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Table of Contents
ORIGINAL ARTICLE
Year : 2018  |  Volume : 11  |  Issue : 2  |  Page : 70-73

Rate of post-tonsillectomy haemorrhage in different tonsillectomy techniques: Retrospective study, Dubai hospital experience in 16-Month period


Department of ENT, Dubai Hospital, DHA, United Arab Emirates

Date of Web Publication26-Jun-2018

Correspondence Address:
Abdelgalil Ali Ragab
Department of ENT, Dubai Hospital, DHA
United Arab Emirates
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/HMJ.HMJ_18_18

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  Abstract 


Introduction: Tonsillectomy is one of the most common otolaryngology procedures performed. Haemorrhage has been divided into two broad categories; primary, occurring <24 h after surgery and secondary, occurring >24 h post-operation although commonly 5–10 days after the operation. Objectives: This study was conducted to determine the rate of post-tonsillectomy bleeding in our hospital, to review the rate of bleeding between different methods of tonsillectomy and to encourage surgeons with high bleeding rate to change to different techniques. Methods: It was a retrospective study conducted at the Department of Otolaryngology (ENT), Dubai Hospital, Dubai, United Arab of Emirates. It was conducted from 1st June 2014 to 30th September 2015. Study population were 554 patients who underwent tonsillectomy or adenotonsillectomy during this period. The patients were grouped into four groups according to the tonsillectomy technique. Results: Twenty-two patient presented with bleeding (3.97%). Out of these, one was primary post-tonsillectomy bleeding and 21 were secondary post-tonsillectomy bleeding. The highest rate of secondary post-tonsillectomy bleeding was in bipolar tonsillectomy group (8.98%), while the lowest rate was in radiofrequency group. The primary bleeding was encountered in one patient in cold dissection group while no primary bleeding was encountered in other groups. 40.9% of cases were managed surgically, while 59.1% were managed medically. Conclusion: Post-tonsillectomy bleeding is still a clinically significant complication despite advances in surgical techniques. Radiofrequency tonsillectomy has the lowest bleeding rate. Our hospital rate of bleeding stand in the international range and we are going to be better regarding secondary bleeding, but we are one of the best regarding primary.

Keywords: Otolaryngology procedures, post tonsillectomy haemorrage, tonsillectomy


How to cite this article:
Ragab AA, Manzlgi MA, Abdulber Fakoury MM. Rate of post-tonsillectomy haemorrhage in different tonsillectomy techniques: Retrospective study, Dubai hospital experience in 16-Month period. Hamdan Med J 2018;11:70-3

How to cite this URL:
Ragab AA, Manzlgi MA, Abdulber Fakoury MM. Rate of post-tonsillectomy haemorrhage in different tonsillectomy techniques: Retrospective study, Dubai hospital experience in 16-Month period. Hamdan Med J [serial online] 2018 [cited 2018 Nov 20];11:70-3. Available from: http://www.hamdanjournal.org/text.asp?2018/11/2/70/235231




  Introduction Top


Tonsillectomy is one of the most common otolaryngology procedures performed, representing ~20% of surgical procedures performed in this field.[1] The main complications of tonsillectomy are post-operative haemorrhage, infection and pain.[2] Haemorrhage has been divided into two broad categories; primary, occurring <24 h after surgery and secondary, occurring >24 h post-operation although commonly 5–10 days after the operation.[3]

Post-tonsillectomy secondary haemorrhage has a reported rate of 3%–5%, leading to re-admission to hospital.[4] To reduce risks for haemorrhage, pre-operative tests should be conducted routinely and carefully history should be taken to assess possible signs and symptoms of coagulopathy, as well as history of drug uses that may increase the risks of bleeding, such as acetylsalicylic acid.[5]

Patients who had primary post-operative bleeding usually bleed more in the intraoperative period.[6] These observations suggest that the main cause of haemorrhage during the middle post-operative period is the difficult technique and haemostasis in some patients, possibly due to adhesions caused by previous inflammation and/or local hypervascularisation.[6]

Blakley analysed 63 studies on post-tonsillectomy haemorrhage and described a mean haemorrhage rate of 4.5% ± 9.4% and a maximum haemorrhage rate of 13.9%.[7] One of the largest reports on post-tonsillectomy haemorrhage was the prospective National Tonsil Audit in the United Kingdom by Lowe and van der Meulen [8] covering about 34,000 patients undergoing tonsillectomy which reported a post-operative haemorrhage rate of 3.5% covering bleeding that occurs during hospitalisation and bleeding leading to re-admission; 0.9% of all patients were returned to theatre.[8] German study conducted by Windfuhr et al. conducted on 15,218 patients found a return-to-theatre rate of 2.86% after tonsillectomy.[9]

Tonsillectomy techniques may be as following: blunt dissection, guillotine excision, electrocautery or cryosurgery dissection, ultrasonic removal and laser tonsillectomy, along with monopolar and bipolar diathermy dissection.[10] The risk factors associated with post-tonsillectomy haemorrhage range from type of surgery, the patients' age and sex, indication for surgery, operation technique and abnormal coagulation tests to post-operative infection of the tonsillar fossa.[11]

Study design

It was a retrospective study conducted at the Department of Otolaryngology (ENT), Dubai Hospital, Dubai, United Arab Emirates.

Study duration

This study duration was 16 months starting from 1st June,2014 to 30th September 2015.

Study population

All patients who underwent tonsillectomy or adenotonsillectomy in Dubai hospital between 1st June 2014 and 30th September 2015 were included in the study. It was 554 patients. In this patient group, primary or secondary post-tonsillectomy bleeding was analysed.

The indication of tonsillectomy was either hypertrophy of tonsils (Grade III or IV) or recurrent tonsillitis >7 times/year for 1 year or 5 times/year for 2 years.

All surgeries were done by specialist doctors with at least 5 years of experience.

Data analysis

All data were entered and analysed with the help of Statistical Package for the Social Sciences (SPSS Inc. 233 South Wacker Drive, 11th Floor Chicago, IL 60606-6412) version 17.0.


  Results Top


The total number of patients reported with post-tonsillectomy bleeding was 22 (3.97%). Out of these, one was primary post-tonsillectomy bleeding and 21 were secondary post-tonsillectomy bleeding [Table 1].
Table 1: Number and percentage of each group

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Regarding male and female distribution of patients, it was 298 female (53.79%) and 256 male (46.21%).

Regarding the age distribution for the studied group, it was ranging from 3 years to 40 years with the main age of 9.6 years.

Regarding hospital care of the patient, there were 248 patients (44.76%) as day case and 306 patients (55.24%) were posted as inpatient (admitted 1 day before surgery and discharged 1 day postoperatively).

Regarding the techniques used in the study, it was divided into four groups [Table 1] and [Table 2]:
Table 2: Study groups and percentage of each

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  • Group A which represent patients who underwent tonsillectomy using cold dissection and it was 100 patients out of 554 (18.05%)
  • Group B represents patients who underwent tonsillectomy using cold dissection plus bipolar diathermy and it was 170 patients (30.68%)
  • Group C represents patients who underwent tonsillectomy using bipolar only and it was 89 patients (16.07%)
  • Group D represents patients who underwent tonsillectomy using radiofrequency and it was 195 patients (35.2%).


Patients were managed either surgically or medically according to the severity of bleeding and the history of bleeding. A total 9 patients out of 22 (40.90%) were managed surgically while 13 patients (59.10%) were managed medically [Figure 1].
Figure 1: Type of management in different groups

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The distribution of these cases between the surgical groups was as the following [Table 1]:

  • Group A: 4 cases out of 100 (4%)
  • Group B: 5 cases out of 170 (2.90%)
  • Group C: 8 cases out of 89 (8.98%)
  • Group D: 5 cases out of 195 (2.50%).


The Chi-square statistic is 7.3613. The P = 0.06123. The result is not significant at P< 0.05 [Table 3].
Table 3: Statistical analysis of the result

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Only one case presented by primary bleeding and it was in Group A (0.18% of the total study) and it was managed surgically [Table 1].

Regarding management, it was surgical or medical and it was as the following [Figure 1]:

  • Group A: Three cases out of four were managed surgically (75%) and one case out of 4 was managed medically (25%)
  • Group B: One case out of five was managed surgically (20%) and four cases out of five were managed medically (80%)
  • Group C: Five cases out of 8 were managed surgically (62.5%) and three cases out of eight were managed medically (37.5%)
  • Group D: All cases were managed medically.


A total of nine cases out of 22 were managed surgically (40.90%), while 13 cases were managed medically (59.10%). Surgical management was in the form of cauterisation or stitching of tonsillar bed.

All bleeding from Group D were managed medically, while in Group A, B and C surgical management was 75%, 20%, and 62.5, respectively [Table 1] and [Figure 1].

All patients were given cefuroxime, paracetamol and dexamethasone intraoperatively.

All the patients were discharged postoperatively in good and stable condition after being sure of starting oral feeding.


  Discussion Top


One of the oldest and most common surgical procedures performed worldwide is tonsillectomy.[12] Otolaryngologists around the globe optimised for various modalities of instrumentation to reduce the morbidity tonsillectomy to the patient.[13] The morbidity of tonsillectomy still high and a variety of techniques have evolved over the years with the hope of decreasing these complications.[14] The resulting morbidity includes intraoperative bleeding, primary and secondary haemorrhage, post-operative pain and dehydration.[15]

In this study, we tried to address the rate of bleeding amongst different methods of tonsillectomy to help surgeons to modify their technique and encourage them to try different methods and to address the rate of bleeding in our hospital in comparison to the international rates to see where we are from the other institutes.

Stavroulaki et al.[12] in their study reported the rate of primary bleeding as 18.75% (3 patients) in the cold dissection group and 2 patients were treated surgically, while the other patient was treated with silver nitrate application.

In our study, the primary post-tonsillectomy bleeding was observed only in one patient in the cold dissection group (1%) (0.18% from the total study) and it was managed surgically, while the other groups have no primary bleeding [Table 1]and [Figure 1].

Post-tonsillectomy secondary haemorrhage has a reported rate of 3%–5% leading to re-admission to hospital.[4]

In our study, the total rate of secondary bleeding was 3.79% and the total rate of post-tonsillectomy bleeding (primary + secondary) was 3.97%, and amongst the different study groups, it was lowest in radiofrequency group i.e. 2.5% and highest in bipolar group i.e., 8.98% [Table 1].

By this information, the surgeons who prefer the bipolar tonsillectomy will take care not to cauterise too much.

Windfuhr et al. compare ligation with cautery attributed a higher rate of primary bleed to the use of suture ligation for haemostasis and a more significant secondary bleed with the use of cautery. Although the use of cautery was effective in preventing primary haemorrhage, there was a tendency to a deeper and more extensive zone of necrosis and subsequent exposure of larger vessels when sloughing of the Eschar occurred.[16] This observations matched with our observation regarding the majority of secondary post-tonsillectomy bleeding was in Group C who underwent tonsillectomy using bipolar technique, and the only case of primary bleeding was in Group A (cold dissection).

In our study, the bleeding from Group D was managed medically, while in Group A, B and C, surgical management was 75%, 20% and 62.5, respectively. This observation reflects that bleeding in Group D was mild followed by Group B, while bleeding was severed in Group A and C [Table 1].


  Conclusion Top


Post-tonsillectomy bleeding is still a clinically significant complication despite advances in surgical techniques. Surgeons must always consider trade-offs between benefits and risks of the procedure and be continually vigilant of this potentially serious complication.

Radiofrequency tonsillectomy has the lowest bleeding rate.

Our hospital rate of bleeding stand in the international range and we are going to be better regarding secondary bleeding, but we are one of the best regarding primary bleeding.

The study needs to be conducted over a larger number of patients to get more solid recommendations.

Each institution should perform its own individualised statistics concerning the occurrence of post-operative bleeding and should use a standardised documentation protocol.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Blair RL, McKerrow WS, Carter NW, Fenton A. The Scottish tonsillectomy audit. Audit sub-committee of the Scottish Otolaryngological Society. J Laryngol Otol 1996;110 Suppl 20:1-25.  Back to cited text no. 1
    
2.
Lee MS, Montague ML, Hussain SS. The admission of patients with peri-tonsillar abscess to a general ENT ward and its influence on secondary post-tonsillectomy haemorrhage. Clin Otolaryngol Allied Sci 2003;28:48-50.  Back to cited text no. 2
    
3.
Windfuhr J, Seehafer M. Classification of haemorrhage following tonsillectomy. J Laryngol Otol 2001;115:457-61.  Back to cited text no. 3
    
4.
Lowe D, van der Meulen J; National Prospective Tonsillectomy Audit. Tonsillectomy technique as a risk factor for postoperative haemorrhage. Lancet 2004;364:697-702.  Back to cited text no. 4
    
5.
Gámiz MJ, López-Escámez JA. Preoperative markers for risk of post-tonsillectomy bleeding in adults. Acta Otorrinolaringol Esp 2000;51:407-11.  Back to cited text no. 5
    
6.
Myssiorek D, Alvi A. Post-tonsillectomy hemorrhage: An assessment of risk factors. Int J Pediatr Otorhinolaryngol 1996;37:35-43.  Back to cited text no. 6
    
7.
Blakley BW. Post-tonsillectomy bleeding: How much is too much? Otolaryngol Head Neck Surg 2009;140:288-90.  Back to cited text no. 7
    
8.
Lowe D, van der Meulen J, Cromwell D, Lewsey J, Copley L, Browne J, et al. Key messages from the national prospective tonsillectomy audit. Laryngoscope 2007;117:717-24.  Back to cited text no. 8
    
9.
Windfuhr JP, Chen YS, Remmert S. Hemorrhage following tonsillectomy and adenoidectomy in 15,218 patients. Otolaryngol Head Neck Surg 2005;132:281-6.  Back to cited text no. 9
    
10.
Gan K, Tomlinson C, El-Hakim H. Post-operative bleeding is less after partial intracapsular tonsillectomy than bipolar total procedure. Int J Pediatr Otorhinolaryngol 2009;73:667-70.  Back to cited text no. 10
    
11.
Krishna P, Lee D. Post-tonsillectomy bleeding: A meta-analysis. Laryngoscope 2001;111:1358-61.  Back to cited text no. 11
    
12.
Stavroulaki P, Skoulakis C, Theos E, Kokalis N, Valagianis D. Thermal welding versus cold dissection tonsillectomy: A prospective, randomized, single-blind study in adult patients. Ann Otol Rhinol Laryngol 2007;116:565-70.  Back to cited text no. 12
    
13.
Morgenstein SA, Jacobs HK, Brusca PA, Consiglio AR, Donzelli J, Jakubiec JA, et al. Acomparison of tonsillectomy with the harmonic scalpel versus electrocautery. Otolaryngol Head Neck Surg 2002;127:333-8.  Back to cited text no. 13
    
14.
Younis RT, Lazar RH. History and current practice of tonsillectomy. Laryngoscope 2002;112:3-5.  Back to cited text no. 14
    
15.
Leinbach RF, Markwell SJ, Colliver JA, Lin SY. Hot versus cold tonsillectomy: A systematic review of the literature. Otolaryngol Head Neck Surg 2003;129:360-4.  Back to cited text no. 15
    
16.
Windfuhr JP, Schloendorff G, Sesterhenn AM, Prescher A, Kremer B. A devastating outcome after adenoidectomy and tonsillectomy: Ideas for improved prevention and management. Otolaryngol Head Neck Surg 2009;140:191-6.  Back to cited text no. 16
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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