International Journal of Pediatric Otorhinolaryngology 117 (2019) 204–209

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International Journal of Pediatric Otorhinolaryngology

journal homepage: www.elsevier.com/locate/ijporl

Review Article

Does suturing tonsil pillars post-tonsillectomy reduce postoperative T

hemorrhage?: A literature review
Jacqueline A. Wulua,∗, Melissa Chuab, Jessica R. Levia
a
Otolaryngology- Head and Neck Surgery, Boston University School of Medicine, Boston, MA, 02118, USA
b
Boston University School of Medicine, Boston, MA, 02118, USA

ARTICLE INFO ABSTRACT

Keywords: Objective: Literature review comparing post-tonsillectomy hemorrhage in pediatric and adult patients with and
Tonsil pillars without suturing tonsil pillars to investigate whether suturing tonsil pillars reduces the risk of post-tonsillectomy
Suturing hemorrhage.
Post tonsillectomy hemorrhage Review methods: Online journal databases were searched using the key phrases “post tonsillectomy hemorrhage”,
“post tonsillectomy bleed”, and “tonsil pillar suture”. 10 published studies were found regarding tonsil pillar
suturing, four directly related to postoperative bleeding and five focusing on postoperative pain reduction. There
was one study that evaluated both pain and bleeding. The pain reduction studies were comprised of 225 patients
while the postoperative bleeding studies included 3987 patients.
Conclusions: Suturing tonsil pillars after tonsillectomy may be beneficial after cold tonsillectomy.
Implications for practice: Post-operative bleeding is one of the most common complications that can result in
increased patient distress and hospitalization. In this article, we provide a literature review of tonsil pillar
suturing and post-tonsillectomy hemorrhage. Our study suggests suturing the tonsil pillars immediately post-
tonsillectomy may reduce the risk of severe post-operative bleeding requiring return to the operating room for
certain patients.

1. Introduction severe bleeding varies but is recognized as bleeding requiring return to

Tonsillectomy is a very commonly performed procedure by
Otolaryngologists, with postoperative hemorrhage being one of the
most serious complications associated with the procedure.
Postoperative hemorrhage can result in increased hospital expenditures
due to emergency room visits, admissions, and in some cases the need
to return to the operating room [1]. Bleeding after a tonsillectomy can
also be very distressing to patients. There are various risk factors for
post-tonsillectomy hemorrhage including surgeon level of training,
operative technique particularly using heat, male sex of patient, and
patient age with adults having an increased risk [2–10]. Primary he-
morrhage occurs within 24 h of surgery while secondary post tonsil-
lectomy bleeding occurs more than 24 h after surgery. Minor post-op-
erative bleeding can serve as an indicator for a subsequent severe
bleeding episode. There is a 10% risk of a severe post tonsillectomy
bleed following a minor episode of bleeding [3]. Due to this, some
providers opt for hospital admission for observation to monitor patients
for any additional bleeding that may occur at least within the first 24 h
after what some may describe as a sentinel bleed. The definition of
the operating room for control. The incidence and mortality related to
post-tonsillectomy hemorrhage are reported to be ∼5% with a range of
0.5–18% and 0.001–0.006% respectively for all comers [11,12]. Ton-
sillectomy is not a benign procedure. Postoperative bleeding associated
with uvulopharyngopalatoplasty (UPPP) has not been investigated in
depth as much as post tonsillectomy bleeding; however, the range noted
in the literature is 0.6%–14% [13]. It has been noted that in the UPPP
patients who had the tonsil pillars re-approximated there was a de-
crease in the rate of bleeding as compared to those without suturing the
tonsil pillars [13].
Often surgeons may suture the tonsil pillars to control post-tonsil-
lectomy bleeding. There is also the general principle that closure of a
wound should facilitate healing and minimize bleeding. Given the
bleeding risk associated with tonsillectomy and the various methods
utilized for this procedure, some advocate for suturing tonsil pillars at
the time of tonsillectomy in an attempt to reduce the risk of post-
operative bleeding. In this paper we review tonsil pillar suturing and its
effect on postoperative bleeding.

∗
Corresponding author. BCD Building 800 Harrison Ave, Boston, MA 02118, USA.
E-mail address: Jacqueline.wulu@bmc.org (J.A. Wulu).

https://doi.org/10.1016/j.ijporl.2018.12.003
Received 7 September 2018; Received in revised form 3 December 2018; Accepted 3 December 2018
Available online 04 December 2018
0165-5876/ © 2018 Elsevier B.V. All rights reserved.
J.A. Wulu et al.
2. Materials and methods
A literature search was performed using Pubmed, Google Scholar,
and Cochrane Review. Key phrases used in the search include: post
tonsillectomy hemorrhage, post tonsillectomy bleed, tonsil pillar su-
ture. All ages, genders, and surgical indications were included. There
were 10 studies describing suturing of the tonsil pillars after tonsil-
lectomy; however, only five studies, which included retrospective and
prospective assessments, were directly related to postoperative
bleeding. Data collection periods were from 1986 to 2016. The study
length ranged from 5 to 8 years. The five studies related to post-
operative bleeding were published in 2012, 2016, and 2017 and in-
cluded pediatric and adult patients. The total number of patients in the
control group (no suturing) and the suture group in each of the four
studies were calculated. However, in a study performed by Matt et al.
and Cetiner et al., each patient served as their own control. This gave a
total of 3189 patients in the control group and 3081 patients in the
pillar suture group across the five studies. The other five studies focused
on reducing postoperative pain by suturing tonsil pillars; however
minimal to no postoperative hemorrhage was noted or specifically
analyzed in these studies.
3. Results
3.1. Age and sex
The male to female ratio was approximately 1:1 among all the
studies included in this review. Ages ranged from 8 months to 77 years
for the studies investigating bleeding risk with tonsil pillar suturing
(Table 1).
3.2. Presentation
Indications for tonsillectomy included chronic or recurrent tonsil-
litis, recurrent pharyngitis, tonsil hyperplasia with upper airway ob-
struction associated with obstructive sleep apnea, snoring, halitosis, or
feeding difficulty, and suspicion of malignancy.
3.3. Treatment
Matt et al. performed tonsillectomies either via electrocautery dis-
section, cold dissection and snare, or harmonic scalpel with majority
(99%) of the tonsillectomies being performed with electrocautery dis-
section. There were 763 subjects in a randomized single group trial in
which tonsillectomies were performed and only one tonsil pillar was
sutured using 2–3 interrupted chromic sutures with the open tonsil
fossa serving as the control [14]. Postoperative bleeding occurred in
5.6% of the patients. This is consistent with the reported average per-
centage of patients who experience post tonsillectomy bleeding. The
bleeding needed to be controlled in 62% of these patients; however, it is
unclear if these patients went to the operating room or if it was man-
aged at the bedside. There was no discussion regarding the severity of
the bleeding or if bleeding was primary or secondary. Of those who had
postoperative bleeding, this bleeding was determined to come from the
sutured tonsil fossa side in 40% of those patients however this was not
considered statistically significant (p = 0.86). Bleeding occurred from
both fossa 9% of the time and 9% of the time it was unknown which
fossa the bleeding was coming from. This means that the bleeding from
the sutured side is greater than the 40% when the unknown side and
bleeding from both fossa is included in the analysis. Additionally, the
bleeding location was determined by the patient or caregiver which is
unreliable. This study concluded that there was no benefit to suturing
the tonsil fossa in order to reduce postoperative bleeding.
Nguyen et al. found similar results in their retrospective study of
424 patients who underwent either a diathermy tonsillectomy (266
patients) or diathermy tonsillectomy with single horizontal mattress
205
International Journal of Pediatric Otorhinolaryngology 117 (2019) 204–209
suture using silk or vicryl suture through the tonsil pillars (158 patients)
[15]. There was no primary postoperative bleeding. Secondary post-
operative bleeding was noted in 7.52% of the patients in the control
group and 5.7% of patients who had tonsil pillars sutured. There was
again no statistical significance between the groups (p = 0.47). Of these
patients that experienced secondary hemorrhage, 5.26% of the patients
in the control group and 1.9% of the patients who had tonsil pillars
sutured required return to the operating room (p = 0.13). The severity
of the bleeding was not discussed in this paper. They determined that
there was no benefit to suturing the tonsil pillars to reduce post-
operative bleeding. Given that silk suture was used, many patients at
their one-month follow up still had retained suture that required re-
moval. Also, within this study the number of patients in each treatment
group were not evenly distributed and the ages of the patients in each
group were not equivalent as there were younger patients in the control
group. The average age of the patients in the control group was 12
while the sutured group average age was 18 which was a statistically
significant difference (p < 0.001).
On the other hand, Cetiner et al. performed a randomized pro-
spective study with 760 patients who had one tonsil fossa sutured with
three interrupted 3–0 vicryl sutures (group 1) while the other tonsil
fossa served as the control and was not sutured (group 2) [16]. The
tonsillectomy was performed with scissors and hemostasis was achieved
with bipolar cautery. Interestingly the sutured tonsil fossa would also
have Surgicel, a hemostatic agent composed of cellulose, sutured into
the wound bed. There were 8 secondary bleeding episodes in the tonsil
sutured group and 23 patients with postoperative bleeding noted in the
control group (p < 0.05). None of the patients from group 1 required
return to the operating room while two patients in group 2 required a
return to the operating room. Group 2 also had 0.26% of patients need a
second surgical procedure. This study concluded that Surgicel and su-
turing the tonsil pillars reduced the severity of bleeding as well as the
incidence of post tonsillectomy bleeding. This study did not describe
how the bleeding site was determined and patients served as their own
control. Additionally, Surgicel as a hemostatic agent is confounding in
this comparison between pillar suturing or not suturing the pillars as in
this study the use of Surgicel irrespective to suturing could be the
reason that there was a reduction in the bleeding and bleeding severity.
Senska et al. performed a retrospective study comparing cold steel
tonsillectomy, which included 1000 patients from 2003 to 2005 and
1000 patients from 2007 to 2009 who also had tonsil pillars sutured
with two chain block sutures of unknown suture material [17]. He-
mostasis during the tonsillectomy was achieved with suture ligation. In
the 2003–2005 group postoperative bleeding was 8.6% with 41.9%
requiring the operating room to control the bleeding. In the 2007–2009
group, post tonsillectomy bleeding was 6.6% of which 30.3% of the
patients were taken to the operating room. The study found that the
frequency of overall bleeding was not significant between the two
groups but that there was significance between the two groups when
analyzing the number of patients that went to the operating room to
control postoperative bleeding. Of those patients returning to the op-
erating room there was significantly more primary bleeding occurring
in the tonsillectomy group without suturing. Given that primary post-
operative bleeding is often associated with the surgeon's ability or
quality of surgery, it is possible that the improvement noted in the
second cohort several years later could be secondary to improvement in
surgical skill over time; however, the authors did not find a difference
between the surgeons years of experience and overall hemorrhage
(p = 0.41) or hemorrhage requiring return to the operating room
(p = 0.81). Of note, residents under the supervision of senior physicians
performed majority of the operations; however, the resident level or the
supervising surgeon's years of experience were not listed. Together, this
study demonstrates that suturing the tonsil pillars does reduce the risk
of primary postoperative bleeding and bleeding requiring return to the
operative room particularly using cold steel methods. This study did not
provide criteria for the need to return to the operating room.
 J.A. Wulu et al.

Table 1
Overview of literature investigating reduction of post-tonsillectomy hemorrhage with tonsil pillar suturing. Where appropriate, control group values are listed first followed by sutured group values.
Study Year # of patients Age Male (%) Indications Bilateral or Suture and stitch Primary post- Secondary post- Follow up Comments
(control/ Unilateral operative operative (postop)
sutured) bleeding bleeding

Matt et al. 2012 763 8–264mo 58.5 Pharyngitis (7.9%), velopharyngeal Unilateral 3-0 chromic-2-3 Unclear 43 tonsil bleeds 14 days No significant difference in risk
Prospective (75.7mo) insufficiency in preparation for interrupted 18 control of postoperative bleed
pharyngeal flap (1.4%), feeding 17 sutured p =
problems (0.1%), other (1%) 0.86
Ngyyen et al. 2014 424 (226/ 1-59y (12) 41.0/47.5 Recurrent tonsillitis (63.2%/41.8%), Bilateral 2-0 silk or vicryl – None 20 control 4 weeks No significant difference in
Retrospective 158) 2-68y (18) OSA (33.8%/28.5%), malignancy (1.5%/ single horizontal 9 sutured p = secondary tonsil bleed
6.3%) mattress 0.47
Senska el al. 2012 2000 (1000/ 1-77y (17) 44.5/42.8 Chronic or recurrent tonsillitis or Bilateral Unspeficied 2-chain 36 control 50 control 15 days Time to bleed and time to bleed

206
Retrospective 1000) 2-77y (16) hyperplasia of the tonsils block (interrupted) 7 sutured p = 49 sutured requiring OR occur later in
0.06 sutured group (p < 0.001; p =
Required OR: 0.04)
20 control
4 sutured p =
0.01
Elkholy 2016 800 (400/ 4-19.5y 50.5 Paradise criteria (≥7 episodes of sore Bilateral 2-0 chromic or vicryl 32 control 8 control (2 1 week Significant difference in overall
Prospective 400) (13.34) throat within past year, ≥5 episodes in – 3–4 interrupted 18 sutured p required OR) postoperative bleed (p < 0.05).
3.5–20.1y each of previous 2y, or ≥3 episode in < 0.05 0 sutured
(12.23) each of previous 3y) Required OR:
16 control
2 sutured p <
0.05
Cetiner 2018 760 4-35y (13.46) 51.7 Recurrent tonsillitis, chronic tonsillitis, Unilateral 3-0 vicryl – 3 14 control 9 control NA Significant difference in overall
Prospective or hypertrophic tonsils interrupted 0 sutured p < 8 sutured postoperative bleed (p < 0.05)
0.05
Required OR:
2 control
0 sutured
International Journal of Pediatric Otorhinolaryngology 117 (2019) 204–209
J.A. Wulu et al. International Journal of Pediatric Otorhinolaryngology 117 (2019) 204–209

Importantly, this study highlighted that there is a 30% increase in op-

Significant pain reduction by POD 3 (p

41/49 with significant pain reduction
erative time when tonsil pillars are sutured.
Elkholy's study also supports suturing the tonsil pillars to reduce

No significant difference in pain

No significant difference in pain

No significant difference in pain

post tonsillectomy hemorrhage. This was an eight-year prospective
study, which included 800 patients randomized to two groups con-
sisting of tonsillectomy performed with scissors. Hemostasis in the
control group was achieved with gauze, diathermy, and silk ligature.

Overview of literature investigating pain reduction with tonsil pillar suturing in tonsillectomies. Where appropriate, control group values are listed first followed by sutured group values.
Hemostasis in the suture group was achieved with gauze and tonsil

(p = 0.0001)
pillar suture using 3–4 interrupted chromic or vicryl sutures. Primary

Comments

< 0.01)
postoperative hemorrhage was noted in 4% of patients in the control
group of which 50% were returned to the operating room compared to
2.25% of the patients in the suture group having postoperative he-

Palatal hematomas
morrhage and 11.1% of these patients requiring the operating room to
control the bleeding. This study also classified secondary hemorrhage in
the setting of infections and found that within the control group 1% of
patients had bleeding of which 25% returned to the operating room,

None

NR

NR
while there was no secondary bleeding noted in the suture group.

2
Operative time was also evaluated in this study, again supporting that
there is an increase in the amount of time of the procedure when the
tonsil pillars are sutured. This study concluded that suturing the tonsil

Follow up
(postop)

6 weeks
10 days

10 days

10 days
pillars is beneficial in reducing the rate of postoperative bleeding ne-

24 h
cessitating return to the operating room. Interestingly, this study found
an increase in the frequency of primary hemorrhage after tonsillectomy,

Postoperative bleeding
but there was no evaluation of surgeon experience level. It is also un-
clear whether the tonsillectomy was mostly performed by residents
which could serve as a possible explanation for increase in primary
bleeding. The control group also had intraoperative hemostasis ob-
tained using diathermy while no heat was use in the suture group.

None
None

None

None

None
3.4. Follow up 3.0 catgut – interrupted ×3
2.0 PDS – interrupted ×3

Follow up ranged from 7 days to 4 weeks post-operation (Table 1). 3.0 chromic - continuous

3.0 catgut vicryl –

4.0 plain catgut –
Suture and stitch

interrupted x4-5
4. Discussion

interrupted ×2
There is no gold standard technique for tonsillectomy. The literature
sites increased risk of postoperative bleeding with hot techniques
compared to cold techniques. Interestingly, the studies in support of
suturing the tonsil pillars all utilized a cold steel approach for the
tonsillectomy. There are a limited number of studies evaluating the
benefit of suturing tonsil pillars after tonsillectomy. The idea of su-
Bilateral or
Unilateral

Unilateral
Unilateral

Unilateral

Unilateral

turing tonsil pillars stems from the theory that this would facilitate
Bilateral

healing since the body would not need to bring the raw surfaces to-
gether [14].
Suturing the tonsil pillars after performing a tonsillectomy is not
Male (%)

common practice, although it is commonly used in UPPP procedures

52.6

56.4

44.4
NR

NR

and to control difficult postoperative tonsillectomy bleeds.

Tonsillectomy compared to UPPP was studied in a retrospective case
3-35y (11.5/

3-15y (6.98)

7-36y (14.2)

series with results showing 5% secondary bleeding in the tonsillectomy

group compared to 1.5% in the UPPP group in which the tonsil pillars
> 16y
> 15y

were sutured after the tonsillectomy [13]. This study also found that the
9.8)
Age

incidence of surgical management to control postop bleeding was 4.5%

in the tonsillectomy group and only 0.97% in the UPPP demonstrating a
# of patients

lower incidence of secondary bleeding when the tonsil pillars are su-
tured [13].
60
50

40

39

36

While this paper reviews the literature to examine the effect of

tonsil pillar suturing in reducing postoperative bleeding, there are also
1986
1994

1996

2005

2009
Year

studies that have looked at the possibility of achieving better pain

control with suturing the tonsil pillars closed. From some of these pain
studies we are able to extrapolate bleeding risks if documented. There
Ramjettan and Singh

were five studies that also investigated tonsil pillar suturing with the
Nandapalan and

primary outcome evaluating reduction of post-tonsillectomy pain

McIlwain

(Table 2). Pain reduction postoperatively after suturing the tonsil pillars
Sendi et al.
Genc et al.
Prospective

will likely need further investigation, as there are many factors that can
Weighill
Table 2

Study

influence pain perception. None of the studies reported postoperative

bleeding but two of the studies noted palatal hematomas. One study

207
J.A. Wulu et al.
had three patients develop palatal hematomas within 48 h of tonsil-
lectomy and reported the need for return to the operating room [18].
Another study documented two patients with palatal hematomas
however; there was no mention as to whether the palatal hematomas
required any intervention [19]. In the studies reviewed for post-
operative bleeding there was no documented palatal hematomas that
required operative management.
The type of tonsillectomy performed and the technique used to
suture the tonsil pillars varied in the studies examined. There were
different type of sutures and stitch methods used in each study as well.
The depth of the stitch was not discussed but it is possible that this can
contribute to the bleed risk as deeper suture bites may be associated
with increased risk of arterial injury. The tonsils are supplied by a
number of arterial vessels. There is also a risk for an aberrant or
medialized carotid artery. Suture ligation in the tonsil fossa has been
associated with pseudoaneurysm which can lead to postoperative he-
morrhage [20]. The internal carotid artery is typically found between
20 and 60% of the tonsillar fossa width, measured from the posterior
pillar, or in pediatric patients at about 6–28 mm lateral to the tonsil
fossa indicating the possibility for internal carotid artery injury with
deep suture bites [21,22]. Arterial injury of the facial or lingual artery
has also been discussed in the literature as a risk for suturing the tonsil
pillars or suturing within the tonsil fossa. There is concern that suturing
can create a fistula within the vessel that can lead to hemorrhage as the
suture or suture knot dissolves [20,23]. The use of a more permanent
suture such as silk did not appear to reduce the risk of postoperative
bleeding and in fact this suture had to be removed in the clinic in a
number of patients which is why one study switched to vicryl suture;
although, this suture type can be retained for a long period of time as
well. Removing sutures from the mouth postoperatively is likely not
comfortable for the patient and would be difficult in pediatric patients.
Suturing tonsil pillars adds time to the procedure and places the
patient under anesthesia for a longer period of time. The study by
Elkholy and Senska highlighted the increase in time associated with
suturing the tonsil pillars. There was an average increase of 8 min noted
in the Senska study (p = 0.01) where one horizontal mattress suture
was placed compared to the 5-min increase with multiple interrupted
sutures placed in the Elkholy study. The increased time under an-
esthesia may be negligible for healthy adult patients; however for pa-
tients who are critically ill and pediatric patients the risks of prolonged
anesthesia may outweigh the potential benefits.
A potential complication of tonsil pillar suturing in tonsillectomies
could be velopharyngeal insufficiency due to the fixation or scarring of
the palatal pillars. Velopharyngeal insufficiency (VPI) is a complication
seen in UPPP where tonsil pillar suturing is common [24,25]. VPI has
been associated with tonsillectomies and more so with the combined
adenotonsillectomy patients even in patients without a palatal cleft
[24]. VPI postoperatively is often temporary but can be permanent.
Nguyen et al. noted that some patients required suture removal sec-
ondary to patient intolerance and gag insensitivity; it is unclear if there
was also associated velopharyngeal insufficiency in these patients [15].
Senska et al. noted that there was no evidence of VPI in their patients
[17]. Thus, further investigation into velopharyngeal insufficiency after
tonsil pillar suturing should be explored.
The cohort groups were similar between each other in the studies
regarding age, sex, and indication. Often patients were having tonsil-
lectomy performed in conjunction with another procedure such as an
adenoidectomy. The inclusion criteria for hemorrhage varied between
studies and included self reported bleeding, minimal bleeding, up to
severe bleeding which is defined as bleeding requiring the operating
room. The classification and management of post tonsillectomy
bleeding varies by institution. In the literature there is also a variation
in the rates of hemorrhage as there is no consistent grading system or
measurement used. The criteria for returning to the operating room was
also unclear in the studies. This is typically the surgeon's preference as
some surgeons may prefer more conservative bedside maneuvers and
208
International Journal of Pediatric Otorhinolaryngology 117 (2019) 204–209
observation, while others may want to take even minimal bleeding to
the operating room to get a better examination and opportunity to
obtain hemostasis. This practice can vary within a single institution.
None of the patients in these studies required a blood transfusion. One
study mentioned the need for a second surgical procedure but only in
the group without tonsil pillar suturing. Recurrent bleeding episodes
remain a risk and it unclear from these studies whether tonsil pillar
suturing can reduce this risk.
There are a number of risk factors associated with an increased risk
of post tonsillectomy bleeding including being over the age of 12, male
sex, history of recurrent tonsillitis, and surgical technique. In this re-
view, the studies included pediatric patients, adult patients, males, fe-
males, and patients with various indications for tonsillectomy including
recurrent tonsillitis. Of note, the studies that utilized cold steel tech-
niques were in favor of suturing the tonsil pillars while the studies
performing tonsillectomy with diathermy did not find any benefit to
suturing the tonsil pillars. It has been noted that at present majority of
tonsillectomies are performed using diathermy [15].
5. Conclusion
In conclusion, there are a number of factors that can influence a
patient's risk of postoperative bleeding after a tonsillectomy. Primary
hemorrhage is often related to surgical technique, surgeon experience,
and obtaining adequate hemostasis intraoperatively. There also appears
to be an increase in primary hemorrhage associated with use of cold
techniques. Although the literature surrounding tonsil pillar suturing is
limited and involves the use of various tonsillectomy techniques, su-
turing material, and type of stitch there are a few inferences that can be
drawn. Suturing the tonsil pillars could be beneficial for reducing pri-
mary bleeding and severe bleeding requiring control in the operating
room as demonstrated by Senska et al. and Elkholy et al. Patients who
may be at a known higher risk for postoperative bleeding may benefit
from having their tonsil pillars sutured at the completion of their ton-
sillectomy particularly if the tonsillectomy is performed via cold steel
technique. The type of suture material and or the type of stitch used
could also influence the outcomes of the studies; however, future stu-
dies would be needed. In theory, sutures that remain in place for at least
two weeks post tonsillectomy could contribute to decreased bleeding
risk as the pillars would remain together which may facilitate healing
during the timeframe when the tonsil fossa eschar is known to slough
off increasing bleeding risk.
There has also been a shift to performing more tonsillotomy or in-
tracapsular tonsillectomies as compared to the extracapsular tonsil-
lectomy and it is possible that suturing tonsil pillars after a tonsillotomy
may provide benefit to the patient by further reducing postoperative
bleeding. This is another area that could benefit from additional ex-
ploration.
5.1. Implications for practice
Tonsillectomy is one of the most widely and commonly performed
surgeries among the pediatric and adult population. While complication
rates are generally low for such procedures, postoperative hemorrhage
is the most serious complication leading to unnecessary costs, morbidity
and in rare cases death [1]. There have been several studies examining
various techniques to reduce post-operative bleeding.
Suturing tonsil pillars is common practice in uvulopalatophar-
yngoplasty with a lower risk of associated postoperative bleeding
[3,26] Postoperative bleeding with UPPP has not been studied as
thoroughly as post tonsillectomy bleeding but the literature has de-
monstrated that there is a lower risk of bleeding and need to surgically
manage the bleeding when the tonsil pillars are sutured. This finding is
important given that it signifies less severe post-tonsillectomy bleeding
and the potential to reduce hospital expenditures. On the contrary,
suturing the tonsil pillars does increase the operative time and the
J.A. Wulu et al.
length of time that a patient is under anesthesia. Overall, suturing tonsil
pillars will require further investigation; however, one can consider
using this technique after tonsillectomy for patients identified as having
a higher risk for post-tonsillectomy bleeding or for tonsillectomies
performed using cold steel techniques.
Conflicts of interest
No Conflict of Interest.
References
[1] R. Arora, S. Saraiya, X. Niu, R.L. Thomas, N. Kannikeswaran, Post tonsillectomy
hemorrhage: who needs intervention? Int. J. Pediatr. Otorhinolaryngol. 79 (2015)
165–169, https://doi.org/10.1016/j.ijporl.2014.11.034.
[2] A. Tomkinson, W. Harrison, D. Owens, S. Harris, V. McClure, M. Temple, Risk
factors for postoperative hemorrhage following tonsillectomy, Laryngoscope 121
(2011) 279–288, https://doi.org/10.1002/lary.21242.
[3] S. Sarny, G. Ossimitz, W. Habermann, H. Stammberger, Hemorrhage following
tonsil surgery: a multicenter prospective study, Laryngoscope 121 (2011)
2553–2560, https://doi.org/10.1002/lary.22347.
[4] A.R. Betancourt, C. López, V. Zerpa, M. Carrasco, J. Dalmau, Does surgical tech-
nique influence post-tonsillectomy haemorrhage? Our experience, Acta
Otorrinolaringol. Esp. 66 (2015) 218–223, https://doi.org/10.1016/j.otorri.2014.
09.009.
[5] A.-C. Hessén Söderman, E. Ericsson, C. Hemlin, E. Hultcrantz, I. Månsson, K. Roos,
J. Stalfors, Reduced risk of primary postoperative hemorrhage after tonsil surgery in
Sweden: results from the National Tonsil Surgery Register in Sweden covering more
than 10 years and 54,696 operations, Laryngoscope 121 (2011) 2322–2326,
https://doi.org/10.1002/lary.22179.
[6] A.-C.H. Söderman, E. Odhagen, E. Ericsson, C. Hemlin, E. Hultcrantz,
O. Sunnergren, J. Stalfors, Post-tonsillectomy haemorrhage rates are related to
technique for dissection and for haemostasis. An analysis of 15734 patients in the
National Tonsil Surgery Register in Sweden, Clin. Otolaryngol. 40 (2015) 248–254,
https://doi.org/10.1111/coa.12361.
[7] J.P. Windfuhr, Y.S. Chen, S. Remmert, Hemorrhage following tonsillectomy and
adenoidectomy in 15,218 patients, Otolaryngol. Head Neck Surg. 132 (2005)
281–286, https://doi.org/10.1016/j.otohns.2004.09.007.
[8] D.W. Kim, J.-W. Koo, S.-H. Ahn, C.H. Lee, J.-W. Kim, Difference of delayed post-
tonsillectomy bleeding between children and adults, Auris Nasus Larynx 37 (2010)
456–460, https://doi.org/10.1016/j.anl.2009.11.011.
[9] J.L. Wei, C.W. Beatty, R.O. Gustafson, Evaluation of posttonsillectomy hemorrhage
and risk factors, Otolaryngol. Head Neck Surg. 123 (2000) 229–235, https://doi.
org/10.1067/mhn.2000.107454.
[10] D. Lowe, J. van der Meulen, D. Cromwell, J. Lewsey, L. Copley, J. Browne, M. Yung,
P. Brown, Key messages from the national prospective tonsillectomy audit,
Laryngoscope 117 (2007) 717–724, https://doi.org/10.1097/mlg.
0b013e318031f0b0.
209
International Journal of Pediatric Otorhinolaryngology 117 (2019) 204–209
[11] S.D. Handler, L. Miller, K.H. Richmond, C.C. Baranak, Post-tonsillectomy hemor-
rhage: incidence, prevention and management, Laryngoscope 96 (1986)
1243–1247.
[12] D.A. Randall, M.E. Hoffer, Complications of tonsillectomy and adenoidectomy,
Otolaryngol. Head Neck Surg. 118 (1998) 61–68, https://doi.org/10.1016/S0194-
5998(98)70376-6.
[13] E.A. Aksoy, G.M. Serin, S. Polat, O.F. Unal, H. Tanyeri, Comparison of postoperative
bleeding between submucosal uvulopalatopharyngoplasty and tonsillectomy, J.
Res. Med. Sci. 19 (2014) 310–313.
[14] B.H. Matt, B.J. Krol, Y. Ding, B.E. Juliar, Effect of tonsillar fossa closure on post-
operative pain and bleeding risk after tonsillectomy, Int. J. Pediatr.
Otorhinolaryngol. 76 (2012) 1799–1805, https://doi.org/10.1016/j.ijporl.2012.09.
004.
[15] T.B.V. Nguyen, R.Y. Chin, S. Paramaesvaran, G.D. Eslick, Routine tonsillar bed
oversew after diathermy tonsillectomy: does it reduce secondary tonsillar hae-
morrhage? Eur. Arch. Oto-Rhino-Laryngol. 271 (2014) 3005–3010, https://doi.org/
10.1007/s00405-014-3075-6.
[16] H. Cetiner, I. Cavusoglu, S. Duzer, O. Sakallioglu, N. Susaman, Y.S.S. Yildirim,
Effect of suturation plus Surgicel application on post-tonsillectomy bleeding and
pain, J. Craniofac. Surg. 28 (2017), https://doi.org/10.1097/SCS.
0000000000003827 e672–e675.
[17] G. Senska, H. Schröder, C. Pütter, P. Dost, Significantly reducing post-tonsillectomy
haemorrhage requiring surgery by suturing the faucial pillars: a retrospective
analysis, PloS One 7 (2012) e47874, , https://doi.org/10.1371/journal.pone.
0047874.
[18] J.S. Weighill, D.W. Proops, D. Jeffries, J. Brandrick, Pain relief following tonsil-
lectomy (does sewing the faucial pillars together help?), J. Laryngol. Otol. 100
(1986) 307–310.
[19] S. Ramjettan, B. Singh, Are sutured faucial pillars really an advantage in tonsil-
lectomy? S. Afr. J. Surg. 34 (1996) 189–191.
[20] J.P. Windfuhr, A.M. Sesterhenn, G. Schloendorff, B. Kremer, Post-tonsillectomy
pseudoaneurysm: an underestimated entity? J. Laryngol. Otol. 124 (2010) 59–66,
https://doi.org/10.1017/S0022215109990922.
[21] R.A. Hendrix, C.K. Bacon, M.E. Hoffer, Localization of the carotid artery within the
tonsillar fossa by Doppler flow mapping, Laryngoscope 100 (1990) 853–856,
https://doi.org/10.1288/00005537-199008000-00011.
[22] J.D. Osguthorpe, W.Y. Adkins, F.J. Putney, G.D. Hungerford, Internal carotid artery
as source of tonsillectomy and adenoidectomy hemorrhage, Otolaryngol. Head
Neck Surg. 89 (1981) 758–762, https://doi.org/10.1177/019459988108900513.
[23] J.F. Gardner, Sutures and disasters in tonsillectomy, Arch. Otolaryngol. 88 (1968)
551–555.
[24] M. Khami, S. Tan, J.T. Glicksman, M. Husein, Incidence and risk factors of velo-
pharyngeal insufficiency postadenotonsillectomy, Otolaryngol. Head Neck Surg.
153 (2015) 1051–1055, https://doi.org/10.1177/0194599815596494.
[25] J.A. Tang, A.M. Salapatas, L.B. Bonzelaar, M. Friedman, Long-term incidence of
velopharyngeal insufficiency and other sequelae following uvulopalatophar-
yngoplasty, Otolaryngol. Head Neck Surg. 156 (2017) 606–610, https://doi.org/10.
1177/0194599816688646.
[26] T.A. Elkholy, Modified surgical technique with pillars repair in reducing post ton-
sillectomy haemorrhage, International Invention Journal of Medicine and Medical
Sciences 3 (2016) 108–114.