Abstract
ObjectiveManagement of patients with post-tonsillectomy hemorrhage (PTH) is not well defined but may include observation, topical bedside treatments, or return to the operating room. Data on the use and efficacy of silver nitrate as a topical bedside agent for the management of PTH remain unexplored. Our primary objective was to assess the efficacy of silver nitrate in reducing the need for operative control of PTH.MethodsSingle-institution retrospective chart review included patients aged 5-18 years who presented with tonsillar bleeding within 30 days of tonsillectomy. Patients undergoing observation or bedside silver nitrate cautery were compared based on clinical characteristics and experience of the physician performing the procedure. The outcome of interest was rebleeding requiring operative control. Sample characteristics according to treatment modality were described using Fisher’s exact tests and ANOVA.ResultsOf the patients eligible for inclusion, 29 (20%) were observed and 70 (48.3%) were treated with topical silver nitrate. Age was the only statistically significant clinical difference among treatment groups. The silver nitrate group had more patients who underwent operative control of PTH compared to the observation group (p = 0.004). When comparing the need for operative control between the observation group and patients who had initial success with silver nitrate, there was no difference (p = 0.29). No differences were found in the rate of bleeding requiring operative control when comparing experience of the physician performing the procedure (p = 0.20).ConclusionMore patients who underwent silver nitrate cautery required PTH control in the operating room compared to the observation group. This may be due to patient selection as our results also suggest that there is no statistical difference in rates of operative control of PTH when comparing initial successful treatment with topical silver nitrate to observation. Age is likely a factor that was used by physicians in this study to decide the initial management of PTH. Provider experience does not appear to affect rebleeding rates. Future studies are necessary to evaluate the clinical impact of silver nitrate in the context of PTH and will benefit from more robust sample sizes and enhanced diversity in the sample group.
Highlights
The silver nitrate group had more patients who underwent operative control of post-tonsillectomy hemorrhage (PTH) compared to the observation group (p = 0.004)
Age is likely a factor that was used by physicians in this study to decide the initial management of PTH
Many patients presenting with active bleeding will be taken to the operating room, but that still leaves the question of how to manage patients who have a convincing history of hemorrhage with either a normal oropharyngeal exam or oropharyngeal clot
Summary
More than 500,000 tonsillectomies are performed annually in the United States in children younger than 15 years, making it the second most common pediatric surgery performed in the country [1,2]. Though tonsillectomy is generally considered safe, post-tonsillectomy hemorrhage (PTH) is a well-known complication. Primary PTH occurs within the first 24 hours post-tonsillectomy, while secondary PTH can occur any time following the initial 24-hour post-operative period. Peak presentation of secondary hemorrhage is from post-operative days six to seven with a usual range from days two to 15, though presentation with secondary PTH up to postoperative day 21 has been reported [3,4]. Secondary PTH is more common than primary hemorrhage and may be considered more serious as the patient is often at home in a non-hospital setting [5]
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