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Analysis of risk factors for post-tonsillectomy hemorrhage in adults

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Investigation of Adult Post-Tonsillectomy Hemorrhage Rates and the Impact of NSAID Use

OBJECTIVES/HYPOTHESIS

Tonsillectomy is one of the most common ambulatory surgeries performed in the United States, yet the incidence of post-tonsillectomy hemorrhage (PTH) in adults remains unclear. In addition, any association between non-steroidal anti-inflammatory drugs (NSAIDs) and PTH in adults is currently unknown. The aim of this study is to examine the incidence and management of adult PTH at a single academic center and to assess for any association between NSAID use and PTH in adults.

STUDY DESIGN

Retrospective chart review.

METHODS

We conducted a retrospective chart review of adult tonsillectomies performed at our institution between January 1, 2012, and December 30, 2019. Demographics, past medical history, medications, NSAID use, surgical indication, bleeding events, and interventions were documented. The rate of PTH was calculated, logistic regression was performed to assess for any predictive factors, and odds ratios were calculated for NSAID use and PTH.

RESULTS

A total of 1,057 adult tonsillectomies were performed within the aforementioned time period. A total of 126 patients experienced 163 bleeding events for a postoperative hemorrhage rate of 11.9%. Most were controlled with bedside interventions, while 29 (23%) bled more than once. The hemorrhage rate for those who were not prescribed NSAIDs postoperatively (n = 625) was 11.7%, compared to 12.6% for those who did receive NSAIDs postoperatively (n = 432), which was not significantly different (adjusted odds ratio 1.01, 95% confidence interval 0.69-1.49; P = .95).

CONCLUSIONS

This retrospective cohort study of 1,057 adult patients found the incidence of PTH to be 11.9%. This study found no association between the use of NSAIDs and the rate of PTH, although a higher-powered study is needed.

LEVEL OF EVIDENCE

3 Laryngoscope, 132:949-953, 2022.

Tonsillectomy Outcomes for Coblation Versus Bipolar Diathermy Techniques in Adult Patients: A Systematic Review and Meta-Analysis

INTRODUCTION AND AIMS

There is no consensus on the optimal tonsillectomy technique in adult patients. The study aims to identify all studies comparing the outcomes of coblation versus bipolar diathermy in adult patients undergoing tonsillectomy.

METHODS

A systematic review and meta-analysis were performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Primary outcomes were hemorrhage and postoperative pain. Secondary outcome measures included return to theatre, analgesia, intraoperative bleeding, diet, tonsillar healing, and operation time. Fixed-effects modeling was used for the analysis.

RESULTS

Six studies were identified enrolling a total of 1824 patients. There were no significant differences in terms of reactionary hemorrhage (OR = 1.81, P = .51), delayed hemorrhage (OR = 0.72, P = .20), or postoperative pain (mean difference = -0.15, P = .45); however, there is a general trend favuring coblation. For secondary outcomes, no significant differences noted in terms of intraoperative bleeding, diet, and cases returning to theatre. Analgesia administration was either insignificant or higher in the coblation group. The coblation group had longer operation time and greater healing effect on tonsillar tissue.

CONCLUSIONS

There were no significant differences in outcomes for coblation and bipolar diathermy for adult tonsillectomy patients in this systematic review and meta-analysis.

Evaluation of post-tonsillectomy hemorrhage and assessment of risk factors

PURPOSE

Tonsillectomy is one of the most common surgical procedures in otorhinolaryngology. Hemorrhage in the postoperative period has an incidence of up to 20% and is a potentially fatal complication. We aim to assess the incidence of hemorrhage after tonsillectomy in our institution, and to evaluate and identify the possible associated risk factors.

METHODS

This retrospective study included 897 patients who underwent tonsillectomy between January 2015 and December 2018, 50.7% women and 49.3% men, aged between 2 and 83 years. No coagulopathies were identified. Comparison of age, gender, surgical indication, coagulation profile, concomitant adenoidectomy, surgical technique, surgeon's experience and hemostasis method between groups with and without post-operative bleeding was made.

RESULTS

Our incidence of post-tonsillectomy hemorrhage was 6%. Most patients (83.3%) had secondary bleeding (> 24 h after surgery). In 22.2% of the bleeding cases, it was necessary to revise the hemostasis in the operating room. Adulthood (age ≥ 18 years) (p < 0.001), INR values ≥ 1.2 (p = 0.014), aPTT values ≥ 35 s (p = 0.001), as well as concomitant adenoidectomy (p < 0.001) were the predictors of post-tonsillectomy bleeding.

CONCLUSION

Recognition of adult age, INR ≥ 1.2, aPTT ≥ 35 s and concomitant adenoidectomy as risk factors can be useful in identifying the patients at higher risk for bleeding complications.

Does suturing tonsil pillars post-tonsillectomy reduce postoperative hemorrhage?: A literature review

OBJECTIVE

Literature review comparing post-tonsillectomy hemorrhage in pediatric and adult patients with and without suturing tonsil pillars to investigate whether suturing tonsil pillars reduces the risk of post-tonsillectomy hemorrhage.

REVIEW METHODS

Online journal databases were searched using the key phrases "post tonsillectomy hemorrhage", "post tonsillectomy bleed", and "tonsil pillar suture". 10 published studies were found regarding tonsil pillar suturing, four directly related to postoperative bleeding and five focusing on postoperative pain reduction. There was one study that evaluated both pain and bleeding. The pain reduction studies were comprised of 225 patients while the postoperative bleeding studies included 3987 patients.

CONCLUSIONS

Suturing tonsil pillars after tonsillectomy may be beneficial after cold tonsillectomy.

IMPLICATIONS FOR PRACTICE

Post-operative bleeding is one of the most common complications that can result in increased patient distress and hospitalization. In this article, we provide a literature review of tonsil pillar suturing and post-tonsillectomy hemorrhage. Our study suggests suturing the tonsil pillars immediately post-tonsillectomy may reduce the risk of severe post-operative bleeding requiring return to the operating room for certain patients.

Risk Factors for Multiple Hemorrhages Following Tonsil Surgery in Children

OBJECTIVES/HYPOTHESIS

Although much is known about the incidence and risk factors for hemorrhage after tonsil surgery, the incidence and factors related to multiple episodes of hemorrhage are not well examined. Our objective was to identify risk factors that may contribute to multiple hemorrhages following tonsil surgery in children.

STUDY DESIGN

Retrospective chart review.

METHODS

A retrospective review was conducted of pediatric patients who experienced one or more hemorrhages following tonsillectomy/tonsillotomy, with or without adenoidectomy, between 2010 and 2016 at a single, tertiary-care hospital. Risk factors for multiple hemorrhages were examined using a multivariable logistic regression model.

RESULTS

Among the 11,140 patients who underwent tonsil surgery, 452 patients experienced one or more hemorrhages; 32 of these had multiple episodes of hemorrhage (7.1% of all patients with bleeds/0.3% of all patients). Older age (≥12 years: adjusted odds ratio [OR]: 3.13; 95% confidence interval [CI]: 1.47-6.68) and high body mass index for age (≥85th percentile: adjusted OR: 2.26; 95% CI: 1.06-4.85) were significantly associated with an increased risk of multiple hemorrhages in the multivariable model. Medical comorbidities, indications for surgery, surgical technique, intraoperative blood loss, and perioperative medications were not associated with multiple episodes of bleeding.

CONCLUSIONS

Multiple hemorrhages after tonsillectomy/tonsillotomy are uncommon. The risk of a second PTH after an initial episode is 7.1%, almost double the risk of a bleed after the initial tonsil surgery. Age > 12 years and high BMI for age may be associated with increased risk of rebleeding. After an initial bleed, increased surveillance may be warranted, particularly for patients with risk factors.

LEVEL OF EVIDENCE

4 Laryngoscope, 129:2765-2770, 2019.

Is weight a predictive risk factor of postoperative tonsillectomy bleed?

Objective

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

Study Design

Retrospective study.

Methods

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

Results

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

Conclusion

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

Level of Evidence

4.

Tonsillectomy in adults: Analysis of indications and complications

OBJECTIVE

Tonsillectomy is one of the surgical techniques most practiced by otolaryngologists, and despite being a relatively simple technique; it presents a considerable percentage of complications, such as postoperative bleeding. The aim of this study is to describe the surgical indications and most frequent complications, analyze whether surgical suture of the tonsillar pillars has an influence on bleeding, and study the data of hospital stay and its importance for the control of complications.

METHODS

A retrospective study of 326 patients who underwent a tonsillectomy in our Department of Otolaryngology from 2006 to 2014 was conducted. The obtained data were statistically analyzed using the Excel and SPSS 21.0 programs.

RESULTS

The most frequent indication was recurrent tonsillitis, with a 74.85% (244) occurrence, and the most recurrent complication was bleeding, in 5.21% (17) of the tonsillectomies, requiring surgical revision 13 of the 17 patients. No statistically significant differences in the risk of bleeding were observed in patients in whom tonsil pillars were sutured comparing to those that were not. No statistically significant differences were detected associating surgical indication and oropharyngeal post-tonsillectomy hemorrhage. All operated patients were admitted, with a postoperative average hospital stay of 2.17 days, gaining a quick and effective control of the immediate complications.

CONCLUSION

Bleeding is the most common and important complication. No statistically significant association between bleeding and tonsil pillar suture or surgical indication was found. Tonsillectomy was not set as outpatient surgery at the time.

Haemorrhage Rates After Two Commonly Used Tonsillectomy Methods: a Multicenter Study

Introduction:

Tonsillectomy is a frequently used, low-risk surgical procedure. The post-tonsillectomy haemorrhage occurs rarely, but is a life-threatening complication. Some studies show that the surgical technique affects the haemorrhage rate.

Aims:

To analyse the post-tonsillectomy haemorrhage rate, and to determine whether the effect of the surgical technique on the haemorrhage rate exists.

Methods:

We retrospectively reviewed data of all patients who underwent a tonsillectomy in three regional ENT departments in Bosnia and Herzegovina (Tuzla, Zenica and Bihac) between January 1^st 2015 and October 31^st 2016. Disorders which could affect the post-tonsillectomy haemorrhage rate were excluded. Tonsillectomy techniques used in these three centers were the hot technique (monopolar/bipolar forceps dissection and haemostasis) and the combined technique (cold steel dissection with monopolar/bipolar forceps haemostasis).

Results:

1087 patients that underwent a tonsillectomy were analysed in this study. 864 (79.48%) of those were children. 922 (84.82%) patients were operated using the combined technique, 165 (15.17%) underwent a tonsillectomy using the hot technique. Post-tonsillectomy haemorrhage occured in 46 (4.23%) patients. 45 (4.88%) patients had a postoperative haemorrhage after tonsillectomy using the combined technique, whereas haemorrhage occured in 1 patient (0.6%) after using the hot technique. The haemorrhage rate was about eight times lower after tonsillectomy using the hot technique (p=0.012).

Conclusion:

We conclude that the surgical technique used for tonsillectomy and adenotonsillectomy with the lowest post-tonsillectomy haemorrhage rate is the hot technique; these results are statistically significant. This technique should be used whenever possible, in order to lower the risk of post-tonsillectomy haemorrhage.

Postoperative Pain in Adult Tonsillectomy: Is There Any Difference Between the Technique?

Tonsillectomy is one of the most common surgical procedures performed worldwide. Several techniques have been developed to reduce morbidity and enhance recovery after tonsillectomy. Our study was designed to compare post-operative pain with three different techniques: cold dissection (CD), monopolar-bipolar dissection (MBD) and coblation dissection (CBD). 103 adults were scheduled for elective tonsillectomy from September 2014 to December 2015, and were randomized to CD, MBD and CBD. Post-operative pain was assessed using visual analogue scale (VAS) and Lattinen Test (LT). We did not find significant differences between the groups in the VAS pain scores (p > 0.05), except for the first day, when CBD tonsillectomy showed a higher pain score (p < 0.05). The differences in LT scores between the three techniques were not statistically significant (p > 0.05). Comparison of analgesic consumption between CD, MBD and CBD did not found any significant differences irrespective of the technique used. When first and second week after surgery were compared, differences in analgesics requirements were statistically significant (p < 0.05). Seventeen cases (16.5%) of secondary haemorrhage were reported, but there were no statistical differences in the rate of postoperative bleeding between the three groups (p > 0.05). We conclude that in our study comparison of the three techniques, CD, MBD and CBD, did not show significant differences in the post-tonsillectomy pain scores and bleeding rate.

The Use of Ibuprofen in Posttonsillectomy Analgesia and Its Effect on Posttonsillectomy Hemorrhage Rate

Objective

To determine the effect of ibuprofen on posttonsillectomy bleeding when compared with codeine in posttonsillectomy analgesia.

Study Design

Case series with chart review.

Setting

Tertiary care children’s hospital, Philadelphia, Pennsylvania.

Subjects and Methods

On July 1, 2012, our institution transitioned from acetaminophen with codeine to ibuprofen for posttonsillectomy analgesia. Pediatric patients (0-18 years old) who underwent surgery from July 1, 2010, to June 30, 2012, were placed in the codeine cohort, and those who underwent surgery from July 1, 2012, to June 30, 2014, were placed in the ibuprofen cohort.

Results

A total of 6014 patients underwent tonsillectomy between July 1, 2010, and June 30, 2014, and 211 patients presented for posttonsillectomy hemorrhage during the same period. The incidence of readmission for posttonsillectomy hemorrhage was 3.4% and 3.6% ( P = .63; odds ratio [OR] = 1.07; 95% confidence interval [95% CI]: 0.811-1.410) for the codeine and ibuprofen groups, respectively, and the incidence of second operation for control of posttonsillectomy bleeding for the codeine and ibuprofen groups was 1.9% and 2.2% ( P = .54; OR = 1.117; 95% CI: 0.781-1.600), respectively. Patients aged 11 to 18 years demonstrated a higher incidence of posttonsillectomy bleeding events overall. When age is controlled, multivariate logistic regression demonstrated no statistically significant increase in posttonsillectomy bleeding events among pediatric patients treated with ibuprofen versus patients treated with codeine (readmission: P = .617; OR = 0.932; 95% CI: 0.707-1.228; reoperation: P = .513; OR = 0.887; 95% CI: 0.618-1.272).

Conclusion

Age is an independent risk factor for posttonsillectomy bleeding. When age is controlled, there is no statistically significant increase in the incidence of posttonsillectomy bleeding events among patients treated with ibuprofen when compared to patients treated with codeine.