Hemorrhage after Tonsillectomy: Does the Surgical Technique Really Matter?

Abstract

A thorough review of the publications on surgical techniques used for tonsillectomy is provided, emphasizing randomized studies and meta-analysis. In the assessment of the data it is important to clearly define and categorize the types of posttonsillectomy bleeding (PTB), as well as the various factors that have been associated with increased PTB. In recent audits of a large number of tonsillectomies, the PTB rates seem to concur: 1% early and 2.5% delayed PTB; 10% anamnestic, 2% objective, and 2% re-operation PTB. Objective PTB rates beyond 10% should require an audit. The bipolar technique seems associated with the least early PTB, while the cold technique is associated with the least delayed PTB. Because of the lack of large well-conducted randomized trials, it is difficult to conclude which technique is the best. With electrocautery techniques, the current power should be adjusted to the minimal level providing hemostasis. Surgical techniques for tonsillectomy that should probably be abandoned include monopolar electrocautery, Coblation, various lasers, and the harmonic scalpel. Vesselsealing systems might hold promise and deserve further evaluation. Tonsillotomy might be associated with less postoperative pain, but the hemorrhagic advantage in randomized studies is not obvious. Tonsil regrowth rates and efficacy to treat obstruction need also further evaluation.

Does Surgical Technique Influence Post-Tonsillectomy Haemorrhage? Our Experience

“…11 By contrast, the technique with the highest bleed rate was dissection and haemostasis by monopolar forceps (20.4%); these results coincide with other studies. 5,6,11 This result is higher than those obtained in other studies such as that of the NPT (4.6%). 11 This result is all the more striking if we consider that this technique was the least frequentlyused in this study.…”

“…In order to study this data properly, it is important to highlight the crucial importance of the definition of ''post-tonsillectomy haemorrhage''. 5,6 Studies where it is defined as ''patients who present with bleeding which is sufficient to require reintervention'', will obviously present lower bleeding rates. For others, as in our case, because we define post-tonsillectomy haemorrhage as ''patients who require medical attention (surgical or medical)'', the rates will be higher.…”

The utility of common surgical instruments for pediatric adenotonsillectomy

“…Postoperative adenotonsillectomy hemorrhage is a feared complication and has a reported occurrence ranging from 2.7% to 15.9% . Postoperative hemorrhage has also been examined in many studies comparing monopolar cautery and radiofrequency ablation, but few to none have included PlasmaBlade analysis . Hong and colleagues compared monopolar cautery to radiofrequency ablation regarding primary and secondary hemorrhage rates and reported no significant difference .…”

Risk Factors for Multiple Hemorrhages Following Tonsil Surgery in Children

“…Post‐tonsillectomy hemorrhage is defined by the time it occurs following the initial surgery: primary (occurring within the first 24 hours postoperatively) and secondary (occurring after 24 hours). Though primary PTH is often more severe in nature, secondary PTH is more common …”

“…Though primary PTH is often more severe in nature, 6 secondary PTH is more common. 7 Reports of hemorrhage rates vary from as low as 1.6% to as high as 17.3% depending on the definitions used. 5,8 Some institutions describe a hemorrhage as any report of bleeding, whereas others define a hemorrhage strictly as return to the operating room for control.…”