapse
|
7
|
Kandemir S, Pamuk AE, Özel G, Şencan Z. Comparison of Three Tonsillectomy Techniques: Cold Dissection, Monopolar Electrocautery, and Coblation. Int Arch Otorhinolaryngol 2023; 27:e694-e698. [PMID: 37876704 PMCID: PMC10593530 DOI: 10.1055/s-0042-1758715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 08/24/2022] [Indexed: 03/31/2023] Open
Abstract
Introduction Tonsillectomy is among the most common otolaryngological surgeries. Objective To evaluate and compare three tonsillectomy techniques: cold steel dissection (CSD), monopolar electrocautery (MEC), and coblation. Methods The present study retrospectively reviewed the medical records of patients who underwent tonsillectomy between January 2014 and January 2016. Postoperative visual analog scale (VAS) pain scores, analgesic use, surgical duration, time to return to normal activity, and postoperative bleeding status were noted. Results The CSD group had less analgesic use and shorter return to normal activity than the MEC group ( p = 0.037 and p < 0.001, respectively). The coblation group had lower VAS pain scores than the MEC group only at 1 hour to 4 hours postsurgery ( p < 0.016). The postoperative bleeding rate was similar in all groups ( p = 0.096). Conclusion Cold steel dissection tonsillectomy is associated with less postoperative pain and shorter recovery than MEC. Coblation is better than MEC in terms of postoperative pain at 1 hour to 4 hours only, whereas CSD is associated with less postoperative pain than coblation at 2 days to 7 days.
Collapse
Affiliation(s)
- Süheyla Kandemir
- Department of Otorhinolaryngology, Kırıkkale Yüksek İhtisas Hospital, Kırıkkale, Turkey
| | - Ahmet Erim Pamuk
- Department of Otorhinolaryngology, Private Practice, Ankara, Turkey
| | - Gökçe Özel
- Department of Otorhinolaryngology, Private Practice, Ankara, Turkey
| | - Ziya Şencan
- Department of Otorhinolaryngology, Kırıkkale University, Faculty of Medicine, Kırıkkale Turkey
| |
Collapse
|
8
|
Hu X, Yang Z, Ma Y, Wang M, Liu W, Qu G, Zhong C. Development and validation of a machine learning-based predictive model for secondary post-tonsillectomy hemorrhage. Front Surg 2023; 10:1114922. [PMID: 36824494 PMCID: PMC9941337 DOI: 10.3389/fsurg.2023.1114922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 01/16/2023] [Indexed: 02/10/2023] Open
Abstract
Background The main obstacle to a patient's recovery following a tonsillectomy is complications, and bleeding is the most frequent culprit. Predicting post-tonsillectomy hemorrhage (PTH) allows for accurate identification of high-risk populations and the implementation of protective measures. Our study aimed to investigate how well machine learning models predict the risk of PTH. Methods Data were obtained from 520 patients who underwent a tonsillectomy at The 940th Hospital of Joint Logistics Support Force of Chinese People's Liberation Army. The age range of the patients was 2-57 years, and 364 (70%) were male. The prediction models were developed using five machine learning models: decision tree, support vector machine (SVM), extreme gradient boosting (XGBoost), random forest, and logistic regression. The performance of the models was evaluated using the area under the receiver operating characteristic curve (AUC). Shapley additive explanation (SHAP) was used to interpret the results of the best-performing model. Results The frequency of PTH was 11.54% among the 520 patients, with 10.71% in the training group and 13.46% in the validation set. Age, BMI, season, smoking, blood type, INR, combined secretory otitis media, combined adenoidectomy, surgical wound, and use of glucocorticoids were selected by mutual information (MI) method. The XGBoost model had best AUC (0.812) and Brier score (0.152). Decision curve analysis (DCA) showed that the model had a high clinical utility. The SHAP method revealed the top 10 variables of MI according to the importance ranking, and the average of the age was recognized as the most important predictor variable. Conclusion This study built a PTH risk prediction model using machine learning. The XGBoost model is a tool with potential to facilitate population management strategies for PTH.
Collapse
Affiliation(s)
- Xiandou Hu
- The First School of Clinical Medicine, Gansu University of Chinese Medicine, Lanzhou, China,Otolaryngology Head and Neck Surgery, The 940th Hospital of Joint Logistics Support Force of Chinese People's Liberation Army, Lanzhou, China
| | - Zixuan Yang
- Otolaryngology Head and Neck Surgery, The 940th Hospital of Joint Logistics Support Force of Chinese People's Liberation Army, Lanzhou, China
| | - Yuhu Ma
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, China
| | - Mengqi Wang
- The First School of Clinical Medicine, Gansu University of Chinese Medicine, Lanzhou, China,Otolaryngology Head and Neck Surgery, The 940th Hospital of Joint Logistics Support Force of Chinese People's Liberation Army, Lanzhou, China
| | - Weijie Liu
- Otolaryngology Head and Neck Surgery, The 940th Hospital of Joint Logistics Support Force of Chinese People's Liberation Army, Lanzhou, China,School of Clinical Medicine, Ningxia Medical University, Yinchuan, China
| | - Gaoya Qu
- Otolaryngology Head and Neck Surgery, The 940th Hospital of Joint Logistics Support Force of Chinese People's Liberation Army, Lanzhou, China
| | - Cuiping Zhong
- Otolaryngology Head and Neck Surgery, The 940th Hospital of Joint Logistics Support Force of Chinese People's Liberation Army, Lanzhou, China,Correspondence: Cuiping Zhong
| |
Collapse
|
9
|
De Ravin E, Banik GL, Buzi A. Effect of ibuprofen on severity of surgically-managed pediatric post-tonsillectomy hemorrhage. Int J Pediatr Otorhinolaryngol 2023; 164:111422. [PMID: 36549016 DOI: 10.1016/j.ijporl.2022.111422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 12/08/2022] [Accepted: 12/17/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVES The association between ibuprofen use and severity of post-tonsillectomy hemorrhage (PTH) remains unclear. We aimed to compare PTH severity in patients who did or did not receive ibuprofen. METHODS A retrospective cohort study of pediatric patients requiring operative control of PTH at a tertiary children's hospital between 2015 and 2019 was performed. PTH severity was assessed using pre-tonsillectomy and post-hemorrhage hemoglobin and hematocrit values, estimated intraoperative blood loss, estimated hemorrhage flow rate, and need for transfusion. Differences in hemorrhage severity markers between the two cohorts were compared. RESULTS A total of 168 consecutive patients were included in this study. The mean age was 8.8 years, and 55.4% of patients were male. Sixty-five patients (38.7%) received ibuprofen postoperatively. There was no statistically significant difference in the mean change in hemoglobin (1.1 vs. 1.1, P = 0.85) or hematocrit (3.1 vs. 3.2, P = 0.97) between patients who received ibuprofen compared to those who did not. Similarly, there were no significant differences in need for transfusion (3.1% vs. 3.9%, P = 1.00) or occurrence of high-flow (arterial) blood loss (33.8% vs. 40.8%, P = 0.42) between the two groups. CONCLUSION Postoperative ibuprofen use does not appear to significantly increase PTH severity, as measured by change in hemoglobin and hematocrit values, need for transfusion, or presence of high-flow blood loss. This study introduces previously unexplored markers to assess PTH severity and supports further prospective studies to determine the effect of ibuprofen on PTH severity.
Collapse
Affiliation(s)
- Emma De Ravin
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, USA; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Grace L Banik
- Division of Otolaryngology, UCSF Benioff Children's Hospital, Oakland, CA, USA
| | - Adva Buzi
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, USA; Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| |
Collapse
|
10
|
Say MA, Bilgin E, Baklacı D. Evaluation of Anterior and Posterior Pillar Suturing Following Adult Tonsillectomy in Terms of Hemorrhage, Pain, and Dysphagia Complications. Indian J Otolaryngol Head Neck Surg 2022; 74:5624-5629. [PMID: 36742830 PMCID: PMC9895593 DOI: 10.1007/s12070-021-02965-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 10/22/2021] [Indexed: 02/07/2023] Open
Abstract
Tonsillectomy is one of the most common surgical procedures performed by otolaryngologists. Postoperative complications, although rare, can be observed in tonsillectomy. This study aimed to investigate the effect of anterior and posterior pillar suturing on dysphagia, hemorrhage, and pain complications following tonsillectomy in adult patients. The study included 80 patients (32 males, 48 females; > 18 years) who underwent tonsillectomy. The patients were divided into two groups: Group 1, in which the tonsillar lodge was closed by anterior-posterior pillar suturing with a 3-0 chromic catgut suture after hemostatic compression and Group 2, in which the tonsillar lodge was exposed following hemostatic compression and bipolar cauterization. Post-surgical pain was assessed using the Numeric Rating Scale (NRS). Oropharyngeal dysphagia was evaluated using the Eating Assessment Tool (EAT)-10. None of the patients experienced postoperative primary hemorrhage. However, postoperative secondary hemorrhage was observed in seven patients, two from Group 1 and five from Group 2. There was no significant difference in postoperative hemorrhage between the two groups (p = 0.449). Furthermore, no statistically significant difference was observed between the two groups in terms of the NRS scores on postoperative day 1 and at postoperative week 2 (p = 0.130 and 0.142, respectively) or the EAT-10 scores at postoperative week 2 and postoperative month 6 (p = 0.925 and 0.090, respectively). Anterior-posterior pillar suturing, which is performed for hemorrhage control after tonsillectomy, is not superior to the conventional bipolar method in terms of postoperative dysphagia, hemorrhage, and pain.
Collapse
Affiliation(s)
- Mehmet Ali Say
- Ear, Nose and Throat, Department of Otolaryngology, Çerkezköy State Hospital, Tekirdağ, Turkey
| | - Ergin Bilgin
- Department Of Otolaryngology, Bülent Ecevit University Medical Faculty, Zonguldak, Turkey
| | - Deniz Baklacı
- Department Of Otolaryngology, Bülent Ecevit University Medical Faculty, Zonguldak, Turkey
| |
Collapse
|
11
|
Fushimi K, Gyo K, Okunaka M, Watanabe M, Sugihara A, Tsuzuki K. Analysis of risk factors for post-tonsillectomy hemorrhage in adults. Auris Nasus Larynx 2022; 50:389-394. [PMID: 36272864 DOI: 10.1016/j.anl.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 10/03/2022] [Accepted: 10/06/2022] [Indexed: 11/06/2022]
Abstract
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.
Collapse
|
12
|
Reference rate for post-tonsillectomy haemorrhage in Australia—A 2000–2020 national hospital morbidity database analysis. PLoS One 2022; 17:e0273320. [PMID: 36006990 PMCID: PMC9409536 DOI: 10.1371/journal.pone.0273320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 08/06/2022] [Indexed: 11/19/2022] Open
Abstract
This study aims to provide a national benchmark rate of post-tonsillectomy haemorrhage (PTH) in Australia. Using data from Australia’s National Hospital Morbidity Database (NHMD) from 1 July 2000 to 30 June 2020, we have conducted a nation-wide population-based study to estimate a reference rate of PTH. Outcomes of interest included the overall rate and time-trend of PTH, the relationship between PTH rates with age and gender as well as the epidemiology of tonsillectomy procedures. A total of 941,557 tonsillectomy procedures and 15,391 PTH episodes were recorded for the study period. Whilst the incidence of tonsillectomy procedures and the number of day-stay tonsillectomy procedures have increased substantially over time, the overall rate of PTH for all ages has remained relatively constant (1.6% [95% CI: 1.61 to 1.66]) with no significant association observed between the annual rates of PTH and time (year) (Spearman correlation coefficient, Rs = 0.24 (95% CI: -0.22 to 0.61), P = 0.3). However, the rate of PTH in adults (aged 15 years and over) experienced a statistically significant mild to moderate upward association with time (year) Rs = 0.64 (95% CI: 0.28 to 0.84), P = 0.003. Analysis of the odds of PTH using the risk factors of increasing age and male gender showed a unique age and gender risk pattern for PTH where males aged 20 to 24 years had the highest risk of PTH odds ratio 7.3 (95% CI: 6.7 to 7.8) compared to patients aged 1 to 4 years. Clinicians should be mindful of the greater risk of PTH in male adolescents and young adults. The NHMD datasets can be continually used to evaluate the benchmark PTH rate in Australia and to facilitate tonsillectomy surgical audit activities and quality improvement programs on a national basis.
Collapse
|
13
|
Stevens BP, Paul O, Donald MC, Berry JM, Carron JD. Effect of post-operative oral steroids on bleeding rate after pediatric tonsillectomy. Am J Otolaryngol 2022; 43:103595. [PMID: 35963105 DOI: 10.1016/j.amjoto.2022.103595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 08/07/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE In 2013, the FDA placed a black box warning on the usage of opioid pain medications in the post-operative setting after pediatric adenotonsillectomy. Since then, alternative pain management regimens have been employed. Some have advocated for post-operative oral steroids, in part due to the effectiveness of intraoperative intravenous steroids in reducing post-operative pain and nausea. The evidence regarding the efficacy and safety of post-operative oral steroids is not as clear. The purpose of this study was to examine whether post-tonsillectomy hemorrhage rates in pediatric patients were affected by post-operative oral steroid usage. MATERIALS AND METHODS Case-control retrospective chart review using a deidentified data set of patients undergoing tonsillectomy with or without adenoidectomy at a single academic medical center between June 2012 and November 2015. RESULTS A total of 1416 patients were included in the study, with 704 in the no post-operative oral steroids group and 712 in the group who did receive post-operative oral steroids. The rate of post-tonsillectomy hemorrhage in the post-operative oral steroid group was 3.1 % compared to 1.8 % in the group who did not receive post-operative oral steroids, however, this was not a statistically significant difference (P = .132). CONCLUSIONS Our study suggests that post-operative oral steroids are safe and do not increase the risk of post-operative hemorrhage after pediatric tonsillectomy.
Collapse
Affiliation(s)
- Benjamin P Stevens
- University of Mississippi Medical Center, Department of Otolaryngology and Communicative Sciences, 2500 North State Street, Jackson, MS 39216, United States of America.
| | - Oishika Paul
- University of Mississippi Medical Center, Department of Otolaryngology and Communicative Sciences, 2500 North State Street, Jackson, MS 39216, United States of America
| | - Matthew C Donald
- University of Mississippi Medical Center, Department of Otolaryngology and Communicative Sciences, 2500 North State Street, Jackson, MS 39216, United States of America
| | - Joseph M Berry
- University of Mississippi Medical Center, Department of Otolaryngology and Communicative Sciences, 2500 North State Street, Jackson, MS 39216, United States of America
| | - Jeffrey D Carron
- University of Mississippi Medical Center, Department of Otolaryngology and Communicative Sciences, 2500 North State Street, Jackson, MS 39216, United States of America
| |
Collapse
|
14
|
Characterization of litigation after tonsillectomy in the United States. Am J Otolaryngol 2022; 43:103566. [DOI: 10.1016/j.amjoto.2022.103566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 07/18/2022] [Accepted: 07/31/2022] [Indexed: 11/20/2022]
|
15
|
Efficacy of tranexamic acid (TXA) for post-tonsillectomy hemorrhage. Am J Otolaryngol 2022; 43:103582. [DOI: 10.1016/j.amjoto.2022.103582] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 08/01/2022] [Indexed: 11/19/2022]
|
16
|
A single center retrospective comparison of post-tonsillectomy hemorrhage between BiZact and Coblator. Int J Pediatr Otorhinolaryngol 2022; 158:111165. [PMID: 35500397 DOI: 10.1016/j.ijporl.2022.111165] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 03/09/2022] [Accepted: 04/24/2022] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Over 550,000 tonsillectomies are performed every year. While post-tonsillectomy hemorrhage (PTH) has been studied in the coblator, bovie, and cold steel technique, there is a dearth of studies examining the post-tonsillectomy outcome using BiZact. This study examines the rate of BiZact PTH requiring control of hemorrhage in the OR and assess resident comfort using the device. METHODS Retrospective chart review for all tonsillectomies performed between January 2018 and December 2020 were performed. Rates of PTH were analyzed. In addition, a 7-question BiZact resident experience survey was administered to 25 otolaryngology residents. RESULTS 1384 patients were included in this study; 444 (32%) Bizact and 940 (68%) Coblation. 11 (2.48%) BiZact patients had PTH requiring OR for control of hemorrhage, compared to 44 (4.68%) Coblation patients. There were no patient deaths because of PTH. The mean age of patients with PTH was 7.44 (SD 4.07) years old. 22 (88%) residents responded to the survey. 17 (77.27%) felt more confident with Coblator while performing tonsillectomy most commonly reported for ease of use, followed by BiZact 4 (18.18%), most commonly reported for improved surgical plane. CONCLUSION BiZact is a safe and effective addition. At our institution, the rate of secondary PTH requiring OR intervention for BiZact is comparable to the national average for other tonsillectomy devices. The rate of BiZact PTH requiring OR intervention in our experience was nearly half of those done with Coblator. Overall residents at SCHC preferred Coblator over BiZact mainly attributed to Coblator's versatility and ability to control intraoperative tonsil bleeding without additional instruments despite BiZact's shorter operative time.
Collapse
|
17
|
Čampara AJ, Brkić S, Cerovac A, Kovačević M. Hemorrhage after adenotonsillectomy in children: tertiary center experiences. Wien Med Wochenschr 2022; 172:317-321. [PMID: 35759051 DOI: 10.1007/s10354-022-00945-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 05/25/2022] [Indexed: 11/29/2022]
Abstract
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.
Collapse
Affiliation(s)
- Alma Jahić Čampara
- Clinic for Anesthesiology and Reanimatology, University Clinical Centre Tuzla, Tuzla, Bosnia and Herzegovina.,Department of Pathophysiology, School of Medicine, University of Tuzla, Tuzla, Bosnia and Herzegovina
| | - Selmira Brkić
- Department of Pathophysiology, School of Medicine, University of Tuzla, Tuzla, Bosnia and Herzegovina
| | - Anis Cerovac
- Department of Gynaecology and Obstetrics, General Hospital Tešanj, Braće Pobrić 17, 74260, Tešanj, Bosnia and Herzegovina. .,Department of Anatomy, School of Medicine, University of Tuzla, Tuzla, Bosnia and Herzegovina.
| | - Mirza Kovačević
- Department of Anaesthesiology and Intensive Care Unit, Cantonal Hospital Zenica, Zenica, Bosnia and Herzegovina
| |
Collapse
|
18
|
Patel SD, Daher GS, Engle L, Zhu J, Slonimsky G. Adult tonsillectomy: An evaluation of indications and complications. Am J Otolaryngol 2022; 43:103403. [PMID: 35210109 DOI: 10.1016/j.amjoto.2022.103403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 02/13/2022] [Indexed: 11/01/2022]
Abstract
OBJECTIVE This study aimed to evaluate current adult tonsillectomy indications along with risk factors associated with postoperative complications. METHODS In this retrospective chart review, demographic, clinical, and surgical data were collected from 2004 to 2020 of adult patients who underwent tonsillectomy. Indications for surgery were categorized as infectious etiology, biopsy, obstructive sleep apnea (OSA), and tonsillar stones. Data regarding postoperative hemorrhage, emergency department (ED) visits, and readmissions were collected. Multivariable logistic regression models were used to evaluate factors associated with postoperative complications. RESULTS 574 adults (mean age 32 years, 69.9% F vs. 30.1% M) were included. The most common indication was infections (62.2%), followed by biopsy (26.5%), tonsillar stones (6.8%), and OSA (4.5%). The highest frequency of postoperative bleeds (17.9%) occurred in the tonsillar stones cohort; however, the indication for surgery was not a significant predictor on multivariate analysis. Male sex and younger age were independent predictors of postoperative bleeding, while younger age was a significant predictor of postoperative ED visits. There was a significant linear trend of an increasing proportion of tonsillectomies performed for tonsillar stones compared to other indications for 2011-2019. CONCLUSION Infectious etiology was the most common indication for tonsillectomy. Indication for surgery was not a significant predictor of postoperative bleeding; however, male sex and younger age had higher odds of postoperative bleeding. The proportion of tonsillectomies performed for tonsillar stones was steadily increasing.
Collapse
|
19
|
Lee AC, Haché M. Pediatric Anesthesia Management for Post-Tonsillectomy Bleed: Current Status and Future Directions. Int J Gen Med 2022; 15:63-69. [PMID: 35027837 PMCID: PMC8749229 DOI: 10.2147/ijgm.s312866] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 12/20/2021] [Indexed: 11/23/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Angela C Lee
- Division of Anesthesiology, Pain and Perioperative Medicine, Children's National Hospital, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Manon Haché
- Division of Pediatric Anesthesia, Department of Anesthesiology, Columbia University Irving Medical Center, New York, NY, USA
| |
Collapse
|
20
|
Levy E, Kuperman A, Sela E, Kashkoush A, Miari AD, Hana RY, Freilich I, Bader A, Gruber M. Utility of the Pediatric Bleeding Questionnaire in Predicting Posttonsillectomy Bleeding. Otolaryngol Head Neck Surg 2021; 167:576-582. [PMID: 34813387 DOI: 10.1177/01945998211061474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Posttonsillectomy bleeding is a dreadful complication that may be life-threatening. Preoperative coagulation tests have not been shown to be effective in predicting this complication. The Pediatric Bleeding Questionnaire (PBQ) is a validated and sensitive tool in diagnosing children with abnormal hemostatic functions, and the objective of our study was to assess its utility as a preoperative screening tool for predicting posttonsillectomy bleeding. STUDY DESIGN Prospective single-blinded cohort study. SETTING Tertiary care hospital system. METHODS All children scheduled for tonsil surgery between 2017 and 2019 in the Galilee Medical Center were included. The PBQ was completed by the caregivers prior to surgery, and all children underwent coagulation tests. Each PBQ item is scored on a scale of -1 to 4, and the total score per candidate is based on summation of all items. RESULTS An overall 272 patients were included in the study with a mean age of 5.2 years; 57.7% were boys. The main finding was that in a multivariable model adjusted to age, a PBQ score of 2 is correlated with increased postoperative bleeding risk (odds ratio, 10.018 [95% CI, 1.20-82.74]; P = .046). The results of the PBQ demonstrated better predictive ability when compared with abnormal coagulation test results (odds ratio, 1.76 [95% CI, 0.63-4.80]; P = .279). Sex was not found to be significant (odds ratio, 1.45 [95% CI, 0.70-3.18]; P = .343). CONCLUSIONS This study demonstrated that a PBQ score ≥2 has a higher yield for detecting children at risk for posttonsil surgery bleeding as compared with coagulation studies.
Collapse
Affiliation(s)
- Einat Levy
- Department of Otolaryngology-Head and Neck Surgery, Galilee Medical Center, Nahariya, Israel.,Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Amir Kuperman
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel.,Blood Coagulation Service and Pediatric Hematology Clinic, Galilee Medical Center, Nahariya, Israel
| | - Eyal Sela
- Department of Otolaryngology-Head and Neck Surgery, Galilee Medical Center, Nahariya, Israel.,Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Adham Kashkoush
- Department of Otolaryngology-Head and Neck Surgery, Galilee Medical Center, Nahariya, Israel
| | - Abeer Dabbah Miari
- Department of Otolaryngology-Head and Neck Surgery, Galilee Medical Center, Nahariya, Israel
| | - Randa Yawer Hana
- Department of Otolaryngology-Head and Neck Surgery, Galilee Medical Center, Nahariya, Israel
| | - Ieva Freilich
- Department of Otolaryngology-Head and Neck Surgery, Galilee Medical Center, Nahariya, Israel
| | - Ahmad Bader
- Department of Otolaryngology-Head and Neck Surgery, Galilee Medical Center, Nahariya, Israel.,Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Maayan Gruber
- Department of Otolaryngology-Head and Neck Surgery, Galilee Medical Center, Nahariya, Israel.,Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| |
Collapse
|
21
|
Pai K, Desai H, Stein D, Cole S. Postoperative tonsil/adenoidectomy bleeding management in patients with diagnosed bleeding disorders. Laryngoscope Investig Otolaryngol 2021; 6:872-877. [PMID: 34401515 PMCID: PMC8356851 DOI: 10.1002/lio2.589] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 04/05/2021] [Accepted: 05/11/2021] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE Tonsil/adenoidectomy (T/A) is a commonly performed procedure with an average post-tonsillectomy bleed (PTB) rate between 3 and 5%. Patients with bleeding disorders (BDs) are believed to have an increased risk of PTB. We hypothesize that our medical management of BD patients using a combination of DDAVP/antifibrinolytic agents has a similar PTB rate to control patients. This study suggests a standardized protocol for patients with BDs to avoid PTB. METHODS A retrospective cohort study was completed for patients with BD who underwent tonsillectomy or T/A at Promedica Toledo or Flower Hospital between 2013 and 2020. Exclusion criteria included incomplete records, diagnosis of BD after surgery, and inability to find age and sex matched control. We defined the control group as patients who underwent T/A without BD. The following variables were collected: age, sex, medical history, BD severity, medications, type of surgery, indication for surgery, estimated blood loss (EBL), pre/postoperative medications, PTB status, and post-PTB intervention. RESULTS A total of 164 patient charts were reviewed. There were 82 patients in both cohorts. The BDs represented were platelet function disorder (80.5%), von Willebrand disease (14.6%), and others such as Factor VII and IX deficiency (4.9%). Of the BD patients included, 13.4% had severe disease. There was no significant difference between the age, sex, EBL, and PTB rates. Of the 8 BD patients with PTB, 62% bled 9-10 days postoperatively and none had severe disease. CONCLUSION Our protocol to prevent PTB in patients with BDs produced similar bleed rates to control patients in this study. Further studies are required to assess postoperative length of antifibrinolytic treatment in BD patients. LEVEL OF EVIDENCE III.
Collapse
Affiliation(s)
- Kavya Pai
- University of Toledo College of Medicine and Life SciencesToledoOhioUSA
| | - Harsh Desai
- University of Toledo College of Medicine and Life SciencesToledoOhioUSA
| | - Dagmar Stein
- Pediatric Hematology/Oncology, Promedica Russell J. Ebeid Children's HospitalToledoOhioUSA
| | | |
Collapse
|
22
|
Ruiz R, Dedhia K. Adenotonsillectomy in high risk patients: Hematologic abnormalities and COVID-19 considerations. World J Otorhinolaryngol Head Neck Surg 2021; 7:174-178. [PMID: 34094629 PMCID: PMC8164470 DOI: 10.1016/j.wjorl.2021.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 04/05/2021] [Indexed: 12/01/2022] Open
Abstract
Adenotonsillectomy is one of the most common surgical procedures performed by otolaryngologists. It is vital that surgeons are aware of the risks in performing this surgery especially during the COVID-19 pandemic and in children with hematologic disorders. In this review we describe common hematologic disorders often noted in pediatric patients undergoing this procedure, as well as proper screening and management of these patients. In addition, we also address the impact of the COVID-19 pandemic and some measures to help mitigate the risks of this procedure during this time.
Collapse
Affiliation(s)
- Ryan Ruiz
- Department of Otolaryngology-Head and Neck Surgery, University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia 19104, USA
| | - Kavita Dedhia
- Department of Otolaryngology-Head and Neck Surgery, University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia 19104, USA
| |
Collapse
|
23
|
Predictive clinical exam findings in post-tonsillectomy hemorrhage. Int J Pediatr Otorhinolaryngol 2021; 144:110671. [PMID: 33730604 DOI: 10.1016/j.ijporl.2021.110671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 02/09/2021] [Accepted: 03/07/2021] [Indexed: 11/24/2022]
Abstract
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.
Collapse
|
24
|
Shotts SD, Welsh DV, Nakamura A, Stromberg AJ. Very-Low Energy Monopolar Reduces Post-Tonsillectomy Hemorrhage Versus Standard Energy Techniques. Laryngoscope 2021; 131:2505-2511. [PMID: 33904597 DOI: 10.1002/lary.29587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 04/04/2021] [Accepted: 04/07/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVES/HYPOTHESIS To compare rates of post-tonsillectomy hemorrhage (PTH) between a very-low energy transfer monopolar technique (VLET) and standard energy techniques. STUDY DESIGN Retrospective controlled cohort study. METHODS All tonsillectomies performed by practice physicians during the period January 1, 2010 to August 31, 2019 were identified. Three groups were created based on surgeon technique utilization: the study group (VLET) and two control groups (exclusive standard energy monopolar [Standard]; exclusive "hot" technique without exclusive monopolar use [Mixed "Hot"]). Each group's PTH occurrences requiring surgical intervention (PTHRSI) were identified and rates compared. RESULTS During the study period 11,348 tonsillectomies were performed (4,427 Standard, 1,374 VLET, 5,547 Mixed "Hot"), and 167 (1.47%) PTHRSI events identified (14 primary (<24 hours), 153 secondary (>24 hours), 12 repeat (>1PTHRSI/patient). Compared to the Standard group secondary and total PTHRSI rates (1.47%, 1.60%), the Mixed "Hot" group experienced similar rates (1.57%, P = .54; 1.68%, P = .64), but the VLET group experienced significantly lower rates (0.15%, P = .0026, adjusted odds ratio [OR] 0.114 [0.028-0.469]; 0.22%, P = .0016, adjusted OR 0.155 [0.048-0.494]). Age was a significant risk factor for both secondary and total PTHRSI (P = .0025, P = .0024, adjusted OR 1.02/year [1.01-1.03]). No significant difference in rate of primary PTHRSI was seen collectively or in any age group. The <12VLET Group experienced 0 episodes of secondary PTHRSI and a total PTHRSI rate of 0.09% in 1060 tonsillectomies. CONCLUSIONS Standard energy techniques had an adjusted odds ratio over 8-fold higher for secondary PTHRSI and over 6-fold higher for total PTHRSI compared to the minimized energy transfer VLET technique. LEVEL OF EVIDENCE 3 Laryngoscope, 2021.
Collapse
Affiliation(s)
| | | | - Aisaku Nakamura
- Dr Bing Zhang Department of Statistics, University of Kentucky, Lexington, Kentucky, U.S.A
| | - Arnold J Stromberg
- Dr Bing Zhang Department of Statistics, University of Kentucky, Lexington, Kentucky, U.S.A
| |
Collapse
|
25
|
Gray ML, Chen S, Kinberg E, Colley P, Malkin BD. Using Lean to Improve Patient Safety and Resource Utilization After Pediatric Adenotonsillectomy. J Patient Saf 2021; 17:95-100. [PMID: 30907784 DOI: 10.1097/pts.0000000000000573] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The objective of this quality improvement project was to decrease the rate of nonemergent use of emergency department (ED) resources in children undergoing adenotonsillectomy by 50% and/or reach a future state of 5% or less overall ED visits among all postoperative patients within 1 year. A secondary objective was to standardize the preoperative, intraoperative, and postoperative management of these patients. METHODS The study was a quality improvement project using Lean. The target population was children younger than 18 years undergoing tonsillectomy with or without adenoidectomy. A retrospective review of adenotonsillectomy was performed for a 12-month period. Lean tools including A3 Thinking, Ishikawa "fishbone" diagram, and value stream mapping were used to analyze the problem and identify interventions. Postintervention data were collected for a 10-month period. RESULTS Compared with the baseline period, the ED visit rate after adenotonsillectomy decreased from 36.2% to 15.5% (P = 0.0095). The rate of ED visits for nonbleeding complaints decreased from 30.4% to 12.1% (P = 0.01748). There was no significant change in rate of ED visits for bleeding (decreased from 5.8% to 3.5% [P = 0.6873]). There was no significant change in the use of intraoperative dexamethasone and acetaminophen. CONCLUSIONS Postadenotonsillectomy patients often use emergency resources better reserved for other patients. Addressing this problem with Lean principles significantly decreased postoperative ED visit rates by more than 50%. IMPLICATIONS FOR PRACTICE To our knowledge, this is the first reported use of Lean principles to decrease utilization of emergency resources in the postoperative period. Lean can be applied to other processes in our field to eliminate waste and add value to improve patient outcomes. LEVEL OF EVIDENCE NA.
Collapse
Affiliation(s)
- Mingyang L Gray
- From the Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | | | | | | |
Collapse
|
26
|
Gross JH, Lindburg M, Kallogjeri D, Molter M, Molter D, Lieu JEC. Predictors of Occurrence and Timing of Post-Tonsillectomy Hemorrhage: A Case-Control Study. Ann Otol Rhinol Laryngol 2020; 130:825-832. [PMID: 33291963 DOI: 10.1177/0003489420978010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To describe cases and timing of pediatric post-tonsillectomy hemorrhage (PTH), to evaluate predictors of PTH, and to determine the optimal amount of postoperative care unit (PACU) monitoring time. STUDY DESIGN Using the Pediatric Health Information System (PHIS) database and electronic medical records, a matched case-control study from 2005 to 2015 was performed. SETTING A single, tertiary-care institution. SUBJECTS AND METHODS Each case of PTH was matched with 1 to 4 controls for the following factors: age, sex, surgeon, and time of year. A total of 124 cases of PTH and 479 tonsillectomy controls were included. The rate and timing of postoperative bleeding were assessed, and matched pair analysis was performed using conditional logistic regression. RESULTS Our institutional PTH rate of 1.9% (130 of 6949) included 124 patients; 15% (19) were primary (≤24 hours), with 50% (9) occurring within 5 hours. Twenty-one percent (4 of 19) of primary PTH patients received operative intervention. Eighty-five percent (105 of 124) of all cases were secondary PTH, and 47% (49) of those patients received operative intervention. Cold steel (OR 1.9, 95% CI 1.1-3.3) and Coblation (OR 1.9, 95% CI 1.2-3.1) techniques and tonsillectomy alone (OR 3.7, 95% CI 1.9-7.2) increased odds of PTH. Patients who developed PTH had 4 times the odds of having a preceding postoperative respiratory event than controls (OR 4.0, 95% CI 1.6-10.0). CONCLUSION We conducted a rigorous case-control study for PTH, finding that PTH was associated with use of cold steel and Coblation techniques and with tonsillectomy alone. Patients with a postoperative respiratory event may be more likely to develop a PTH and should be counseled accordingly. A PACU monitoring time of 4 hours is sufficient for outpatient tonsillectomy.
Collapse
Affiliation(s)
- Jennifer H Gross
- Department of Otolaryngology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Miranda Lindburg
- Department of Otolaryngology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Dorina Kallogjeri
- Department of Otolaryngology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Michelle Molter
- Department of Otolaryngology, Washington University School of Medicine, Saint Louis, MO, USA
| | - David Molter
- Department of Otolaryngology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Judith E C Lieu
- Department of Otolaryngology, Washington University School of Medicine, Saint Louis, MO, USA
| |
Collapse
|
27
|
Leung P, DeVore EK, Kawai K, Yuen S, Kenna M, Irace AL, Roberson D, Adil E. Does Ibuprofen Increase Bleed Risk for Pediatric Tonsillectomy? Otolaryngol Head Neck Surg 2020; 165:187-196. [PMID: 33170769 DOI: 10.1177/0194599820970943] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To evaluate risk factors for pediatric posttonsillectomy hemorrhage (PTH) and the need for transfusion using a national database. STUDY DESIGN Retrospective cohort study. SETTING The study was conducted using the Pediatric Health Information System (PHIS) database. METHODS Children ≤18 years who underwent tonsillectomy with or without adenoidectomy (T±A) between 2004 and 2015 were included. We evaluated the risk of PTH requiring cauterization according to patient demographics, comorbidities, indication for surgery, medications, year of surgery, and geographic region. RESULTS Of the 551,137 PHIS patients who underwent T±A, 8735 patients (1.58%) experienced a PTH. The risk of PTH increased from 1.33% (95% confidence interval [CI]: 1.15%, 1.53%) in 2010 to 1.91% (95% CI: 1.64%, 2.24%) in 2015 (P < .001). Older age (≥12 vs <5 years old: adjusted odds ratio [aOR] 3.17; 95% CI: 2.86, 3.52), male sex (aOR 1.11; 95% CI: 1.05, 1.17), medical comorbidities (aOR 1.18; 95% CI: 1.08, 1.29), recurrent tonsillitis (aOR 1.15; 95% CI: 1.07, 1.24), and intensive care unit admission (aOR 1.74; 95% CI: 1.55, 1.95) were significantly associated with an increased risk of PTH. Use of ibuprofen (aOR 1.36; 95% CI: 1.22, 1.52), ketorolac (aOR 1.39; 95% CI: 1.14, 1.69), anticonvulsant (aOR 1.23; 95% CI: 1.03, 1.76), and antidepressants (aOR 1.35; 95% CI: 1.03, 1.76) were also associated with an increased risk of PTH. The need for blood transfusion was 2.1% (181/8735). CONCLUSION The incidence of PTH increased significantly between 2011 and 2015, and ibuprofen appears to be one contributing factor. Given the benefits of ibuprofen, it is unclear whether this increased risk warrants a change in practice.
Collapse
Affiliation(s)
- Peggy Leung
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, USA
| | | | - Kosuke Kawai
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School Department of Otolaryngology, Boston, Massachusetts, USA
| | - Sonia Yuen
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Margaret Kenna
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School Department of Otolaryngology, Boston, Massachusetts, USA
| | - Alexandria L Irace
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, USA
| | - David Roberson
- Bayhealth Medical Center, Milford, Delaware, USA.,The Global Tracheostomy Collaborative, Raleigh, North Carolina, USA
| | - Eelam Adil
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School Department of Otolaryngology, Boston, Massachusetts, USA
| |
Collapse
|
28
|
Chorney SR, Weinberger R, Weintraub AY, Buzi A. Post-Tonsillectomy Hemorrhage and the Diagnosis of Occult Pediatric Coagulopathies. Laryngoscope 2020; 131:E2069-E2073. [PMID: 33146421 DOI: 10.1002/lary.29244] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 10/21/2020] [Indexed: 12/15/2022]
Abstract
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.
Collapse
Affiliation(s)
- Stephen R Chorney
- Department of Otolaryngology - Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A.,Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, U.S.A
| | - Rena Weinberger
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, U.S.A
| | - Ari Y Weintraub
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, U.S.A.,Department of Anesthesiology & Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Adva Buzi
- Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, U.S.A.,Department of Otorhinolaryngology - Head and Neck Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| |
Collapse
|
29
|
Hizli O, Kayabasi S, Cengiz B, Acar A. A Novel Proposal for Classifying Pediatric Tonsillectomy Complications: Modified Clavien Classification. Cureus 2020; 12:e8701. [PMID: 32699697 PMCID: PMC7370679 DOI: 10.7759/cureus.8701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Introduction Tonsillectomy is one of the most common operations performed in the otolaryngology practice and there does not exist a systematic classification for tonsillectomy complications in the prior literature. In this study, we aimed at presenting a novel classification system to the current literature and analyzing complications of pediatric tonsillectomy based on this novel classification system. Methods A novel classification system based on modified Clavien classification was constituted for pediatric tonsillectomy complications. Medical records of 534 patients underwent tonsillectomy were retrospectively investigated and complication rates of tonsillectomy between children and adults were compared using this classification Results In total, 454 pediatric patients (258 males and 196 females, age range = 3-17 years) who underwent cold-knife tonsillectomy were eligible for the study. To compare the complication rates of the pediatric patients with adults, 80 adults with tonsillectomy (50 males and 30 females, age range 18-46) were also included. In children, the most common complication was dehydration, seen in 13 (2.86%) patients. The most serious complication was tooth aspiration (Grade 4a), seen in only one (0.22%) patient. Fifteen (3.3%) pediatric patients experienced more than one complication. Overall complication rate of pediatric tonsillectomy was 10.13% (46 patients). In adults, the most common complication was postoperative bleeding, seen in 11 (13.75%) adult patients. The most serious complication was Grade 3a postoperative bleeding, seen in four (5%) patients. Overall complication rate of adult tonsillectomy was 21.25% (17 patients). Overall complication rate of pediatric tonsillectomy was significantly lower compared with the complication rate of adult tonsillectomy (10.13% vs. 21.25%, p = 0.004, X2 = 8.07). Conclusion Modified Clavien classification is a novel and simple tool to analyze and categorize complications of pediatric tonsillectomy.
Collapse
Affiliation(s)
- Omer Hizli
- Otolaryngology, Prof. Dr. A. Ilhan Ozdemir Education and Research Hospital, Giresun University, Giresun, TUR
| | - Serkan Kayabasi
- Otolaryngology, Faculty of Medicine, Aksaray University, Aksaray, TUR
| | - Bugra Cengiz
- Otorhinolaryngology, Bagcilar Trainining and Research Hospital, İstanbul, TUR
| | - Aydin Acar
- Otolaryngology, Kecioren Education and Research Hospital, Ankara, TUR
| |
Collapse
|
30
|
Diercks GR, Comins J, Bennett K, Gallagher TQ, Brigger M, Boseley M, Gaudreau P, Rogers D, Setlur J, Keamy D, Cohen MS, Hartnick C. Comparison of Ibuprofen vs Acetaminophen and Severe Bleeding Risk After Pediatric Tonsillectomy: A Noninferiority Randomized Clinical Trial. JAMA Otolaryngol Head Neck Surg 2020; 145:494-500. [PMID: 30946442 DOI: 10.1001/jamaoto.2019.0269] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Ibuprofen is an effective analgesic after tonsillectomy alone or tonsillectomy with adenoidectomy, but concerns remain about whether it increases postoperative hemorrhage. Objective To investigate the effect of ibuprofen compared with acetaminophen on posttonsillectomy bleeding (PTB) requiring surgical intervention in children. Design, Setting, and Participants A multicenter, randomized, double-blind noninferiority trial was conducted at 4 tertiary medical centers (Massachusetts Eye and Ear Infirmary, Boston; Naval Medical Center, San Diego, California; Naval Medical Center, Portsmouth, Virginia; Madigan Army Medical Center, Tacoma, Washington). A total of 1832 children were assessed for eligibility (presence of sleep-disordered breathing or obstructive sleep apnea, adenotonsillar hypertrophy, or infectious tonsillitis undergoing extracapsular tonsillectomy by electrocautery). Of these, 1091 were excluded because they did not meet eligibility criteria (n = 681) or refused to participate (n = 410); thus, 741 children aged 2 to 18 years undergoing tonsillectomy alone or tonsillectomy with adenoidectomy were enrolled between May 3, 2012, and January 20, 2017. Interventions Participants were randomized to receive ibuprofen, 10 mg/kg (n = 372), or acetaminophen, 15 mg/kg (n = 369), every 6 hours for the first 9 postoperative days. Main Outcomes and Measures Rate and severity of posttonsillectomy bleeding were recorded using a postoperative bleeding severity scale: type 1 (bleeds that were observed at home or evaluated in the emergency department without further intervention), type 2 (bleeds that required readmission for observation), and type 3 (bleeds that required a return to the operating room for control of hemorrhage). Type 3 bleeding was the main outcome measure. The noninferiority margin was set at 3%, and modified intention-to-treat analysis was used. Results Of the 741 children enrolled, 688 children (92.8%) (median [interquartile range] age, 5 [4] years; 366 boys [53.2%]) received the study medication and were included in a modified intention-to-treat analysis. The rate of bleeding requiring operative intervention was 1.2% in the acetaminophen group and 2.9% in the ibuprofen group (difference, 1.7%; 97.5% CI upper limit, 3.8%; P = .12 for noninferiority). There were no significant adverse events or deaths. Conclusions and Relevance This study could not exclude a higher rate of severe bleeding in children receiving ibuprofen after tonsillectomy alone or tonsillectomy with adenoidectomy. This finding should be considered when selecting a postoperative analgesic regimen. Further studies are needed to understand if bleeding risk is affected when ibuprofen is used for a shorter duration or in combination with acetaminophen for postoperative analgesia. Trial Registration ClinicalTrials.gov identifier: NCT01605903.
Collapse
Affiliation(s)
- Gillian R Diercks
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts
| | - Jill Comins
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts
| | - Kara Bennett
- Bennett Statistical Consulting Inc, Ballston Lake, New York
| | - Thomas Q Gallagher
- Department of Otolaryngology, Naval Medical Center Portsmouth, Portsmouth, Virginia
| | - Matthew Brigger
- Department of Otolaryngology, Naval Medical Center San Diego, San Diego, California
| | - Mark Boseley
- Department of Otolaryngology, Madigan Army Medical Center, Tacoma, Washington
| | - Philip Gaudreau
- Department of Otolaryngology, Naval Medical Center San Diego, San Diego, California
| | - Derek Rogers
- Department of Otolaryngology, Madigan Army Medical Center, Tacoma, Washington
| | - Jennifer Setlur
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts
| | - Donald Keamy
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts
| | - Michael S Cohen
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts
| | - Christopher Hartnick
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
31
|
Seyhun N, Dizdar SK, Çoktur A, Bektaş ME, Albuz O, Erol ZN, Turgut S. Risk factors for post-tonsillectomy hemorrhage in adult population: Does smoking history have an impact? Am J Otolaryngol 2020; 41:102341. [PMID: 31732315 DOI: 10.1016/j.amjoto.2019.102341] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 11/03/2019] [Accepted: 11/06/2019] [Indexed: 12/11/2022]
Affiliation(s)
- Nurullah Seyhun
- Sisli Hamidiye Etfal Training and Research Hospital, ENT Clinic, Sisli, Istanbul, Turkey.
| | - Senem Kurt Dizdar
- Sisli Hamidiye Etfal Training and Research Hospital, ENT Clinic, Sisli, Istanbul, Turkey
| | - Alican Çoktur
- Sisli Hamidiye Etfal Training and Research Hospital, ENT Clinic, Sisli, Istanbul, Turkey
| | - Merve Ekici Bektaş
- Sisli Hamidiye Etfal Training and Research Hospital, ENT Clinic, Sisli, Istanbul, Turkey
| | - Onuralp Albuz
- Sisli Hamidiye Etfal Training and Research Hospital, ENT Clinic, Sisli, Istanbul, Turkey
| | - Zeynep Nur Erol
- Sisli Hamidiye Etfal Training and Research Hospital, ENT Clinic, Sisli, Istanbul, Turkey
| | - Suat Turgut
- Sisli Hamidiye Etfal Training and Research Hospital, ENT Clinic, Sisli, Istanbul, Turkey
| |
Collapse
|
32
|
Screening for undiagnosed bleeding disorders in post-tonsillectomy bleed patients: Retrospective review and systematic review of the literature. Int J Pediatr Otorhinolaryngol 2019; 124:210-214. [PMID: 31229837 DOI: 10.1016/j.ijporl.2019.06.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 05/01/2019] [Accepted: 06/06/2019] [Indexed: 02/06/2023]
Abstract
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.
Collapse
|
33
|
Bitar M, Dunya G, Khalifee E, Muwakkit S, Barazi R. Risk of post-operative hemorrhage after adenoidectomy and tonsillectomy: Value of the preoperative determination of partial thromboplastin time and prothrombin time. Int J Pediatr Otorhinolaryngol 2019; 116:62-64. [PMID: 30554709 DOI: 10.1016/j.ijporl.2018.10.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Revised: 10/16/2018] [Accepted: 10/16/2018] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Tonsillectomy and adenoidectomy (T& A) are the most common pediatric surgical procedures performed world-wide. Bleeding remains the most common complication of these procedures with 1-5.7% prevalence. METHODS We recruited 1269 patients who were scheduled for either tonsillectomy, adenoidectomy or both. All patients had preoperative CBC, PT, and aPTT ordered. According to the results, patients were labelled as either "abnormal group" or "normal group". RESULTS 35 patients had abnormal lab results 18 of these patients were diagnosed with coagulation disorders on further laboratory testing.9 of these patients had no pertinent history of bleeding. Even though an association is noted between abnormal lab tests and preoperative history of risk of bleeding, the correlation did not have high sensitivity (28.6%). CONCLUSION This study provides evidence that preoperative history can give some information on patients with abnormal coagulation profile but may underestimate the prevalence of such diseases. In addition, patients with abnormal coagulation profile have more risk of postoperative bleeding even after adequate medical treatment perioperative. Thus, identifying these patients will help the clinician in providing the best surgical management with the least morbidity and mortality.
Collapse
Affiliation(s)
- Mohamad Bitar
- Department of Otolaryngology Head and Neck Surgery, Al Jalila Children's Hospital, Dubai, United Arab Emirates
| | - Gabriel Dunya
- Department of Otolaryngology Head and Neck Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Elie Khalifee
- Department of Otolaryngology Head and Neck Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Samar Muwakkit
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Randa Barazi
- Department of Otolaryngology Head and Neck Surgery, American University of Beirut Medical Center, Beirut, Lebanon.
| |
Collapse
|
34
|
Day-case tonsillectomy in children: Experience from a Teaching Hospital in Jordan. INTERNATIONAL JOURNAL OF SURGERY OPEN 2019. [DOI: 10.1016/j.ijso.2019.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
|
35
|
A review of adenotonsillar hypertrophy and adenotonsillectomy in children after solid organ transplantation. Int J Pediatr Otorhinolaryngol 2018; 114:29-35. [PMID: 30262363 DOI: 10.1016/j.ijporl.2018.08.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 08/16/2018] [Accepted: 08/17/2018] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Paediatric solid organ transplantation is an increasingly successful treatment. Improved survival is paralleled by increased secondary complications of immunosuppression, including post-transplant lymphoproliferative disease (PTLD). PTLD frequently presents in Waldeyer's lymphatic ring. Adenotonsillar hypertrophy (ATH) is common in children, however in children after transplant, ATH may indicate PTLD. We review the literature on ATH and the role of adenotonsillectomy in children after transplantation. METHODS A comprehensive literature search was performed on the 26 th September 2017 of Ovid Medline (1996-September 2017), Embase (1996-2017) and EBM reviews (Cochrane database of systematic reviews 2005-September 20 th 2017). Results were limited to English language publications within the last 20 years. Abstracts were screened for relevance to PTLD and ATH in the paediatric solid organ transplantation population. Screening of the bibliographies identified further articles. RESULTS 85 unique articles were screened to yield 18 relevant publications. 10 were retrospective studies and 8 were prospective studies. CONCLUSION In children, we report a PTLD incidence of up to 15%, with up to 63% of cases presenting in the head and neck. Histological examination of adenotonsillectomy specimens found PTLD in a mean 5.7% (range 0-39%). We found a lack of prospective studies into this topic and further high quality research is needed. Clinical assessment of ATH in children after transplantation and when to perform a diagnostic adenotonsillectomy remains challenging. Children with ATH warrant prompt further investigation and support from colleagues in transplantation and oncology is required. .
Collapse
|
36
|
Peritonsillar infiltration of lidocaine with adrenaline is associated with increased risk of secondary post-tonsillectomy haemorrhage. The Journal of Laryngology & Otology 2018; 132:911-922. [PMID: 30296953 DOI: 10.1017/s0022215118001731] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES In order to evaluate the safety of tonsillectomy among children, we retrospectively studied the incidence of post-operative complications, adverse events and their association with peri-operative medication. METHODS Data were collected from the medical records of 691 patients aged 1-16 years, including details of post-operative complications (any unplanned contact with the hospital), analgesics, dexamethasone, 5-HT3 antagonists, local anaesthetic and haemostatic agents. RESULTS Recovery was complicated in 13.6 per cent of patients, of whom 8.4 per cent were re-admitted to the ward. The most common complication was post-tonsillectomy haemorrhage, experienced by 7.1 per cent of patients. Re-operation under general anaesthesia (for grade III post-tonsillectomy haemorrhage) was required by 4.2 per cent of patients. Peritonsillar infiltration of lidocaine with adrenaline increased the risk of post-tonsillectomy haemorrhage (odds ratio = 4.1; 95 per cent confidence interval = 2.1 to 8.3). CONCLUSION Every seventh paediatric patient experienced a complicated recovery after tonsillectomy, caused by post-tonsillectomy haemorrhage in most cases. Local peritonsillar infiltration of lidocaine with adrenaline was associated with an increased risk of post-tonsillectomy haemorrhage.
Collapse
|
37
|
Susaman N, Kaygusuz I, Karlıdag T, Keles E, Yalcın S, Cilibas RE. Risk Factors For Post-Tonsillectomy Hemorrhage. ENT UPDATES 2018. [DOI: 10.32448/entupdates.459027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
|
38
|
Postoperative care after tonsillectomy: what's the evidence? Curr Opin Otolaryngol Head Neck Surg 2017; 25:498-505. [DOI: 10.1097/moo.0000000000000420] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
|
39
|
Epithelial separation theory for post-tonsillectomy secondary hemorrhage: evidence in a mouse model and potential heparin-binding epidermal growth factor-like growth factor therapy. Eur Arch Otorhinolaryngol 2017; 275:569-578. [PMID: 29188436 DOI: 10.1007/s00405-017-4810-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Accepted: 11/09/2017] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To provide histological evidence to investigate a theory for post-tonsillectomy secondary hemorrhage (PTH) in a mouse model and to evaluate the potential for heparin-binding epidermal growth factor-like growth factor (HB-EGF) treatment on wound healing in this model. METHODS A prospective randomized single-blinded cohort study. A uniform tongue wound was created in 84 mice (day 0). Mice were randomized to HB-EGF (treatment, n = 42) or saline (control, n = 42). In treatment mice, HB-EGF 5 µg/ml was administered intramuscularly into the wound daily (days 0-14). In control mice, normal saline was administered daily. Three mice from each group were sacrificed daily through day 14 and the wounds evaluated histologically by blinded reviewers. RESULTS Key stages of wound healing, including keratinocyte proliferation and migration, wound contraction, epithelial separation, and neoangiogenesis, are defined with implications for post-tonsillectomy wound healing. Epithelial separation (59 vs. 100%, p = 0.003) and wound reopening (8 vs. 48%, p < 0.001) were reduced with HB-EGF. Epithelial thickness (220 vs. 30 µm, p = 0.04) was greater with HB-EGF. Wound closure (days 4-5 vs. day 6, p = 0.01) occurred earlier with HB-EGF. CONCLUSIONS In healing of oral keratinocytes on muscle epithelial separation secondary to muscle, contraction occurs concurrently with neoangiogenesis in the base of the wound, increasing the risk of hemorrhage. This potentially explains why post-tonsillectomy secondary hemorrhage occurs and its timing. HB-EGF-treated wounds showed greater epithelial thickness, less frequent epithelial separation and wound reopening, and earlier wound closure prior to neovascularization, suggesting that HB-EGF may be a potential preventative therapy for PTH. LEVEL OF EVIDENCE NA-animal studies or basic research.
Collapse
|
40
|
El Rassi E, de Alarcon A, Lam D. Practice patterns in the management of post-tonsillectomy hemorrhage: An American Society of Pediatric Otolaryngology survey. Int J Pediatr Otorhinolaryngol 2017; 102:108-113. [PMID: 29106855 DOI: 10.1016/j.ijporl.2017.09.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 09/07/2017] [Accepted: 09/07/2017] [Indexed: 01/14/2023]
Abstract
OBJECTIVES To evaluate practice patterns amongst pediatric otolaryngologists in the management of post-tonsillectomy hemorrhage. METHODS A cross-sectional survey of the American Society of Pediatric Otolaryngology membership was administered electronically. The survey contained questions related to practice type, availability of resident and fellow call coverage, and management of different scenarios of post-tonsillectomy hemorrhage. Anonymous responses were collected and tabulated. RESULTS The response rate was 157/443 (35%). For patients presenting with a convincing history of post-tonsillectomy hemorrhage but no clot or bleeding on exam, the most common management was overnight observation (55%) or discharge home with close follow-up (29%). In patients presenting with tonsillar clot but no active bleeding, the most common management was operating room for control (50%), followed by observation (25%) and bedside topical treatment (13%). In the same scenario with a cooperative teenager, bedside topical treatment was most common (45%), followed by operating room for control (27%) and observation (16%). In patients presenting with active tonsillar bleeding, operating room for control was most common (83%) while few (6%) attempted bedside treatment. If the patient was a cooperative teenager, 38% attempted bedside treatment while 52% would still go to the operating room. CONCLUSIONS There is substantial variation in the management of post-tonsillectomy hemorrhage amongst the pediatric otolaryngologists. Further studies to determine outcomes associated with differing treatment strategies would be useful in establishing practice recommendations.
Collapse
Affiliation(s)
- Edward El Rassi
- Department of Otolaryngology - Head and Neck Surgery, Oregon Health and Science University, Portland, OR, USA.
| | - Alessandro de Alarcon
- Department of Otolaryngology - Head and Neck Surgery, University of Cincinnati, Cincinnati, OH, USA; Pediatric Otolaryngology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Derek Lam
- Department of Otolaryngology - Head and Neck Surgery, Oregon Health and Science University, Portland, OR, USA; Pediatric Otolaryngology, Doernbecher Children's Hospital, Portland, OR, USA
| |
Collapse
|
41
|
Østvoll E, Sunnergren O, Stalfors J. Increasing Readmission Rates for Hemorrhage after Tonsil Surgery: A Longitudinal (26 Years) National Study. Otolaryngol Head Neck Surg 2017; 158:167-176. [PMID: 28828912 DOI: 10.1177/0194599817725680] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Objective To investigate the readmission rates due to postoperative hemorrhage in relation to tonsil surgery clinical practice in a national population. Study Design Retrospective longitudinal population-based cohort study. Setting Based on register data from the Swedish National Patient Register (NPR). Subjects and Methods All benign tonsil operations (256 053) performed in Sweden from 1987 to 2013 were identified through a search in the NPR. For all identified cases, data on gender, age, date of surgery, indication, type of surgery, level of care, length of stay (LOS) for inpatient surgery, readmission and reoperation because of postoperative bleeding (within 31 days) were collected. Results Overall frequency of readmission for hemorrhage was 2.61%, and the reoperation rate for hemostasis was 0.84%. The longitudinal analysis showed an increase from 1% (1987) to 5% (2013) in readmissions caused by hemorrhage. Tonsillectomies, surgery performed for infectious disease, and surgery on adult patients (age >18 years) showed readmission rates approaching 10% (2013). Male gender, increasing age, tonsillectomy, infectious indication, and recent year of surgery were identified as risk factors for readmission and reoperation due to hemorrhage. An increasing share of patients readmitted for hemorrhage underwent reoperation for hemostasis: 18% (1987) versus 43% (2013). Conclusion Readmissions for hemorrhage have increased by a factor of 5 in Sweden from 1987 to 2013. The design of the study and the data in NPR do not allow determination of the true reasons behind the alarming results.
Collapse
Affiliation(s)
- Eirik Østvoll
- 1 Department of Otorhinolaryngology, Head and Neck Surgery, Sahlgrenska University Hospital and Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Ola Sunnergren
- 2 Department of Otorhinolaryngology, Ryhov County Hospital, Jönköping, Sweden
| | - Joacim Stalfors
- 3 Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden and Sheikh Khalifa Medical City, Ajman, United Arab Emirates
| |
Collapse
|
42
|
Experience is more important than technology in paediatric post-tonsillectomy bleeding. The Journal of Laryngology & Otology 2017; 131:S35-S40. [PMID: 28393742 DOI: 10.1017/s0022215117000755] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Paediatric tonsillectomy is a common procedure and one of the first skills acquired by surgical trainees. Post-tonsillectomy bleeding is one of the most significant complications. This study examined post-tonsillectomy bleed rates associated with technology and level of surgical experience. METHODS Data were collected on all tonsillectomies performed by surgical consultants (n = 6) and trainees (n = 10) at affiliated hospitals over a nine-month period. Hospital records were audited for post-tonsillectomy bleeding re-admissions and returns to the operating theatre. RESULTS A total of 1396 tonsillectomies were performed (279 by trainees, 1117 by consultant surgeons). Primary post-tonsillectomy bleed rates were equivalent between trainees and consultants. Secondary bleed rates were significantly greater for trainees (10.0 per cent) compared to consultants (3.3 per cent), as were return to operating theatre rates (2.5 per cent vs 0.7 per cent). Amongst consultants, technology used was not associated with differences in secondary post-tonsillectomy bleeding and returns to the operating theatre. CONCLUSION Our data suggest that experience of the surgeon may have greater bearing on post-tonsillectomy bleed rates than the technology used.
Collapse
|
43
|
Abstract
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.
Collapse
Affiliation(s)
- Ryan M Mitchell
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, 1959 NE Pacific St, Box 256515, Seattle, WA 98195, USA
| | - Sanjay R Parikh
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, 1959 NE Pacific St, Box 256515, Seattle, WA 98195, USA; Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, 4800 Sand Point Way Northeast, OA.9.329, Seattle, WA 98105, USA.
| |
Collapse
|
44
|
Is celecoxib a useful adjunct in the treatment of post-tonsillectomy pain in the adult population? A randomised, double-blind, placebo-controlled study. The Journal of Laryngology & Otology 2017; 131:S18-S28. [PMID: 28164777 DOI: 10.1017/s0022215116009476] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of celecoxib for pain management in post-tonsillectomy adult patients. DESIGN A randomised, double-blind, placebo-controlled, phase 3 clinical trial was conducted in an adult population (aged 18-55 years), with a parallel group design using an allocation ratio of 1:1. METHODS Eighty patients underwent elective tonsillectomy or adenotonsillectomy, operated on by one surgeon. They were discharged home with randomly assigned celecoxib or placebo, together with regular post-tonsillectomy medications (paracetamol and Endone). Pain scores were measured from post-operative days 1 to 10. All patients were assessed on post-operative days 5, 12 and 28. RESULTS There were no statistically significant differences in the daily or overall pain scores, the total intake of Endone, or the time taken to achieve freedom from pain after tonsillectomy between the study arms (n = 40 each arm). The celecoxib-treated group experienced significantly more vomiting (celecoxib vs placebo p < 0.001 (Mann-Whitney test), confidence interval = 0.57 to 0.76). CONCLUSION Celecoxib usage was associated with significantly more vomiting and did not reduce narcotic analgesia requirement post-tonsillectomy.
Collapse
|
45
|
Negm H, Atef A, Lasheen H, Kamel AA, Azooz K, Elhoussainy O. Factors affecting secondary post-tonsillectomy hemorrhage: a case—control study. THE EGYPTIAN JOURNAL OF OTOLARYNGOLOGY 2017. [DOI: 10.4103/1012-5574.199414] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
|
46
|
Mohammed H, ALtamimi ZAR, Sheikh R, Al Taweel H, Ganesan S. Recurrent Post Tonsillectomy Secondary Hemorrhage in Patients with Factor XIII Deficiency: A Case Series and Review of Literature. AMERICAN JOURNAL OF CASE REPORTS 2016; 17:850-854. [PMID: 27843132 PMCID: PMC5111571 DOI: 10.12659/ajcr.900391] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Case series Patients: Male, 20 • Male, 4 • Male, 27 • Male, 25 • Female, 5 • Female, 26 Final Diagnosis: Post tonsillectomy secondary hemorrhage Symptoms: Bleeding • bleeding per oral Medication: — Clinical Procedure: Control of post tonsillectomy secondary hemorrhage Specialty: Otolaryngology
Collapse
Affiliation(s)
- Hassen Mohammed
- Department of Otorhinolaryngology and Head & Neck Surgery (ORL-HNS), Rumailah Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Zaid Abu Rajab ALtamimi
- Department of Otorhinolaryngology and Head & Neck Surgery (ORL-HNS), Rumailah Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Rashid Sheikh
- Department of Otorhinolaryngology and Head & Neck Surgery (ORL-HNS), Rumailah Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Hayam Al Taweel
- Department of Otorhinolaryngology and Head & Neck Surgery (ORL-HNS), Rumailah Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Shanmugam Ganesan
- Department of Otorhinolaryngology and Head & Neck Surgery (ORL-HNS), Rumailah Hospital, Hamad Medical Corporation, Doha, Qatar
| |
Collapse
|
47
|
Saravakos P, Hartwein J. Surgical technique and post-tonsillectomy hemorrhage: a single institution’s retrospective study. Eur Arch Otorhinolaryngol 2016; 274:947-952. [DOI: 10.1007/s00405-016-4271-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 08/16/2016] [Indexed: 12/18/2022]
|
48
|
Increased immediate postoperative hemorrhage in older and obese children after outpatient tonsillectomy. Int J Pediatr Otorhinolaryngol 2016; 84:119-23. [PMID: 27063766 DOI: 10.1016/j.ijporl.2016.02.019] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 02/17/2016] [Accepted: 02/18/2016] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Postoperative hemorrhage is one of the serious complications of adenotonsillar surgery. This study seeks to investigate the relationship between post-tonsillectomy/adenotonsillectomy hemorrhage in the pediatric population and obesity, obstructive sleep apnea (OSA), adenotonsillar hypertrophy (ATH), chronic tonsillitis (CT), and peritonsillar abscess (PTA) in the immediate post-operative setting. METHODS The California Ambulatory Surgery Data for the years 2005-2011 were reviewed. The records of patients aged less than 18 years undergoing tonsillectomy (T) or adenotonsillectomy (AT) were extracted using relevant ICD-9 diagnosis codes. The association between hemorrhage and obesity, OSA, AH, CT, PTA, and patients' demographics among surgeries performed in the outpatient setting was evaluated. RESULTS A total of 138,998 procedures, 22,478 Ts and 116,520 ATs, were performed during 2005-2011, of which 3.0% were performed on obese children. Hemorrhage occurred in 156 cases (0.1%), and was associated with an age from 9 to 18 years (p=0.01), and obesity (p=0.02). There was no association between hemorrhage and gender (p=0.8), OSA (p=0.6), ATH (p=0.5), CT (p=0.35), PTA (p=0.47), or T versus AT (p=0.3). Multivariate analysis revealed that hemorrhage was about 2.3 times more likely to occur in obese children (odds ratio [OR]=2.3; 95% Confidence Interval: 1.1-5.1; p=0.03). CONCLUSIONS Obesity and older age are associated with an increased risk of immediate post-operative hemorrhage following tonsillectomy with or without adenoidectomy in the outpatient setting. Gender, OSA, ATH, CT, PTA, and T versus AT did not alter the risk of post-operative hemorrhage.
Collapse
|
49
|
Betancourt AR, López C, Zerpa V, Carrasco M, Dalmau J. ¿Influye la técnica quirúrgica en las hemorragias postamigdalectomía? Nuestra experiencia. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2015; 66:218-23. [DOI: 10.1016/j.otorri.2014.09.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2014] [Revised: 09/10/2014] [Accepted: 09/19/2014] [Indexed: 11/28/2022]
|
50
|
Betancourt AR, López C, Zerpa V, Carrasco M, Dalmau J. Does Surgical Technique Influence Post-Tonsillectomy Haemorrhage? Our Experience. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2015. [DOI: 10.1016/j.otoeng.2014.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|