ORIGINAL ARTICLE Factors associated with post-tonsillectomy hemorrhage Patrick J. Collison, MD, FACS Bret Mettler, MD Abstract Despite the otolaryngologist’s most diligent efforts to Prevent it, hemorrhage is the most common, albeit spo- rradic, significant complication of tonsillectomy. For this retrospective study of post-tonsillectomy hemorrhage rates, we examined the charts of 430 consecutive tonsil- lectomy patients who had been operated on by one of two general otolaryngologists at our institution. The two sur geons used the same removal technique (cold dissection and snare), but slightly different methods of hemostasis. We found that the overall bleeding rate was 4%; the primary (<24 hr) hemorrhage rate was 0.23%, and the secondary rate was 3.7%, Factors that were positively correlated with postoperative bleeding were the patient's ser, the time of year the surgery was performed, the length ofthe procedure, the amount of blood lost during surgery, and the use of intraoperative vasoconstrictors and ster- ids. However, we believe the use of steroids can prob- ably be discounted as a causative factor. The 2 test was used to determine statistical signifi- cance. None of the 21 patients who were operated on for eritonsillar abscess experienced any delayed postop- erative bleeding. The mean decrease in hemoglobin was 2.3 grams; the lowest postoperative level was 6.6 grams. The highest incidence of delayed bleeding occurred on the eighth postoperative day. Two patients required trans- Susions, and both recovered without any adverse conse- quences. Ieappears that one controllable variable in preventing delayed bleeding following tonsillectomy andadenoidec- tomy might be related to certain details of hemostatic technique. Vasoconstrictors and “field” cauterization might be associated with an increased temporal and spatial application of coagulating current. Although this technique is very effective in preventing primary hemor rhage, itdoes result in a deeper and more extensive zone of necrosis and the exposure of more and larger vessels when sloughing of the eschar occurs. From the Yankton (S. Dak.) Medical Clinic and Avera Sacred Heart Hospital, Yankton. Reprint requests: Patrick J. Collison, MD, Yankton Medical Clini, 1104. 8thSt, Yankton, SD $7078. Phone: (605) 665-1722; fax: (605) 665-0546; e-mail: pjcent@dignet.com 640 Introduction ‘Tonsillectomy and adenoidectomy (T&A) is an effective and safe surgical procedure when the appropriate indica- tions are present. Although the number of these opera- tions has declined from approximately 2 million in 1965! to 1 million in 1970" to 750,000 in 1987,) it is still a relatively common procedure. Postoperative hemorrhage is the most common complication, and when it occurs, the experience is frightening and uncomfortable for the pa- tient and worrisome for the surgeon. In rare instances, post-T&A bleeding can even be life threatening.** Prior to 1985, the incidence of post-T&A bleeding was reported to range from less than 1% to as high as 20%,*7 but more recent reports put the rate closer to 3%." Bleeding is usually classified as primary (onset: <24 hr postoperatively) and secondary (224 hr, usually 5-10 days). The cause of primary bleeding is generally ac- knowledged to be inadequate hemostasis during the pro- cedure." Although the cause of secondary (delayed) bleed- ing is less certain, the sloughing of the superficial eschar from the tonsillar fossa is believed to be the inciting event." Early studies reported an equal incidence of pri- mary and delayed bleeding, but most recent articles cite a lower rate of primary hemorrhage; they alsvdescribe the rate of secondary hemorrhage as low and stable." ‘The literature on post-T&A bleeding—specifically re- jing its incidence, timing, and predisposing factors— is often contradictory. Some of the differences can be attributed to incomplete data in the older studies and to different definitions of what constitutes significant bleed- ing. Factors that are usually not correlated with a higher incidence of bleeding are the type of anesthetic, the use of antibiotics and steroids, the indication for surgery, the method of excision, the surgeon's experience, and post- operative dietary and activity restrictions." In a 1988 review of 6,842 patients, Chowdhury et al claimed that “secondary post T&A hemorrhage....is unrelated to surgi- cal technique.” Other reports, however, seem to show a higher rate of delayed bleeding when cautery is used for hemostasis." Also, when ligature is compared with cautery, a higher rate of primary bleeding is attributed to the former, and a higher rate of delayed bleeding is ascribed to the latter.'* According to some reviews, the Nose & Throat Journal + August 2000COLLISON, METTLER bleeding rate seems to be somewhat higher among older patients and males, and it appears to be higher during the spring and summer.2""° Despite the surgeon’s diligent efforts to achieve com- plete hemostasis, post-T&A hemorrhage is an occasional concern for both patient and otolaryngologist. The loss of blood notwithstanding, minimizing the incidence of this, complication is important because postoperative hemor- Thage can lead to airway compromise and the need for additional intervention and anesthesia, and it increases costs and overall inconvenience for physician and patient alike. The question then is, Can delayed post-T&A bleed- ing—which seems to occur in a sporadic, unpredictable ‘manner—be prevented? In this article, we examine the incidence, severity, and factors associated with post- ‘T&A hemorthage in a community hospital. Materials and methods We reviewed the medical records of all patients who had undergone tonsillectomy, with or without adenoidec- tomy, between May 1, 1995, and Dec. 31, 1998. We gathered the following data from each record: (1) the date of the procedure, (2) the age and sex of the patient, (3) the indication for surgery, (4) the presence of any concurrent diseases, (5) the personal and family history of bleeding, (6) medication use, (7) the results of preoperative clotting studies, (8) the surgical technique (including the method of removal and hemostasis, the use of preoperative ster- ids and antibiotics, and the length of the procedure) and the estimated intraoperative blood loss, (9) the length of stay, (10) the nature of the postoperative instructions, (11) the tonsil size, and (12)the incidence, amount, timing, and treatment of postoperative bleeding. ‘All patients had been admitted on the morning of the procedure and discharged at the discretion of the surgeon, with input from parents and nurses. All patients had been scheduled to return for a routine followup appointment 1 week following surgery, and - all had been placed on similar dietary and the peritonsillar space before making the incision, and packed the fossae with oxymetazoline-soaked tonsil sponges after removal. Surgeon B used noIV dexametha- sone and no injected or topical vasoconstrictors. Both surgeons used Valley Lab (Model No. E 2505-10FR) suction electrocautery for hemostasis, with the coagulat- ing cautery set at 30 to 35. The administration of perioperative antibiotics and postoperative analgesics was similar for all patients. Statistical analysis. Medical records data were entered intoa computer spreadsheet program for statistical analy- sis, The 7? test was used to identify statistically significant differences. Results During the 3.5-year study period, 430 patients had under- gone tonsillectomy, with or without adenoidectomy, at ‘Avera Sacred Heart Hospital in Yankton, S. Dak. A total of 213 procedures had been performed by surgeon A and 217 by surgeon B. These cases were seen consecutively. No other surgeon had performed T&A at this institution during this span. Following surgery, 17 patients (4%) experienced post- operative hemorrhage. One patient (0.23%) developed primary hemorrhage, and 16 (3.7%) developed secondary hemorrhage. The onset of bleeding occurred anywhere from less than 24 hours to 15 days following surgery (mean: 8 days) (figure 1). Of the 17 patients who experi- enced postoperative hemorrhage, 14 required a return to the operating room (and general anesthesia) to control the bleeding. Of the remaining three patients, one underwent cautery inthe emergency room, and two were admitted for observation only. The mean decrease in hemoglobin after the bleeding episodes was 2.3 grams; the lowestlevel was, 66 grams. Two patients received blood trarfStusions. ‘There were no deaths. activity restrictions and given instructions to call if persistent bleeding occurred. Post- ‘operative hemorrhage was defined as any bleeding event that required any type of medical intervention. Surgical technique. All of the procedures had been performed by one of two general Patients (n) ‘otolaryngologists—213 by “surgeon A” and 217 by “surgeon B.” Both used the same dissection and snare technique for tonsil removal. Allprocedureshad been performed ‘with the use of general anesthesia. Surgeon A administered 8 mg of IV dexamethasone prior to the procedure, injected 5 ml of 1% lidocaine with 1:100,000 epinephrine into 642 2345 67 8 9 wt Postoperative day win ws 16 Figure 1. The highest incidence of detayed bleeding occurred on the eighth ‘postoperative day. ENT-Ear, Nose & Throat Journal + August 2000COLSON, METTLER Variables associated with bleeding. Whenbleeders were compared with nonbleeders, several differences were noted with respect to sex, the time of year, and several particular aspects of surgical technique (table): +The male-to-female ratio ‘was0.41-to-Lamongthe group as a whole, but 0.65-to-1 among the bleeders (p<0.05).. + Asignificantly largerpro- portion of bleeds occurred among patients who had un- dergone their surgery during the late spring or summer (figure 2) (p<0.05). + Anassociation was seen between postoperative bleed- ing and the length of the procedure (35 min for bleeders vs. 27 min for nonbleeders; p = 0.0673), the estimated ‘blood loss (41 mi for bleeders vs. 49 ml for nonbleeders; p=0.11389), and the use of injected and topical vasocon- strictors and steroids (6.1% bleeding rate with these agents vs. 1.8% without them; p<0.05).. Variables not associated with bleeding. As expected, ‘most of the variables we considered were not correlated with postoperative bleeding. They included the patient's age, indications for surgery. concurrent illnesses, per~ sonal and family bleeding history, medication use, preop- erative coagulation profile, the length of stay, and tonsil size (table): «The mean age of all patients was 11.1 postoperative bleeding Sex (p<0.05) Time of year (p<0.08) Use of vasoconstrictors, and steroids (p<0.05) + Not statistically significant Table. Relationship between studied variables and the Factors associated with bleeding Length of procedure (p= 0.0873)" Estimated blood loss (p = reliably predict this risk. jence of ws CES, tee Factors not associated with bleeding Age Indication for surgery Concurrent illnesses Personal/family bleeding history Medication use Preoperative coagulation profile Length of stay i Tonsil size 1389)* OO syndrome (2), cerebellar ataxia (1), panhypopituitarism (1), and autism (1). These conditions were not associated with bleeding risk. + No patient had a personal or family history of bleed- ing disorder. ‘Prior to surgery, four patients had been taking a nonsteroidal anti-inflammatory drug, and 15 had been taking a cephalosporin. None of these patients bled. * The results of clotting studies showed that all 430 patients had platelets within normal limits, 15 had an < elevated partial thromboplastin time (PTT), and two had an elevated prothrombin time. Because only one of the . = patients with an elevated PTT developed delayed bleed- ing, it was evident that an abnormal PTT value does not years (range: 2-54); the mean age of the 17 “4 patients who experienced postoperative bleed ing was 12.0 years. 2 *The surgical indications for the nonbleeders included recurrent adenoton- 10] sillitis (40%), adenotonsillar hypertrophy | = (28%), recurrent adenotonsillitis and ade- | =, notonsillar hypertrophy (28%), and periton- 2 sillar abscess (5%). There was no significant | Q difference between the bleeders and | 3 nonbleeders with respect to surgical indica- | #9 a tion (figure 3). Where documented, the mean number of episodes of recurrent ade- and strep cultures were positive in 21% of notonsillitis per year was 5.5 (range: 3-12), 2 patients. None of the patients with periton- sillar abscess experienced postoperative | bleeding, + Most patients had no other medical prob- Jems, Among those who did, their concurrent diseases included asthma (10 patients), se zure disorder (3), cerebral palsy (3), Down's L 644 Figure 2. significantly larger proportion of bleeds occurred among patents twho had undergone their surgery during the late spring or summer (p<0.03) VANS “3 Pas 34544 FF % 4 ; 5 4% ENT-Ear, Nose & Throat Journal * August 2000Nonbleeders Figu 3 There were no significar differences bereen + Ten percent of the patients were discharged on the evening of the day they underwent the procedure, and the reston the following morning. The length of stay was not related to bleeding risk. + The mean tonsil size for both bleedersand nonbleeders was 2.9 em (range: 14 to 4.5 Discussion The statistically significant variables associated with an increased risk of delayed hemorthage in this study were the patient's sex. the time of year the su ery was per formed, and the use of intraoperative vasoconstrictorsand, steroids. The length of the procedure and the estimated blood loss were inversely correlated with delayed bleed- ing. but the differences did not reach statistical signifi- cance, Several earlier prospective double-blind studies found noassociation between steroid use and bl and so even though we found a statistically significant difference. we believe that this variable can probably be discountedasa causative factor. Others have noted higher bleeding rates among young males and during 1 more ten months of the year. as did we."""*"* Although no definite conclusions can be drawn from these observa- tions. itcan be reasonably inferred that an early return to vigorous activity makes delayed bleeding more likely The avoidance of strenuous activity for a full 2 weeks is, probably pradent, althou: Aninieraction between the effect of focal vasoconstric- tors and the application of electrocautery to peritonsillar jcult to enfor tissue can be offered to explain the results of this study Intense vasoconstriction with 1% lidocaine plus epineph- rine is useful in limiting intraoperative bleedi ing a dry operative field. and maki However, because it hinders visualization of actively achiev- dissection easier. COLLISON, METTLER Hl Recurrent adenotonsiltis Adenotonsillar hypertrophy Recurrent adenotonsilitis & adenotonsillar hypertrophy Peritonsillar abscess ders andl non Bleeders leedlers bused om their indications for surgery bleeding vessels. it encour: s surgeons to use random or field” cauterization rather than a point application with coagulating current. Also, the marked diminution of blood flow through submucosal tissue can prevent the dissipa- tion of applied thermal energy. Both of these factors result in a deeper, more extensive zone of necrosis and the exposure of more and larger vessels when the eschar later sloughs, Kennedy and Strom supported this conclusion in their study entitled. “A comparison of postoperative bleedit incidence between general and local anesthesia tonsill tomies." A close look at their data reveals that 15 of 120 patients (12.5%) who received lidocaine with epineph- rine developed postoperative bleeding. while only 1 of 72 patients (1.45) who were not injected with eBinephrine bled. This statistically significant difference is compa rable to the threefold increase in bleeding seen in our study. In replying to Kennedy and Strom’s article, Blatt reported that the bleeding rate after local tonsillectomy was only 1% when lidocaine 1% is used without epineph- rine. He wrote that “the exclusion of epinephrine assures the surgeon of a more accurate hemostasis in the oper ating room Some authors have noted a lower rate of delayed bleed- ing when tonsillectomy is performed for acute peritonsil- Jar abscess (tonsillectomy a chad), but a higher tisk of bleeding when surgery is performed electively after @ peritonsillarabscess has resolved (tonsillectomy afroid).” Thisis probably brought about by a fibrosis of the periton- sillar space and the loss of a discrete tissue plane around the tonsillar capsule. which can result in a more difficult dissection and the exposure of deeper vessels. The fact that none of the 21 peritonsillar abscess patients in our study developed delayed hemorrhage tends to support these observations. Therefore. concerns aboutan increased ENT-Ear, Nose & Throat Journal + August 2000COLLISON, METTLER, risk of bleeding cannot be used as an excuse to withhold “abscess tonsillectomy” in patients who prefer this more definitive method of treatment.* In our study, the 17 patients who bled experienced no apparent long-term sequelae. However, the amount of blood loss (mean Hgb decrease: 2.3 grams; lowest level: 6.6 grams) serves as a reminder that post-T&A hemor- rhage is not a trivial matter. Isolated case reports of catastrophic bleeding can be found, and no single tech- nique can be recommended as an absolute guarantee against these rare but worrisome events. Gardner does caution specifically against the use of deeply placed sutures to control bleeding.‘ The adventitia or even the lumen of named vessels—specifically the tonsillar branches of the facial artery—can be engaged by the needle and cause profuse delayed bleeding. Tonsillecto- mies by laser and by electrocautery dissection have been touted for their lessening of intraoperative blood loss and. operative time, but they offer no advantage in terms of postoperative bleeding and discomfort. ‘Although an ideal method of tonsillectomy has never been devised—and probably never will be—suctionelec- trocautery is certainly an efficient and relatively safe method of achieving hemostasis. Several authors have stressed the importance of point coagulation directed only at the visible, actively bleeding vessel.'"? The findings of our study support the use of directed suction electro- cautery without vasoconstiictors for hemostasis in tonsi lectomy. References 1. TalbotH. Adenotonsillectomy, technique, and postoperativecare, Laryngoscope 1965;75:1877-92, 2. Pratt LW. Tonsillectomy and adenoidectomy: Mortality and morbidity. Trans Am Acad Ophthalmol Otolaryngol 1970;74:1146-58. 3, Chowdhury K, Tewtik TL, Schloss MD. Posttonsllectomy and adenoidectomy hemorrhage. J Otolaryngot 1988;17:46-9. 4. Gardner JF. Sutures and disasters in tonsillectomy. Arch Otolaryngol 1968;88:551-5. 5. Mann DG, StGeorge C, Scheiner E, etal. Tonsillectomy—some like ithot. Laryngoscope 1984:94:677-9. 6. Rey A, Dela Rosa C, Vecchio Y. Bleeding following tonsillee- tomy. A study of electrecoagulation and ligation techniques. ‘Arch Otolaryngol 1976;102:9-10. 7. Goycoolea MV, Cubillos PM, Martinez GC. Tonsillectomy with a suction coagulator. Laryngoscope 1982;92:818-9. Suroistar The Cutting Edge of Tomorrow Visit us at AAO-HNS Booth #636 Don't Blink. Or you just might miss the sharpest kites ever for your ENT incisions. We're going to change the way you look at microsurgical blades. See for Yourself Call for a Free Sample 800-995-7086 Check out our website at www.surgistarcom For mote information Circle 153 on Reader Service Card 648 ENT-Ear, Nose & Throat Journal = August 2000 es 4FACTORS ASSOCIATED WITH POST-TONSILLECTOMY HEMORRHAGE“ 8. Handler SD, Miller L, Richmond KH, Baranak CC. Posttonsil- 18 Fox SL. Bleeding following tonsillectomy. Laryngoscope lectomy hemorthage: Incidence, prevention and management. 1952:62:414- Laryngoscope 1986:96:1243-7, 19, Siodlak MZ, Gleeson MJ, Wengraf CL. Posttonsillestomy sec- 9, MyssiorekD, Alvi A. Posttonsillectomy hemorchage: Anassess- ondary haemorrhage. Ana R Coll Surg Engl 1985;67:167-8 iment of risk Factors, Int J Pegiats Otorhinolaryngol 1996:37:3 20. Schroeder WA Jr. Post tonsillectomy hemorrhage: A ten-year 43, retrospective study. Mo Med 1995:92:5 10. Williams JD, Pope TH Je. Prevention of primary tonsillectomy 21. OhimsLA. Wilder RT, Weston B. Use of intraoperative conticos- bleeding. An argument for electrocautery. Arch Otolaryngol teroids in pediatric tonsillectomy. Arch Otolaryngol Head Neck. 1973:98:306-9. Surg 1995:121:737-42, 1. Papangelow L. Hemostasis in tonsillectomy. A comparison of 22, Volk MS, Martin P, Brodsky L, etal. The effect of preoperative lestcocoagulation and ligation, Arch Otolaryngol 1972:96:358- steroids on tonsillectomy patients, Otolaryngol ead Neck Surg, 60. 1993;109:726-30, 12, Pang YT. Paediatric tonsillectomy: Bipolarelectrodissectionand 23. Kristensen S, Tveteras K. Post-onsillectomy haemorrhage. A Aissection/snare compared. J Laryngol Otol 1995;108:733-6. retrospective study of 1150 operations, Clin Otolaryngol 13. Roberts C, Jayaramachandran S, Raine CH. A prospective study 1984;9:347.-50, of factors which may predispose to post-operative tonsillar fossa 24. Kennedy KS, SiromCG. A comparison of postoperative bleeding. hhemortnage. Clin Otolaryngol 1992:17:13-7, incidence between general and local anesthesia tonsillectomies. 14, Kumar R. Secondary haemorrhage following tonsillectomylad- Otolaryngol Head Neck Surg 1990;102:654-7. cenoidectomy. J Laryngol Otol 1984:98:997-8 25, Blatt IM. Postoperative bleeding incidence after local anesthesia 15, April MM, Callan ND, Nowak DM, Hausdorff MA. The effect of tonsillectomies [letter]. Otolaryngol Head Neck Surg. intravenous dexamethasone in pediatric adenotonsillectomy. Arch 1991;108:135-6. Otolaryngol Head Neck Surg 1996;122:117-20. 26, Bonding P. Tonsillectomy a chaud. J Laryngol Otol 197: 16, Brodsky L, Radomski K, Gendler J. The effect of post-operative 1171-82, instructions on recovery after tonsillectomy and adenoidectomy. 27. Conley SF, Ellison MD. Avoidance of primary posttonsillec- Int J Pediatr Otorhinolaryngol 1993;25:133-40. tomy hemorthage in a teaching program. Arch Otolaryngol Head 17, Carmody D, Vamadevan T, Cooper SM. Post tonsillectomy Neck Surg 1999;125:330-3, haemorrhage. J Laryngol Otol 1982:96:635-8 impedance test = including a choice automatic reflex t \ Interacoustics USA _ contralateral reflex \ Phone: 1-800-847-6334 _test and pure tone \ Fax: 1-707-746-6374 E-mail: Info@ interacoustics.com “s-Two probe systems are qeglab@ @ International a small and lightweight aft new Phone: +45 6371 S555, clinical probe or a standard hand=""*""" Fax: +45 6371 3522 held diagngstic pencil type probe XS E-mail Info@interacoustee ck design. \ ~ \ sat. whites pote alli eceeecoaie \ “Syst us at AAO-HNS Booth #382 and #304, For more information Circle 154 on Reader Service Card Volume 79, Number 8 649