Risk Factors for Multiple Hemorrhages Following Tonsil Surgery in Children

Abstract

Objectives/Hypothesis Although much is known about the incidence and risk factors for hemorrhage after tonsil surgery, the incidence and factors related to multiple episodes of hemorrhage are not well examined. Our objective was to identify risk factors that may contribute to multiple hemorrhages following tonsil surgery in children. Study Design Retrospective chart review. Methods A retrospective review was conducted of pediatric patients who experienced one or more hemorrhages following tonsillectomy/tonsillotomy, with or without adenoidectomy, between 2010 and 2016 at a single, tertiary‐care hospital. Risk factors for multiple hemorrhages were examined using a multivariable logistic regression model. Results Among the 11,140 patients who underwent tonsil surgery, 452 patients experienced one or more hemorrhages; 32 of these had multiple episodes of hemorrhage (7.1% of all patients with bleeds/0.3% of all patients). Older age (≥12 years: adjusted odds ratio [OR]: 3.13; 95% confidence interval [CI]: 1.47‐6.68) and high body mass index for age (≥85th percentile: adjusted OR: 2.26; 95% CI: 1.06‐4.85) were significantly associated with an increased risk of multiple hemorrhages in the multivariable model. Medical comorbidities, indications for surgery, surgical technique, intraoperative blood loss, and perioperative medications were not associated with multiple episodes of bleeding. Conclusions Multiple hemorrhages after tonsillectomy/tonsillotomy are uncommon. The risk of a second PTH after an initial episode is 7.1%, almost double the risk of a bleed after the initial tonsil surgery. Age > 12 years and high BMI for age may be associated with increased risk of rebleeding. After an initial bleed, increased surveillance may be warranted, particularly for patients with risk factors. Level of Evidence 4 Laryngoscope, 129:2765–2770, 2019

Management of Recurrent and Delayed Post-Tonsillectomy and Adenoidectomy Hemorrhage in Children

“…Previous studies have suggested that older patients, those with recurrent tonsillitis, and those with a higher body mass index were more likely to have recurrent PTAH. 13,14 However, this was not reflected in our study, with no association found between age, gender, appearance of oropharynx, and recurrent PTAH. In addition, we did not find any association between abnormalities in hemoglobin concentrations and coagulation profile and risk of multiple bleeding episodes.…”

“…12 Furthermore, choice of surgical technique, severity of first bleed, and NSAIDs use have not been found to increase the risk of recurrent PTAH. 12,14 The risk of recurrent PTAH is therefore difficult to predict for any given child.…”

“…Recurrent PTAH was defined as 2 or more episodes of PTAH. Delayed presentation was defined as any bleeding after postoperative day 14.…”

Evaluation of Secondary Post-Tonsillectomy Bleeding among Children in Saudi Arabia: Risk Factor Analysis

“…However, there have been questions over the use of ibuprofen and other NSAIDs in posttonsillectomy patients. 34 While recent studies failed to find an association between NSAIDs and post-tonsillectomy bleeding, 35 2 studies reported that the administration of ibuprofen increases hemorrhage in the postoperative phase. 36,37 In regard with the use of antibiotic, our findings were in consistent with a recent, meta-analysis which showed that, the use of antibiotic did not reduce the incidence posttonsillectomy bleeding.…”

“…However, there have been questions over the use of ibuprofen and other NSAIDs in post-tonsillectomy patients. 34 While recent studies failed to find an association between NSAIDs and post-tonsillectomy bleeding, 35 2 studies reported that the administration of ibuprofen increases hemorrhage in the postoperative phase. 36,37…”