Post-Tonsillectomy Bleeding: A National Perspective

Post-Tonsillectomy Bleeding and Analgesic Use Before and After the FDA Boxed Warning Against Codeine

OBJECTIVE

The aim of this study was to investigate the trends in post-tonsillectomy analgesic utility and incidence of post-tonsillectomy hemorrhage before and after the 2013 FDA Boxed Warning against codeine use after pediatric tonsillectomy.

METHODS

A retrospective study was conducted using TriNetX. A search for patients up to 18 years from 2008 to 2022 within the US Collaborative Network identified 15,648,542 subjects. CPT and ICD-10 codes were used to identify children who experienced post-tonsillectomy hemorrhage within 14 days of a tonsillectomy. Analgesics given within 14 days of tonsillectomy were tabulated annually from 2008 to 2022, including codeine, ibuprofen, acetaminophen, oxycodone, ketorolac, and hydrocodone. Bleeding percentage and analgesic utility were grouped into events before and after 2013.

RESULTS

Mean age at tonsillectomy was 5.6 years (SD = 3.0). Before 2013, the median percentage of children who experienced postoperative bleeding was 1.8% with 0.73% returning to the OR for bleeding control. After 2013, the median percentage of children who experienced postoperative bleeding was 2.4% (p = 0.029), and 0.99% returned to the OR (p = 0.008). Use of post-tonsillectomy codeine fell from 10.4% to 0.5% (p = 0.003) whereas ibuprofen rose from 2.0% to 63.9% (p = <0.001), acetaminophen from 42.8% to 77.2% (p = <0.001), ketorolac from 1.2% to 9.2% (p = <0.001), and oxycodone from 2.0% to 30.9% (p = <0.001). No change was detected in use of hydrocodone.

CONCLUSION

Analgesics used post-tonsillectomy in children have changed since the FDA Boxed Warning against codeine. There has been a small but statistically significant increase in post-tonsillectomy bleeding.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:4783-4788, 2024.

Actinomyces status and inflammatory biomarkers in post-tonsillectomy hemorrhage cases

BACKGROUND

The presence of Actinomyces can be associated with complications.

AIMS

This study aimed to determine the frequency of post-tonsillectomy hemorrhage (PTH), the presence of Actinomyces in palatine tonsils and serum inflammatory biomarker levels in PTH.

MATERIAL AND METHODS

The cases who underwent tonsillectomy at a single center were included in the study. Neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), systemic immune inflammation index (SII) and systemic inflammation response index (SIRI) values were calculated from the complete blood count test. The presence of Actinomyces was recorded from histopathological tonsillectomy material.

RESULTS

A total of 1137 patients were included in the study. Actinomyces was detected in 93 (8.18%) patients. Bleeding complications were encountered in 65 cases (5.72%). No relationship was detected between the presence of Actinomyces and PTH rates (p = 0.433). While a relationship was found between age, NLR, and SIRI values and Actinomyces status (respectively, p < 0.001, p = 0.017, p = 0.038), no statistically significant relationship was found between tonsil size, PLR, and SII (p > 0.05).

CONCLUSION AND SIGNIFICANCE

According to the data in our study, NLR and SIRI values were elevated in subjects with Actinomyces. Our findings suggest that this entity has a systemic manifestation. Serum inflammatory biomarkers and the presence of Actinomyces were not found to be associated with PTH.

Implementation and impact of a surgical dashboard on pediatric tonsillectomy outcomes: A quality improvement study

Introduction

In pediatric tonsillectomy management, the consistent tracking of surgical outcomes and adherence to guidelines are vital. This study explores how a surgical dashboard can serve as a tool in research analysis, translating AAO-HNSF guidelines into measurable performance improvements.

Methods

Using a prospective registry from three pediatric hospitals, a Tableau dashboard was constructed to graphically visualize key demographic and postoperative outcomes (including intensive care unit [ICU] utilization, 30-day emergency department (ED) visits, and postoperative bleed rates) in children undergoing tonsillectomy from 2020 to 2024. From the dashboard data, a retrospective cohort study analyzing 6767 tonsillectomies was conducted from January 2, 2020, to June 20, 2023. Patients were categorized into low-risk, OSA-only (by ICD-10 codes), and high-risk groups based on comorbidities. Logistic regression identified factors influencing ED revisits and unplanned nursing calls. Three quality initiatives were assessed: preoperative school absence notes, perioperative dexamethasone recording, and post-tonsillectomy parental education.

Results

A total of 2122 (31%) were low-risk, 2648 (39%) were OSA-only, and 1997 (30%) high risk. Risk factors that increased the likelihood of ED visits were high-risk comorbidities (OR = 1.46; 95% CI = 1.24-1.74; p < 0.001) and older age (OR = 1.05; 95% CI = 1.03-1.08; p < 0.001). Risk factors that increased the likelihood of an unplanned nursing communication were high-risk comorbidities (OR = 1.53; 95% CI = 1.34-1.75; p < 0.001), older age (OR = 1.03, 95% CI = 1.01-1.04; p = 0.001), and Medicaid insurance (OR = 1.25; 95% CI = 1.09-1.43; p = 0.002). Postoperative bleed control was generally comparable between the groups, at 2.8% (low risk), 2.7% (OSA), 3.2 (high risk) (p = 0.651).

Conclusion

The dashboard aided in data collection, data visualization, and data analysis of quality improvement initiatives, effectively translating guidelines into tangible measures to enhance care.

Level of evidence

NA.

Influence of Economic Connectedness on Pediatric Obstructive Sleep Apnea Severity and Adenotonsillectomy Outcomes

OBJECTIVE

To examine the influence of economic connectedness (EC), a measure of social capital, on obstructive sleep apnea (OSA) severity and adenotonsillectomy outcomes in children.

STUDY DESIGN

Retrospective study.

SETTING

Single tertiary medical center.

METHODS

The study population included 286 children who were referred for full-night polysomnography for OSA and underwent adenotonsillectomy. The primary outcome was the relationship between EC and the presence of severe OSA, and secondary outcomes included postoperative emergency room visits and residual OSA after adenotonsillectomy. Linear regression, Kruskal-Wallis test, Pearson's χ2 test, and multiple logistic regression were used for categorical and continuous data as appropriate.

RESULTS

In this population, the median age was 9.0 (interquartile range [IQR] = 6.9-11.7) and 144 (50.3%) were male. The majority were white (176, 62.0%), black (60, 21.1%), and/or of Hispanic ethnicity (173, 60.9%). The median EC of this population was 0.64 (IQR = 0.53-0.86). Higher EC was associated with decreased odds of having severe OSA (odds ratio: 0.17, 95% confidence interval = 0.05-0.61). However, EC was not associated with either postoperative emergency room visits or residual OSA.

CONCLUSION

EC was significantly associated with severe OSA (ie, apnea-hypopnea index ≥ 10) but not with postoperative emergency room visits or residual OSA after adenotonsillectomy. Further research is needed to understand the effects of various social capital measures on pediatric OSA and adenotonsillectomy outcomes.

Postoperative Bleeding in Children With Tonsillectomy: A Retrospective Cohort

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Parents' Perception on Post-tonsillectomy Hemorrhage: A Local Survey

INTRODUCTION

Tonsillectomy (often combined with adenoidectomy) is one of the oldest and most common surgical procedures performed in otolaryngology. Post-operative complications following tonsillectomy are generally rare and include post-tonsillectomy hemorrhage, dehydration, velopharyngeal insufficiency, and others. Parents play a crucial role in the care and recovery of their children after tonsillectomy. Their perception and understanding of post-tonsillectomy hemorrhage are essential in managing and addressing this potential complication.

AIM

The purpose of this study is to assess parents' perception of post-tonsillectomy hemorrhage and factors that would lead to its development.

METHODS

A descriptive cross-sectional study was conducted targeting parents of children who had undergone surgical tonsillectomy. Data were collected using a pre-structured online questionnaire, biographical data, tonsillectomy data, child medical and drug history, healthcare staff role, and post-surgical complications and bleeding.

RESULTS

A total of 847 parents completed the study questionnaire, and 431 (50.9%) were fathers. As for education, 164 (19.4%) had a university level of education, and 279 (32.9%) had a post-graduate degree. As for child gender, 445 (52.5%) were males, 232 (27.4%) had undergone the surgery in the first five years of their age, 208 (24.6%) at the age of 6-10 years, and 221 (26.1%) undergone the surgery at the age of 16-18 years. The most reported post-surgical complications included headaches and nausea (52.4%), swelling of the roof of the mouth (51.8%), and infection (48.9%). Primary or secondary post-tonsillectomy hemorrhage was reported among 47 (5.5%) of the children, which was during surgery among 12 (25.5%), within 24 hours after surgery among 14 (29.8%), and after 24 hours of surgery among 21 (44.7%).

CONCLUSION

The current study revealed a high rate of tonsillectomy-associated bleeding with a shortage regarding the role of healthcare staff in child pre-surgical assessment and also in parents' education regarding expected complications.

Socioeconomic and racial disparities in revisits, indication, and readmission or reoperation in pediatric tonsillectomy

INTRODUCTION

Pediatric tonsillectomy is a frequent otolaryngologic procedure. This study aimed to characterize disparities in post-tonsillectomy revisits, including emergency department evaluation, readmission, or reoperation as well as indication for revisit.

METHODS

Cases of inpatient and ambulatory pediatric tonsillectomy in New York and Florida in 2016 constituted the analytic sample. Patients were extracted from the State Ambulatory Surgery Databases (SASD) and State Inpatient Databases (SID) and linked to the SID and State Emergency Department Database (SEDD) and SASD. Outcomes include 3 types of revisits within 30 days: ED visits, hospital readmissions, and reoperation. Indication for revisit was also analyzed. Multivariable analysis determined the association of each outcome with gender, age, race/ethnicity, primary payer, urbanicity, and zip code median household income quartile. The Holm Bonferroni test was used to correct for multiple hypothesis testing.

RESULTS

15,264 pediatric tonsillectomies were included. The revisit rate was 6.77% (N = 1,034, 49.1% female; 6 years median age [interquartile range: 5]). The 30-day ED revisit rate was 4.85%, readmission rate was 1.27%, and reoperation rate was 0.65%. On multivariate analysis, Latinx patients (OR = 3.042, 95% CI = 1.393-6.803) and those who identify as other race/ethnicity (OR = 6.116, 95% CI = 1.989-19.245) have greater odds of requiring inpatient care for indications including pain, dehydration, nausea, and vomiting compared to white patients. No significant differences in tier of care for the management of post-tonsillectomy hemorrhage were identified.

CONCLUSION

Disparities in pediatric post-tonsillectomy ED presentation, readmission and reoperation demonstrate opportunities to improve patient safety and equity.

The relationship between posttonsillectomy bleeding to hemogram and coagulation parameters

PURPOSE

Tonsillectomy is a common surgery performed for indications such as chronic tonsilitis, tonsil hypertrophy and obsructive sleep apnea. Although posttonsillectomy bleeding (PTB) is rare and can be controlled with simple interventions in many patients, it is one of the most feared complications of tonsillectomy surgery. In our study, we investigated the effects of changes in hemogram and coagulation values and seasonal effects on PTB.

METHODS

Pediatric and adult patients who underwent tonsillectomy with cold knife method between August 2020 and August 2023 in our clinic were retrospectively reviewed. Demographic data, hemogram and coagulation values of the patients in the control and study groups were recorded and the differences between the two groups in terms of these parameters were evaluated.

RESULTS

Our study included 991 patients aged 1-51 years. The rate of PTB was calculated as 2.82%. No patient with primary PTB was found. The duration of bleeding development was 7.03 days. Age, WBC and neutrophil values were statistically significantly higher in the study group. There were no significant differences between two groups in terms of gender, season and other hemogram and coagulation parameters.

CONCLUSIONS

Age, high WBC and neutrophil levels were determined as possible risk factors for PTB. Seasonal and gender distribution, aPTT and INR values were similar in the two groups. In order to prevent and predict bleeding, detailed infection investigation should be performed and the risk of bleeding should be considered to increase with increasing age.

Post-tonsillectomy bleeding rate decreases with limitation in maximum post-operative ibuprofen dosage: A quality improvement study

OBJECTIVE

The objective of this study is to investigate the effect of a reduction in the prescribed post-operative ibuprofen dosage on frequency of post-tonsillectomy bleeding.

METHODS

A quality improvement study was conducted at a single tertiary care pediatric hospital with patients weighing >40 kg undergoing tonsillectomy. The intervention was limiting the post-operative ibuprofen dosage to a maximum of 400 mg per dose. Data was collected on all patients returning to the hospital with bleeding after tonsillectomy. The primary outcome was the rate of post-tonsillectomy bleeding. Statistical analysis was conducted using nonparametric comparisons and a run chart.

RESULTS

A total of 199 tonsillectomy patients >40 kg were included in the study. There were 119 (59.8 %) females and 80 (40.2 %) males total. The pre-intervention group had a total of 56 patients while the post-intervention group had a total of 143 patients. There was no statistical difference in age, weight, or sex between the pre- and post-intervention groups (p > .05). The post-tonsillectomy hemorrhage rate was 11/56 (19.6 %) before the intervention, and 11/143 (7.7 %) after the intervention (p = .016). Children who experienced a bleeding event were significantly older (mean 15.9 years, 95 % CI 14.5-17.3) than those who did not (13.5 years, 95 % CI 12.9-14.1; p = .011). The run chart revealed that the intervention resulted in a nonrandom decrease in rate of post-tonsillectomy bleeding.

CONCLUSIONS

Post-tonsillectomy bleeding rate decreased with a ceiling post-operative ibuprofen dose of 400 mg/dose in this quality improvement study. Further research is warranted.

Risk factors for late postoperative bleeding after partial glossectomy for tongue cancer

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.

Pediatric Otolaryngology Short-Term Mission Outcomes at a Surgical Mission Hospital in Guatemala

OBJECTIVE

The frequency of humanitarian surgical mission trips has grown over recent decades. Unfortunately, research on patient outcomes from these trips has not increased proportionately. We aim to analyze the safety and efficacy of surgeries in a low- and middle-income country missions-based surgery center in Guatemala City, Guatemala, and identify factors that influence surgical outcomes.

STUDY DESIGN

Retrospective cohort study.

SETTING

Guatemalan surgery center is called the Moore Center.

METHODS

Pediatric patients underwent otolaryngology surgery between 2017 and 2019. All patients required follow up. We analyzed the effect of patient, surgical, and geographic factors on follow up and complications with univariate and multivariate analyses.

RESULTS

 A total of 1094 otolaryngologic surgeries were performed between 2017 to 2019, which comprised 37.4% adenotonsillectomies, 26.8% cleft lip (CL)/cleft palate (CP) repairs, 13.6% otologic, and 20% "other" surgeries. Patients traveled on average 88 km to the center (±164 km). Eighty-nine percent attended their first follow up and 55% attended their second. The 11% who missed their first follow up lived farther from the center (p < .001) and had a higher ASA classification (p < .001) than the 89% who did attend. Sixty-nine (6.3%) patients had 1 or more complications. CL/CP surgery was associated with more complications than other procedures (p < .001). Of 416 tonsillectomies, 4 patients (1%) had a bleeding episode with 2 requiring reoperation.

CONCLUSION

This surgical center models effective surgical care in low-resource areas. Complications and follow-up length vary by diagnosis. Areas to improve include retaining complex patients for follow up and reducing complications for CL/CP repair.

Assessing the Relationship Between Infection Frequency and Risk of Post-Tonsillectomy Hemorrhage

OBJECTIVE

To determine the relationship between frequency of tonsillitis and the risk of post-tonsillectomy hemorrhage (PTH) in pediatric patients undergoing tonsillectomy for recurrent tonsillitis.

METHODS

After obtaining IRB approval from Nationwide Children's Hospital, charts for all patients who underwent a total tonsillectomy in 2017 for recurrent or chronic tonsillitis were retrospectively reviewed (n = 424). Patients were divided into 2 cohorts based on the frequency of tonsillitis prior to surgery: those meeting the 1-year criteria with 7 or more infections in the past year (n = 100), and those who did not meet criteria defined as those with fewer than 7 infections in the past year (n = 324). The primary outcome of interest was PTH. Comparison of cohorts and frequency of PTH were assessed using bivariate analyses. Kaplan-Meier curves were used to compare time to onset of hemorrhage between primary vs. secondary PTH. Generalized mixed and logistic regression models were used to evaluate risk of hemorrhage following tonsillectomy.

RESULTS

Among a total cohort of 424 patients undergoing tonsillectomy, 23.58% (n = 100) met criteria while 76.42% (n = 324) did not. A total of 8.73% (n = 37) patients experienced PTH. Compared to those who did not meet criteria, those who met criteria had a higher odds of developing PTH; however, this was not significant (OR: 1.42 [95% CI: 0.67, 2.98], P = .3582). Estimated probability of developing PTH for those who met criteria was 11% [95% CI: 6.19, 18.81] compared to 8.03% [95% CI: 5.52, 11.54] for those who did not meet criteria. Among all PTH cases, 5.41% (n = 2) were primary hemorrhage while 94.59% (n = 35) were secondary hemorrhage with 50% of those with secondary PTH having experienced hemorrhage within 6 days [95% CI: 5, 7] of tonsillectomy. Patients with neuromuscular conditions had significantly higher odds of PTH (OR: 4.75 [95% CI: 1.19, 18.97], P = .0276).

CONCLUSION

Patients who met the 1-year criteria for tonsillectomy did not have a significantly higher odds of PTH. Further research is needed to better evaluate the relationship between infection frequency and risk of PTH.

Lidocaine aerosol preoperative application for improving the comfort of pediatric patients undergoing tonsillectomy and adenoidectomy: A prospective randomized controlled trial

Background and Aims

The use of lidocaine aerosol for pediatric tonsil and adenoidectomy has been reported less frequently. We hope to improve the perioperative comfort of pediatric patients undergoing these procedures by applying lidocaine aerosol.

Methods

A total of 122 pediatric patients receiving tonsil and adenoidectomy were randomly divided into a lidocaine aerosol group (Group L) and a saline group (Group C), with 61 patients in each group; 2.4% alkaline lidocaine aerosol and saline were sprayed in the pharynx before induction. Our primary outcome were the incidence and rate ratio (RR) of postoperative pharyngeal complications (oropharyngeal dryness, dysphagia, hoarseness, and sore throat) and the pharyngeal comfort score, the latter of which was assessed by the occurrence of the above complications (yes = 0 point, none = 1 point). The secondary outcomes included preoperative and intraoperative blood pressure and heart rate, the incidence of choking during the induction period, the intraoperative opioid dosage, and the pain level and depth of sedation at 2, 6, and 24 h postoperatively. Statistical software used in this study included PASS15.0, SPSS 26.0, and GraphPad Prism 9.3.1, and statistical methods used included the t-test, the χ² test, the Mann-Whitney U test, and the repeated measures analysis of variance.

Results

The incidence and RR of postoperative pharyngeal complications such as oropharyngeal dryness (RR: 0.667, 95% confidence interval [CI]: 0.458-0.970, p = 0.03), dysphagia (RR: 0.333, 95% CI: 0.114-0.976, p = 0.03), hoarseness (RR: 0.647, 95% CI: 0.433-0.967, p = 0.03), and sore throat (RR: 0.727, 95% CI: 0.547-0.967, p = 0.03) were significantly lower in Group L than in Group C at 2 h postoperatively, and the incidence and RR of postoperative sore throat was significantly lower in Group L than in Group C at 6 h postoperatively (RR: 0.717, 95% CI: 0.547-0.942, p = 0.01). The postoperative pharyngeal comfort scores were significantly higher in Group L than in Group C at all postoperative time points (p < 0.05). The Ramsay sedation score was significantly higher (p < 0.01) and FLACC (face, legs, activity, crying, and consolability) score was significantly lower (p < 0.01) in Group L than in Group C at 2 h postoperatively. In Group C, the blood pressure and heart rate significantly faster at all time points immediately after intubation and afterward, except at the end of surgery (p < 0.05).

Conclusions

In pediatric tonsil and adenoidectomy, the application of lidocaine aerosol before induction can reduce the incidence of postoperative pharyngeal complications, improve the child's postoperative pharyngeal comfort, and better realize perioperative "comfort medical treatment."

Is it possible to predict post-adenotonsillectomy hemorrhage in children with preoperative blood tests? Single-center retrospective study

Introduction: Post-adenotonsillectomy (PAT) bleeding, a life-threatening surgical complication, remains unpredictable despite preoperative blood tests. Every surgeon would like predictive markers for this complication of one of the most common procedures performed in pediatric ear, nose, and throat (ENT). Objective: The purpose of the study is to see whether the results of the blood tests we perform routinely preoperatively in children undergoing adenotonsillectomy (AT) (lymphocyte count and percentage, C reactive protein, fibrinogen, or coagulation variables International Normalized Ratio and activated partial thromboplastin time) can potentially predict early post-AT bleeding. Focus has been placed on the presence of relative lymphocytosis (a value of lymphocyte percentage above 55%) in the blood cell count of the patients and its possible connection to postoperative hemorrhage. Method: We conducted an observational retrospective study on 801 children undergoing adenoidectomy, tonsillectomy, or AT over a period of 6 months in our ENT department. Statistical analysis was performed to compare the data. Results: we did not find a statistically significant correlation between preoperative blood markers (coagulation or inflammatory) and early post-AT bleeding. An important blood marker in relation to PAT bleeding appears to be relative lymphocytosis. Relative lymphocytosis has a weak predictive value of early postoperative bleeding in children with AT (sensitivity of only 31.58%, but acceptable specificity of above 80%). In other words, 80% of patients without relative lymphocytosis will not bleed in the first 24 h postoperatively. Children with relative lymphocytosis may need tighter surveillance in the first 24 h after AT. Conclusions: Relative lymphocytosis has a weak predictive value of early postoperative bleeding in children with AT children.

The Impact of Surgical Indication on Posttonsillectomy Hemorrhage: A Systematic Review and Meta-Analysis

OBJECTIVE

To investigate the impact of the surgical indication on posttonsillectomy bleed rates.

DATA SOURCES

PubMed, Scopus, CINAHL.

REVIEW METHODS

A systematic review was performed searching for articles published from the date of inception to July 6, 2022. English language articles describing posttonsillectomy hemorrhage rates in pediatric patients (age ≤ 18) stratified by indication were selected for inclusion. A meta-analysis of proportions with comparison (Δ) of weighted proportions was conducted. All studies were assessed for risk of bias.

RESULTS

A total of 72 articles with 173,970 patients were selected for inclusion. The most common indications were chronic/recurrent tonsillitis (CT/RT), obstructive sleep apnea/sleep-disordered breathing (OSA/SDB), and adenotonsillar hypertrophy (ATH). Posttonsillectomy hemorrhage rates for CT/RT, OSA/SDB, and ATH were 3.57%, 3.69%, and 2.72%, respectively. Patients operated on for a combination of CT/RT and OSA/SDB had a bleed rate of 5.99% which was significantly higher than those operated on for CT/RT alone (Δ2.42%, p = .0006), OSA/SDB alone (Δ2.30%, p = .0016), and ATH alone (Δ3.27%, p < .0001). Additionally, those operated on for a combination of ATH and CT/RT had a hemorrhage rate of 6.93%, significantly higher than those operated on for CT/RT alone (Δ3.36%, p = .0003), OSA/SDB alone (Δ3.01%, p = .0014), and ATH alone (Δ3.98%, p < .0001).

CONCLUSION

Patients operated on for multiple indications had significantly higher rates of posttonsillectomy hemorrhage than those operated on for a single surgical indication. Better documentation of patients with multiple indications would help further characterize the magnitude of the compounding effect described here.

Unveiling the Enigmatic Adenoids and Tonsils: Exploring Immunology, Physiology, Microbiome Dynamics, and the Transformative Power of Surgery

Within the intricate realm of the mucosal immune system resides a captivating duo: the adenoids (or pharyngeal tonsils) and the tonsils (including palatine, tubal, and lingual variations), which harmoniously form the Waldeyer's ring. As they are strategically positioned at the crossroads of the respiratory and gastrointestinal systems, these exceptional structures fulfill a vital purpose. They function as formidable "gatekeepers" by screening microorganisms-both bacteria and viruses-with the mission to vanquish local pathogens via antibody production. However, under specific circumstances, their function can take an unsettling turn, inadvertently transforming them into reservoirs for pathogen incubation. In this review, we embark on a fascinating journey to illuminate the distinctive role of these entities, focusing on the local immune system inside their tissues. We delve into their behavior during inflammation processes, meticulously scrutinize the indications for surgical intervention, and investigate the metamorphosis of their microbiota in healthy and diseased states. We explore the alterations that occur prior to and following procedures like adenoidectomy, tonsillectomy, or their combined counterparts, particularly in pediatric patients. By comprehending a wealth of data, we may unlock the key to the enhanced management of patients with otorhinolaryngological disorders. Empowered with this knowledge, we can embrace improved therapeutic approaches and targeted interventions/surgeries guided by evidence-based guidelines and indications.

A comparison of coblation and modified monopolar tonsillectomy in adults

OBJECTIVE

To compare the intraoperative records and postoperative clinical outcomes of adults who underwent coblation and modified monopolar tonsillectomy tonsillectomies.

MATERIALS AND METHODS

Adult patients with tonsillectomy were randomly divided into the coblation and modified monopolar tonsillectomy groups. The estimated blood loss, postoperative pain score, operation time, post-tonsillectomy hemorrhage (PTH), and cost of disposable equipment were compared.

RESULTS

Pain intensity in the coblation and monopolar groups was similar on postoperative days 3 and 7. However, the mean maximum pain score in the monopolar group was significantly higher compared to the coblation group on postoperative days 1 (P < 0.01) and 2 (P < 0.05).Secondary PTH occurred in 7.1% (23/326) of patients in the coblation group and 2.8% (9/327) of patients in the monopolar group (P < 0.05).

CONCLUSION

Although pain was significantly increased on postoperative days 1 and 2 in the modified monopolar tonsillectomy group, the operation time, secondary PTH, and medical costs were significantly decreased compared to the coblation technique group.

Estimated Probability Distribution of Bleeding After Pediatric Tonsillectomy: A Retrospective National Cohort Study of US Children

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.

Adult tonsillectomy-increased pain scores are correlated with risk of bleeding: a retrospective cohort study

PURPOSE

Tonsillectomy is among the most common surgical procedures performed worldwide, and post-tonsillectomy bleeding is a serious complication. This study aims to investigate the role of post-operative pain as a risk factor for bleeding in adults.

METHODS

A retrospective cohort study of adults who underwent tonsillectomy in a tertiary referral center between 2015-2021. Medical records were reviewed for demographics, diagnoses, surgical technique, treatments, pain scores (measured by visual analogue scale 0-10), readmissions, and bleeding events. The primary outcome was return to the operating room for hemostasis, and secondary outcomes were bleeding events and consumption of additional analgesic doses.

RESULTS

Of the 274 patients, 137 (50%) were males, the mean age was 30.3 ± 12 years (range 18-82), and 33 (12%) were smokers. Indications for tonsillectomy were recurrent throat infections in 213 (77.7%) patients and obstructive sleep apnea in 61 (22.3%). Surgical technique was cold dissection in 238 (86.9%) patients and electrocautery in 36 (13.1%). Primary post-tonsillectomy bleeding (< 24 h of surgery) occurred in 6 (2%) patients, and secondary bleeding (later than 24 h from tonsillectomy) in 43 (15.7%). A total of 19 (7%) patients necessitated surgical hemostasis. After controlling for technique and other confounders, high pain scores (VAS ≥ 5) on post-operative days 1 and 2 were associated with increased risk of bleeding that necessitated surgical hemostasis (adjusted odds ratio 6.9, 95% confidence interval 1.7-44.5). Other independent risk factors were male sex, age < 30 years, smoking, and recurrent throat infections.

CONCLUSIONS

Higher pain scores following tonsillectomy are correlated with bleeding episodes requiring surgical intervention in adults. Further studies may explore the role of different intensive pain regimens in minimizing the risk of bleeding.

Between a Rock and a Hard Place: Anticoagulating an Adolescent with Post-Tonsillectomy Massive PE: A Case Report

OBJECTIVES

To report a case of a morbidly obese 17-year-old boy who presented 4 days post-tonsillectomy with acute deep venous thromboses and a massive pulmonary embolism. To describe a protocol and decision-making tree for providing anticoagulation in the immediate post-tonsillectomy period.

METHODS

A chart review and review of the literature.

RESULTS

The patient ultimately did well and had no bleeding from the tonsil beds or further thromboembolic complications. A review of the literature revealed no available data regarding the safety of anticoagulation in the immediate post-tonsillectomy period.

CONCLUSIONS

We propose that if anticoagulation is needed within 14 days of tonsillectomy, submaximal anticoagulation with a reversible and titratable anticoagulant may be optimal. A multidisciplinary team approach is needed for these complex cases. Future reporting and investigation of anticoagulation post-tonsillectomy is needed.

Development and validation of a machine learning-based predictive model for secondary post-tonsillectomy hemorrhage

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.

Estimations of Inpatient and Ambulatory Pediatric Tonsillectomy in the United States: A Cross-sectional Analysis

OBJECTIVE

To estimate the incidence of inpatient and ambulatory pediatric tonsillectomies in the United States in 2019.

STUDY DESIGN

Cross-sectional analysis.

SETTING

Healthcare Cost and Utilization Project databases.

METHODS

We determined national incidences of hospital-based ambulatory procedures, inpatient admissions, and readmissions among pediatric tonsillectomy patients, ages 0 to 20 years, using the Kids Inpatient Database, Nationwide Ambulatory Surgery Sample, and Nationwide Readmission Database. We described the demographics, commonly associated conditions, complications, and predictors of readmission.

RESULTS

An estimated 559,900 ambulatory and 7100 inpatient tonsillectomies were performed in 2019. Among inpatients, the majority were male (59%) and the largest ethnic group was white (37%). Adenotonsillar hypertrophy (ATH), 79%, and obstructive sleep apnea (OSA), 74%, were the most frequent diagnosis and Medicaid (61%) was the most frequent primary payer. The majority of ambulatory tonsillectomy patients were female (52%) and white (65%); ATH, OSA, and Medicaid accounted for 62%, 29%, and 45% of cases, respectively, (all p < .001 when compared to inpatient cases). Common inpatient complications were bleeding (2%), pain/nausea/vomiting (5.6%), and postprocedural respiratory failure (1.7%). On the other hand, ambulatory complications occurred in less than 1% of patients. The readmission rate was 5.2%, with pain/nausea/vomiting and bleeding accounting for 35% and 23% of overall readmissions. All Patient Refined Diagnosis Related Groups severity of illness subclass predicted readmission (odds ratio = 2.18, 95% confidence interval = 1.73-2.73, p < .001).

CONCLUSION

A total of 567,000 pediatric ambulatory and inpatient tonsillectomies were performed in 2019; the majority were performed in ambulatory settings. The index admission severity of illness was associated with readmission risk.

Tonsillectomy Outcomes in Children After Solid-Organ Transplantation: A 15-Year Single-Center Experience

OBJECTIVE

Solid-organ transplantation (SOT) has become the standard of care for children with terminal organ failure. Long-term immunosuppression has improved survival substantially but is associated with secondary malignancies and impaired wound healing. Our goal was to review the incidence, outcomes, complications, and rate of posttransplant lymphoproliferative disorder on pathologic examination following tonsillectomy/adenotonsillectomy (T/AT) in children after SOT.

STUDY DESIGN

A retrospective cohort study.

SETTING

Tertiary care children's hospital.

METHODS

Data were extracted from charts of children with a history of kidney, heart, or liver transplantation, who underwent T/AT between 2006 and 2021.

RESULTS

A total of 110 patients met the inclusion criteria, including 46 hearts, 41 kidneys, 19 livers, and 4 liver-and-kidney transplants. The mean age at transplantation was 4.2 years, and the mean transplantation-to-T/AT time interval was 28.8 months. The posttransplant lymphoproliferative disorder was diagnosed in 52 (47.3%) patients, and 25% of these had no tonsillar hypertrophy. There was no difference in age at transplantation, organ received, transplantation-to-T/AT time interval, immunosuppressive medications, tonsil size, or tonsillar asymmetry between patients diagnosed with the posttransplant lymphoproliferative disorder and patients with benign tonsillar/adenotonsillar hypertrophy. Posttonsillectomy complications were similar between the groups.

CONCLUSION

The incidence of posttransplant lymphoproliferative disorder undergoing tonsillectomy for any indication was 47.3%. There was no association between preoperative signs and symptoms and the histopathological diagnosis of posttransplant lymphoproliferative disorder. Stratification by organ received and immunosuppressive medications did not identify differences among the groups relative to the incidence of posttransplant lymphoproliferative disorder and other postoperative complications.

The Effect of Tranexamic Acid Local Injection on Bleeding during and after Tonsillectomy: A Double-Blind Randomized Placebo-Controlled Trial

Background

Tonsillectomy-related bleeding is one of the most prevalent and potentially fatal complications of this common surgical procedure. We aimed to assess the effect of tranexamic acid (TXA) local injection on bleeding during and after tonsillectomy.

Methods

This double-blind, randomized placebo-controlled trial included 20 candidates for tonsillectomy referred to Al-Zahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran, in 2022. The subjects were randomized into two groups. Ten patients received TXA on their left side and the other ten on their right side 10 min before surgery. Placebo was administered to the contralateral side. The primary outcome was the volume of blood loss during tonsillectomy and up to 24 hours post-tonsillectomy. The secondary outcomes were surgeon satisfaction (rated 0-10), hemodynamic complications (patients' heart rate (HR) and mean arterial pressure (MAP) were recorded every 10 min), and rebleeding. The duration of surgery was also noted.

Results

The mean age of the patients was 21.35 ± 3.16 years, of whom 8 (30%) were male and 12 (60%) were female. there was no significant difference between groups in terms of HR and MAP at any time point. The median of surgery duration did not differ significantly between the two groups; however, the surgeon satisfaction with the procedure was significantly higher with TXA compared to placebo. None of the patients developed hemodynamic complications, and rebleeding did not occur in any of the subjects.

Conclusions

TXA local injection was not superior to placebo in terms of bleeding control during and after tonsillectomy, hemodynamic complications, rebleeding, and surgery duration.

Perioperative management in chronically anticoagulated children undergoing tonsillectomy

BACKGROUND

When undergoing tonsillectomy, patients at high risk of thrombosis who require chronic anticoagulation therapy pose a special challenge as bleeding may occur up to 2 weeks after surgery. Because of a lack of evidence-based data, there is no consensus on the best management for such patients. The objective of our study was to review perioperative anticoagulation bridging strategies in children undergoing tonsillectomy.

METHODS

The study group were a retrospective series of patients on chronic anticoagulation therapy at high risk of a thromboembolic event, who underwent tonsillectomy from 2010 to 2021. Patients whose anticoagulation treatment was discontinued because of a low risk of thromboembolic events were excluded.

RESULTS

Four patients met the inclusion criteria (age range, 1.5-16.1 years). All patients were admitted prior to surgery for bridging therapy with intravenous unfractionated heparin (UFH), drip-titrated to a therapeutic dose until 4-6 h prior to surgery. The estimated blood loss during surgery was minimal in all surgeries. Unfractionated heparin was readministered according to the hospital protocol on the night of surgery and titrated to a therapeutic dose. Warfarin was restarted within 2 days postsurgery for all patients. High-risk patients were kept in hospital until postoperative day 6-8 because of concern for delayed bleeding. One patient was noticed to have blood-tinged sputum requiring no intervention; none of the patients developed early or delayed hematemesis.

CONCLUSIONS

Our data show that bridging therapy with UFH has been successful in chronically anticoagulated patients undergoing tonsillectomy. These patients require multidisciplinary care for the management of their pre- and postoperative course.

[The role of tonsillectomy in the treatment of chronic tonsillitis]

The problem of chronic tonsillitis remains one of the urgent problems of modern otorhinolaryngology. The article discusses the statistics and complications of chronic tonsillitis, provides indications for tonsillectomy and its main complications.

OBJECTIVE

Generalization and systematization of data on the impact of surgical treatment on the quality of life of patients with chronic tonsillitis.

MATERIAL AND METHODS

Search for literary sources, carried out using the search engines of the RSCI, PubMed, Web of Science, and eLibrary.

RESULTS

A review of literature sources demonstrates a significant improvement in the quality of life of patients after tonsillectomy; however, data from some studies show a trend towards a decrease in the number of planned tonsillectomies and an associated increase in the detection of local purulent-septic complications.

Sustaining standardized opioid prescribing practices after pediatric tonsillectomy

INTRODUCTION

Opioid prescribing patterns after pediatric tonsillectomy are highly variable, and opioids may not improve pain control compared to over-the-counter pain relievers. We evaluated whether a standardized, opioid-sparing analgesic protocol effectively reduced opioid prescriptions without compromising patient outcomes.

METHODS

A quality improvement project was initiated in July 2019 to standardize analgesic prescribing after hospital-based tonsillectomy with/without adenoidectomy. An electronic order set provided weight-based dosing and defaulted to non-opioid prescriptions (acetaminophen and ibuprofen). Patients ages 0-6 received non-opioid analgesics alone. Patients ages 7-18 received non-opioid analgesics as first-line pain control, and providers could manually add hydrocodone-acetaminophen for breakthrough pain. Opioid prescriptions and quantities were compared for 18 months of cases pre- versus post-standardization. Postoperative returns to the system were reviewed as a balancing measure.

RESULTS

From 2018 through 2020, 1817 cases were reviewed. The frequency of opioid prescriptions decreased significantly post-standardization, from 64.9% to 33.5% of cases (P < .001). Opioid prescribing for young children steadily decreased from over 50% to 2.4%. Protocol adherence improved over time; outlier prescriptions were eliminated. Opioid quantities per prescription decreased by 16.3 doses on average (P < .001), and variance decreased significantly post-standardization (P < .001). The incidence of returns to the system did not change (P = .33), including returns for pain or decreased intake (P = .28).

CONCLUSION

An age-based and weight-based analgesic protocol reduced post-tonsillectomy opioid prescriptions without a commensurate increase in returns for postoperative complaints. Standardized protocols can facilitate sustained changes in prescribing patterns and limit potentially unnecessary pediatric opioid exposure.

A prospective, randomized, single-blind study comparing coblation and monopolar extracapsular tonsillectomy

Objective

The aim of this study was to compare intraoperative blood loss, postoperative pain, post-tonsillectomy hemorrhage (PTH), and medical costs associated with extracapsular tonsillectomy between coblation and monopolar electrocautery in children.

Materials and methods

This study included 293 patients aged 6-15 years planned to undergo extracapsular tonsillectomy. Data on estimated blood loss, postoperative pain score, operation time, PTH, and the cost of disposable equipment were collected.

Results

Coblation extracapsular tonsillectomy was associated with significantly lower mean pain scores than monopolar technique on postoperative days 1 (p <.001) and 2 (p = 0.02). However, the pain score was similar between the groups at all other time points. The monopolar group had a significantly shorter operation time compared to the coblation group (11.09 ± 7.53 vs. 17.12 ± 4.29 min, p <.001). Intraoperative estimated blood loss was not significantly different between the groups (p = .43).The cost of extracapsular tonsillectomy was significantly lower in the monopolar compared to the coblation group (US$ 28.18 vs. US$ 430.48, p <.001). PTH occurred in 17 patients (5.80%) and required a second surgery. Secondary PTH occurred in 6.16% (9/146) and 0.68% (1/147) of patients in the coblation and monopolar groups, respectively (p <.001). The PTH was significantly higher in the tonsillitis compared to in the tonsillar hypertrophy (12.37% vs. 2.55%, p = .002), However, the difference of PTH was not significant among mean pain scores subgroups. Of the 17 patients with PTH, the lower pole, middle portion, and upper pole were involved in 15 (88.24%), 2 (11.76%), and 0 cases, respectively.

Conclusions

Coblation and novel monopolar electrocautery extracapsular tonsillectomy are associated with similar postoperative pain scores except on postoperative days 1 and 2. However, monopolar technique offers significant advantages over coblation method with less operative time, decreased secondary PTH, and cost.Level of Evidence: NA.

Pediatric Obstructive Sleep Apnea: Update for the Primary Care Provider

Pediatric obstructive sleep apnea (OSA) is a common entity that can cause both daytime and nighttime issues. Children with symptoms should be screened for OSA. If possible, polysomnography should be performed to evaluate symptomatic children. Depending on the severity, first-line options for treatment of pediatric OSA may include observation, weight loss, medication, or surgery. Even after adenotonsillectomy, about 20% of children will have persistent OSA. Sleep endoscopy and cine MRI are tools that may be used to identify sites of obstruction, which in turn can help in the selection of site-specific treatment.

Tonsillectomy and Adenoidectomy - Pediatric Clinics of North America

Tonsillectomy and adenoidectomy are among the most commonly performed major pediatric operations in the United States, with more than 500,000 procedures performed annually. This procedure can be performed with or without adenoidectomy. These procedures were traditionally performed for recurrent tonsillitis; however, the vast majority of tonsillectomies are currently performed for obstructive symptoms. When performed for appropriate indications, tonsillectomy and adenoidectomy can greatly improve a child's quality of life and general health. Given the prevalence of these conditions and subsequent surgical procedures, evidence-based recommendations are regularly evaluated and updated. As such, familiarity with these guidelines is necessary for pediatric practitioners. This review summarizes the indications, complications, and outcomes for tonsillectomy and adenoidectomy, as well as provides a brief overview of operative techniques.

Considerations in Surgical Management of Pediatric Obstructive Sleep Apnea: Tonsillectomy and Beyond

Obstructive sleep apnea (OSA) is an increasingly recognized disorder with a reported incidence of 5.7% in children. Tonsillectomy (with or without adenoidectomy) in pediatric OSA in otherwise healthy non-obese children has a success rate of approximately 75%. However, the cure rate reported for all children undergoing tonsillectomy varies from 51% to 83%. This article reviews the history of tonsillectomy, its indications, techniques, various methods, risks, and successes. The article also explores other surgical options in children with residual OSA post-tonsillectomy.