Morbidity and mortality of post-tonsillectomy bleeding: analysis of cases

Association of Patient Characteristics With Postoperative Mortality in Children Undergoing Tonsillectomy in 5 US States

IMPORTANCE

The rate of postoperative death in children undergoing tonsillectomy is uncertain. Mortality rates are not separately available for children at increased risk of complications, including young children (aged <3 y) and those with sleep-disordered breathing or complex chronic conditions.

OBJECTIVE

To estimate postoperative mortality following tonsillectomy in US children, both overall and in relation to recognized risk factors for complications.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study based on longitudinal analysis of linked records in state ambulatory surgery, inpatient, and emergency department discharge data sets distributed by the Healthcare Cost and Utilization Project for 5 states covering 2005 to 2017. Participants included 504 262 persons younger than 21 years for whom discharge records were available to link outpatient or inpatient tonsillectomy with at least 90 days of follow-up.

EXPOSURES

Tonsillectomy with or without adenoidectomy.

MAIN OUTCOME AND MEASURES

Postoperative death within 30 days or during a surgical stay lasting more than 30 days. Modified Poisson regression with sample weighting was used to estimate postoperative mortality per 100 000 operations, both overall and in relation to age group, sleep-disordered breathing, and complex chronic conditions.

RESULTS

The 504 262 children in the cohort underwent a total of 505 182 tonsillectomies (median [IQR] patient age, 7 [4-12] years; 50.6% females), of which 10.1% were performed in young children, 28.9% in those with sleep-disordered breathing, and 2.8% in those with complex chronic conditions. There were 36 linked postoperative deaths, which occurred a median (IQR) of 4.5 (2-20.5) days after surgical admission, and most of which (19/36 [53%]) occurred after surgical discharge. The unadjusted mortality rate was 7.04 (95% CI, 4.97-9.98) deaths per 100 000 operations. In multivariable models, neither age younger than 3 years nor sleep-disordered breathing was significantly associated with mortality, but children with complex chronic conditions had significantly higher mortality (16 deaths/14 299 operations) than children without these conditions (20 deaths/490 883 operations) (117.22 vs 3.87 deaths per 100 000 operations; adjusted rate difference, 113.55 [95% CI, 51.45-175.64] deaths per 100 000 operations; adjusted rate ratio, 29.39 [95% CI, 13.37-64.62]). Children with complex chronic conditions accounted for 2.8% of tonsillectomies but 44% of postoperative deaths. Most deaths associated with complex chronic conditions occurred in children with neurologic/neuromuscular or congenital/genetic disorders.

CONCLUSIONS AND RELEVANCE

Among children undergoing tonsillectomy, the rate of postoperative death was 7 per 100 000 operations overall and 117 per 100 000 operations among children with complex chronic conditions. These findings may inform decision-making for pediatric tonsillectomy.

The efficacy of Tranexamic Acid Administration in Patients Undergoing Tonsillectomy: An Updated Meta-Analysis

OBJECTIVE

There is controversy regarding the efficacy and safety of tranexamic acid (TXA) in reducing tonsillectomy-related hemorrhage. We conducted a systematic review and meta-analysis to evaluate the prophylactic role of TXA in tonsillectomy.

METHODS

We searched 6 databases to identify studies that directly compare the effect of TXA versus controls in tonsillectomy patients. Standardized mean difference was applied to summate the findings across the studies. Dichotomous data were expressed as relative risk.

RESULTS

Ten studies representing a total of 111 898 patients were included. The pooled results showed a significant reduction of intraoperative blood loss by 39.02 ml (SMD = -1.05, 95% CI: -1.91 to -0.20, P = .016) and the rate of post-tonsillectomy hemorrhage (RR = 0.42, 95% CI: 0.28 to 0.65, P < .0001), with no significant difference in reduction of further intervention risk (RR = 0.78, 95% CI: 0.45 to 1.35, P = .373).

CONCLUSIONS

Overall, this study indicates that TXA may reduce blood loss and frequency of post-operative hemorrhage associated with tonsillectomy. Further large, high-quality clinical trials are still needed to explore TXA's effect on post-tonsillectomy hemorrhage and the safety of its use.

Respiratory complications after adenotonsillectomy in high-risk children with obstructive sleep apnea: A retrospective cohort study

BACKGROUND

Obstructive sleep apnea (OSA) occurs in 1%-4% of children; adenotonsillectomy is an effective treatment. Mortality/severe brain injury occurs among 0.6/10 000 adenotonsillectomies; in children, 60% are secondary to airway/respiratory events. Earlier studies identified that children aged <2 years, extremes of weight, with co-morbidities of craniofacial, neuromuscular, cardiac/respiratory disease, or severe OSA are at high risk for adverse post-operative respiratory events (AE). We aimed to: Firstly, investigate which risk factors were associated with AEs either in the post-anesthesia care unit (PACU), pediatric intensive care unit (PICU), or both in this population. Secondly, we investigated factors associated with post-operative PICU AE despite no event in the PACU in order to predict need of post-operative PICU after their PACU stay.

METHODS

Retrospective study of children admitted to the PICU after adenotonsillectomy between 08/2006-09/2015. Demographics, risk factors, and occurrence of AE (oxygen saturation <92, stridor, bronchospasm, pneumonia, pulmonary edema, re-intubation) were recorded.

RESULTS

During the studied time period 4029 tonsil/adenoid procedures were performed in 3997 children. 179, admitted to the PICU post-operatively, met criteria for analysis. PICU AEs occurred in 59%: 44%-83% in any particular risk category. PACU AEs occurred in 42%. Of those with PACU events: 92% suffered AEs in the PICU; however, 35% of those without a PACU AE still suffered a PICU AE.

CONCLUSIONS

Among high-risk children undergoing TA, absence of adverse events in PACU during a 2-hour observation period does not predict absence of subsequent AEs in the PICU.

Intra-capsular complete tonsillectomy, a modification of surgical technique to eliminate delayed post-operative bleeding

Pediatric tonsillectomy is a frequently performed procedure using a variety of surgical techniques. Despite decades of modern surgical experience and advances in tools and techniques, a consensus on which technique is superior for minimizing complications has not been established. In a 2014 study, the authors examined differing surgical techniques and devices to determine if there was a significant difference in the bleed rates based on technique and device [1]. In that study 7024 children were evaluated, of which a total of 1.4% (n = 99) of children experienced a postoperative hemorrhage that required a second surgery. There was no significant difference found between the four different techniques that were evaluated. Although the combined rates of post-operative hemorrhage requiring a second surgery was lower compared to many other published reports, we hypothesized that continued improvement in surgical techniques could eliminate post-operative hemorrhage completely. As follow up to that study, we decided on a collective change in technique, and subsequent analysis of our post-operative results with respect to only one outcome, post-operative hemorrhage requiring a second surgery. With a new standardized technique in place, we retrospectively evaluated one year of surgical outcomes. These procedures were performed using the technique of a modified and complete, intra-capsular Coblator tonsillectomy. Of the 783 tonsillectomies done in 12 months, we found there were 0 patients that had experienced a postoperative hemorrhage requiring a second surgery. Based on our previous study with a rate of 1.4% post-operative hemorrhage we would have expected to have 11 episodes of post-operative hemorrhage requiring a second surgery.

Mucosal bacterial immunotherapy with MV130 highly reduces the need of tonsillectomy in adults with recurrent tonsillitis

Recurrent tonsillitis in adults is a common ENT disease. The current standard treatment is tonsillectomy. However, continuous prophylaxis with antibiotics has been prescribed in order to avoid tonsillectomy. The objective was to evaluate if the bacterial immunotherapy (Bactek MV130) together with the prophylactic antibiotic therapy can produce clinical improvement and to avoid the tonsillectomy. Material and methods: The medical records of 88 patients with recurrent tonsillitis were reviewed. Sixty-six were treated during 3 months with a course of antibiotics and 22 received, in addition to the antibiotics, immunotherapy with Bactek MV130 during this Globally, 53 (60%) patients had clinical improvement and 35 were tonsillectomized. In the The group of patients who received only antibiotic, 35 (53%) avoided tonsillectomy and 31 (47%) did not. In the group that, in addition to antibiotics, were treated with Bactek MV130, 18 patients (82%) experi- enced clinical improvement avoiding tonsillectomy and 4 (18%) didn't improve and the tonsils were surgically removed. The difference between both groups was significant (P = 0.023).he results obtained in this evaluation support this combined treatment as an effective strategy to reduce the need of tonsillectomy.

Post-tonsillectomy hemorrhage rates in children compared by surgical technique

Despite the sheer number of pediatric tonsillectomies performed in the United States annually, there is no clear consensus as to which surgical technique is superior. One way to compare surgical techniques is to study the morbidity associated with each. We report postoperative hemorrhage rates, one of the frequently encountered major adverse events, as part of a retrospective chart review across four different surgical techniques. These surgeries involved either (1) Coblation, (2) Co-blation with partial suture closure of the tonsillar fossa, (3) diathermy, or (4) partial intracapsular tonsillectomy (PIT). Of the 7,024 children we evaluated, 99 (1.4%) experienced a postoperative hemorrhage that required a second surgery; hemorrhage occurred after 33 of the 3,177 Coblation-alone procedures (1.04%), 28 of the 1,633 Coblation with partial suture closure procedures (1.71%), 29 of the 1,850 diathermies (1.57%), and 9 of the 364 PIT procedures (2.47%). Statistical analysis of hemorrhage rates with each surgical technique yielded p values >0.05 in each case (Coblation alone and Coblation with partial suture closure: p = 0.29; diathermy: p = 0.47; PIT, p = 0.20). Based on these data, we conclude that none of these techniques is significantly superior in terms of decreasing the risk of post-tonsillectomy hemorrhage in children. Therefore, surgeons should continue to use the surgical procedure they are most familiar with to optimize recovery in the postoperative period.

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.

Does Microscope Assistance in Cold Steel Tonsillectomy Reduce the Risk of Postoperative Hemorrhage? Results of a Prospective Cohort Study

Background

Posttonsillectomy hemorrhage (PTH) is the most feared complication. Dissection near the tonsillar capsule under microscopic view (TE_mic) could be assumed to decrease PTH compared to traditional tonsillectomy (TE_trad).

Methods

In this study, patients were evaluated with respect to the need for surgical control (R/N: return/no return to theater (RTT): the day of surgery [0] or thereafter [1]). The findings at resection site and pain were measured.

Results

869 patients were included (183 TE_mic; 686 TE_trad). PTH requiring RTT was not seen in the TE_mic group on the day of surgery (R0) while PTH requiring RTT subsequently (R1) was seen in 1.1% of the cases. In the TE_mic group, hemorrhages without a need for surgical control were observed in 0.6% (N0) and 3.4% (N1), respectively. The corresponding rates for TE_trad were as follows: R0, 0.3%; R1, 1.7%; N0, 0.6%; and N1, 3.6% (p > 0.05). Postoperative edema and local infection at resection site were proven to be predictive of PTH (p = 0.007).

Conclusion

Microscope assistance in tonsillectomy did not statistically have an influence on the PTH even though there was a trend towards lower PTH rate in the TE_mic group. Benefit for TE_mic was observed in high-volume and long experienced surgeons.

Recurrent Post Tonsillectomy Secondary Hemorrhage in Patients with Factor XIII Deficiency: A Case Series and Review of Literature

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

ENT and airways in the emergency department: national survey of junior doctors' knowledge and skills

BACKGROUND

Given the urgent nature of ENT emergencies, appropriate knowledge is required amongst front-line staff. Junior doctors account for almost one quarter of emergency department doctors. It has been shown that undergraduate coverage of ENT is variable. This study therefore aimed to determine whether emergency department junior doctors were confident in dealing with ENT emergencies, with special focus on the airway.

METHOD

An online survey was circulated to junior doctors working in emergency medicine, at the discretion of their training co-ordinators.

RESULTS

A total of 104 responses were received. Junior doctors were not confident in managing patients who have undergone tracheostomy or laryngectomy. Management of stridor varied, with 51 per cent giving oxygen and only 77 per cent referring such patients as an emergency to ENT. Most training on the management of airway emergencies was not provided through hospital induction.

CONCLUSION

Training should be provided to junior doctors starting work in the emergency department. We suggest mandatory multidisciplinary induction training for such staff.

Malpractice claims and unintentional outcome of tonsil surgery and other standard procedures in otorhinolaryngology

BACKGROUND

Septoplasty, tonsillectomy (with and without adenoidectomy) and cervical lymph node excision are amongst the most common 50 inpatient operations in Germany. Intracapsular tonsillectomies (i.e. tonsillotomies) are increasingly performed. The aim of this study was to evaluate technical traps and pitfalls as well as alleged medical malpractice associated with tonsillectomy (TE), adenoidectomy (AE), tonsillotomy (TT), septoplasty (SP) and cervical lymph node excision (LN).

METHODS

A questionnaire was sent to the Regional Medical Conciliation Boards, Medical Services of the Health Insurance Companies (MDK) and Regional Institutes of Forensic Medicine in Germany to collect anonymized cases of complications following TE, TT, AE, LN and SP. The results were discussed in the light of the contemporary medical literature and published trials and verdicts in Germany.

RESULTS

The response rate of our survey was 55.9%. The Institutes of Forensic Medicine contributed nine cases, 49 cases were submitted by the Regional Conciliation Boards and none by MDK. All forensic cases were associated with exsanguinations following tonsillectomy including two children (5 and 8 years of age) and seven adults (aged 20 to 69 years). The fatal post-tonsillectomy hemorrhage (PTH) had occurred 8.7 days on average; four patients experienced the bleeding episode at home (day 5, 8, 9 and 17, respectively). Repeated episodes of bleeding requiring surgical intervention had occurred in 6 patients. Three Conciliation Boards submitted decicions associated with TT (1), AE (4), LN (3), SP (16) and TE (25). Cases with lethal outcome were not registered. Only three of the 49 cases were assessed as surgical malpractice (6.1%) including lesion of the spinal accessory nerve, wrong indication for TE and dental lesion after insertion of the mouth gag. The review of the medico legal literature yielded 71 published verdicts after AE and TE (29), LN (28) and SP (14) of which 37 resulted in compensation of malpractice after LN (16; 57%), TE (10; 37%), SP (8; 57%) and AE (2; 100%). There were 16 cases of PTH amongst 27 trials after TE resulting either in death (5) or apallic syndrome (5). Bleeding complications had occurred on the day of surgery in only 2 patients. 16 trials were based on malpractice claims following SP encompassing lack of informed consent (6), anosmia (4), septal perforation (2), frontobasal injury (2) and dry nose (2). Trials after LN procedures were associated exclusively with a lesion of the spinal accessory nerve (28), including lack of informed consent in 19 cases. 49 cases (69%) were decided for the defendant, 22 (31%) were decided for the plaintiff with monetary compensation in 7 of 29 AE/TE-trials, 9 of 28 LN-trials and 6 of 14 SP-trials. Lack of informed consent was not registered for AE/TE but LN (11) and SP (2).

CONCLUSION

Complicated cases following TE, TT, ATE, SP and LN are not systematically collected in Germany. It can be assumed, that not every complicated case is published in the medical literature or law journals and therefore not obtainable for scientific research. Alleged medical malpracice is proven for less than 6% before trial stage. Approximately half of all cases result in a plaintiff verdict or settlement at court. Proper documentation of a thourough counselling, examination, indication, informed consent and follow-up assists the surgeon in litigation. An adequate complication management of PTH is essential, including instructions for the patients/parents, instructions for the medical staff and readily available surgical instruments. Successful outcome of life-threatening PTH is widely based on a proper airway management in an interdisciplinary approach. Electrosurgical tonsillectomy techniques were repeatedly labeled as a risk factor for bleeding complications following TE. Institutions should analyse the individual PTH rate on a yearly basis. Contradictory expert opinions and verdicts of the courts concerning spinal accesory nerve lesions following LN are due to a lack of a surgical standard.

Death after adenotonsillectomy secondary to massive pulmonary embolism

Tonsillectomy is one of the most common surgical procedures performed in the United States. Although relatively safe, there is a small risk of post-operative mortality. The majority of deaths come from airway compromise or hemorrhage. The authors present a case of a 32-month-old child who underwent routine adenotonsillectomy for sleep disordered breathing and chronic pharyngitis who was found unresponsive and pulseless in his bed on the morning of postoperative day 2. The cause of death determined by post mortem autopsy was massive pulmonary embolism (PE). PE is a rare event in children and has never been reported as the cause of death following adenotonsillectomy in a child. This case is reviewed in addition to recent literature regarding obstructive sleep apnea (OSA) as a risk factor for venous thrombosis and PE.

Mortality and major morbidity after tonsillectomy: etiologic factors and strategies for prevention

OBJECTIVE/HYPOTHESIS

To report data on death or permanent disability after tonsillectomy.

STUDY DESIGN

Electronic mail survey.

METHODS

A 32-question survey was disseminated via the American Academy of Otolaryngology-Head and Neck Surgery electronic newsletter. Recipients were queried regarding adverse events after tonsillectomy, capturing demographic data, risk factors, and detailed descriptions. Events were classified using a hierarchical taxonomy.

RESULTS

A group of 552 respondents reported 51 instances of post-tonsillectomy mortality, and four instances of anoxic brain injury. These events occurred in 38 children (71%), 15 adults (25%), and two patients of unstated age (4%). The events were classified as related to medication (22%), pulmonary/cardiorespiratory factors (20%), hemorrhage (16%), perioperative events (7%), progression of underlying disease (5%), or unexplained (31%). Of unexplained events, all but one occurred outside the hospital. One or more comorbidities were identified in 58% of patients, most often neurologic impairment (24%), obesity (18%), or cardiopulmonary compromise (15%). A preoperative diagnosis of obstructive sleep apnea was not associated with increased risk of death or anoxic brain injury. Most events (55%) occurred within the first 2 postoperative days. Otolaryngologists who reported performing <200 tonsillectomies per year were more likely to report an event (P < .001).

CONCLUSIONS

This study, the largest collection of original reports of post-tonsillectomy mortality to date, found that events unrelated to bleeding accounted for a preponderance of deaths and anoxic brain injury. Further research is needed to establish best practices for patient admission, monitoring, and pain management.

LEVEL OF EVIDENCE

N/A.

Occurrence of coagulation factor deficiency in post-tonsillectomy hemorrhage

INTRODUCTION

Tonsillectomy is one of the most common surgical procedures in Otorhinolaryngology and approximately 500 tonsillectomies are performed annually at the University Hospital of Vienna. Substantial postoperative bleeding is observed in 1.8% of cases, which is comparable to frequencies of 2-4% reported in other studies. Currently, routine pre-surgical coagulation investigations to predict bleeding status do not include the analysis of individual coagulation factors.

MATERIAL AND METHODS

Within 2007 complete coagulation diagnostics were carried out in three patients presenting with recurrent (2-7 times) post-tonsillectomy hemorrhage but normal pre-surgical coagulation status parameters.

RESULTS

After the appearance of recurrent late bleeding, single factor diagnostic analysis revealed the causes to be factor XIIa deficiency, reduced factor XIIIa or von Willebrand disease. Recurrent late bleeding was stopped by the application of coagulation active plasma.

CONCLUSION

This study shows that, even if routine diagnostics show normal pre-surgical coagulation findings, the investigation of single factors in cases of post-surgical late bleeding may identify coagulation disorders allowing the application of tailored therapy. Including such analysis in pre-operative diagnostics could therefore significantly help to limit postoperative bleeding.

Anesthetic management of the pediatric bleeding tonsil

BACKGROUND

Anesthetic management of the child with post-tonsillectomy hemorrhage is challenging and fraught with hazards such as anemia, hypovolemia, and risk of difficult airway. The aim of this retrospective cohort study was to determine the incidence and further define the anesthetic complications in this population.

METHODS

Retrospective cohort study of all children who underwent operative intervention for post-tonsillectomy hemorrhage (with or without adenoidectomy) from 1998 to 2005 at The Children's Hospital of Philadelphia. Anesthetic records were examined for independent (anesthetic techniques and patient characteristics) and dependent variables (ventilatory and hemodynamic complications).

RESULTS

Four hundred and seventy-five patients required surgery for exploration of post-tonsillectomy hemorrhage (incidence 2.9%). Intravenous rapid sequence induction was used in 401 (84.4%) patients. Succinylcholine was used in 420 (88%) patients. The most common adverse event (9.9%) was hypoxemia; most episodes occurred during emergence or extubation. Bradycardia during anesthetic induction occurred in 20 (4.2%) patients, and hypotension was noted in 12 (2.5%) patients. Thirteen (2.7%) patients were noted to be difficult to intubate, none of whom were difficult to intubate during the initial tonsillectomy.

CONCLUSIONS

We determined our incidence of ventilatory and hemodynamic complications in a relatively large cohort of children with post-tonsillectomy hemorrhage. Transient hypoxemia was the most common complication and was not related to difficult intubation.

A review of malpractice cases after tonsillectomy and adenoidectomy

OBJECTIVE

To examine sources of litigation following tonsillectomy and/or adenoidectomy.

STUDY DESIGN

Analysis of malpractice claims filed after tonsillectomy or adenoidectomy provided by 16 medical liability insurance companies.

SETTING

Not applicable.

SUBJECTS AND METHODS

Data was obtained from 16 members of the Physician Insurers Association of America. All claims were either filed or closed between 1985 and 2006. Claims were evaluated and categorized according to the type of complication.

RESULTS

One hundred and fifty-four claims were identified between 1985 and 2006. Six categories were created based on frequency of claims (bleeding complication n=27 [17.5%], airway fire n=2 [1.5%], burns n=28 [18.2%], consent related n=9 [5.8%], medication related n=9 [5.8%] and residual tissue/recurrence n=9 [5.8%]). Other less frequent claims were grouped as miscellaneous n=70 [45.5%].

CONCLUSIONS

A significant portion of malpractice claims following tonsillectomy or adenoidectomy are related to complications not commonly discussed in the literature.

Lethal outcome of post-tonsillectomy hemorrhage

Despite the large number of tonsillectomies performed little knowledge exists about post-tonsillectomy hemorrhage (PTH) with lethal outcome. This study was performed to evaluate clinical features in a larger patient population with emphasis on the onset of this complication. A nationwide collection of cases was performed based on personal communication, expert reports to lawsuits and professional boards, and case reports received after a plea published in a professional national journal. Clinical data of 29 patients were collected of whom the 18 were children (64%). With one exception all patients experienced secondary PTH (>24 h) occurring 1-28 days after tonsillectomy. Aspiration contributed to lethal outcome in 13 cases. Fatalities were unavoidable although 21 patients were in the hospital. Massive vomiting of blood was observed in 11 patients. There were 11 patients without (group A) and 18 with (group B) episodes of repeated bleeding. This study suggests that particularly children are endangered by lethal PTH. Inpatient treatment was unable to prevent lethal outcome in this selected patient population. However, it appears wise to re-admit patients with delayed PTH, since excessive PTH may occur. These unexpected and unpredictable situations require an immediate and adequate medical treatment by a skilled staff. The paucity of data currently does not allow calculation of a cut-off point at which the risk of life-threatening PTH significantly decreases. Secondary PTH remains a substantial complication.