- Email: [email protected]
Hemorrhage following tonsillectomy and adenoidectomy in 15,218 patients
Hemorrhage following tonsillectomy and adenoidectomy in 15,218 patients J. P. WINDFUHR,
MD,
Y. S. CHEN,
MD,
and S. REMMERT,
MD,
Duisburg and Aachen, Germany
OBJECTIVE: To evaluate potential risk factors and the incidence of bleeding following adenoidectomy or tonsillectomy, with or without adenoidectomy requiring surgical treatment under general anesthesia. STUDY DESIGN AND SETTING: 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). RESULTS: 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. CONCLUSIONS: 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 lifethreatening. (Otolaryngol Head Neck Surg 2005; 132:281-6.)
A denoidectomy and tonsillectomy remain as the most common surgical procedures in otorhinolaryngology. Post-tonsillectomy hemorrhage (PTH) is recognized as the most serious complication, and occurs as primary (⬎24 h) or secondary (⬎24 h) hemorrhage. Primary bleeding is considered to be related to surgical technique, with a decreasing incidence, and to be more dangerous because of the possible risk of aspiration, laryngospasm, and invisible swallowing of blood with a From the Department of Otorhinolaryngology, Plastic Head and Neck Surgery, St. Anna Hospital, Duisburg (Drs Windfuhr and Remmert) and the Department of Otorhinolaryngology–Head and Neck Surgery, University Hospital of Aachen, Aachen, Germany (Dr Chen). Reprint requests: Jochen P. Windfuhr, MD, St. Anna Hospital, Department of Otolaryngology–Head and Neck Surgery, Albertus Magnus Str. 33, Duisburg 47259, Germany; e-mail, [email protected]. 0194-5998/$30.00 Copyright © 2005 by the American Academy of Otolaryngology–Head and Neck Surgery Foundation, Inc. doi:10.1016/j.otohns.2004.09.007
consequent collapse of blood circulation. Secondary bleeding is considered not to be related to surgical technique, with a constant prevalence in the past. Secondary bleeding happens rarely and is predominantly observed within the first 10 postoperative days.1 This retrospective chart review was undertaken, to evaluate the incidence and potential risk factors of postoperative hemorrhage requiring surgical treatment under general anesthesia in a large population including children and adults. Techniques of anesthesia, surgery, and methods to achieve hemostasis remained unchanged during the study. Tonsillectomy was always performed on an inpatient basis, thus providing reliable data concerning the incidence of delayed hemorrhage. PATIENTS AND METHODS Between January 1, 1988, and September 30, 2001, a total of 15,218 patients underwent adenoidectomy or tonsillectomy, with or without adenoidectomy. We indicated tonsillectomy (with or without adenoidectomy) in 7,132 patients with chronic or recurrent tonsillitis despite adequate medical therapy or associated with the streptococcal carrier state not responding to beta-lactamase-resistant antibiotics, peritonsillar abscess (immediate tonsillectomy), recurrent suppurative or otitis media with effusion in children despite previous adenoidectomy, tonsillar remants after previous surgery, tonsillar hypertrophy causing dental malocclusion, adversely affecting orofacial growth, upper airway obstruction, severe dysphagia, sleep disorders or obstructive airway sleep apnea, or cardiopulmonary complications associated with upper airway obstruction. Adenoidectomy was indicated in 8,086 patients for patients with recurrent purulent therapy-resistant rhinorrhea in children despite previous treatment with antibiotics, sleep disturbances, impaired breathing, nasal speech, cardiopulmonary diseases related to upper airway obstruction caused by adenoids, otitis media with effusion for at least 3 months, dental malocclusion, or if remnants of adenoid tissue were identified. In adults, adenoidectomy was suggested if significant findings in endoscopy were associated with symptoms of nasal obstruction. Preoperative studies included full blood count, coagulation values (activated partial thromboplastin time, prothrombin time), and ECG. Risk factors for hemorrhage, such as hypertension, hyperthyroidism, intake of oral anticoagulants were treated preoperatively and patients with lasting abnor281
282 WINDFUHR et al
mal values did not undergo surgery. Moreover, patients with symptoms of immunodeficiency, malignant diseases, and patients with carcinoma of unknown primary in whom tonsillectomy was performed to identify an obscure malignancy of the tonsils were also excluded from the study. Prophylactic antibiotics were administered to prevent endocarditis according to current national guidelines prior to surgery. The procedure was always performed under general anesthesia with oral intubation. The tonsils were dissected with scissors, raspatory, and snare (cold technique). Hemostasis was achieved by suture ligation; electrosurgical means were never used. Adenoid tissue was removed with an adenotome, and hemostasis was achieved by temporary packing of the nasopharynx with sponges soaked in epinephrine. If bleeding persisted, bipolar cautery was used under visual control. If this was not sufficient, the nasopharynx was packed overnight. Patients had to refrain from eating or drinking for 6 hours postoperatively, exceptions were made for children under 2 years of age. Postoperative monitoring included 2 rounds per day on the ward by the surgeon and a continuous observation by the nursing staff. Patients were discharged 6 days following tonsillectomy. Adenoidectomy was performed on an outpatient basis with discharge 4 hours after surgery with exceptions made for the following reasons: age less than 3 years, travel time 20 minutes or more, minor social conditions/compliance, evidence of obstructive sleep disorder or apnea, cardiopulmonary, metabolic, or neurological diseases, or general disorders or abnormalities. In the literature, the term “hemorrhage” is not uniformly used. Hemorrhage in our study was defined as a postoperative bleeding episode sufficient enough to require surgical treatment under general anesthesia. Therefore, patients with blood-tinged sputum or those without active bleeding at presentation and who had no signs of hemorrhagic shock were by definition not included in the group of postoperative bleeders. Patients with postoperative hemorrhage were discharged according to their general condition, hemoglobin concentration, and state of wound healing. Prolonged inpatient observation was indicated for those patients in whom excessive bleeding required ligation of the external carotid artery. According to our management protocol, every patient who presented with a history of bleeding (regardless of the intensity) after discharge at our emergency department was re-admitted for at least overnight observation. Because of the retrospective character of our study, this group of patients was not the subject of further studies. All patients with an active bleeding of low intensity at presentation who tolerated treatment under local anesthesia (injection of adrenalincontaining local anesthesia or bipolar coagulation in
Otolaryngology– Head and Neck Surgery February 2005
case of failure) were treated in our emergency department and readmitted. Only patients with an intense and active bleeding were returned to the operating room. The risk of postoperative bleeding was calculated by the relative rate. Mann-Whitney U-test was used for statistical analysis, comparing the incidence of PTH in male and female patients or hemorrhage following immediate abscess-tonsillectomy versus elective tonsillectomy. Because of the small number of patients with infectious mononucleosis, this rate was described but not statistically compared. RESULTS The youngest patient of the adenoidectomy group was 4 months and the oldest was 94 years of age (median, 4 years; mean, 5.9 years; SD, 7.5 years); 57.9% were male. The majority of patients (90.5%) were younger than 9 years of age. The youngest patient of the tonsillectomy group was 5 months and the oldest was 93 years of age (median, 18 years; mean, 21.7 years; SD: 17.1 years); 51.6% were male (Fig 1). The adenoidectomy group consisted of 8,086 patients of whom 215 underwent recurrent adenoidectomy. The group of tonsillectomy patients included a number of 3146 with elective tonsillectomy, 2206 adenoidectomy and tonsillectomy, 1643 immediate abscess tonsillectomy, 107 recurrent tonsillectomy, and 30 patients to resolve dysphagia/dyspnea in patients with infectious mononucleosis. Hemorrhage from the nasopharynx occurred in 25 patients. A total of 20 patients were in the adenoidectomy group (0.25%), of whom 50% were male and only 1 patient had previously undergone adenoidectomy (Fig 2). The youngest patient was 47 months of age and the oldest was 69 years of age (mean, 9.7 years; median, 5 years; SD: ⫾14.8 years). Post-adenoidectomy bleeding occurred in 4 patients following 2,206 adenotonsillectomies and 1 single patient after 36 abscess tonsillectomy with adenoidectomy. None of the 30 patients who underwent adenoidectomy and tonsillectomy in case of infectious mononucleosis experienced post-adenoidectomy bleeding. Post-tonsillectomy hemorrhage occurred in 204 patients (2.86% of which 63.2% were male) requiring 218 interventions. The youngest patient was 32 months of age and the oldest was 86 years of age (mean, 27.5 years; median, 24 years; SD, ⫾17.3 years). Bleeding from both sites occurred in a 13-year old female patient 265 minutes after adenoidectomy and tonsillectomy. Primary hemorrhage (⬍24 h) occurred in 80% in the adenoidectomy group and 77% following the tonsillectomy procedure (mean, 318 minutes following adenoidectomy and 247 minutes post-tonsillectomy including the earliest onset of hemorrhage in repeated bleeding). The
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WINDFUHR et al 283
Fig 1. Age distribution. A total of 15,214 patients underwent adenoidectomy or tonsillectomy, with or without adenoidectomy.
Fig 2. Incidence of postoperative hemorrhage. Primary bleeding (⬍24 hr) prevailed following adenoidectomy and tonsillectomy, with a mean of onset of 263 minutes following adenoidectomy and 193 minutes secondary to tonsillectomy. The latest bleeding occurred 6 (adenoidectomy) and 18 days (tonsillectomy) after surgery.
latest episode of bleeding occurred 6 (adenoidectomy) and 18 days (tonsillectomy) following surgery. Recurrent episodes of bleeding required surgical treatment only in 14 patients of the tonsillectomy group, 2 of whom had 3 episodes of bleeding. Excessive bleeding following tonsillectomy required ligation of the external carotid artery in 8 patients (Table 1) including 1 42-month-old boy in whom massive bleeding at home resulted in lethal outcome. During private transportation to a pediatric clinic, a massive hemorrhagic shock developed with a total cardiovascular collapse at the beginning of emergency treatment (resuscitation, blood transfusion). Ligature of the external artery was performed to accomplish the safest surgical treatment of PTH but could not avoid the lethal outcome.
In addition to endoral suture ligation, a total of 4 patients received blood transfusions post-tonsillectomy (0.06%) including 1 female (84 years) and 3 male patients (16, 43, and 49 years of age). There was only 1 patient with a previously undiagnosed coagulation disorder (factor XIII deficiency). He became symptomatic with a diffuse and prolonged bilateral bleeding immediately after tonsillectomy. Despite administration of highly purified factor XIII, recurrent episodes of bleeding did occur 7 days following tonsillectomy. Hemorrhage occurred in 6 of 30 patients with infectious mononucleosis (20%). Mann-Whitney U-test (P ⫽ 0.661) did not reveal a significant difference of
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284 WINDFUHR et al
Table 1. Excessive PTH requiring ligation of the external carotid artery Age (y)
Gender
History
Onset
30 17 55 22 19 17 3 51
M F M M M F M M
Bilateral PTA PTA Tonsillitis Tonsillitis Tonsillitis IM Tonsillitis Recurrent PTA
Day 10 Day 5 DOS 6 Day 5 8 63lethal DOS
Previous bleeding Day 9 Did not occur 3 Episodes Day 5 Day 1-5 Day 7 Day 4 Did not occur
PTA, peritonsillar abscess; IM, infectious mononucleosis; DOS, day of surgery.
postoperative bleeding in patients with immediate abscess tonsillectomy (3.1%) versus elective tonsillectomy (2.89%). In all, the lowest rate of PTH was found in children less than 10 years of age and the highest rate was in patients 70 years of age or older (Fig 3). The increased risk of hemorrhage following tonsillectomy (P ⫽ 0.046) or adenoidectomy (P ⫽ 0.004) related to age groups is of statistical significance (Mann-Whitney U test). DISCUSSION It has been repeatedly stated that tonsillectomy and adenoidectomy can safely be performed on an outpatient basis after careful patient selection. Exceptions are accepted for risk factors such as age less than 3 years, sleep apnea, underlying diseases, distance to the hospital, coagulation disorders, and others but still a matter of debate.2 The scientific impact resulted in the fact, that some health insurance companies in the United States and Europe mandate outpatient surgery for both surgical procedures or will pay only for a minimal hospital stay for patients with identified risk factors.3,4 Although the term “hemorrhage” lacks a standardized definition, it is acknowledged as the most significant and potentially life-threatening complication following tonsillectomy. Moreover, dehydration and poor oral intake due to postoperative pain and upper airway problems are significant additional sequelae, particularly in the pediatric age group. Experiences with excessive, near-fatal bleeding in patients who had undergone tonsillectomy elsewhere focused our interest to excessive and delayed hemorrhage, lethal outcome, and management strategies. Because our institution follows the current national concept of tonsillectomy performed on an inpatient basis, reliable data for a follow-up of at least 7 days could be collected, which contrasts sharply to numerous studies or questionnaires. In our opinion, data collected from a small number of patients are not reliable enough and susceptible to statistical bias to evaluate the rate of bleeding complications following adenoidectomy and
tonsillectomy. Studies in greater populations (not restricted by age) are uncommon and suggested conclusions not transferable to our institution are due to the poor study design or restriction to pediatric patients (Table 2). It is common knowledge that data exclusively obtained from pediatric patients differ from those observed in adults. In our study, primary hemorrhage clearly prevailed in patients who underwent tonsillectomy as well as adenoidectomy (78% in total).This finding is partly confirmed,4 although different results have been reported with a higher5 or same6 incidence of secondary hemorrhage. Our data may support the opinion that a postoperative monitoring for 6 to 8 hours7 may be sufficient to warrant safety for outpatient surgery in selected patients. Moreover, secondary hemorrhage after day 10 is an extremely rare finding (3 patients in total) and peaks at day 6.5 In contrast to other statements, it should be emphasized, that secondary hemorrhage has the potential to be life-threatening: excessive bleeding required ligation of the external carotid artery in 8 patients, 6 of whom experienced secondary hemorrhage between day 5 and 10, including a single case with lethal outcome (Table 1). Our impression, that repeated episodes of bleeding are a warning sign for an excessive hemorrhage certainly needs further analysis and comments from the literature. Nevertheless, we strongly suggest overnight observation of patients with repeated episodes of bleeding after tonsillectomy. Our concept to indicate surgical means early to treat postoperative hemorrhage rather than wishful waiting is reflected by the fact that no patient of the adenoidectomy group and only five patients of the tonsillectomy group (0.07%) received blood transfusions. The rates of blood transfusions administered have been quoted as 0%6 to 2.3%.8 Postoperative hemorrhage occurred in 18 patients of the adenoidectomy group (0.22%) and compares favorably with incidences rarely reported as separate dates in the literature ranging from 0.16%4 to 0.9%.9 Again, primary bleeding prevailed supporting the statement that outpatient adenoidectomy is a safe procedure.
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WINDFUHR et al 285
Fig 3. Postoperative hemorrhage: age distribution. The lowest incidence of hemorrhage following tonsillectomy and adenoidectomy with tonsillectomy occurred in younger patients (⬍4 years of age), whereas elderly patients (⬎70 years of age) in particular were at risk for bleeding.
Table 2. Studies ⬎ 5000 patients Crysdale19 Mutz8
1986 1993
9409 Children ⬍ 17y 7743 Children, adults
Chiang20
1968
40.000 Outpatient
Williams21 Pratt22 Pratt23
1967 1970 1979
18.184 Children 3.617 Otolaryngologists 6.759 Hospitals
There was no case with lethal outcome, to our knowledge, one case was reported in the literature.10 Immediate abscess-tonsillectomy, with or without adenoidectomy, was not associated with an increased risk of bleeding. This finding compares to reports of Myssiorek5 and Rakover,11 but contrasts sharply to results reported by Capper12 and Randall,1 who observed an increased rate of hemorrhage in cases with additional adenoidectomy. A history of recurrent tonsillitis was identified as a risk factor by Myssiorek.5 Tonsillectomy, with or without adenoidectomy, performed to relieve dysphagia or dyspnea in patients with infectious mononucleosis was associated with a 5-fold higher risk of post-tonsillectomy. Tonsillectomy had no influence on the rate of bleeding from the epipharynx following adenoidectomy. An increased rate of bleeding occurred after recurrent adenoidectomy less significant than in recurrent tonsillectomy. Postsurgical hemorrhage was clearly related to age: patients of 4 years and younger were at least likely to bleed, whereas patients older than 70 years of age had a significant risk to bleed (Fig 3). This finding is only partly confirmed in the literature;13,14 some authors denied any such influence.11,15 In our study, male patients had a significantly higher risk for postoperative
Follow-up? Age distribution? Follow-up? Follow-up? Indications? Guillotine vs. dissection Questionnaire, 40% response rate Questionnaire, 27.6% response rate
bleeding, which was confirmed in the literature,16-18 although other authors denied any such difference.5,15 CONCLUSIONS Hemorrhage following adenoidectomy is a rare complication occurring predominantly on the day of surgery with a good response to local treatment, if necessary, under general anesthesia. A higher rate of hemorrhage can be expected in patients who undergo tonsillectomy, also occurring in the majority of patients as primary bleeding within several hours after surgery. Dissection technique of the tonsils and suturing of bleeding vessels should be performed with great care to avoid vascular injuries. Patients of male gender, who are more than 70 years of age, who have infectious mononucleosis, and who have a history of recurrent tonsillitis were found to be of risk for PTH. Recurrent episodes of bleeding following tonsillectomy should be regarded as a warning sign for an abrupt an excessive bleeding from the tonsillar fossae. Surgeons should tend to recommend readmission to patients reporting of the latter symptom. REFERENCES 1. Randall DA, Hoffer ME. Complications of tonsillectomy and adenoidectomy. Otolaryngol Head Neck Surg 1998;118:61-8.
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2. American Academy of Otolaryngology–Head and Neck Surgery. Tonsillectomy and adenoidectomy inpatient guidelines. Recommendations of the AAO-HNS Pediatric Otolaryngology Committee. St. Louis, MO; 1996:1-4. 3. Raymond CA. Study questions safety, economic benefits of outpatient tonsil/adenoid surgery. JAMA 1986;256:311-2. 4. Peeters A, Van Rompaey D, Schmelzer B, et al. Tonsillectomy and adenotomy as a one day procedure? Acta Otorhinolaryngol Belg 1999;53:91-7. 5. Myssiorek D, Alvi A. Post-tonsillectomy hemorrhage: an assessment of risk factors. Int J Pediatr Otorhinolaryngol 1996;37: 35-43. 6. Gabalski EC, Mattucci KF, Setzen M, et al. Ambulatory tonsillectomy and adenoidectomy. Laryngoscope 1996;106:77-80. 7. Helmus C, Grin M, Westfall R. Same-day-stay adenotonsillectomy. Laryngoscope 1990;100:593-6. 8. Mutz I, Simon H. Hemorrhagic complications after tonsillectomy and adenoidectomy. Experiences with 7,743 operations in 14 years. Wien Klin Wochenschr 1993;105:520-2. 9. Manning SC, Beste D, McBride T, et al An assessment of preoperative coagulation screening for tonsillectomy and adenoidectomy. Int J Pediatr Otorhinolaryngol 1987;13:237-44. 10. Gardner JF. Sutures and disasters in tonsillectomy. Arch Otolaryngol 1968;88:551-5. 11. Rakover Y, Almog R, Rosen G. The risk of postoperative haemorrhage in tonsillectomy as an outpatient procedure in children. Int J Pediatr Otorhinolaryngol 1997;41:29-36. 12. Capper JW, Randall C. Post-operative haemorrhage in tonsillectomy and adenoidectomy in children. J Laryngol Otol 1984;98: 363-5.
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13. Carmody D, Vamadevan T, Cooper SM. Post tonsillectomy haemorrhage. J Laryngol Otol 1982;96:635-8. 14. Reiner SA, Sawyer WP, Clark KF, et al. Safety of outpatient tonsillectomy and adenoidectomy. Otolaryngol Head Neck Surg 1990;102:161-8. 15. Tami TA, Parker GS, Taylor RE. Post-tonsillectomy bleeding: an evaluation of risk factors. Laryngoscope 1987;97:1307-11. 16. Kristensen S, Tveteras K. Post-tonsillectomy haemorrhage. A retrospective study of 1150 operations. Clin Otolaryngol 1984;9:347-50. 17. Roberts C, Jayaramachandran S, Raine CH. A prospective study of factors which may predispose to post-operative tonsillar fossa haemorrhage. Clin Otolaryngol 1992;17:13-7. 18. Colclasure JB, Graham SS. Complications of outpatient tonsillectomy and adenoidectomy: a review of 3,340 cases. Ear Nose Throat J 1990;69:155-60. 19. Crysdale WS, Russel D. Complications of tonsillectomy and adenoidectomy in 9409 children observed overnight. CMAJ 1986;135:1139-42. 20. Chiang TM, Sukis AE, Ross DE. Tonsillectomy performed on an outpatient basis. Report of a series of 40,000 cases performed without a death. Arch Otolaryngol 1968;88:307-10. 21. Williams RG. Haemorrhage following tonsillectomy and adenoidectomy. A review of 18,184 operations. J Laryngol Otol 1967;81:805-8. 22. Pratt LW. Tonsillectomy and adenoidectomy: mortality and morbidity. Trans Am Acad Ophthalmol Otolaryngol 1970;74: 1146-54. 23. Pratt LW, Gallagher RA. Tonsillectomy and adenoidectomy: incidence and mortality, 1968-1972. Otolaryngol Head Neck Surg 1979;87:159-66.
MD,
Y. S. CHEN,
MD,
and S. REMMERT,
MD,
Duisburg and Aachen, Germany
OBJECTIVE: To evaluate potential risk factors and the incidence of bleeding following adenoidectomy or tonsillectomy, with or without adenoidectomy requiring surgical treatment under general anesthesia. STUDY DESIGN AND SETTING: 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). RESULTS: 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. CONCLUSIONS: 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 lifethreatening. (Otolaryngol Head Neck Surg 2005; 132:281-6.)
A denoidectomy and tonsillectomy remain as the most common surgical procedures in otorhinolaryngology. Post-tonsillectomy hemorrhage (PTH) is recognized as the most serious complication, and occurs as primary (⬎24 h) or secondary (⬎24 h) hemorrhage. Primary bleeding is considered to be related to surgical technique, with a decreasing incidence, and to be more dangerous because of the possible risk of aspiration, laryngospasm, and invisible swallowing of blood with a From the Department of Otorhinolaryngology, Plastic Head and Neck Surgery, St. Anna Hospital, Duisburg (Drs Windfuhr and Remmert) and the Department of Otorhinolaryngology–Head and Neck Surgery, University Hospital of Aachen, Aachen, Germany (Dr Chen). Reprint requests: Jochen P. Windfuhr, MD, St. Anna Hospital, Department of Otolaryngology–Head and Neck Surgery, Albertus Magnus Str. 33, Duisburg 47259, Germany; e-mail, [email protected]. 0194-5998/$30.00 Copyright © 2005 by the American Academy of Otolaryngology–Head and Neck Surgery Foundation, Inc. doi:10.1016/j.otohns.2004.09.007
consequent collapse of blood circulation. Secondary bleeding is considered not to be related to surgical technique, with a constant prevalence in the past. Secondary bleeding happens rarely and is predominantly observed within the first 10 postoperative days.1 This retrospective chart review was undertaken, to evaluate the incidence and potential risk factors of postoperative hemorrhage requiring surgical treatment under general anesthesia in a large population including children and adults. Techniques of anesthesia, surgery, and methods to achieve hemostasis remained unchanged during the study. Tonsillectomy was always performed on an inpatient basis, thus providing reliable data concerning the incidence of delayed hemorrhage. PATIENTS AND METHODS Between January 1, 1988, and September 30, 2001, a total of 15,218 patients underwent adenoidectomy or tonsillectomy, with or without adenoidectomy. We indicated tonsillectomy (with or without adenoidectomy) in 7,132 patients with chronic or recurrent tonsillitis despite adequate medical therapy or associated with the streptococcal carrier state not responding to beta-lactamase-resistant antibiotics, peritonsillar abscess (immediate tonsillectomy), recurrent suppurative or otitis media with effusion in children despite previous adenoidectomy, tonsillar remants after previous surgery, tonsillar hypertrophy causing dental malocclusion, adversely affecting orofacial growth, upper airway obstruction, severe dysphagia, sleep disorders or obstructive airway sleep apnea, or cardiopulmonary complications associated with upper airway obstruction. Adenoidectomy was indicated in 8,086 patients for patients with recurrent purulent therapy-resistant rhinorrhea in children despite previous treatment with antibiotics, sleep disturbances, impaired breathing, nasal speech, cardiopulmonary diseases related to upper airway obstruction caused by adenoids, otitis media with effusion for at least 3 months, dental malocclusion, or if remnants of adenoid tissue were identified. In adults, adenoidectomy was suggested if significant findings in endoscopy were associated with symptoms of nasal obstruction. Preoperative studies included full blood count, coagulation values (activated partial thromboplastin time, prothrombin time), and ECG. Risk factors for hemorrhage, such as hypertension, hyperthyroidism, intake of oral anticoagulants were treated preoperatively and patients with lasting abnor281
282 WINDFUHR et al
mal values did not undergo surgery. Moreover, patients with symptoms of immunodeficiency, malignant diseases, and patients with carcinoma of unknown primary in whom tonsillectomy was performed to identify an obscure malignancy of the tonsils were also excluded from the study. Prophylactic antibiotics were administered to prevent endocarditis according to current national guidelines prior to surgery. The procedure was always performed under general anesthesia with oral intubation. The tonsils were dissected with scissors, raspatory, and snare (cold technique). Hemostasis was achieved by suture ligation; electrosurgical means were never used. Adenoid tissue was removed with an adenotome, and hemostasis was achieved by temporary packing of the nasopharynx with sponges soaked in epinephrine. If bleeding persisted, bipolar cautery was used under visual control. If this was not sufficient, the nasopharynx was packed overnight. Patients had to refrain from eating or drinking for 6 hours postoperatively, exceptions were made for children under 2 years of age. Postoperative monitoring included 2 rounds per day on the ward by the surgeon and a continuous observation by the nursing staff. Patients were discharged 6 days following tonsillectomy. Adenoidectomy was performed on an outpatient basis with discharge 4 hours after surgery with exceptions made for the following reasons: age less than 3 years, travel time 20 minutes or more, minor social conditions/compliance, evidence of obstructive sleep disorder or apnea, cardiopulmonary, metabolic, or neurological diseases, or general disorders or abnormalities. In the literature, the term “hemorrhage” is not uniformly used. Hemorrhage in our study was defined as a postoperative bleeding episode sufficient enough to require surgical treatment under general anesthesia. Therefore, patients with blood-tinged sputum or those without active bleeding at presentation and who had no signs of hemorrhagic shock were by definition not included in the group of postoperative bleeders. Patients with postoperative hemorrhage were discharged according to their general condition, hemoglobin concentration, and state of wound healing. Prolonged inpatient observation was indicated for those patients in whom excessive bleeding required ligation of the external carotid artery. According to our management protocol, every patient who presented with a history of bleeding (regardless of the intensity) after discharge at our emergency department was re-admitted for at least overnight observation. Because of the retrospective character of our study, this group of patients was not the subject of further studies. All patients with an active bleeding of low intensity at presentation who tolerated treatment under local anesthesia (injection of adrenalincontaining local anesthesia or bipolar coagulation in
Otolaryngology– Head and Neck Surgery February 2005
case of failure) were treated in our emergency department and readmitted. Only patients with an intense and active bleeding were returned to the operating room. The risk of postoperative bleeding was calculated by the relative rate. Mann-Whitney U-test was used for statistical analysis, comparing the incidence of PTH in male and female patients or hemorrhage following immediate abscess-tonsillectomy versus elective tonsillectomy. Because of the small number of patients with infectious mononucleosis, this rate was described but not statistically compared. RESULTS The youngest patient of the adenoidectomy group was 4 months and the oldest was 94 years of age (median, 4 years; mean, 5.9 years; SD, 7.5 years); 57.9% were male. The majority of patients (90.5%) were younger than 9 years of age. The youngest patient of the tonsillectomy group was 5 months and the oldest was 93 years of age (median, 18 years; mean, 21.7 years; SD: 17.1 years); 51.6% were male (Fig 1). The adenoidectomy group consisted of 8,086 patients of whom 215 underwent recurrent adenoidectomy. The group of tonsillectomy patients included a number of 3146 with elective tonsillectomy, 2206 adenoidectomy and tonsillectomy, 1643 immediate abscess tonsillectomy, 107 recurrent tonsillectomy, and 30 patients to resolve dysphagia/dyspnea in patients with infectious mononucleosis. Hemorrhage from the nasopharynx occurred in 25 patients. A total of 20 patients were in the adenoidectomy group (0.25%), of whom 50% were male and only 1 patient had previously undergone adenoidectomy (Fig 2). The youngest patient was 47 months of age and the oldest was 69 years of age (mean, 9.7 years; median, 5 years; SD: ⫾14.8 years). Post-adenoidectomy bleeding occurred in 4 patients following 2,206 adenotonsillectomies and 1 single patient after 36 abscess tonsillectomy with adenoidectomy. None of the 30 patients who underwent adenoidectomy and tonsillectomy in case of infectious mononucleosis experienced post-adenoidectomy bleeding. Post-tonsillectomy hemorrhage occurred in 204 patients (2.86% of which 63.2% were male) requiring 218 interventions. The youngest patient was 32 months of age and the oldest was 86 years of age (mean, 27.5 years; median, 24 years; SD, ⫾17.3 years). Bleeding from both sites occurred in a 13-year old female patient 265 minutes after adenoidectomy and tonsillectomy. Primary hemorrhage (⬍24 h) occurred in 80% in the adenoidectomy group and 77% following the tonsillectomy procedure (mean, 318 minutes following adenoidectomy and 247 minutes post-tonsillectomy including the earliest onset of hemorrhage in repeated bleeding). The
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Fig 1. Age distribution. A total of 15,214 patients underwent adenoidectomy or tonsillectomy, with or without adenoidectomy.
Fig 2. Incidence of postoperative hemorrhage. Primary bleeding (⬍24 hr) prevailed following adenoidectomy and tonsillectomy, with a mean of onset of 263 minutes following adenoidectomy and 193 minutes secondary to tonsillectomy. The latest bleeding occurred 6 (adenoidectomy) and 18 days (tonsillectomy) after surgery.
latest episode of bleeding occurred 6 (adenoidectomy) and 18 days (tonsillectomy) following surgery. Recurrent episodes of bleeding required surgical treatment only in 14 patients of the tonsillectomy group, 2 of whom had 3 episodes of bleeding. Excessive bleeding following tonsillectomy required ligation of the external carotid artery in 8 patients (Table 1) including 1 42-month-old boy in whom massive bleeding at home resulted in lethal outcome. During private transportation to a pediatric clinic, a massive hemorrhagic shock developed with a total cardiovascular collapse at the beginning of emergency treatment (resuscitation, blood transfusion). Ligature of the external artery was performed to accomplish the safest surgical treatment of PTH but could not avoid the lethal outcome.
In addition to endoral suture ligation, a total of 4 patients received blood transfusions post-tonsillectomy (0.06%) including 1 female (84 years) and 3 male patients (16, 43, and 49 years of age). There was only 1 patient with a previously undiagnosed coagulation disorder (factor XIII deficiency). He became symptomatic with a diffuse and prolonged bilateral bleeding immediately after tonsillectomy. Despite administration of highly purified factor XIII, recurrent episodes of bleeding did occur 7 days following tonsillectomy. Hemorrhage occurred in 6 of 30 patients with infectious mononucleosis (20%). Mann-Whitney U-test (P ⫽ 0.661) did not reveal a significant difference of
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284 WINDFUHR et al
Table 1. Excessive PTH requiring ligation of the external carotid artery Age (y)
Gender
History
Onset
30 17 55 22 19 17 3 51
M F M M M F M M
Bilateral PTA PTA Tonsillitis Tonsillitis Tonsillitis IM Tonsillitis Recurrent PTA
Day 10 Day 5 DOS 6 Day 5 8 63lethal DOS
Previous bleeding Day 9 Did not occur 3 Episodes Day 5 Day 1-5 Day 7 Day 4 Did not occur
PTA, peritonsillar abscess; IM, infectious mononucleosis; DOS, day of surgery.
postoperative bleeding in patients with immediate abscess tonsillectomy (3.1%) versus elective tonsillectomy (2.89%). In all, the lowest rate of PTH was found in children less than 10 years of age and the highest rate was in patients 70 years of age or older (Fig 3). The increased risk of hemorrhage following tonsillectomy (P ⫽ 0.046) or adenoidectomy (P ⫽ 0.004) related to age groups is of statistical significance (Mann-Whitney U test). DISCUSSION It has been repeatedly stated that tonsillectomy and adenoidectomy can safely be performed on an outpatient basis after careful patient selection. Exceptions are accepted for risk factors such as age less than 3 years, sleep apnea, underlying diseases, distance to the hospital, coagulation disorders, and others but still a matter of debate.2 The scientific impact resulted in the fact, that some health insurance companies in the United States and Europe mandate outpatient surgery for both surgical procedures or will pay only for a minimal hospital stay for patients with identified risk factors.3,4 Although the term “hemorrhage” lacks a standardized definition, it is acknowledged as the most significant and potentially life-threatening complication following tonsillectomy. Moreover, dehydration and poor oral intake due to postoperative pain and upper airway problems are significant additional sequelae, particularly in the pediatric age group. Experiences with excessive, near-fatal bleeding in patients who had undergone tonsillectomy elsewhere focused our interest to excessive and delayed hemorrhage, lethal outcome, and management strategies. Because our institution follows the current national concept of tonsillectomy performed on an inpatient basis, reliable data for a follow-up of at least 7 days could be collected, which contrasts sharply to numerous studies or questionnaires. In our opinion, data collected from a small number of patients are not reliable enough and susceptible to statistical bias to evaluate the rate of bleeding complications following adenoidectomy and
tonsillectomy. Studies in greater populations (not restricted by age) are uncommon and suggested conclusions not transferable to our institution are due to the poor study design or restriction to pediatric patients (Table 2). It is common knowledge that data exclusively obtained from pediatric patients differ from those observed in adults. In our study, primary hemorrhage clearly prevailed in patients who underwent tonsillectomy as well as adenoidectomy (78% in total).This finding is partly confirmed,4 although different results have been reported with a higher5 or same6 incidence of secondary hemorrhage. Our data may support the opinion that a postoperative monitoring for 6 to 8 hours7 may be sufficient to warrant safety for outpatient surgery in selected patients. Moreover, secondary hemorrhage after day 10 is an extremely rare finding (3 patients in total) and peaks at day 6.5 In contrast to other statements, it should be emphasized, that secondary hemorrhage has the potential to be life-threatening: excessive bleeding required ligation of the external carotid artery in 8 patients, 6 of whom experienced secondary hemorrhage between day 5 and 10, including a single case with lethal outcome (Table 1). Our impression, that repeated episodes of bleeding are a warning sign for an excessive hemorrhage certainly needs further analysis and comments from the literature. Nevertheless, we strongly suggest overnight observation of patients with repeated episodes of bleeding after tonsillectomy. Our concept to indicate surgical means early to treat postoperative hemorrhage rather than wishful waiting is reflected by the fact that no patient of the adenoidectomy group and only five patients of the tonsillectomy group (0.07%) received blood transfusions. The rates of blood transfusions administered have been quoted as 0%6 to 2.3%.8 Postoperative hemorrhage occurred in 18 patients of the adenoidectomy group (0.22%) and compares favorably with incidences rarely reported as separate dates in the literature ranging from 0.16%4 to 0.9%.9 Again, primary bleeding prevailed supporting the statement that outpatient adenoidectomy is a safe procedure.
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Fig 3. Postoperative hemorrhage: age distribution. The lowest incidence of hemorrhage following tonsillectomy and adenoidectomy with tonsillectomy occurred in younger patients (⬍4 years of age), whereas elderly patients (⬎70 years of age) in particular were at risk for bleeding.
Table 2. Studies ⬎ 5000 patients Crysdale19 Mutz8
1986 1993
9409 Children ⬍ 17y 7743 Children, adults
Chiang20
1968
40.000 Outpatient
Williams21 Pratt22 Pratt23
1967 1970 1979
18.184 Children 3.617 Otolaryngologists 6.759 Hospitals
There was no case with lethal outcome, to our knowledge, one case was reported in the literature.10 Immediate abscess-tonsillectomy, with or without adenoidectomy, was not associated with an increased risk of bleeding. This finding compares to reports of Myssiorek5 and Rakover,11 but contrasts sharply to results reported by Capper12 and Randall,1 who observed an increased rate of hemorrhage in cases with additional adenoidectomy. A history of recurrent tonsillitis was identified as a risk factor by Myssiorek.5 Tonsillectomy, with or without adenoidectomy, performed to relieve dysphagia or dyspnea in patients with infectious mononucleosis was associated with a 5-fold higher risk of post-tonsillectomy. Tonsillectomy had no influence on the rate of bleeding from the epipharynx following adenoidectomy. An increased rate of bleeding occurred after recurrent adenoidectomy less significant than in recurrent tonsillectomy. Postsurgical hemorrhage was clearly related to age: patients of 4 years and younger were at least likely to bleed, whereas patients older than 70 years of age had a significant risk to bleed (Fig 3). This finding is only partly confirmed in the literature;13,14 some authors denied any such influence.11,15 In our study, male patients had a significantly higher risk for postoperative
Follow-up? Age distribution? Follow-up? Follow-up? Indications? Guillotine vs. dissection Questionnaire, 40% response rate Questionnaire, 27.6% response rate
bleeding, which was confirmed in the literature,16-18 although other authors denied any such difference.5,15 CONCLUSIONS Hemorrhage following adenoidectomy is a rare complication occurring predominantly on the day of surgery with a good response to local treatment, if necessary, under general anesthesia. A higher rate of hemorrhage can be expected in patients who undergo tonsillectomy, also occurring in the majority of patients as primary bleeding within several hours after surgery. Dissection technique of the tonsils and suturing of bleeding vessels should be performed with great care to avoid vascular injuries. Patients of male gender, who are more than 70 years of age, who have infectious mononucleosis, and who have a history of recurrent tonsillitis were found to be of risk for PTH. Recurrent episodes of bleeding following tonsillectomy should be regarded as a warning sign for an abrupt an excessive bleeding from the tonsillar fossae. Surgeons should tend to recommend readmission to patients reporting of the latter symptom. REFERENCES 1. Randall DA, Hoffer ME. Complications of tonsillectomy and adenoidectomy. Otolaryngol Head Neck Surg 1998;118:61-8.
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2. American Academy of Otolaryngology–Head and Neck Surgery. Tonsillectomy and adenoidectomy inpatient guidelines. Recommendations of the AAO-HNS Pediatric Otolaryngology Committee. St. Louis, MO; 1996:1-4. 3. Raymond CA. Study questions safety, economic benefits of outpatient tonsil/adenoid surgery. JAMA 1986;256:311-2. 4. Peeters A, Van Rompaey D, Schmelzer B, et al. Tonsillectomy and adenotomy as a one day procedure? Acta Otorhinolaryngol Belg 1999;53:91-7. 5. Myssiorek D, Alvi A. Post-tonsillectomy hemorrhage: an assessment of risk factors. Int J Pediatr Otorhinolaryngol 1996;37: 35-43. 6. Gabalski EC, Mattucci KF, Setzen M, et al. Ambulatory tonsillectomy and adenoidectomy. Laryngoscope 1996;106:77-80. 7. Helmus C, Grin M, Westfall R. Same-day-stay adenotonsillectomy. Laryngoscope 1990;100:593-6. 8. Mutz I, Simon H. Hemorrhagic complications after tonsillectomy and adenoidectomy. Experiences with 7,743 operations in 14 years. Wien Klin Wochenschr 1993;105:520-2. 9. Manning SC, Beste D, McBride T, et al An assessment of preoperative coagulation screening for tonsillectomy and adenoidectomy. Int J Pediatr Otorhinolaryngol 1987;13:237-44. 10. Gardner JF. Sutures and disasters in tonsillectomy. Arch Otolaryngol 1968;88:551-5. 11. Rakover Y, Almog R, Rosen G. The risk of postoperative haemorrhage in tonsillectomy as an outpatient procedure in children. Int J Pediatr Otorhinolaryngol 1997;41:29-36. 12. Capper JW, Randall C. Post-operative haemorrhage in tonsillectomy and adenoidectomy in children. J Laryngol Otol 1984;98: 363-5.
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13. Carmody D, Vamadevan T, Cooper SM. Post tonsillectomy haemorrhage. J Laryngol Otol 1982;96:635-8. 14. Reiner SA, Sawyer WP, Clark KF, et al. Safety of outpatient tonsillectomy and adenoidectomy. Otolaryngol Head Neck Surg 1990;102:161-8. 15. Tami TA, Parker GS, Taylor RE. Post-tonsillectomy bleeding: an evaluation of risk factors. Laryngoscope 1987;97:1307-11. 16. Kristensen S, Tveteras K. Post-tonsillectomy haemorrhage. A retrospective study of 1150 operations. Clin Otolaryngol 1984;9:347-50. 17. Roberts C, Jayaramachandran S, Raine CH. A prospective study of factors which may predispose to post-operative tonsillar fossa haemorrhage. Clin Otolaryngol 1992;17:13-7. 18. Colclasure JB, Graham SS. Complications of outpatient tonsillectomy and adenoidectomy: a review of 3,340 cases. Ear Nose Throat J 1990;69:155-60. 19. Crysdale WS, Russel D. Complications of tonsillectomy and adenoidectomy in 9409 children observed overnight. CMAJ 1986;135:1139-42. 20. Chiang TM, Sukis AE, Ross DE. Tonsillectomy performed on an outpatient basis. Report of a series of 40,000 cases performed without a death. Arch Otolaryngol 1968;88:307-10. 21. Williams RG. Haemorrhage following tonsillectomy and adenoidectomy. A review of 18,184 operations. J Laryngol Otol 1967;81:805-8. 22. Pratt LW. Tonsillectomy and adenoidectomy: mortality and morbidity. Trans Am Acad Ophthalmol Otolaryngol 1970;74: 1146-54. 23. Pratt LW, Gallagher RA. Tonsillectomy and adenoidectomy: incidence and mortality, 1968-1972. Otolaryngol Head Neck Surg 1979;87:159-66.