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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.
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Affiliation(s)
- Zahir Mughal
- Department of Otolaryngology, Russells Hall Hospital, Dudley, UK
| | | | | | | | - Matthew Weller
- Department of Otolaryngology, Russells Hall Hospital, Dudley, UK
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2
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Johnson RF, Beams DR, Zaniletti I, Chorney SR, Kou YF, Lenes-Voit F, Ulualp S, Liu C, Mitchell RB. Estimated Probability Distribution of Bleeding After Pediatric Tonsillectomy: A Retrospective National Cohort Study of US Children. JAMA Otolaryngol Head Neck Surg 2023; 149:431-438. [PMID: 36995688 PMCID: PMC10064285 DOI: 10.1001/jamaoto.2023.0268] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 02/06/2023] [Indexed: 03/31/2023]
Abstract
Importance The American Academy of Otolaryngology-Head and Neck Surgery Foundation has recommended yearly surgeon self-monitoring of posttonsillectomy bleeding rates. However, the predicted distribution of rates to guide this monitoring remain unexplored. Objective To use a national cohort of children to estimate the probability of bleeding after pediatric tonsillectomy to guide surgeons in self-monitoring of this event. Design, Settings, and Participants This retrospective cohort study used data from the Pediatric Health Information System for all pediatric (<18 years old) patients who underwent tonsillectomy with or without adenoidectomy in a children's hospital in the US from January 1, 2016, through August 31, 2021, and were discharged home. Predicted probabilities of return visits for bleeding within 30 days were calculated to estimate quantiles for bleeding rates. A secondary analysis included logistic regression of bleeding risk by demographic characteristics and associated conditions. Data analyses were conducted from August 7, 2022 to January 28, 2023. Main Outcomes and Measures Revisits to the emergency department or hospital (inpatient/observation) for bleeding (primary/secondary diagnosis) within 30 days after index discharge after tonsillectomy. Results Of the 96 415 children (mean [SD] age, 5.3 [3.9] years; 41 284 [42.8%] female; 46 954 [48.7%] non-Hispanic White individuals) who had undergone tonsillectomy, 2100 (2.18%) returned to the emergency department or hospital with postoperative bleeding. The predicted 5th, 50th, and 95th quantiles for bleeding were 1.17%, 1.97%, and 4.75%, respectively. Variables associated with bleeding after tonsillectomy were Hispanic ethnicity (OR, 1.19; 99% CI, 1.01-1.40), very high residential Opportunity Index (OR, 1.28; 99% CI, 1.05-1.56), gastrointestinal disease (OR, 1.33; 99% CI, 1.01-1.77), obstructive sleep apnea (OR, 0.85; 99% CI, 0.75-0.96), obesity (OR,1.24; 99% CI, 1.04-1.48), and being more than 12 years old (OR, 2.48; 99% CI, 2.12-2.91). The adjusted 99th percentile for bleeding after tonsillectomy was approximately 6.39%. Conclusions and Relevance This retrospective national cohort study predicted 50th and 95th percentiles for posttonsillectomy bleeding of 1.97% and 4.75%. This probability model may be a useful tool for future quality initiatives and surgeons who are self-monitoring bleeding rates after pediatric tonsillectomy.
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Affiliation(s)
- Romaine F. Johnson
- Department of Otolaryngology–Head and Neck Surgery, University of Texas Southwestern Medical Center at Dallas
- Department of Pediatric Otolaryngology, Children’s Medical Center, Dallas, Texas
| | - Dylan R. Beams
- Department of Otolaryngology–Head and Neck Surgery, University of Texas Southwestern Medical Center at Dallas
| | | | - Stephen R. Chorney
- Department of Otolaryngology–Head and Neck Surgery, University of Texas Southwestern Medical Center at Dallas
- Department of Pediatric Otolaryngology, Children’s Medical Center, Dallas, Texas
| | - Yann-Fuu Kou
- Department of Otolaryngology–Head and Neck Surgery, University of Texas Southwestern Medical Center at Dallas
- Department of Pediatric Otolaryngology, Children’s Medical Center, Dallas, Texas
| | - Felicity Lenes-Voit
- Department of Otolaryngology–Head and Neck Surgery, University of Texas Southwestern Medical Center at Dallas
- Department of Pediatric Otolaryngology, Children’s Medical Center, Dallas, Texas
| | - Seckin Ulualp
- Department of Otolaryngology–Head and Neck Surgery, University of Texas Southwestern Medical Center at Dallas
- Department of Pediatric Otolaryngology, Children’s Medical Center, Dallas, Texas
| | - Christopher Liu
- Department of Otolaryngology–Head and Neck Surgery, University of Texas Southwestern Medical Center at Dallas
- Department of Pediatric Otolaryngology, Children’s Medical Center, Dallas, Texas
| | - Ron B. Mitchell
- Department of Otolaryngology–Head and Neck Surgery, University of Texas Southwestern Medical Center at Dallas
- Department of Pediatric Otolaryngology, Children’s Medical Center, Dallas, Texas
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McLean JE, Hill CJ, Riddick JB, Folsom CR. Investigation of Adult Post-Tonsillectomy Hemorrhage Rates and the Impact of NSAID Use. Laryngoscope 2022; 132:949-953. [PMID: 34473351 DOI: 10.1002/lary.29844] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 08/14/2021] [Accepted: 08/20/2021] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- James E McLean
- Department of Otolaryngology - Head and Neck Surgery, Naval Medical Center Portsmouth, Portsmouth, Virginia, U.S.A
| | - Christopher J Hill
- Department of Otolaryngology - Head and Neck Surgery, Naval Medical Center Portsmouth, Portsmouth, Virginia, U.S.A
| | - Jeanelle B Riddick
- Clinical Investigations Department, Naval Medical Center Portsmouth, Portsmouth, Virginia, U.S.A
| | - Craig R Folsom
- Department of Otolaryngology - Head and Neck Surgery, Naval Medical Center Portsmouth, Portsmouth, Virginia, U.S.A
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A novel electrosurgical divider: performance in a self-controlled tonsillectomy study. Eur Arch Otorhinolaryngol 2022; 279:2109-2115. [PMID: 34338876 PMCID: PMC8930875 DOI: 10.1007/s00405-021-07008-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 07/19/2021] [Indexed: 01/05/2023]
Abstract
PURPOSE Tonsillectomies are among the most common surgeries in otorhinolaryngology. A novel electrosurgical temperature-controlled instrument (device) promises rapid tonsillectomies and might reduce postoperative pain, but comparative studies to assess performance are warranted. METHODS This randomized self-controlled clinical trial was conducted from October 2019 to October 2020 at the Department of Otorhinolaryngology, Head and Neck Surgery of the Medical University of Vienna. Forty-eight patients underwent a tonsillectomy with the device on one side and using cold-steel with localized bipolar cauterization on the other side (control). Main outcomes were the time for tonsil removal (per side) and the time to stop bleeding (per side). Secondary measurements were postoperative pain, assessed once on day 0 and five times on days 1, 3, 5, 7, and 10. Postoperative bleeding episodes and consequences were recorded. RESULTS Device tonsillectomies were performed significantly faster than controls; the mean surgical time difference was 209 s (p < 0.001, 95% CI 129; 288). Intraoperative blood loss was significantly lower on the device side (all p < 0.05). Postoperative measurements of pain and bleeding were similar for both sides. Two return-to-theatre secondary bleeding events were recorded for the control side. CONCLUSION The novel electrosurgical temperature-controlled divider reduced the tonsillectomy surgical time and intraoperative blood loss, with no apparent negative effects on postoperative pain or bleeding, compared to a cold-steel tonsillectomy with localized bipolar cauterization. In time-restricted settings, the device could be beneficial, particularly after familiarization with device handling. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03793816.
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5
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Grasl S, Mekhail P, Janik S, Grasl CM, Vyskocil E, Erovic BM, Arnoldner C, Landegger LD. Temporal fluctuations of post-tonsillectomy haemorrhage. Eur Arch Otorhinolaryngol 2021; 279:1601-1607. [PMID: 34557959 PMCID: PMC8897317 DOI: 10.1007/s00405-021-07080-1] [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: 08/15/2021] [Accepted: 09/06/2021] [Indexed: 12/25/2022]
Abstract
Purpose Although haemorrhage is a common and in some cases life-threatening complication after tonsillectomy, surprisingly little is known about the temporal fluctuations of the onset of bleeding. The purpose of this study was to assess circadian and seasonal rhythms of post-tonsillectomy haemorrhage (PTH) and potential ramifications to educate patients and health care staff. Methods This retrospective study carried out at a tertiary referral hospital included paediatric and adult patients requiring emergency surgery due to severe PTH between 1993 and 2019. Medical records were reviewed and patient demographics, details regarding the initial procedure, postoperative day of haemorrhage, and start time of emergency surgery were extracted. Descriptive statistics, Kruskal–Wallis test, Mann–Whitney U test, and Chi-square goodness of fit tests were used to detect potential differences. Results A total of 300 patients with severe PTH and subsequent emergency surgery were identified. The median postoperative duration until PTH was 6 (range: < 1–19) days. 64.7% (n = 194) of all emergency surgeries had to be performed during evening and night hours (6 pm—6 am) (p < 0.0001). Compared to diurnal incidents, the risk of a nocturnal PTH event increased, the longer ago the initial surgery was (p < 0.0001). No seasonal variations were identified. Age, sex, and details of the initial procedure had no significant influence on the start time according to the surgical protocol. Conclusion The discovered temporal fluctuations of PTH are of relevance for patient awareness and preoperative education. Due to possible life-threatening complications, management of severe PTH requires specific resources and trained medical staff on call.
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Affiliation(s)
- Stefan Grasl
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna, Vienna, Austria
| | - Patrick Mekhail
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna, Vienna, Austria
| | - Stefan Janik
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna, Vienna, Austria
| | - Christoph M Grasl
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna, Vienna, Austria
| | - Erich Vyskocil
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna, Vienna, Austria
| | - Boban M Erovic
- Institute of Head and Neck Diseases, Evangelical Hospital, Vienna, Austria
| | - Christoph Arnoldner
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna, Vienna, Austria
| | - Lukas D Landegger
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna, Vienna, Austria.
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Windsor AM, Soldatova L, Elden L. Endovascular Embolization for Control of Post-Tonsillectomy Hemorrhage. Cureus 2021; 13:e13217. [PMID: 33728170 PMCID: PMC7946606 DOI: 10.7759/cureus.13217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Post-operative hemorrhage is a potentially life-threatening complication of tonsillectomy. While standard surgical maneuvers including the use of electrocautery, application of topical hemostatic agents, direct pressure, and suturing of the tonsillar pillars have traditionally been used for the treatment of severe bleeding, endovascular approaches are an important adjunct when other techniques are unsuccessful. Here, we describe the case of a 10-year-old female who presented with severe bleeding four days after tonsillectomy and adenoidectomy for chronic tonsillitis. She was taken emergently to the operating room where pulsatile bleeding was noted from the right inferior tonsillar pole. Hemostasis could not be achieved using electrocautery despite multiple attempts. The patient was taken for emergent angiography, which demonstrated an irregularity of the right tonsillar artery consistent with arterial vasospasm, and which corresponded to the intraoral site of bleeding localized by the surgeon. Coil embolization of the tonsillar artery was successfully performed, and the patient experienced no further bleeding. We conclude that endovascular embolization of branches of the external carotid artery is an effective treatment for severe post-tonsillectomy hemorrhage in children and should be considered when attempts at surgical control are ineffective. This procedure requires exceptional collaboration between the surgical, radiology, and anesthesia teams.
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Affiliation(s)
- Alanna M Windsor
- Otorhinolaryngology - Head and Neck Surgery, Montefiore Medical Center, Bronx, USA
| | - Liuba Soldatova
- Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, USA
| | - Lisa Elden
- Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, USA.,Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, USA
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7
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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
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8
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Tertiary hospital retrospective observational audit of tonsillectomy. Int J Pediatr Otorhinolaryngol 2019; 121:20-25. [PMID: 30852447 DOI: 10.1016/j.ijporl.2019.02.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Revised: 01/26/2019] [Accepted: 02/12/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Tertiary hospitals see a wide array of complex paediatric patients requiring the procedure of tonsillectomy to alleviate airway symptoms. To investigate the implications of patient-specific factors on postoperative morbidities and hospital stay length, including the role of BMI and AH as predictors for airway complications following surgery. METHODS A retrospective chart review was performed for all patients presenting at The Children's Hospital at Westmead for routine tonsillectomy between July 2010 and July 2014. RESULTS Of 500 charts, 420 patients met inclusion criteria. 155 (37%) patients had a pre-existing comorbidity. Polysomnogram (PSG) was conducted prior to surgery (n = 129). BMI results showed a mean BMI of 20.0, n = 25 were overweight, n = 70 were obese and n = 11 underweight. 84 patients (20%) experienced a postoperative complication/unexpected morbidity. There were no returns to theatre and no mortality. 24 patients had more than one complication. Complication rate was highest in the patients <2 years of age. There was a statistically significant difference in the number of desaturation related complications between obese and non-obese groups p = 0.00480. There was statistically significant difference in length of hospital stay between the two groups. 16% of children with co-morbidities stayed for >2 nights in hospital (25/155) compared to 7.5% of children without co-morbidities p = 0.00607. 9% of children with co-morbidities stayed for 3 nights in hospital (14/155) compared to patients without co-morbidities (6/256), p = 0.00167. CONCLUSIONS This audit confirms the impact of age, obesity and certain co-morbidities on the potential costs to the hospital in managing complications and length of stay after surgery.
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Paediatric Posttonsillectomy Haemorrhage Rates in Auckland: A Retrospective Case Series. Int J Otolaryngol 2019; 2019:4101034. [PMID: 30956663 PMCID: PMC6431364 DOI: 10.1155/2019/4101034] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 02/11/2019] [Indexed: 01/05/2023] Open
Abstract
Background Tonsillectomy is one of the most commonly performed surgical procedures in children. It is performed for sleep-disordered breathing and infective symptoms. Despite advances in instrumentation and perioperative care, posttonsillectomy haemorrhage (PTH) remains a significant complication, which should be audited regularly. Methods A retrospective case series of all tonsillectomies performed in patients <15 years old in the Auckland region during 2017 was performed. Demographic, clinical, and surgical data were extracted and analysed. Univariate analysis was performed to compare patients with and without PTH. Results A total of 2177 tonsillectomies were performed during the study period, 64% in a public hospital and 36% in a private hospital. The overall PTH rate was 3.6% (0.23% occurring within the first 24 hours (primary) and 3.4% after 24 hours (secondary)). Mean time to PTH was 6.6 ± 3 days (range: 1-16 days). 90% of PTH occurred within the first 10 days and 99% by 14 days. Return to theatre was required in 28% of these cases, representing 1% of all tonsillectomies. There were no deaths or major complications in this cohort. The only differences observed between patients with PTH and those without were that children with PTH had smaller tonsils (p=0.004) and were less likely to have associated OME (p<0.001). Conclusion It is important to report institutional tonsillectomy outcomes and associated complications. These results show that PTH rates in Auckland remain within acceptable limits according to the literature.
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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
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11
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Ordemann AG, Hartzog AJ, Seals SR, Spankovich C, Stringer SP. Is weight a predictive risk factor of postoperative tonsillectomy bleed? Laryngoscope Investig Otolaryngol 2018; 3:238-243. [PMID: 30062141 PMCID: PMC6057213 DOI: 10.1002/lio2.155] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 06/16/2017] [Accepted: 03/13/2018] [Indexed: 12/27/2022] Open
Abstract
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.
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Affiliation(s)
- Allison G Ordemann
- Department of Otolaryngology University of Mississippi Medical Center Jackson Mississippi U.S.A
| | - Anna Jade Hartzog
- Department of Anesthesiology Vanderbilt University Medical Center Nashville Tennessee U.S.A
| | - Samantha R Seals
- Department of Mathematics and Statistics University of West Florida Pensacola Florida U.S.A
| | - Christopher Spankovich
- Department of Otolaryngology University of Mississippi Medical Center Jackson Mississippi U.S.A
| | - Scott P Stringer
- Department of Otolaryngology University of Mississippi Medical Center Jackson Mississippi U.S.A
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Vlok R, Melhuish TM, Chong C, Ryan T, White LD. Adjuncts to local anaesthetics in tonsillectomy: a systematic review and meta-analysis. J Anesth 2017; 31:608-616. [PMID: 28120104 DOI: 10.1007/s00540-017-2310-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 01/14/2017] [Indexed: 10/20/2022]
Abstract
The infiltration of local anaesthetic agents has been shown to reduce post-tonsillectomy pain. A number of recent studies have shown that the addition of agents such as clonidine and dexamethasone improve the efficacy of nerve blocks and spinal anaesthesia. The aim of this review was to determine whether additives to local anaesthetic agents improve post-tonsillectomy outcomes. Four major databases were systematically searched for all relevant studies published up to August 2016. All study designs with a control group receiving local anaesthetic infiltration and an intervention receiving the same infiltration with an added agent were included in this review. These studies were then assessed for level of evidence and risk of bias. The data were then analysed both qualitatively and where appropriate by meta-analysis. We reviewed 11 randomised controlled trial (RCTs) that included 854 patients. Due to inconsistencies in the methods used to report outcomes, both quantitative and qualitative comparisons were required to analyse the extracted data. Overall, we found that dexamethasone, magnesium, pethidine and tramadol reduce post-operative pain and analgesia use, with dexamethasone in particular significantly reducing post-operative nausea and vomiting and magnesium infiltration significantly reducing the incidence of laryngospasm. This systematic review of RCTs provides strong evidence that the use of dexamethasone and magnesium as additives to local anaesthetics reduces post-tonsillectomy pain and analgesia requirement. There is limited evidence that pethidine and tramadol have a similar effect on pain and analgesia requirement. The studies in this pooled analysis are sufficiently strong to make a level one recommendation that the addition of magnesium to local anaesthetics reduces the incidence of laryngospasm, a potentially lethal post-operative complication. Review level of evidence: 1.
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Affiliation(s)
- R Vlok
- Wagga Wagga Rural Referral Hospital, Wagga Wagga, NSW, Australia.,School of Medicine, Sydney, University of Notre Dame, Fremantle, NSW, Australia
| | - T M Melhuish
- Wagga Wagga Rural Referral Hospital, Wagga Wagga, NSW, Australia.,School of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - C Chong
- School of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - T Ryan
- School of Medicine, Sydney, University of Notre Dame, Fremantle, NSW, Australia
| | - Leigh D White
- Wagga Wagga Rural Referral Hospital, Wagga Wagga, NSW, Australia. .,School of Medicine, University of Wollongong, Wollongong, NSW, Australia.
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13
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Postoperative tonsillectomy bleeding complications in children: A comparison of three surgical techniques. Int J Pediatr Otorhinolaryngol 2016; 88:184-8. [PMID: 27497410 DOI: 10.1016/j.ijporl.2016.07.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 05/25/2016] [Accepted: 07/08/2016] [Indexed: 12/26/2022]
Abstract
OBJECTIVE & HYPOTHESIS Stated in the Null form: There will be no difference in primary or secondary hemorrhage rate in children undergoing tonsillectomy or adenotonsillectomy across three surgical techniques: PEAK Plasmablade, electric monopolar cautery, coblation. STUDY DESIGN Retrospective chart analysis. SETTING Academic Medical Center: Children's Hospital. SUBJECTS & METHODS Electronic chart data were collected from patient's age 2-18 years who underwent tonsillectomy, with or without adenoidectomy, at a tertiary pediatric hospital between June 2011 to May 2013 by electric monopolar cautery, coblation, or PEAK PlasmaBlade. Treatment outcomes following each of these surgical approaches, relative to rate of post-operative primary and secondary bleeding, hospital admission, and emergency department visits were compared. RESULTS A total of 1780 patients that had tonsillectomy or adenotonsillectomy were evaluated. There was a significant difference in bleed rate by age with older patients having more bleeding post-procedure than their younger counterparts. There was also a difference in bleeding frequency by diagnosis. Patients with a diagnosis of OSA were less likely to experience a postoperative bleed than children with either recurrent tonsillitis or both. Significance was evident between post-op hemorrhage rate and instrumentation (χ(2) = 11.17, df = 2, p = 0.004). The majority of bleeds occurred with coblation (58.9%), while PEAK had only 17.8% and cautery 23%. CONCLUSION The null hypothesis was rejected. That is, PEAK PlasmaBlade was safe and effective, with statistically less postoperative bleeding and ED visits, especially when compared to coblation techniques. Coblation patients had the highest rates of postoperative bleeding.
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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]
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Relihan K, Bhullar I. Carotid Artery Injury from Hemorrhage Control during Routine Tonsillectomy. Am Surg 2016. [DOI: 10.1177/000313481608200702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Kathleen Relihan
- Department of Surgical Education Orlando Regional Medical Center Orlando, Florida
| | - Indermeet Bhullar
- Department of Surgical Education Orlando Regional Medical Center Orlando, Florida
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Optical magnification devices in tonsillectomy: a prospective randomised clinical study. Eur Arch Otorhinolaryngol 2014; 272:3031-7. [PMID: 25245863 DOI: 10.1007/s00405-014-3296-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Accepted: 09/17/2014] [Indexed: 10/24/2022]
Abstract
Tonsillectomy is one of the most common surgical procedure in otorhinolaryngology. A plethora of approaches has been undertaken so far to limit postoperative pain, one of the major problems patients are concerned with. Thermal damages of the surrounding tissue caused by coagulation during surgery are discussed to correlate with postoperative pain. Therefore, we studied whether the use of magnification devices reduced coagulation procedures and consequently limited post-operative pain. Following an intraindividual design, we performed tonsillectomy on one side using a microscope or magnifying glasses whereas the opposite side was operated with unsupported vision. As verified by a visual analogue scale, our study shows that neither the use of a microscope, nor the use of magnifying glasses leads to less post-operative pain. Other parameters like post-operative bleeding, duration of surgery, and total applied energy by bipolar coagulation were also comparable in the different treatment groups. Taken together, magnification-supported tonsillectomy does not seem to be appropriate for limiting complications of tonsillectomy, especially not for reducing post-operative pain.
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Embolization in the management of recurrent secondary post-tonsillectomy haemorrhage in children. Eur Radiol 2014; 25:239-45. [DOI: 10.1007/s00330-014-3387-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Revised: 07/19/2014] [Accepted: 08/06/2014] [Indexed: 11/30/2022]
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18
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Torres AC, Guerrero JS, Silva HC. A Modified Transoral Approach for Carotid Artery Type Eagle Syndrome. Ann Otol Rhinol Laryngol 2014; 123:831-4. [DOI: 10.1177/0003489414538770] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective: This article aimed to summarize our clinical experience with a standardized tonsil-sparing transoral surgical approach used for treatment of styloid process-carotid artery Eagle’s syndrome. Methods: Eleven consecutive patients, from 2007 to 2013, underwent surgical treatment to remove elongated styloid apophyses transorally. Outcomes were assessed in terms of intraoperative and postoperative complications and patients’ evolution. Results: No patient experienced any intraoperative or postoperative complications. All patients have been followed up to present and 10 of them have shown complete relief of the symptoms and improvement of functional ability. Conclusion: The tonsil-sparing transoral surgical approach described is suitable for treating patients with elongated styloid apophyses.
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Affiliation(s)
- Arnulfo C. Torres
- Department of Otolaryngology, Hospital Universitario del Caribe, Faculty of Medicine, University of Cartagena, Cartagena, Colombia
| | - Jaime S. Guerrero
- Division of Stomatology and Oral Surgery, Faculty of Dentistry, University of Cartagena, Cartagena, Colombia
| | - Helen C. Silva
- Department of Otolaryngology, Hospital Universitario del Caribe, Faculty of Medicine, University of Cartagena, Cartagena, Colombia
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Chávez-Delgado ME, Kishi-Sutto CV, Albores de la-Riva XN, Rosales-Cortes M, Gamboa-Sánchez P. Topic usage of kaolin-impregnated gauze as a hemostatic in tonsillectomy. J Surg Res 2014; 192:678-85. [PMID: 24952410 DOI: 10.1016/j.jss.2014.05.040] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2013] [Revised: 04/09/2014] [Accepted: 05/16/2014] [Indexed: 01/04/2023]
Abstract
BACKGROUND The main postoperative complications after tonsillectomy are due to bleeding, and effective hemostasis may lead to a reduction of overall postoperative morbidity. This study was undertaken to determine the efficacy and safety of a novel kaolin-based hemostatic dressing in tonsillectomy. METHODS A pilot, single-blind, open label study was performed in patients aged 3-20 y with history of chronic or hypertrophic tonsillitis. Cold dissection tonsillectomy (CDT) + ligature was performed by the same surgeon. Hemostasis on each tonsillar fossa was achieved using kaolin-impregnated gauze (KG; study group) or standard surgical cotton gauze (CG; control). Time to complete hemostasis, operative time, intraoperative blood loss, pain score, analgesic use, and return to normal diet and activity were recorded for all children. RESULTS A total of 230 patients with a mean age of 8.0 y (138 in the study group and 92 in the control group) were included in the study. Both operative time and intraoperative blood loss were significantly reduced in the KG group (P < 0.0001) versus the CG group. At 5 min, 84.8% patients using the KG successfully achieved complete hemostasis versus 34.8% in the CG group where standard gauze controlled bleeding only partially. Results show significantly less pain for the KG group at 6- and 12-h postoperative when compared with the CG group (P < 0.0001). Also, the KG group required less analgesic medications, returned to normal diet and normal activities faster than the CG group (P < 0.01). CONCLUSIONS Preliminary findings show that the KG is effective and safe in managing surgical bleeding after tonsillectomy. In addition to rapid bleeding control, the dressing causes minimal inflammation and pain and allows patients to quickly return to normal activities. This novel dressing is a promising tool for ear, nose and throat surgical hemostasis.
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Affiliation(s)
- Maria Estela Chávez-Delgado
- Research Department, Instituto Jalisciense de Cirugía Reconstructiva "Dr. José Guerrerosantos", Guadalajara, Jalisco, México.
| | - Celina Verónica Kishi-Sutto
- Research Division, Ethical and Research Department, Instituto Jalisciense de Cirugía Reconstructiva "Dr. José Guerrerosantos", Guadalajara, Jalisco, México
| | - Xellic Nallely Albores de la-Riva
- Department of Plastic Surgery and Reconstructive, Instituto Jalisciense de Cirugía Reconstructiva "Dr. José Guerrerosantos", Guadalajara, Jalisco, México
| | - Manuel Rosales-Cortes
- Biological Sciences Division, CUCBA, Universidad de Guadalajara, Zapopan, Jalisco, Mexico
| | - Paulino Gamboa-Sánchez
- Department of Surgical Oncology, Hospital General Regional 46, IMSS, Guadalajara, Jalisco, México
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