Secondary post-tonsillectomy haemorrhage and informed consent

Recurrent severe secondary haemorrhage due to facial artery pseudoaneurysm following styloidectomy via tonsillectomy approach: A case report

A 41-year-old female who underwent right-sided styloidectomy via tonsillectomy approach experienced refractory short-lasting severe secondary haemorrhage on the third, seventh and thirteen postoperative days. On examination under general anaesthesia, no major vessel injury was noticed. Contrast-enhanced computerized tomography scan of the neck was done because no obvious bleeder was seen and refractory nature of bleeding. Contrast-enhanced computerized tomography scan neck showed pseudoaneurysm of facial artery which was managed with endovascular embolization successfully.

Postoperative Morbidity of Different Tonsillectomy Techniques: A Systematic Review and Network Meta-Analysis

OBJECTIVE

To compare different tonsillectomy techniques in terms of postoperative bleeding incidence and postoperative pain.

METHODS

An arm-based network analysis was conducted using a Bayesian hierarchical model. The primary and secondary outcomes were postoperative bleeding incidence and mean postoperative pain score.

RESULTS

A total of 6464 patients were included for five different interventions (cold dissection tonsillectomy; extracapsular coblation tonsillectomy; intracapsular coblation tonsillectomy [ICT]; bipolar diathermy tonsillectomy [BDT]; monopolar diathermy tonsillectomy). ICT showed the lowest absolute risk (4.44%) of postoperative bleeding incidence (73.31% chance of ranking first) and the lowest mean postoperative pain score (1.74 ± 0.68) with a 94.0% chance of ranking first, whereas BDT showed both the highest absolute risk of bleeding incidence (10.75%) and the highest mean postoperative pain score (5.67 ± 1.43).

CONCLUSIONS

ICT seems to offer better postoperative outcomes, in terms of reduced risk of bleeding and reduced pain. Further prospective studies are advised to confirm these findings.

LEVEL OF EVIDENCE

NA Laryngoscope, 134:1696-1704, 2024.

BiZact™ tonsillectomy: Predictive factors for post-tonsillectomy haemorrhage from a 1717 case series

OBJECTIVE

To determine primary and secondary post-tonsillectomy haemorrhage (PTH) rates and identify predictive factors in a cohort of consecutive adult and paediatric BiZact™ tonsillectomy cases.

SETTING

Retrospective cohort study. Patients from Flinders Medical Centre, Noarlunga Hospital and private otolaryngology practices who underwent BiZact™ tonsillectomy from 2017 to 2020.

DATA COLLECTED

patient age, indication for tonsillectomy, surgeon experience, time and severity of PTH, including return to theatre. Each secondary PTH was graded using the Stammberger classification. Logistic regression was utilised to identify predictors of secondary PTH.

RESULTS

One thousand seven hundred and seventeen patient medical records were assessed (658 adults and 1059 children). The primary PTH rate was 0.1%, and secondary PTH rate was 5.9%. The majority of secondary PTH cases were Stammberger grade A (80/102, 78.4%) requiring observation only. Few secondary PTH required medical intervention (grade B; 9/102, 8.8%), return to theatre (grade C; 12/102, 11.8%), or blood transfusion (grade D; 1/102, 1.0%), with no death reported (grade E; 0/102, 0.0%). Recurrent secondary PTH occurred in 8 patients (0.5%). Predictive factors of secondary PTH in children were surgeon experience with trainees having greater chance of PTH (OR 2.502, 95% CI 1.345-4.654; p = .004) and age of child (OR 1.095, 95% CI 1.025-1.170; p = .007). Surgeon experience was a predictive factor for adults (OR 3.804, 95% CI 2.139-6.674; p < .001).

CONCLUSIONS

BiZact™ tonsillectomy has a low primary PTH rate, with a secondary PTH rate comparable to other 'hot tonsillectomy' techniques. The majority of PTH events were minor and self-reported. There appears to be a learning curve for trainee surgeons.

Time to Functional Recovery After Laser Tonsillotomy Performed Under Local Anesthesia vs Conventional Tonsillectomy With General Anesthesia Among Adults: A Randomized Clinical Trial

IMPORTANCE

Carbon dioxide laser tonsillotomy performed under local anesthesia may be an effective and less invasive alternative than dissection tonsillectomy for treatment of tonsil-related afflictions.

OBJECTIVE

To compare functional recovery and symptom relief among adults undergoing tonsillectomy or tonsillotomy.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial was conducted at 5 secondary and tertiary hospitals in the Netherlands from January 2018 to December 2019. Participants were 199 adult patients with an indication for surgical tonsil removal randomly assigned to either the tonsillectomy or tonsillotomy group.

INTERVENTIONS

For tonsillotomy, the crypts of the palatine tonsil were evaporated using a carbon dioxide laser under local anesthesia, whereas tonsillectomy consisted of total tonsil removal performed under general anesthesia.

MAIN OUTCOMES AND MEASURES

The primary outcome was time to functional recovery measured within 2 weeks after surgery assessed for a modified intention-to-treat population. Secondary outcomes were time to return to work after surgery, resolution of primary symptoms, severity of remaining symptoms, surgical complications, postoperative pain and analgesics use, and overall patient satisfaction assessed for the intention-to-treat population.

RESULTS

Of 199 patients (139 [70%] female; mean [SD] age, 29 [9] years), 98 were randomly assigned to tonsillotomy and 101 were randomly assigned to tonsillectomy. Recovery within 2 weeks after surgery was significantly shorter after tonsillotomy than after tonsillectomy (hazard ratio for recovery after tonsillectomy vs tonsillotomy, 0.3; 95% CI, 0.2-0.5). Two weeks after surgery, 72 (77%) patients in the tonsillotomy group were fully recovered compared with 26 (57%) patients in the tonsillectomy group. Time until return to work within 2 weeks was also shorter after tonsillotomy (median [IQR], 4.5 [3.0-7.0] days vs 12.0 [9.0-14.0] days; hazard ratio for return after tonsillectomy vs tonsillotomy, 0.3; 95% CI, 0.2-0.4.). Postoperative hemorrhage occurred in 2 patients (2%) in the tonsillotomy group and 8 patients (12%) in the tonsillectomy group. At 6 months after surgery, fewer patients in the tonsillectomy group (25; 35%) than in the tonsillotomy group (54; 57%) experienced persistent symptoms (difference of 22%; 95% CI, 7%-37%). Most patients with persistent symptoms in both the tonsillotomy (32 of 54; 59%) and tonsillectomy (16 of 25; 64%) groups reported mild symptoms 6 months after surgery.

CONCLUSIONS AND RELEVANCE

This randomized clinical trial found that compared with tonsillectomy performed under general anesthesia, laser tonsillotomy performed under local anesthesia had a significantly shorter and less painful recovery period. A higher percentage of patients had persistent symptoms after tonsillotomy, although the intensity of these symptoms was lower than before surgery. These results suggest that laser tonsillotomy performed under local anesthesia may be a feasible alternative to conventional tonsillectomy in this population.

TRIAL REGISTRATION

Netherlands Trial Register Identifier: NL6866 (NTR7044).

Cauterization tonsillectomy as compared to traditional tonsillectomy technique

Background:

Tonsillectomy is one of the most frequently applied and oldest surgical procedures in otorhinolaryngology. Various surgical techniques are used to perform this operation including traditional and cauterization techniques.

Objectives:

To assess morbidity and efficacy and compare objectively the techniques in tonsillectomy, i.e., traditional technique and cauterization technique. This study compares the traditional and cauterization tonsillectomy techniques in view of their advantages and complications.

Methods:

This is a retrospective study and comparative study, conducted during the period from January 2017 to March 2018 from the patients attending to Alnamas General Hospital, Aseer Region, Saudi Arabia. The questionnaire was designed to compare the traditional and cauterization tonsillectomy. Fifty patients underwent traditional technique and fifty patients underwent cauterization method. The data analyzed using SPSS V.16.0 (SPSS Inc; Chicago, IL, USA).

Results:

A total of 100 patients, 62 males and 38 females, aged 8 to 16 years were included in the study. A total of 100 patients were enrolled in the study. Traditional and cauterization tonsillectomy were performed. 50 (27 male and 23 female) patients, whose ages ranged from 9 to 16 years old underwent the traditional tonsillectomy, 50 (35 male and 15 female) patients whose ages ranged from 8 to 16 years underwent cauterization. The two groups were similar for demographic parameters. The difference between mean operative times of the two methods was statistically significant. Postoperative bleeding is significantly higher in the traditional technique compared to cauterization method. Postoperative pain is significantly less in cauterization method. Only a few patients experienced fever, bleeding, and other complications related to anesthesia. The bleeding severity is significantly lower in the cauterization technique. Postoperative pain was less in cauterization technique on day 1 and day 5. Postoperative pain was from mild to severe.

Conclusion:

This study revealed significantly less postoperative complications in traditional tonsillectomy in comparison with the cauterization method. Healing time was significantly faster in cauterization technique than in traditional method.

Tonsillectomy in adults: Analysis of indications and complications

OBJECTIVE

Tonsillectomy is one of the surgical techniques most practiced by otolaryngologists, and despite being a relatively simple technique; it presents a considerable percentage of complications, such as postoperative bleeding. The aim of this study is to describe the surgical indications and most frequent complications, analyze whether surgical suture of the tonsillar pillars has an influence on bleeding, and study the data of hospital stay and its importance for the control of complications.

METHODS

A retrospective study of 326 patients who underwent a tonsillectomy in our Department of Otolaryngology from 2006 to 2014 was conducted. The obtained data were statistically analyzed using the Excel and SPSS 21.0 programs.

RESULTS

The most frequent indication was recurrent tonsillitis, with a 74.85% (244) occurrence, and the most recurrent complication was bleeding, in 5.21% (17) of the tonsillectomies, requiring surgical revision 13 of the 17 patients. No statistically significant differences in the risk of bleeding were observed in patients in whom tonsil pillars were sutured comparing to those that were not. No statistically significant differences were detected associating surgical indication and oropharyngeal post-tonsillectomy hemorrhage. All operated patients were admitted, with a postoperative average hospital stay of 2.17 days, gaining a quick and effective control of the immediate complications.

CONCLUSION

Bleeding is the most common and important complication. No statistically significant association between bleeding and tonsil pillar suture or surgical indication was found. Tonsillectomy was not set as outpatient surgery at the time.

Gabapentin in the Management of Pain following Tonsillectomy: A Randomized Double-Blind Placebo-Controlled Trial

Objective To determine if a single dose of oral gabapentin given prior to tonsillectomy decreases postoperative morbidity. Study Design Prospective randomized double-blind placebo-controlled trial. Setting Southern District Health Board University Hospitals, New Zealand, over a 10-month period. Subjects and Methods Seventy-three adults undergoing tonsillectomy were randomized to receive either a single preoperative dose of oral gabapentin (600 mg) or placebo. A standard analgesic protocol was prescribed for 14 postoperative days. The primary outcome was a patient-assigned visual analog scale pain score during rest and swallow; secondary outcomes were analgesic consumption, nausea, vomiting, and return to normal diet and activities. Complications and adverse effects were also recorded. Results Thirty-seven participants were allocated to the placebo group and 36 to the gabapentin group. After withdrawals, data were analyzed from 31 in the placebo group and 27 in the gabapentin group. Pain scores between groups were not significantly different within the first 6 hours. The gabapentin group recorded significantly higher pain scores between days 5 and 10 (maximal difference, day 8: 17.6 mm; effect size, -8.87; P = .03; 95% CI, -16.883 to -0.865). There was no significant difference in swallow pain scores or early postoperative fentanyl consumption. Consumption of paracetamol ( P = .01 at day 13 and P = .004 at day 14) and codeine ( P < .05 at days 3-5, 7, 8, 10, 14) was higher in the gabapentin group. No significant difference between groups was found for the other outcomes. Conclusions Preemptive gabapentin (600 mg) was associated with greater postoperative pain scores and analgesic consumption following adult tonsillectomy when compared with placebo.

Risk factors for secondary post-tonsillectomy haemorrhage following tonsillectomy with bipolar scissors: four-year retrospective cohort study

Objective:

To analyse risk factors associated with secondary post-operative bleeding when only one technique, namely bipolar scissors, is used.

Methods:

The medical records of all consecutive patients aged six years or older who underwent tonsillectomy or adenotonsillectomy between 1 December 2010 and 30 November 2014 were retrospectively analysed.

Results:

A total of 1734 patients were included in the study. A secondary haemorrhage occurred in 208 patients (12 per cent). Patients aged 15 years or older were 4.5 times (95 per cent confidence interval = 2.6–7.9;p< 0.001) more likely to experience secondary haemorrhage. In cases of acute quinsy, patients aged 15 years or older had an 8.1-fold (95 per cent confidence interval = 1.1–59.6;p= 0.02) increased likelihood of experiencing secondary haemorrhage.

Conclusion:

Patients aged 15 years or older have a higher risk for bleeding regardless of the primary indication for the tonsillectomy. The risk for secondary haemorrhage does not seem to depend on the primary indication itself.

Control of bleeding by silk ligation and diathermy coagulation during tonsillectomy: A comparison of efficacy of the two techniques in the first 24 hours after surgery

OBJECTIVE

To assess and compare the relative efficacy of silk ligation and diathermy coagulation techniques in controlling bleeding during tonsillectomy in the first 24 hours.

METHODS

This prospective study was conducted at the Department of ENT, Khalifa Gul Nawaz Teaching Hospital, Bannu and this department related consultants' private clinics from January 1, 2012 to December 31, 2014. The study included 180 cases. All patients included were having history of recurrent, acute tonsillitis, with more than 6-7 episodes in one year, five episodes per year for two years, or three episodes per year for three years. All the surgeries were performed by dissection method. Haemostasis during the procedure was secured by either ligation with silk 1 or using diathermy. The results were analyzed using SPSS 16.0 for windows.

RESULTS

A total of180 cases were included in the study. The ages of the patients ranged from 5 to 40 years with the mean age of 15.56 years and a std.deviation of +/- 8.24. The male to female ratio was 1.25:1. The number of hemorrhages occurring was greater in the 'diathermy coagulation' group as compared to the 'silk ligation' group. However, the observed difference was statistically insignificant (p >.05).

CONCLUSION

Primary haemorrhage occurring during tonsillectomy is a serious threat and control of bleeding during the procedure should therefore be meticulous. Both suture ligation and coagulation diathermy for control of bleeders during the procedure by dissection method are equally effective.

Developing a Registry for Complications in Otorhinolaryngologic Surgery: Tonsil Surgery as a Pilot Cohort

OBJECTIVE

To find a suitable method to prospectively register all tonsil surgery-related complications.

STUDY DESIGN

Prospective cohort study.

SETTING

Tertiary care center.

SUBJECTS AND METHODS

From September 2011 to February 2012, patients undergoing tonsillectomy or tonsillotomy were enrolled. A wide range of demographic and clinical data including incidents of postoperative complications was recorded prospectively, and patient records were reviewed 9 months after the end of study period. We evaluated the coverage of prospective data recording, analyzed the complication rates, and assessed the process of registration.

RESULTS

A total of 573 patients were recruited. The study registry including 57 variables required the completion of missing data before analysis. Of all 79 patients with a complication, 69.6% were captured prospectively at the emergency department, and the rest were found when reviewing the patient records. The proportion of prospectively captured complications was highest for the most common complications (eg, 81.1% for secondary hemorrhage). The overall complication rate was 13.8%. Secondary hemorrhage was the most common complication, with the incidence of 9.6%.

CONCLUSION

We have demonstrated the initial feasibility of a prospective complication registry for otorhinolaryngology procedures, and the results can be applied accordingly. We also present 5 practical recommendations when initiating a functional registry. Particular attention should be paid to recognition and registration of both rare and serious events. Regular analysis of the results is required in order to respond to possible changes in the incidence or nature of complications.

Malpractice claims and unintentional outcome of tonsil surgery and other standard procedures in otorhinolaryngology

BACKGROUND

Septoplasty, tonsillectomy (with and without adenoidectomy) and cervical lymph node excision are amongst the most common 50 inpatient operations in Germany. Intracapsular tonsillectomies (i.e. tonsillotomies) are increasingly performed. The aim of this study was to evaluate technical traps and pitfalls as well as alleged medical malpractice associated with tonsillectomy (TE), adenoidectomy (AE), tonsillotomy (TT), septoplasty (SP) and cervical lymph node excision (LN).

METHODS

A questionnaire was sent to the Regional Medical Conciliation Boards, Medical Services of the Health Insurance Companies (MDK) and Regional Institutes of Forensic Medicine in Germany to collect anonymized cases of complications following TE, TT, AE, LN and SP. The results were discussed in the light of the contemporary medical literature and published trials and verdicts in Germany.

RESULTS

The response rate of our survey was 55.9%. The Institutes of Forensic Medicine contributed nine cases, 49 cases were submitted by the Regional Conciliation Boards and none by MDK. All forensic cases were associated with exsanguinations following tonsillectomy including two children (5 and 8 years of age) and seven adults (aged 20 to 69 years). The fatal post-tonsillectomy hemorrhage (PTH) had occurred 8.7 days on average; four patients experienced the bleeding episode at home (day 5, 8, 9 and 17, respectively). Repeated episodes of bleeding requiring surgical intervention had occurred in 6 patients. Three Conciliation Boards submitted decicions associated with TT (1), AE (4), LN (3), SP (16) and TE (25). Cases with lethal outcome were not registered. Only three of the 49 cases were assessed as surgical malpractice (6.1%) including lesion of the spinal accessory nerve, wrong indication for TE and dental lesion after insertion of the mouth gag. The review of the medico legal literature yielded 71 published verdicts after AE and TE (29), LN (28) and SP (14) of which 37 resulted in compensation of malpractice after LN (16; 57%), TE (10; 37%), SP (8; 57%) and AE (2; 100%). There were 16 cases of PTH amongst 27 trials after TE resulting either in death (5) or apallic syndrome (5). Bleeding complications had occurred on the day of surgery in only 2 patients. 16 trials were based on malpractice claims following SP encompassing lack of informed consent (6), anosmia (4), septal perforation (2), frontobasal injury (2) and dry nose (2). Trials after LN procedures were associated exclusively with a lesion of the spinal accessory nerve (28), including lack of informed consent in 19 cases. 49 cases (69%) were decided for the defendant, 22 (31%) were decided for the plaintiff with monetary compensation in 7 of 29 AE/TE-trials, 9 of 28 LN-trials and 6 of 14 SP-trials. Lack of informed consent was not registered for AE/TE but LN (11) and SP (2).

CONCLUSION

Complicated cases following TE, TT, ATE, SP and LN are not systematically collected in Germany. It can be assumed, that not every complicated case is published in the medical literature or law journals and therefore not obtainable for scientific research. Alleged medical malpracice is proven for less than 6% before trial stage. Approximately half of all cases result in a plaintiff verdict or settlement at court. Proper documentation of a thourough counselling, examination, indication, informed consent and follow-up assists the surgeon in litigation. An adequate complication management of PTH is essential, including instructions for the patients/parents, instructions for the medical staff and readily available surgical instruments. Successful outcome of life-threatening PTH is widely based on a proper airway management in an interdisciplinary approach. Electrosurgical tonsillectomy techniques were repeatedly labeled as a risk factor for bleeding complications following TE. Institutions should analyse the individual PTH rate on a yearly basis. Contradictory expert opinions and verdicts of the courts concerning spinal accesory nerve lesions following LN are due to a lack of a surgical standard.

A 7-Year Review of the Safety of Tonsillectomy during Short-Term Medical Mission Trips

Objective. To evaluate the safety of tonsillectomy in a short-term medical mission setting.

Study Design. Retrospective chart review.

Setting. Catholic mission hospital in Guatemala.

Subjects and Methods. During 7 consecutive annual mission trips from 2004 to 2010, patients received tonsillectomy and adenotonsillectomy. Established safety protocol requires candidates for tonsillectomy to agree to stay within 1 hour of the hospital for 10 days following the operation. This study includes all tonsillectomy patients regardless of age or indication for tonsillectomy. The primary outcome measures include posttonsillectomy hemorrhage, nasopharyngeal reflux, readmission for dehydration, and mortality. This is a novel study as the work performed by most short-term medical missions is unregulated and unevaluated.

Results. Medical charts were available for 197 (96.6%) of the 204 patients receiving tonsillectomy in the 7-year period; this was the only inclusion criterion. Ninety-nine (50.3%) patients had tonsillectomy concomitantly with adenoidectomy. Patients ranged in age from 3 to 66 years. The mean (SD) age was 17.2 (14.0) years. The study team found documentation of postoperative complications in 3 (1.5%) patients; 2 experienced postoperative hemorrhage, 1 within the first postoperative hour and 1 at 96 hours. The final patient returned to the hospital within 24 hours symptomatic for dehydration.

Conclusions. The authors have evaluated a protocol for tonsillectomy patients in a specific setting and believe their data represent satisfactory outcomes for the reviewed patients. The generalizability of this information is uncertain, but safety protocols should be established on all short-term medical missions to prevent untoward complications.

Comparison of three techniques in pediatric tonsillectomy

The objective of this study was to compare the thermal welding technique (TWT), classic dissection (CD) tonsillectomy and bipolar cautery dissection (BCD) for pediatric tonsillectomy. Three hundred and five consecutive children with chronic tonsillitis and/or upper airway obstruction were alternately assigned to the TWT, CD, or BCD tonsillectomy groups. Age, gender, operation time, intraoperative blood loss, early postoperative pain, time to regain normal diet, and extent of healing of the tonsillar fossa on the tenth postoperative day were evaluated. The rate of intraoperative blood loss was significantly lower in the thermal welding and BCD groups (p < 0.001). The difference between mean operative time of TWT and BCD groups was not statistically significant (p > 0.001). The difference between mean operative time of the two groups against cold dissection group was statistically significant (p < 0.001). No significant difference was found in the incidence of posttonsillectomy hemorrhage between the three patient groups (p > 0.001). The mean pain score was 4.8 ± 1.2 (median 5, range 4-6) in the TWT group, 8.3 ± 1.3 (median 8, range 7-10) in the BCD group, and 5.1 ± 1.2 (median 5, range 4-7) in the CD group 6 h to 7 days post-surgery. The difference between mean pain score between TWT and CD was not statistically significant (p > 0.001). The difference between mean pain score of the two groups against BCD group was statistically significant (p < 0.001). The results showed TWT as a new tonsillectomy technique with advantages such as shorter operation time and minimal intraoperative blood loss for children patient's post operative comfort. When we compared TWT with the cold dissection and bipolar cautery tonsillectomy, we found that TWT tonsillectomy offered an innovative new tonsillectomy method with significantly reduced blood loss and reduced surgical time and without any increase in the postoperative pain.

Post-tonsillectomy late haemorrhage: is it a preferably night-time event?

AIM

To evaluate the relationship between the incidence of late post-tonsillectomy haemorrhage and its prevalence in a definite period of the day.

STUDY DESIGN AND SETTING

This retrospective study was carried out in the Ear Nose Throat (ENT) Unit of Giannina Gaslini Institute, Genoa, Italy on children operated for adenotonsillectomy (AT) or tonsillectomy (T) between January 2003 and February 2008. We considered in the study all the post-tonsillectomy late haemorrhages irrespective of their severity and for each case we evaluated whether they recurred in the day-time (B) (between 9.00 a.m. and 9.00 p.m.) or in the night-time (A) (between 9.00 p.m. and 9.00 a.m.). Finally we considered the number of haemorrhages per hour in the whole day.

RESULTS

Out of 3306 patients undergoing elective adenotonsillectomy or tonsillectomy, post-operative late haemorrhage occurred in 59 (1.78%). We noted that 42 episodes (71.2%) occurred in the night-time and 17 (28.8%) in the day-time. The average time from the operation was 8.4 days. A statistically significant difference (p=0.002) was found when comparing the frequencies of night-time and day-time haemorrhages. We did not observe any significant difference in the distribution per hour of the haemorrhages.

CONCLUSIONS

The incidence of post-tonsillectomy late haemorrhage in our study population was 1.78%. A statistically significant difference was found between night-time and day-time haemorrhages. Even though no significant distribution of haemorrhages per hour was observed, we underline that we recorded 32 (54.2%) events in 2 periods of the day: from 10 p.m. to 1 a.m. and from 6 to 9 a.m.

Life-threatening posttonsillectomy hemorrhage

OBJECTIVES/HYPOTHESIS

In rare cases, the intensity of posttonsillectomy hemorrhage (PTH) may become life-threatening requiring major surgical means and intensive care. This study was conducted to assess the outcome of life-threatening PTH and its clinical features in a larger patient population.

STUDY DESIGN AND METHODS

Cases occurring during the clinical career of the authors were collected and added by own expert reports to lawsuits and professional boards in cases who had undergone tonsillectomy elsewhere. PTH resulting in hemorrhagic shock requiring resuscitation, ligature of greater arteries in the neck, tracheotomy, packing of the pharynx, embolization, and/or blood transfusions were labeled as life threatening.

RESULTS

Seventy-nine patients had experienced life-threatening PTH between 1980 and 2006, comprising 36 children and 39 adults (age not stated for 4 patients). There were 42 female and 34 male patients (gender not stated for 3 patients). Only nine patients experienced primary bleeding, secondary PTH clearly prevailed (n = 70; 89.6%) in this patient population. Single episodes of life-threatening PTH were reported for 11 cases including two patients with and nine without remaining neurological sequelae. Three of the 11 patients were children (age not stated for 2 patients). Repeated episodes of life-threatening PTH occurred in 68 patients (32 children) including eight with remaining sequelae.

CONCLUSIONS

Life-threatening PTH is an apparently rare, most commonly unpredictable state of emergency requiring a clear management protocol. However, repeated episodes of bleeding classified most clinical courses and should alert the medical staff. Although the bleeding rate after tonsillectomy in children is generally acknowledged to be very low, the rate of life-threatening PTH is apparently higher than in adults. Gender seems not to be a risk factor. Secondary PTH can no longer be assessed to be less dangerous than primary PTH.

Serious post-tonsillectomy hemorrhage with and without lethal outcome in children and adolescents

BACKGROUND

Serious post-tonsillectomy hemorrhage (PTH) is an uncommon complication requiring immediate and adequate medical treatment. This study was undertaken to describe and evaluate the clinical data and courses of serious PTH, with and without lethal outcome in children and adolescents.

MATERIALS AND METHODS

Bleeding episodes accompanied by hemorrhagic shock requiring resuscitation and/or major medical treatment were labeled as serious PTH, with or without lethal outcome. Personal experiences as surgeons and expert reports in connection with lawsuits and Professional Boards, as well as reports collected after a published request contributed to the data collection.

RESULTS

Thirty-one boys and 21 girls (gender not stated for three patients) younger than 18 years of age were enrolled in our study (mean: 8.47; median: 6; S.D.: 4.73 years). Thirty-three children were 8 years of age or younger (60%). Lethal outcome was reported for 19 patients of whom 11 had experienced repeated episodes of bleeding. The majority of the surviving children experienced serious PTH without remaining sequelae (32), however, four children suffered from remaining sequelae. Forty-three children experienced repeated episodes of PTH. The first episode of PTH occurred either at home (32) or in the hospital (22; location not stated for one child). Primary hemorrhage (<24h) was reported for three, secondary bleeding (>24h) for 52 children (94.5%). A total of 169 bleeding episodes was reported of whom 149 were specified as massive (56), major (31), minor (15), diffuse (12), with spontaneous cessation (19) or vomiting of considerable amounts of blood (16). Aspiration was confirmed at the autopsy of seven patients. Ligature of greater arteries in the neck was performed in 35 cases, suturing of the faucal pillars in four and packing of the oropharynx in six patients. Twenty-four children received blood transfusions. Resuscitation was performed in 17 cases but remained ineffective in seven patients.

CONCLUSION

Repeated episodes of bleeding should be considered as a warning sign of serious PTH. Inpatient observation does not eliminate the risk of lethal outcome. Children up to 8 years of age seem to be more susceptible to serious PTH, whereas gender remained irrelevant as a contributing risk factor. Life-threatening PTH is likely to occur as secondary PTH.

Unusual complications of tonsillectomy: a systematic review

AIMS

Common complications of tonsillectomy are well recognized and are frequently explained to patients during the process of informed consent. This systematic review serves as a reminder of the unusual complications of this routine procedure.

METHODS

Studies were located using systematic searches in Medline, Embase, Cinahl, and the Cochrane Library electronic databases, together with hand searching of key texts, references, and reviews relevant to the field. Keywords used included the terms tonsillectomy, complications, unusual, and rare. References from the relevant articles were also searched for.

INCLUSION CRITERIA

The review was limited to English-language articles. Because of the low incidence of these complications, all cases were included regardless of age.

EXCLUSION CRITERIA

Complications of tonsillectomy in children with various syndromes were excluded.

RESULTS

Based on our criteria, 20 articles were identified. Only 10 articles were found suitable for review. All articles were either single case reports or small case series. Because of the small study cohort, the patients' ages ranged widely, from 3 to 21 years, with no sex dominance. The complications were categorized into intraoperative and immediate postoperative (<24 hours), intermediate (<2 weeks), and long-term (>2 weeks) unusual complications. Rare complications reviewed include intraoperative vascular injury, subcutaneous emphysema, mediastinitis, Eagle syndrome, atlantoaxial subluxation, cervical osteomyelitis, and taste disorders.

CONCLUSIONS

It is important that the otolaryngologist is aware that although the complications discussed are rare and interesting, they are associated with significant morbidity and mortality risks. Tonsillectomy, a very common ear, nose, and throat procedure, may not be so straightforward after all.

Radiofrequency coblation tonsillectomy

Radiofrequency coblation is a new technology that is finding favour as a method for performing tonsillectomy. Its benefits include reduced pain and postoperative morbidity but there is controversy regarding possible increased postoperative haemorrhage rates.