Post-tonsillectomy Hemorrhage Research Articles

Comparison of celecoxib and acetaminophen for pain relief in pediatric day case tonsillectomy: A randomized double-blind study.

ObjectivePost‐tonsillectomy pain is a common morbidity in children. The aim of this study was to compare the efficacy of celecoxib with acetaminophen on pain relief in pediatric day‐case tonsillectomy.MethodsWe compared the analgesic effect of celecoxib (99 patients) with acetaminophen (100 patients) for the management of post‐tonsillectomy pain. Post‐tonsillectomy pain score was evaluated three times a day for 7 days. In addition, the incidence of post‐tonsillectomy bleeding and the rate of patients who returned to regular diet were evaluated.ResultsIn the first day, we observed lower mean pain score in the celecoxib group, than the acetaminophen group (P = 0.013). The overall pain score in other days was not significantly different between the two groups. In the celecoxib group, more patients resumed regular amount of oral intake within the first 3 days. Also, the rate of post‐tonsillectomy bleeding in the two groups was not statistically different.ConclusionWe recommend celecoxib as a more suitable choice than acetaminophen for post‐tonsillectomy pain management in the first day and resuming regular diet within 3 days.Level of Evidence: 1b.

1261 Incidence and Risk of Post Tonsillectomy Bleeds for Tonsillitis And/Or Peritonsillar Abscess (Quinsy) In Adult Patients

Abstract Aim Determine the incidence of post tonsillectomy bleeds (PTB) in patients 16 years and over with a background of tonsillitis and/or quinsy. Explore factors that can increase the risk of a haemorrhage. Assess the operation notes for completeness. Method A retrospective review was conducted of 30 tonsillectomies for quinsy and recurrent or chronic tonsillitis from the 01/08/20 to 10/12/20. They were followed up for 28 days. Patient notes including operation notes were reviewed. Results Following surgery 8 out of the 30 patients (26.7%) had a secondary PTB. There were no primary PTB. 4 out of the 8 patients (50%) had to return to theatre to arrest the haemorrhage. The median time was 6 days post-op. Only 1 PTB (12.5%) occurred following a cold dissection and the other 7 (87.5%) following electro dissection. This equated to 39% of the electro dissections resulting in PTB compared to 8.3% of the cold techniques. There were 6 robot-assisted surgeries with 3 (50%) resulting in a haemorrhage. Just over a third (35%) of patients 25 years of age and over had a PTB vs. 10% of those under 25. Only 1 out of the 30 operation notes was completed fully. Examples of details omitted are estimated bloods loss, power settings, findings, and indications. Conclusions A 3.5 times greater rate of PTB is seen in those aged 25 years and over. Hot techniques, in particular those that were robot-assisted, showed a higher incidence of haemorrhages. A pro forma should be utilised to improve the completeness of operation notes.

709 A Prospective Analysis of Post-Tonsillectomy Haemorrhage and Hospital Reamission Rates in A Tertiary Pediatric Centre

Abstract Introduction Tonsillectomies are one of the most commonly performed procedures., with one particular leading tertiary paediatric centre performing 1,067 tonsillectomies within the last year. Post-tonsillectomy haemorrhage is a considerable complication leading to further primary care costs, readmission, and surgical intervention. Previous national audits have suggested that post-tonsillectomy haemorrhage rates are between 3.0-3.5%1 and readmission rates are approximately 8.8%2. Aim Assess post-tonsillectomy haemorrhage and readmission rates at a leading tertiary paediatric centre. Method A prospective phone survey was completed for every patient receiving a tonsillectomy 6 weeks post-operatively, using a 2-month inclusion period. Results Of the 51 patients included, 51 responded to phone survey. The total post-tonsillectomy haemorrhage rate was 23.5%. Of the 51 respondents, 10 (19.6%) were readmitted through A&E, all of which had extracapsular tonsillectomies. 1 (10%) of those readmitted had further surgical intervention whilst the remaining 9 (90%) were treated conservatively. A further 4 (7.8%) attended their GP, with 3 (75%) of those requiring antibiotics. Conclusions This data shows that both the post-tonsillectomy haemorrhage and readmission rates at the tertiary paediatric centre were higher than the national average. We suggest that previous national data audits describing bleeding rates lack the granularity to reveal true post-operative complication rates. Our prospective cohort has demonstrated that there may be a large proportion of patients with morbidity that never reach the attention of the ENT surgeon and additionally that subgroups in particular may benefit from interventions designed to minimise patients’ post-operative risks, including specific perioperative management and advice.

1251 Risk Stratification in the Management of Post-Tonsillectomy Haemorrhage

Abstract Aim Tonsillectomy represents 17% of the elective workload in ENT and post-tonsillectomy haemorrhage is the most significant complication of this procedure. Accordingly, the GIRFT (Getting It Right First Time) report for ENT surgery focusses on the prevention of post-tonsillectomy bleeding. However, there is little guidance on the management of post-tonsillectomy haemorrhage. A local guideline for the management of post-tonsillectomy haemorrhage was introduced in 2020 based on expert consensus. This audit examines the management of patients readmitted with post-tonsillectomy haemorrhage in 2019 and compares this to the management suggested in the new guideline. Method Patients readmitted with post-tonsillectomy haemorrhage within 30 days of a tonsillectomy performed in 2019 were identified. These were retrospectively stratified into risk categories according to both patient and clinical factors. Management was audited against the new guideline including both the initial patient assessment and the treatment suggested for their respective risk category. Results Fifteen patients were identified and stratified into low, medium and high-risk categories. All patients in the “low risk” category were successfully treated conservatively. One patient from the “medium risk” category had a further bleed as an inpatient during the proposed period of observation in the new guideline and was thereafter treated as “high risk”. Within the “high risk” category two patients required return to theatre for arrest of post-tonsillectomy haemorrhage. Conclusions These results show that the risk stratification proposed in these guidelines may be useful in the management of post-tonsillectomy haemorrhage. Amendments to the guideline and a re-audit are in progress.

400 A Comparative Study of Intracapsular & Extracapsular Coblation Paediatric Tonsillectomy in A Tertiary Centre

Abstract Background Intracapsular tonsillectomy has emerged as a novel alternative to traditional tonsillectomy where the tonsillar capsule is left intact with a small amount of overlying tonsillar tissue. There is growing evidence to suggest that intracapsular tonsillectomy is associated with reduced post-operative pain, haemorrhage and readmission rates. The aim of this study was to assess the reported benefits of intracapsular tonsillectomy within the ENT department at a tertiary paediatric hospital. Method Retrospective analysis comparing two cohorts of 72 consecutive paediatric patients undergoing coblation intracapsular and extracapsular tonsillectomy between March-2019 and November-2020. Patient age at procedure, removal of adenoids, indication, surgeon grade, and discharge time were recorded. Post-tonsillectomy bleeding and 30-day readmission rates were used as the main outcome measures. Results The median age in both groups was 5 years. The intracapsular cohort demonstrated a lower 30-day readmission rate (8.3% vs. 15.3%), lower primary (<24 hours) post-op bleed rate (0% vs. 2.78%) and lower secondary (>24hours) post-op bleed rate (4.2% vs. 12.5%) when compared to the extracapsular cohort. Eight cases were conducted as day cases in total, all Intracapsular, with none of these patients requiring readmission within 30 days. Discussion Coblation Intracapsular tonsillectomy is an effective and low-risk alternative to extracapsular techniques. It is hoped with the reduced associated risks and morbidity associated with the procedure, the department can move towards day case tonsillectomy procedures resulting in a reduction in overall healthcare costs and improved patient experience.

1551 Patient Safety Audit: Adherence to The ENT Referral Proforma

Abstract Medway Hospital’s ENT on-call team triages referrals according to the local ENT Emergency referral guideline. Recently, a poor referral and handover resulted in a patient with post-tonsillectomy bleeding collapsing while on an immovable trolley in ED minors. Following reflection, a referral proforma was formulated to help the on-call ENT doctor ensure safe patient management through a traffic light system. The proforma includes patient and referrer detail along with four referral outcomes or colours, depending on patient stability, each with prompts for initial management. This audit aims to measure adherence to the ENT referral proforma. We performed a retrospective cohort analysis of compliance to the new ENT referral pathway. Proformas completed between 18th October and 17th November 2020 were included. A quasi-random method of sampling was utilized, every two of three paper forms. The data was inputted on Excel. Each proforma was marked for documentation of ten aspects. Of the total seventy-seven proformas, one scored 100%. On average, proformas were 80% completed. The most documented, at 100%, was patient detail. While the least documented, at 8%, was stating if ED were informed of the plan. 5% of referrals required potential resuscitation in ED, of which none met all criteria for a safe handover. The audit shows that the referral proforma is currently not adequately completed. This provides a basis for further intervention to improve patient safety for ENT referrals. The next step would be to inform the department to discuss why adherence is poor and maximize future documentation.

Screening for von Willebrand disease does not impact posttonsillectomy bleeding in a low-risk population.

Bleeding is an important complication in children following tonsillectomy. Screening with coagulation tests prior to procedure is common to assess bleeding risk in the perioperative period, although ASH/ASPHO Choosing Wisely guidelines recommend against routine PT/PTT testing. Our aim was to compare von Willebrand factor antigen (VWF:Ag) and activity levels among patients with postoperative bleeding following tonsillectomy to evaluate for potential risk for bleeding. Eligible subjects were aged 0-18 without significant personal or family history of major bleeding. Postoperative bleeding diaries were collected and symptoms measured using a postoperative bleeding score. Plasma VWF levels were drawn at time of anesthesia administration. Postoperative bleeding occurred in 248 cases out of 1399 total subjects. Median VWF:Ag was 86 in patients with postoperative bleeding scores of 1-2, 86 for scores 3-4, 84 for scores 5-6, and 83 for scores >6, with no significant difference among groups (p=.98). Additionally, no difference was observed for subjects with multiple days of postoperative bleeding as compared to those with only 1day of postoperative bleeding. Finally, no difference in VWF:Ag was observed for subjects whose first reported bleed occurred early in the postoperative course compared to those whose first reported bleed occurred later. VWF:Ag does not correlate with severity of bleeding, time of onset of first bleeding event, or recurrence of bleeding in healthy children with no personal or family history of bleeding who have postoperative bleeding following tonsillectomy. This data does not support routine von Willebrand disease screening prior to tonsillectomy.

Tranexamic acid in otorhinolaryngology - A contemporary review.

Tranexamic acid (TXA) is an anti-fibrinolytic agent which has been proven beneficial in multiple surgical specialties where significant bleeding can occur. Whilst it has been widely available for over 40 years its use within Otorhinolaryngology is still limited. Operations in Otorhinolaryngology are particularly varied with some such as tonsillectomy having the potential for significant life threatening bleeding. Other operations are performed within small confined surgical fields and even small amounts of bleeding can significantly detriment surgical field and increase technical difficulty and operative time. This review evaluated the current literature on the benefits of tranexamic acid within the field of Otorhinolaryngology and Head and Neck Surgery. Overall TXA was demonstrated to be a safe drug with no major adverse effects including thromboembolic events reported in any study. It has been shown to be of particular benefit in rhinology by improving surgical field, reducing operative time and reducing postoperative swelling and ecchymosis. The benefit in tonsillectomy is less clear and further studies are required to evaluate its potential use in the reduction of post tonsillectomy haemorrhage rates.

Post-Tonsillectomy Ibuprofen: Is There a Dose-Dependent Bleeding Risk?

Post-tonsillectomy hemorrhage (PTH) is a potentially life-threatening complication. A recent meta-analysis suggests that ibuprofen may increase the risk of PTH. The aims of this study were to 1) re-evaluate the effect of ibuprofen on PTH given additional recent evidence and 2) to evaluate a potential dose effect of ibuprofen. Meta-analysis and meta-regression; single-institution retrospective review. We conducted a systematic review of the literature and a meta-analysis of 12 studies comparing postoperative ibuprofen analgesia to non-nonsteroidal anti-inflammatory drug (NSAID) controls. Next, we performed a meta-regression analysis to assess for an effect of dose, if any, on rates of PTH. Five studies specifying a dose of 5 mg/kg (828 patients, 1,411 controls) and 7 studies using 10 mg/kg (5,633 patients, 7,656 controls) were included. We then conducted a novel single-institution, retrospective review of data for 1,046 patients prescribed intermediate-dose 7.5 mg/kg ibuprofen. Ibuprofen was not associated with an increased rate of PTH (log odds ratio [OR], 0.21; 95% confidence interval [CI] -0.15, 0.57). Meta-regression showed that ibuprofen dose (5 and 10 mg/kg) did not have a statistically significant effect on PTH (OR, 1.32; 95% CI 0.30, 5.84). Uncontrolled, aggregate rates of PTH across all studies were 2.29% (N=828) for 5 mg/kg and 4.65% (N=5,633) for 10 mg/kg dosing. The rate of secondary hemorrhage in patients prescribed 7.5 mg/kg ibuprofen was 3.10% (N=1,046). We found no statistically significant increased risk of PTH when ibuprofen is prescribed at the low or high range of commonly used clinical dosages, compared to a non-ibuprofen regimen. Further studies with less heterogeneity are needed to determine if there is a clinically relevant dose-dependent difference in PTH with ibuprofen. 3 Laryngoscope, 132:1473-1481, 2022.

Temporal fluctuations of post-tonsillectomy haemorrhage

PurposeAlthough 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.MethodsThis 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.ResultsA 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.ConclusionThe 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.

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

There is controversy regarding the efficacy and safety of tranexamic acid (TXA) in reducing tonsillectomy-related hemorrhage. We conducted a systematic review and meta-analysis to evaluate the prophylactic role of TXA in tonsillectomy. We searched 6 databases to identify studies that directly compare the effect of TXA versus controls in tonsillectomy patients. Standardized mean difference was applied to summate the findings across the studies. Dichotomous data were expressed as relative risk. Ten studies representing a total of 111 898 patients were included. The pooled results showed a significant reduction of intraoperative blood loss by 39.02 ml (SMD = -1.05, 95% CI: -1.91 to -0.20, P = .016) and the rate of post-tonsillectomy hemorrhage (RR = 0.42, 95% CI: 0.28 to 0.65, P < .0001), with no significant difference in reduction of further intervention risk (RR = 0.78, 95% CI: 0.45 to 1.35, P = .373). Overall, this study indicates that TXA may reduce blood loss and frequency of post-operative hemorrhage associated with tonsillectomy. Further large, high-quality clinical trials are still needed to explore TXA's effect on post-tonsillectomy hemorrhage and the safety of its use.

Impact of COVID-19 lockdown on a tertiary center pediatric otolaryngology emergency department.

To assess the quantitative and qualitative impact of the COVID-19 lockdown on pediatric otolaryngology emergency activity. A retrospective study was conducted in a pediatric otolaryngology tertiary care center. Emergency activity during the lockdown period from March 17 to May 11, 2020, was compared to the 2019 and 2018 averages for the same period. Study data included a number of emergency consultations and the number and type of surgical procedures: infection management, endoscopic airway procedure, and post-tonsillectomy hemorrhage. Only 350 children were referred to the pediatric otolaryngology emergencies in our center during the lockdown, compared to 761 on the same period the year before (− 54%); 62 emergency surgeries were performed, compared to 93 (− 33%). The ratio between emergency surgeries and consultations was 18% in 2020, versus 12% previously (p = 0.014). The number of surgical procedures for infectious diseases decreased (− 68%), at 16% of surgical emergencies in 2020 compared to 33% previously (p = 0.017). In 2020, 52 emergency endoscopies were performed, versus 59 previously (− 12%), 27% being performed for suspected tracheobronchial or esophageal foreign bodies, compared to 66% in previous years (p < 0.0001). No post-tonsillectomy hemorrhages were managed in 2020.Conclusion: The COVID-19 lockdown changed pediatric ENT emergency activity quantitatively and also qualitatively. What is Known:• SARS-CoV-2 pandemic impacted pediatric ENT emergency activity quantitatively and qualitatively.What is New:• here was a 54% decrease in pediatric ENT emergency consultation and 33% decrease in emergency ENT surgeries.• Rates of surgery for infection of whatever type decreased by 68%.

A Signal Processing Method for Target Phase Stimulation in Neural Regulation

We aimed to evaluate factors associated with time to return to OR in children presenting with post-tonsillectomy hemorrhage to a tertiary children's hospital.Retrospective study of pediatric patients presenting to a single institution from January 2012 to January 2020, with post-tonsillectomy hemorrhage (PTH) requiring surgical intervention for control of bleeding. Correlation, univariate, and multivariate analysis were conducted.Of 15,984 tonsillectomies performed at our institution during the study period, 144 required return to the OR for bleeding control, in addition to 15 other children whose tonsillectomy had been performed at an outside institution. Mean time to the OR was 119.7 min (SD 101.5) in the morning, 77.4 min (SD 60.6) in the afternoon, 55.6 min (SD 34.8) in the evening, and 49.4 min (SD 26.4) overnight (ANOVA p < 0.0001). The mean hemoglobin decline from pre-to post-tonsillectomy was 1.3 g/dl (SD 1.7). Primary hemorrhages had a mean time to OR of 62.39 min (SD 63.42) while secondary hemorrhages mean time to OR was 85.54 min (SD 76.21) (p = 0.0064). There was no significant difference in time to OR among race/ethnicity (p = 0.928), insurance status (p = 0.359), weekday (p = 0.557), surgeon seniority (p = 0.8104) or by hemoglobin drop (p = 0.2773). When controlling for each of these variables, multiple linear regression showed that only time of day had significant correlation with time to OR (p = 0.0003).At a tertiary children's hospital, patients presenting with PTH requiring revision surgery waited the longest to get to the OR in the morning versus all other times of day.These results can aid in individualization of anticipatory guidance in order to reduce morbidity and mortality from complications requiring revision in the operating room.

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

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. Retrospective chart review. 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. 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). 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. 3 Laryngoscope, 132:949-953, 2022.

Post-tonsillectomy Hemorrhage: A Seven-year Retrospective Study.

Introduction:Post-tonsillectomy hemorrhage (PTH) is a serious complication that sometimes requires immediate surgical interventions. The present study aimed to assess the association between patients’ age, the time of onset of PTH, and the need for surgery to control bleeding.Materials and Methods:All patients with PTH were retrospectively admitted to two tertiary hospitals in Mashhad, during 2012-2019. Hospital records were investigated to select eligible cases and retrieve their characteristics such as demographics, source and time of bleeding, and type of intervention. Chi-square, independent samples T-test, and binary logistic regression were used as research tools.Results:A total of 227 patients with PTH and a mean age of 14.99±10.34 years were studied, of whom 128 (56.4%) were male and 63 (27.8%) required surgery to control PTH. The mean onset of PTH was 8.14±3.47 days after the surgery and in 59 cases (26.5%) was the seventh day. Those patients aged 6 years or older in whom PTH occurred during the first postoperative week were significantly more likely to need surgery to control it (P= 0.034). Adult (OR= 4.032, 95%CI= 1.932-8.414, P<0.001), bleeding from both tonsils (OR= 2.380, 95%CI= 1.032-5.487, P= 0.042), and receiving blood transfusion (OR= 7.934, 95%CI= 2.003-31.422, P= 0.002) were independent predictors of the need for surgical treatment to control PTH.Conclusion:PTH within the first postoperative week in patients older than 6 years, adults, bleeding from both tonsils, and receiving a blood transfusion is recommended to be considered as a potential predictor of the need for surgery.

Postulation of the Effect of Unpredicted Predisposing Factors for Post-Tonsillectomy Bleeding

Back ground and objectives Tonsillectomy is the most common surgical procedure in specialty of otorhinolaryngology. Therefore there are frequent premises regarding this procedure to be improved from different aspects, indications, time of surgery, techniques, safety measures, and postoperative care. Hence the tonsils and peritonsillar tissues are highly vascular zone that supplied by direct branches of external carotid artery thus the post-tonsillectomy bleeding remains one of significant issues in relation to this widely performed procedure. The post-tonsillectomy bleeding needs frequently to be postulated for its incidence, prevalence, etiology, predisposing factors, management and prevention. This subject constitutes one of most risky aspects that increase wariness of the surgeons regarding this commonly conducted procedure. Although there are huge numbers of presentative literatures coming from American as well as western institutes that tried to put guidelines for purpose of prevention and management of post-tonsillectomy bleeding but broadly at our middle-east region and locally at our Libyan society we found for some extent difficulties to apply all these guidelines. For this reason this issue has been take the wider spectrum of ENT surgeons’ concentration, discussions, and researches. Therefore this study was conducted prospectively and for long time to confirm the possible predisposing factors that could be responsible for increasing the risk of post-tonsillectomy bleeding at our region and in the same time to illustrate the concluded recommendations to prevent the occurrence of this important complication. Patients and methods 2880 patients aged from 8 months to 85 years presented at ENT department-AL-hawari ENT and urology teaching center- Benghazi-city – Libya as well as AL-thowra central teaching hospital and AL-tarahom private center – Elbyda city – Libya at period in between September 2003 to March 2015 as cases of chronic adeno-tonsillitis and solitary acute as well as chronic related palatine tonsillar disease with variable patterns of indications for tonsillectomy namely snoring and apnea attacks, recurrent attacks of acute tonsillitis, persistent otitis media with effusion, recurrent attacks of acute suppurative otitis media, failure to thrive, recurrent attacks of chest infection, mal-occlusive dental deformity, unilateral enlarged tonsils, post-traumatic avulsed tonsils, history of quinsy abscess and persistent halitosis. All patients were assessed intra-operatively and post-operatively too for any evidences of primary, reactionary, or secondary hemorrhage in relation to wide spectrum of factors as patient's demographic, medical, and socio-habitual factors, in addition to technical as well as post-operative care factors. Results This presenting study confirmed that the most common type of post-tonsillectomy bleeding was the secondary variety (71%) as compared to primary (22%) and reactionary (7%) among all presented post-tonsillectomy bleeding cases. Although through this presenting serial study there were multifactorial pre-dispositions elucidated for secondary post-tonsillectomy hemorrhage but as general poor post-operative care can be considered as the cornerstone for the pathogenesis of this significantly raised incidence of secondary post-tonsillectomy bleeding this may be in form of inadequate patient's hydration and nutritional supply (47%), poor patient's antibiotic compliance (23%), and child's maternal negligence (19%). The time of surgery was found to be another important pre-disposing factor for post-tonsillectomy bleeding, it was postulated that the incidence of reactionary as well as secondary post-tonsillectomy hemorrhage significantly increased at summer and autumn seasons (69%) as compared to other seasons. The place of surgery was another interesting proposed studied factor among this serial presentation it was observed that the incidence of post-tonsillectomy bleeding among patients who operated at AL-hawari ENT and urology teaching center-Benghazi-city significantly higher (63%) than that among cases who interfered at AL-thowra central teaching hospital and AL-tarahom private center – Elbyda city. Conclusion Generally speaking, post-tonsillectomy bleeding is considered as one of important issues in ENT and one of significant post-tonsillectomy complications which may create a critical morbidity that may rarely extend to post-operative mortality. Hence the most common pattern of post-tonsillectomy bleeding is the secondary type; however this type of post-tonsillectomy hemorrhage is pre-disposed and induced by many factors. Most of these factors are treatable and curable thus the prophylaxis against this significant complication can be achievable.

Nebulized Tranexamic Acid in Secondary Post-Tonsillectomy Hemorrhage: Case Series and Review of the Literature.

IntroductionPost-tonsillectomy hemorrhage is a serious postoperative complication, and its acute management can present a challenge for the emergency provider. Although various strategies have been proposed, guidance on the best approach for management of this condition in the emergency department (ED) setting remains limited. Anecdotal reports of the use of nebulized tranexamic acid (TXA) for management of tonsillar bleeding have emerged over the past two years. Two recently published case reports describe the successful use of nebulized TXA for stabilization of post-tonsillectomy hemorrhage in an adult and a pediatric patient.Case SeriesEight patients who presented to our ED with secondary post-tonsillectomy hemorrhage received nebulized TXA for hemostatic management. The most common TXA dose used was 500 milligrams, and all but one patient received a single dose of the medication in the ED. Hemostatic benefit was observed in six patients, with complete bleeding cessation observed in five cases. Interventions prior to nebulized TXA administration were attempted in three of the six patients and included ice water gargle, direct pressure with TXA-soaked gauze, and nebulized racemic epinephrine. All but one of the patients were taken to the operating room for definitive management after initial stabilization in the ED.ConclusionNebulized TXA may offer a hemostatic benefit and aid in stabilization of tonsillectomy hemorrhage in the acute care setting, prior to definitive surgical intervention. Consideration of general principles of nebulization and aerosol particle size may be an important factor for drug delivery to the target tissue site.

The role of sepsis screening, SIRS and qSOFA in head and neck infections: An audit of 104 patients

Sepsis is associated with high morbidity and mortality and is a known complication of infections of the head and neck. Screening for sepsis should be conducted on admission in order to identify patients at risk and provide early intervention. Compliance with sepsis screening was poor on an ENT ward in a district general hospital, however this can be improved further by education and visual reminders such as poster or a clerking proforma. The most common head and neck infections admitted to a district general hospital were tonsillitis, peritonsillar cellulitis and peritonsillar abscesses. The incidence of sepsis as a complication of head and neck infections is very rare if using the qSOFA criteria. Using SIRS criteria may result in overidentification of sepsis and may lead to excessive and inappropriate clinical management in patients who could otherwise be managed less aggressively.

Detecting coagulopathy in pediatric patients with post-tonsillectomy hemorrhage

IntroductionPost-tonsillectomy hemorrhage (PTH) is a serious complication after a tonsillectomy. Utility of lab work at presentation for PTH was low. This study aims to determine the frequency and type of labs drawn at emergency department (ED) presentation and assess the incidence of uncovering a previously unidentified coagulopathy. MethodsA retrospective chart review was performed on pediatric patients who were seen in the ED after tonsillectomy at a tertiary care children's hospital from 2017 to 2019. Exclusion criteria were the following: no tonsillar bleed, history of known coagulopathy, treated by outside provider, ≥18 years old. Lab work included complete blood count (CBC), prothrombin time (PT), partial thromboplastin time (PTT), and von Willebrand factor (VWF). Results364/723 (50.3%) patients met inclusion criteria. 179/364 (49.2%) patients were male and 309/364 (84.9%) patients were Caucasian. Average age at surgery was 8.12 years (SD = 4.0) and average post-operative day at presentation was 6 days (SD = 2.1). Operative control of bleed was performed in 68/364 (18.7%) patients. 334/364 (91.8%) patients had labs drawn in the ED. 64/334 (19.1%) patients were anemic (hemoglobin (Hgb) < 11), 46/334 (13.8%) patients had thrombocytosis (platelets>450,000), 10/334 (3.0%) had elevated PTT and 8/334 (2.4%) had elevated PT. Hematology was consulted in 14/364 (3.8%) patients of whom 6/14 were diagnosed with von Willebrand disease and 1/14 with factor VII deficiency. Aminocaproic acid was used in 8/364 (2.2%) patients due to elevated PTT in 3/8 and multiple episodes of bleeding in 5/8.3/364 (0.8%) patients needed a blood transfusion. No difference was found in incidence of abnormal lab work in patients who did and did not need operative control of bleed (p = .125). Of the 334 patients who had ED labs drawn, 7 (2.1%) had an uncovered coagulopathy. ConclusionUncovering incidental coagulopathies is rare in patients who present with PTH. Though anemia was the most common abnormality noted, only a small percentage required transfusion, with all having abnormal vital signs. Thrombocytosis was the next common abnormality, and this can be seen in an inflammatory state. Developing algorithms is necessary to better guide appropriate lab work in patients who present with PTH and to provide optimal value of care to patients.

Fatal hemorrhage after tonsillectomy

AbstractThis is the first report of a segmental mediolysis occurring in arterioles, affecting the neck/tonsillar region and leading to a fatal hemorrhage after a tonsillectomy in a 20-year-old woman. Arteriolar mediolysis could be observed in tissue layers about 2 cm distant from the tonsillectomy region. Reparative changes were observed in the carotid and small neck arteries as well as in only one intramyocardial arteriole; however, no other vascular regions typically reported in segmental mediolysis arteriopathy were affected and aneurysm formation was not observed. No family history of vascular disease or hypertension was known. Pathophysiologically, previously reported reasons for post-tonsillectomy bleeding could be excluded. Segmental mediolysis may represent a wider spectrum of affected arteriolar vessels besides the reported small and medium sized arteries leading to aneurysms, which impedes radiographic diagnosis.