Risk Of Post-tonsillectomy Hemorrhage Research Articles

Tonsillectomy and the Risk of Post-Tonsillectomy Hemorrhage: A Retrospective Cross-Sectional Study

Introduction. Aim of article was to Retrospectively reviewed occurrence of post-tonsillectomy hemorrhage (PTH) in a population with a wide age range and assessing the association between patients’ age, time of PTH, and the need for surgery to control bleeding. Methods. A retrospective cross-sectional study of 240 patients who underwent a tonsillectomy, tonsilloadenotomy or adenectomy in our Department. Demographic parameters, indication, complication, performed operation and PHD were analyzed in patients. Results. A total of 240 patients with a mean age of 12.29 years, a median age of 8 years and an interquartile range of 5 to 15 years. In relation to the age limit of 16 years, 181 (75.4%) patients were 16 or younger, and 59 (24.6%) were over 16. 9 (5%) children had PTH, primary in 2.2%, and secondary in 2.8%. 8 adults (13.6%) had secondary PTH. Patients older than 16 had a 2.73 times higher risk of bleeding than patients younger than 16 (RR=2.73; p=0.030). In terms of gender, 9 male patients (8%) and 8 female patients (6.3%) experienced bleeding. There was no significant statistical difference (p=0.529). Conclusion. The risk of PTH has increased with age. In terms of gender, there was no difference.

Risk of post-tonsillectomy hemorrhage among COVID-19 positive pediatric patients

ObjectiveCOVID-19 infection has been demonstrated to increase risk for post-operative bleeding. This study investigated the impact of COVID-19 infection on post-tonsillectomy hemorrhage in pediatric patients, a potentially devastating complication. Study designRetrospective cohort study. MethodsThe TriNetX database was queried for pediatric patients who underwent tonsillectomy and evaluated for outcomes of primary and secondary post-tonsillectomy hemorrhage. ResultsAmong subjects 18 years and younger, 1226 were COVID-19 positive and 38,241 were COVID-19 negative in the perioperative period. There was statistically significant increased risk of bleeding with perioperative COVID-19 infection at postoperative days 1, 5, and 10. Additionally, when assessing the role of COVID-19 infection before or after surgery, the risk of bleeding remained statistically significant at all three time points, however these results did not suggest that infection before surgery confers more/less risk compared to infection after. ConclusionThe results of this investigation suggest that the presence of COVID-19 in the perioperative period may pose an increased risk for acute or delayed post tonsillectomy hemorrhage. This study employed a large, diverse population and is the first to address this clinical question.

Effect of Body Mass Index on Post Tonsillectomy Hemorrhages.

Obesity affects adverse outcomes in patients undergoing various surgeries. The study was carried out to assess the clinical association between body mass index and post tonsillectomy hemorrhages. This prospective study was carried out on 60 patients, age between 5 and 40 years, admitted in Department of ENT with chronic tonsillitis. Body mass index and post tonsillectomy hemorrhage were evaluated in all patients who underwent surgery. Bleeding episode were categorized according to the Austrian tonsil study. This prospective study was carried out on 60 patients (adults and children), between December 2021 and November 2022. All patients underwent tonsillectomy under general anaesthesia. It was seen that most of the patients did not have any significant bleeding i.e., Grade A1 (Dry, no clot), and A2 (Clot, but no active bleeding after clot removal) whereas 4 patients (6.7%) had Grade B1 post tonsillectomy hemorrhage (Minimal bleeding requiring minimal intervention by vasoconstriction using adrenaline swab). Post tonsillectomy hemorrhage was seen more in adults. Post tonsillectomy bleeding of Grade B1 was recored in 28.6% of underweight patients, 8% of normal weight patients and no significant bleeding occurred in any of the overweight and obese patients (p-value 0.256). Overweight and obesity (higher BMI) did not increase the risk of post tonsillectomy hemorrhage in either children or adults.

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

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

Comparison of Early versus Interval Tonsillectomy in Cases of Peritonsillar Abscess

Objective: To compare early versus interval tonsillectomy in cases of peritonsillar abscess.Study Design: Comparative study.Place and Duration of Study: The study was carried out at ENT Department of Combined Military Hospital, Mardan from January 2017 to January 2018.Materials and Methods: A total 50 patients were selected from ENT outpatient department. All the cases were randomly divided into two groups of 25 each. Group A underwent early tonsillectomy after initial incision and drainage, Group B underwent interval tonsillectomy after 6 weeks. Both the groups were compared in terms of perioperative blood loss, operation time, ease of dissection and postoperative complications including pain and hemorrhage. Tonsillectomy was done with bipolar cautery in all the cases.Results: The mean age was 30.22 + 8.25. Out of 50 patients, 42 (84%) were males and 8 (16%) were females. The mean operative time of surgery in group A (early tonsillectomy) was 45.04+5.78 minutes compared to 32.72+4.37 minutes for group B (interval tonsillectomy (p=0.00). Mean post-operative pain in group A was 3.68+2.12 compared to group B where mean score was 3.36+1.93 (p=0.579). There were 3 cases of mild perioperative blood loss, 19 cases of moderate and 3 of severe perioperative blood loss in group A. There were 18 cases of mild perioperative blood loss, 7 cases of moderate and no case of severe perioperative blood loss in group B (p=0.00). Dissection was found to be significantly easier in group B (interval tonsillectomy). There were 7 cases of post-op secondary hemorrhage in group A compared to 3 in group B (p=0.289). All these cases of secondary hemorrhage were managed conservatively.Conclusion: Interval tonsillectomy is a safer procedure as compared to early tonsillectomy in terms of perioperative blood loss, operative time, dissection with almost similar post-op pain and similar risk of post tonsillectomy hemorrhage.
 How to cite this: Khan MA, Ahmed A, Khan M. Comparison of Early versus Interval Tonsillectomy in Cases of Peritonsillar Abscess. Life and Science. 2020; 1(1): 24-28. doi: https://doi.org/10.37185/L&S.1.1.13

Post-operative haemorrhage after acute bilateral tonsillectomy in patients with peritonsillar abscess: prevalence, treatment, risk factors, and side of bleeding

Background: Bilateral quinsy tonsillectomy (QT) in patients with peritonsillar abscess (PTA) is associated with the risk of post-tonsillectomy haemorrhage (PTH) and current literature finds a significantly higher risk of PTH contralaterally to the quinsy.Aims: To determine the prevalence of PTH in a large cohort of patients undergoing QT, explore risk factors for PTH, describe our methods of treatment, and evaluate if contralateral haemorrhage is more common than ipsilateral haemorrhage.Materials & methods: All patients undergoing QT at Aarhus University Hospital in the period 2001–2017 were included in the study.Results: One hundred sixteen of 1671 (6.9%) QT patients were admitted with PTH. PTH patients were significantly more frequently males (66%) and infected with Streptococcus group A (GAS) (31%) compared to QT patients without PTH (53% and 18%, respectively) (p = .005 and p = .002, respectively). Haemostasis was obtained in general anaesthesia (n = 61) or local anaesthesia (n = 28) and stopped spontaneously in 25 patients. The side of PTH was not associated with the side of PTA (ipsilateral (n = 41), contralateral (n = 43), and bilateral PTH (n = 23), p = .93).Conclusions and significance: Our findings question if unilateral QT is preferable to bilateral QT when the PTA does not respond to conservative treatment, especially in males with GAS-positive PTA.

Peritonsillar infiltration of lidocaine with adrenaline is associated with increased risk of secondary post-tonsillectomy haemorrhage.

In order to evaluate the safety of tonsillectomy among children, we retrospectively studied the incidence of post-operative complications, adverse events and their association with peri-operative medication. Data were collected from the medical records of 691 patients aged 1-16 years, including details of post-operative complications (any unplanned contact with the hospital), analgesics, dexamethasone, 5-HT3 antagonists, local anaesthetic and haemostatic agents. Recovery was complicated in 13.6 per cent of patients, of whom 8.4 per cent were re-admitted to the ward. The most common complication was post-tonsillectomy haemorrhage, experienced by 7.1 per cent of patients. Re-operation under general anaesthesia (for grade III post-tonsillectomy haemorrhage) was required by 4.2 per cent of patients. Peritonsillar infiltration of lidocaine with adrenaline increased the risk of post-tonsillectomy haemorrhage (odds ratio = 4.1; 95 per cent confidence interval = 2.1 to 8.3). Every seventh paediatric patient experienced a complicated recovery after tonsillectomy, caused by post-tonsillectomy haemorrhage in most cases. Local peritonsillar infiltration of lidocaine with adrenaline was associated with an increased risk of post-tonsillectomy haemorrhage.

Association Between Ibuprofen Use and Severity of Surgically Managed Posttonsillectomy Hemorrhage

Ibuprofen used in postoperative management of pain after tonsillectomy has not been shown to increase the overall risk for posttonsillectomy hemorrhage (PTH). The severity of bleeding is difficult to quantify but may be a more important outcome to measure. To evaluate the association between ibuprofen use and severity of PTH using transfusion events as a marker of severity. This retrospective cohort study identified 8868 patients who underwent tonsillectomy from January 20, 2011, through June 30, 2014, at the tertiary academic Children's Hospital of Philadelphia. Of these patients, 6710 met the inclusion criteria. Data were collected using electronic database acquisition and query. Multivariate analysis was performed to identify independent prognostic factors for PTH and receipt of transfusion. Of the 6710 patients who met criteria for analysis (3454 male [51.5%] and 3256 female [48.5%]; median age, 5.4 years [interquartile range, 3.7-8.2 years]), 222 (3.3%) presented with PTH that required surgical control (sPTH). A total of 15 of the 8868 patients required transfusion for an overall risk for transfusion after tonsillectomy of 0.2%. Fifteen of 222 patients undergoing sPTH (6.8%) received transfusions. No significant independent increased risk for sPTH was associated with use of ibuprofen (adjusted odds ratio [OR], 0.90; 95% CI, 0.68-1.19). A significant independent association was found in the risk for sPTH in patients 12 years or older (adjusted OR, 2.74; 95% CI, 1.99-3.76) and in patients with a history of recurrent tonsillitis (adjusted OR, 1.52; 95% CI, 1.12-2.06). When using transfusion rates as a surrogate for severity of sPTH, transfusion increased by more than 3-fold among ibuprofen users compared with nonusers (adjusted OR, 3.16; 95% CI, 1.01-9.91), and the upper limit of the 95% CI suggests the difference could be nearly 10 times greater. The risk for sPTH is not increased with use of postoperative ibuprofen but is increased in patients 12 years or older and patients undergoing tonsillectomy with a history of recurrent tonsillitis. Hemorrhage severity is significantly increased with ibuprofen use when using transfusion rate as a surrogate marker for severity.

Causes, costs, and risk factors for unplanned return visits after adenotonsillectomy in children

ObjectiveTo review the causes, costs, and risk factors for unplanned return visits and readmissions after pediatric adenotonsillectomy (T&A). MethodsReview of administrative database of outpatient adenotonsillectomy performed at any facility within a vertically integrated health care system in the Intermountain West on children age 1–18 years old between 1998 and 2012. Data reviewed included demographic variables, diagnosis associated with return visit and costs associated with return visits. ResultsData from 39,906 children aged 1–18 years old were reviewed. A total of 2499 (6.3%) children had unplanned return visits. The most common reasons for return visits were bleeding (2.3%), dehydration, (2.3%) and throat pain (1.2%). After multivariate analysis, the main risk factors for any type of return visits were Medicaid insurance (OR=1.64 95% CI 1.47–1.84), Hispanic race (OR=1.36 95% CI 1.13–1.64), and increased severity of illness (SOI) (OR=11.29 95% CI 2.69–47.4 for SOI=3). The only factor associated with increased odds of requiring an inpatient admission on return visit was length of time spent in PACU (p<0.001). A linear relationship was also observed between the child's age and the risk of post-tonsillectomy hemorrhage. ConclusionChildren with increased severity of illness, those insured with Medicaid, and children of Hispanic ethnicity should be targeted with increased education and interventions in order to reduce unplanned visits after T&A. Further studies on post-tonsillectomy complications should include evaluating the effect of surgical technique and post-operative pain management on all complications and not solely post-tonsillectomy hemorrhage.

Dexamethasone and Haemorrhage Risk in Paediatric Tonsillectomy

Bellis, J. R.*; Pirmohamed, M.†; Nunn, A. J.‡; Loke, Y. K.§; De, S.║; Golder, S.¶; Kirkham, J. J.# Author Information

Risk factors for post-tonsillectomy hemorrhage

The aim of the present study was to investigate the rate of post-tonsillectomy hemorrhage (PTH) in a single institution and to evaluate the clinical risk factors for PTH. We reviewed the records of 692 patients who underwent tonsillectomy (TE) at Yokohama Minami Kyosai Hospital in Japan. PTH grades were grouped into three categories according to the severity of the hemorrhagic episode: (I) minimal hemorrhage that stopped after noninvasive treatment, (II) hemorrhage requiring treatment with local anesthesia, and (III) hemorrhage requiring reoperation under general anesthesia in the operating room. Clinical risk factors such as sex, age (adults vs. children), TE indication, surgeon's skill level, operative time, ligature type, and duration of antibiotic administration for PTH were investigated. Among the 692 patients, 80 (11.6%) showed PTH, with primary and secondary hemorrhage accounting for 1.6% and 10.0%, respectively. A category III PTH was observed in 18 patients; thus, the overall risk of reoperation was 2.6%. The PTH episode most frequently occurred on postoperative days 5 and 6. The frequency of PTH was significantly higher in male patients and in adults (P<0.01, for both factors). Surgeon's skill was also associated with PTH rate. A stepwise multivariate logistic regression revealed that adult age (odds ratio [OR]=18.9) and male gender (OR=3.78) were the clinical risk factors for PTH. It also revealed that male gender (OR=82065335), adult age (OR=10.6), and surgeon's skill level (OR=7.50) were the clinical risk factors for the category III PTH. The risk of PTH was higher in this report compared with previous reports, which may be associated with the definition of PTH. Clinical risk factors for PTH were adult age and male gender. The surgeon's skill level was an additional risk factor for category III PTH.

Post-tonsillectomy haemorrhage more common than previously described – an institutional chart review

Conclusions: Risk of post-tonsillectomy haemorrhage (PTH) was higher compared with previous studies and may be associated with the criteria used. Male gender and the use of haemostatic agents in the primary operation were associated with increased risk of PTH, whereas the use of non-steroidal anti-inflammatory drugs (NSAIDs) or dexamethasone was not. Objectives: The aim of the study was to investigate the risk of PTH in adult patients, and its association with the use of NSAIDs, dexamethasone, paracetamol, serotonin (5-HT3) receptor antagonists, haemostatic agents, age and gender during preceding tonsillectomy (TE). Methods: All PTH complications that resulted in an adult TE patient re-contacting the hospital were retrospectively recorded during a 12-month period. PTH types were allocated into three categories: (I) a history of bleeding, (II) bleeding requiring direct pressure or electrocautery under local anaesthesia or (III) reoperation under general anaesthesia. Results: A total of 842 adult TE patients (aged between 16 and 85.8 years) were included in the study. Of these, 122 patients experienced PTH (risk 14.5%). Risk of category III PTH was 1.5%. Risk factors for PTH were the use of haemostatic agents (p = 0.006) and male gender (p = 0.011). The use of NSAID, opioid, 5-HT3 receptor antagonist and dexamethasone medication did not significantly alter the number of postoperative bleeding events.

Risk of post‐tonsillectomy hemorrhage by clinical diagnosis

Obstructive sleep apnea (OSA) has been associated with upregulation of prothrombotic factors. We hypothesize that diagnosis of OSA may be protective against postoperative hemorrhage. This study investigates the relationships between preoperative clinical diagnosis and postoperative hemorrhage. Seven-year retrospective case-control study. Medical records of tonsillectomy subjects with and without hemorrhage were reviewed for demographics, clinical diagnosis, and treatment. Clinical diagnoses included OSA confirmed by polysomnogram, sleep-disordered breathing (SDB), chronic tonsillitis, and a mixed group. A total of 9,023 tonsillectomy patients were identified (52.0% male, 48.0% female; mean age, 6.9 years). Of these, 2.4% (n = 212) presented with hemorrhage. There were 48 (22.6%) primary and 164 (77.4%) secondary hemorrhages. The control group consisted of 1,488 nonhemorrhage patients. A multivariate logistic regression analysis compared the two groups controlling for age, sex, and clinical diagnosis. OSA patients were half as likely to hemorrhage compared to chronic tonsillitis patients (P = .04). SDB patients also had a lower chance of hemorrhage compared to chronic tonsillitis patients; this result was not significant (P = .09). Patients older than 6 years had a higher hemorrhage rate (P < .001). This study demonstrates that patients with OSA may be less likely to have postoperative hemorrhage than patients with chronic tonsillitis. Younger age was associated with fewer hemorrhages.

Hemorrhage following tonsillectomy and adenoidectomy in 15,218 patients

To evaluate potential risk factors and the incidence of bleeding following adenoidectomy or tonsillectomy, with or without adenoidectomy requiring surgical treatment under general anesthesia. Retrospective chart review of 15,218 patients who underwent surgery between January 1, 1988, and September 30, 2001, at our institution (St. Anna Hospital, Duisburg). A total of 229 patients experienced postoperative bleeding (1.5%). Patients of male gender and 70 years of age or older were significantly at risk for post-tonsillectomy hemorrhage. The incidence of bleeding increased with age. Of the bleeding episodes, 76% occurred on the day of surgery; immediate abscess-tonsillectomy was not associated with an increased risk of bleeding. Hemorrhage following tonsillectomy and adenoidectomy is rare and predominantly occurs early after surgery. Male patients, 70 years of age or older, infectious mononucleosis, and a history of recurrent tonsillitis were identified as risk factors for post-tonsillectomy hemorrhage. Delayed hemorrhage has the potential to be life-threatening.

Amigdalectomía por electrodisección: marcadores de riesgo de hemorragia postoperatoria en niños

ObjetivoTo identify pre or intraoperative risk factors that could indicate a higher risk for post-tonsillectomy hemorrhage (PTH) in children undergoing electrocautery dissection. Set-upPrimary referral hospital. DesignA retrospective study of 163 post-tonsillectomy children comparing 7 cases of PTH with 156 cases with no PTH. SampleThis study includes children under the age of 18 that underwent tonsillectomy by dissection between 1997 and 2000. Outcome parametersAge, sex, height, weight, body mass index, hemoglobin level, hematocrit, platelet count activated partial thromboplastin time (APTT), fibrinogen, ASA index (physical state classification of the American Society of Anesthesiology) and type of hemostasis. ResultsPrevalence of PTH was 4.29% in the cohort sample. The risk of PTH in children following tonsillectomy by electrodissection is significantly increased in patients over 15 years of age (OR = 8.46, p=0.04) and when ligatures are used for hemostasis (OR= 8.62, p= 0.02). Activated partial thromboplastin time ≥ 32 seconds is marginally significant (OR= 7.82, p= 0.05). ConclusionsOur findings show that tonsillectomy by electrodissection has an increased risk of bleeding in older children and when ligatures are used for hemostasis.