ENT surgery in children with inherited bleeding disorders

An incidental latent adult hemophilia case found after a tonsillectomy

Severe bleeding after a tonsillectomy may cause airway obstruction and be life-threatening. We report post-tonsillectomy bleeding in a 32-year-old patient with hemophilia A, who had not been aware of his disease for more than 30 years. He underwent tonsillectomy for recurrent tonsillitis. He denied episodes of bleeding tendency. The preoperative workup was normal, including platelet count, prothrombin time, and activated partial thromboplastin time. The surgery itself was uneventful, but severe bleeding from the inferior pole of the tonsillar bed developed 7 days after surgery. Emergency hemostasis was performed under general anesthesia in the operating room. The patient then remembered several episodes of bleeding tendency. Coagulation tests revealed a mild lack of coagulation factor VIII to 35%, and a diagnosis of hemophilia A was made. Hemophilia might only be found after surgery and can cause life-threatening complications. However, latent hemophilia detected after a tonsillectomy in a 32-year-old adult is very rare. A careful history of bleeding tendency is important to achieve a diagnosis of coagulopathy, perform a safer surgery, and prevent postoperative complications.

Perioperative management of a pediatric patient with suspected type 1 von Willebrand disease undergoing tonsillectomy: a case report

Background

Von Willebrand disease (VWD) is the most common inherited bleeding disorder in humans. Coagulopathies such as VWD are evidently risk factors for post-surgical bleeding. Perioperative management of patients with VWD remains controversial and is a major clinical concern.

Case presentation

A 5-year-old girl was scheduled for tonsillectomy under general anesthesia. Preoperative laboratory tests revealed prolongation of activated partial thromboplastin time and a mild decrease in von Willebrand factor (VWF) activity. Prophylactic administration of desmopressin or VWF was not performed. During tonsillectomy, oozing from the surgical wound was uncontrollable by conventional hemostasis techniques, but complete hemostasis was ensured by plasma-derived coagulation factor VIII concentrate containing VWF.

Conclusion

Pediatric patients with mild abnormalities in preoperative laboratory tests may have coagulopathies. Prophylactic intervention and/or the preparation of a sufficient amount of coagulation factor VIII concentrate containing VWF may be required in patients suspected of having VWD or with mild VWF deficiency.

Perioperative Desmopressin for Patients Undergoing Otolaryngologic Procedures: A Systematic Review

Objective

Desmopressin (DDAVP) is a hemostatic agent used to manage bleeding in patients with hemostatic disorders, and there is a lack of published data to guide its use during otolaryngology procedures. The objective of this study was to conduct an evidence-based systematic review of the reported uses, efficacy, and adverse effects of DDAVP in the otolaryngology surgical setting.

Data Sources

PubMed, MEDLINE, and EmBase were searched for articles on the use of DDAVP in otolaryngology.

Review Methods

The Methodological Index for Non-Randomized Studies criteria and Cochrane bias tool were used to assess study quality. Patient demographics, DDAVP dosing and route, and outcomes such as bleeding and adverse events were collected. A summary of evidence table was created specifying levels of evidence, benefits, and harm.

Results

Nineteen studies encompassing 440 patients were included. Sixteen studies discussed DDAVP for prophylaxis, and 3 discussed postoperative use. DDAVP effectively prevented bleeding in high-risk patients and successfully facilitated a dry surgical field when necessary. DDAVP had a 100% success rate when used symptomatically. Five studies described adverse effects, including hyponatremia (12.3%), nausea (2.0%), emesis (0.9%), and seizure (0.2%). The aggregate level of evidence for its use was Level B for adenotonsillectomy, septoplasty, and turbinate procedures and Level C for rhinoplasty.

Conclusion

Current literature supports the use of DDAVP in otolaryngology surgical procedures as both a perioperative prophylactic agent and a postoperative symptomatic intervention for bleeding. Both modalities are effective with minimal adverse events. Further well-designed randomized trials are necessary to conclusively formulate guidelines for DDAVP use in otolaryngology.

Post-tonsillectomy hemorrhagic outcomes in children with bleeding disorders at a single institution

OBJECTIVE

To report on the post-tonsillectomy bleeding outcomes and factors associated with hemorrhage among children with pre- or post-operatively diagnosed bleeding disorders treated with an institutional protocol.

METHODS

Retrospective cohort study of patients with hematologic disorders who underwent tonsillectomy between 2003 and 2016 and were treated with perioperative desmopressin or factor replacement and/or aminocaproic acid. Postoperative outcomes were compared to controls matched for age, sex, and indication for surgery. Analysis of factors associated with hemorrhage was performed in patients with bleeding disorders using Mann-Whitney U or chi-squared tests.

RESULTS

45 patients with hematologic disorders met inclusion criteria. Platelet dysfunction, including von Willebrand Disease (vWD), was the most common diagnosis (77.8%). Most patients had a preoperative diagnosis of a bleeding disorder and received perioperative hematologic medications (86.7%). Compared to matched controls, patients with hematologic disorders experienced more postoperative bleeding (15.5%; 12 bleeds, 7 patients vs. 1.7%; 1 bleed, 1 patient, p = 0.05) and had longer postoperative stays (1.3 days vs. 0.4 days, p < 0.001). Among the patients with hematologic disorders, patients who experienced a postoperative bleed were significantly more likely to have a factor deficiency (e.g. Hemophilia over vWD) and have a postoperative diagnosis (compared to preoperative diagnosis) for which they did not receive perioperative hematologic medication. Of patients with a postoperative bleed, all those diagnosed postoperatively required at least one surgical intervention to control bleeding compared to 33% of patients with a preoperative diagnosis. A history of post-surgical bleeding, male sex, age at surgery, and pharyngitis as surgical indication were not associated with higher hemorrhage rates in this group.

CONCLUSIONS

This study suggests a clinically important magnitude of increased bleeding risk in patients with hematologic disease. This risk appears to decrease with the use of an institutional protocol consisting of desmopressin or factor replacement and an antifibrinolytic agent extending through postoperative day 10.

Post-tonsillectomy hemorrhage in children with hematological abnormalities

OBJECTIVE

Tonsillectomy is a common procedure performed in children with the main complication being post-operative hemorrhage. It is uncertain if patients with hematological abnormalities face a higher risk of post-operative hemorrhage.

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary referral hospital.

PATIENTS SELECTED

All patients with a known hematologic disorder as well as children without a hematologic abnormality undergoing tonsillectomy with or without adenoidectomy in the past two years at our institution were included in this study.

MAIN OUTCOME MEASURE

We sought to determine whether children with hematologic disorders are at an increased risk of post-operative hemorrhage after surgery.

RESULTS

Four-hundred and sixty-two patients were identified who underwent a tonsillectomy during this time period. Fourteen patients with hematological abnormalities were identified with only one patient suffering a post-tonsillectomy hemorrhage. All patients with abnormal laboratory values prior surgery underwent medical treatment in conjunction with pediatric hematology and did not suffer a post-tonsillectomy hemorrhage. Despite a small study group, the low incidence (1/14) of post-tonsillectomy hemorrhage in patients with hematological abnormalities suggests that these patients may not be at an increased risk, especially if appropriately evaluated and treated pre-operatively.

CONCLUSION

Despite small sample size the results of our study suggest that patients with coagulation disorders may not have an increased risk of post-tonsillectomy hemorrhage when evaluated and corrected pre-operatively.

Adenotonsillectomy in children with von Willebrand's disease: how and when. A case report with review of the literature

The presence of coagulation pathology in children who are candidates for adenotonsillectomy (AT) is a challenge to the otolaryngologist. von Willebrand's disease (vWD) is the most common hereditary coagulopathy and is due to a quantitative and/or qualitative deficiency of von Willebrand's factor (vWF). In recent years, the administration of 1-deamino-8-D-arginine vasopressin (DDAVP) has been recommended as coadjuvant therapy for surgical procedure. This synthetic hormone promotes the release of vWF and factor VIII from endothelial cells. In this report, the authors describe the history of a child with vWD undergoing successful AT after administration of DDAVP. Furthermore, a review of the literature with particular emphasis on the use of DDAVP is made.