ebm mandiri ebm mandiri

Eur Arch Otorhinolaryngol (2009) 266:1983–11 Eur Arch Otorhinolaryngol (2009) 266:1983–

1212

DOI 10.1007/s00405-009-0958-z

MI SC E LLANEOUS

The role of histology and other risk factors for post-tonsillectomy haemorrhage

A. Schrock · T. Send · L. Heukamp · A. O. Gerstner · F. Bootz · M. Jakob

Received: 18 November 2008 / Accepted: 13 March 2009 / Published online: 25 March 2009© Springer-Verlag 2009

Abstract Tonsillectomy is a frequently performed surgical procedure in children and adults. Postoperative bleeding is the most severe complication; however, the factors lead- ing to postoperative haemorrhage are still discussed contro- versially. 1,522 tonsillectomies were retrospectively reviewed. Histopathological tonsil composition was correlated with the incidence of postoperative haemorrhage. Patient charts were analysed with regard to demographic data, characteristics of postoperative haemorrhage and indi- cation for surgery. Patients with post-tonsillectomy haemorrhage were compared with uneventful cases. Histopathological signs of cryptic tonsillitis and actinomyces infection displayed a statistically signiWcant correlation with the risk of postoperative haemorrhage (P = 0.018 and P = 0.02), but the odds ratio was low (1.9 and 2.0). 7.7% of all patients had postoperative bleeding and 3.5% had to return to theatre for haemostasis. The incidence of haemorrhages within hospitalization (5 postoperative days) was45% and after discharge 55%, respectively. In 11% of cases bleeding occurred on the fourth or Wfth day after surgery. While gender, season of surgery, abscess tonsillectomy “en chaud” in comparison with elective tonsillectomy were not associated with an increased rate of postoperative haemorrhage (P > 0.05), signiWcant more postoperative

A. Schrock · T. Send · A. O. Gerstner · F. Bootz · M. Jakob Department of Otolaryngology, Head and Neck Surgery, University of Bonn, Bonn, Germany

L. HeukampDepartment of Pathology, University of Bonn, Bonn, Germany

A. Schrock (&)Universität Bonn Klinik und Poliklinik fürHals-Nasen-Ohrenheilkunde/Chirurgie,

Sigmund-Freud Straße 25, 53127 Bonn, Germany e-mail: [email protected]


1212

haemorrhages were detected in the group of adults (P = 0.02). Despite signiWcant correlation of cryptic tonsillitis and actinomyces infection with postoperative haemorrhage, the risk for postoperative bleeding is only slightly elevated and, therefore, the predictive value is low. Because a multifactorial aetiology of post-tonsillectomy haemorrhage has to be assumed, large multicenter studies are necessary to evaluate the signiWcance of diVerent risk factors.

Keywords Tonsillectomy · Haemorrhage · Histology · Risk factor

Introduction

Tonsillectomy is one of the most common surgical proce- dures performed on children and adults. The earliest description of tonsillectomy appears in the medical ency- clopaedia of Cornelius Celsus in AD 30. He enucleated the tonsil with his Wngernails and suggested the fossa should be washed out with vinegar and painted with a medication to reduce bleeding [1]. Postoperative bleeding is still a serious and potentially life-threatening complication. Depending on the deWnition of post-tonsillectomy haemorrhage the reported rates varied from 1 to 40% [2]. Postoperative haemorrhage is classiWed in primary (<24 h after tonsillectomy) or secondary (>24 h after tonsillectomy) bleeding. Up to now numerous potential risk factors for postoperative haemorrhage have been investigated. However, the histopathological Wndings of the tonsil specimen have not been correlated with the risk of postoperative bleeding. There- fore, the aim of this study was to evaluate this correlation. In addition, the incidence of other potential risk factors for postoperative bleeding (season of operation, age, gender) and characteristics of postoperative haemorrhage such as,

Table 1 Correlation of Histology postoperative haemorrhage and Patients with post-OP All patients with the Statistics

histopathological diagnosishaemorrhage (group A) respective histopath

diagnosisological (odds ratio)

Cryptic tonsillitis 101 1,180 0.018 (1.9)Follicular hyperplasia 87 1,051 0.196Fibrosis (peri- and tonsillar) 33 439 0.874Peritonsillitis 24 282 0.565Actinomyces infection 15 113 0.020 (2.0)


1212

postoperative onset, the side of bleeding tonsillar fossa, and type of bleeding whether diVuse or deWned vessel, were assessed.

Materials and methods

All patients undergoing tonsillectomy at the ENT Depart- ment of the University Hospital Bonn/Germany between 1January 2002 and 1 March 2007 were, retrospectively, analysed. The operation was always performed under general anaesthesia by means of dissection technique. Operations performed under local anaesthesia were excluded. Intraop- erative haemostasis was achieved with diathermy. Ligature was only performed if bleeding occurred from larger vessels. In uneventful cases, patients were discharged 5 days after surgery. Postoperative haemorrhage was deWned as any bleeding that led to an additional consultation indepen- dent on the resulting therapy. Patients with postoperative haemorrhage were divided into two subgroups: Group A consisted of all patients with postoperative bleedings. Group B comprises only patients with postoperative haemorrhage who required another surgical treatment in the operating theatre to stop bleeding. Data of patients with postoperative bleeding (group A/B) were compared with those of the tonsillectomy patients without postoperative haemorrhage. Histopathological Wndings of the tonsil spec- imens were correlated with the incidence of postoperative haemorrhage. Other factors taken into consideration were the patient age (patients older than 15 years were assigned to the group of adults) and gender, season of operation, onset of postoperative bleeding, side of aVected tonsillar fossa and type of bleeding vessel. Furthermore, we compared the risk for bleeding in patients with elective versus abscess tonsillectomy “en chaud”.

The data were analysed using Pearson’s 2 test. P < 0.05was considered as statistically signiWcant.

Results

During the respective 5 years, 1,522 tonsillectomies were performed in general anaesthesia at the University Hospital

Bonn/Germany, comprising 1,414 (92.9%) elective and 108 (7.1%) abscess-tonsillectomies. 1,123 (73.8%) patients were adults and 399 (26.2%) were children. 821 (53.9%) patients were male and 701 female (46.1%). 117/1,522 (7.7%) patients were identiWed as having postoperative haemorrhage (group A) of which 53/1,522 (3.5%) had to return to the operation theatre to stop post-tonsillectomy haemorrhage (group B). In none of these patients ligature of the external carotid artery, embolisation or blood transfu- sion was required. One of the patients in group B displayed a previously undiagnosed coagulation disorder (HIV and drug induced malfunction of the thrombocytes), while the other patients with postoperative haemorrhage did not show a bleeding disorder.

Histopathologic tissue composition versus postoperative haemorrhage

No postoperative bleeding occurred in all 91 cases with malignant tonsillar tumours. Of the benign histopathological results (Table 1) only cryptic tonsillitis and actinomyces infection showed a statistically signiWcant correlation with postoperative haemorrhages (P = 0.018 and 0.02, respectively). The odds ratio was 1.9 and 2.0, respectively.

Age and gender versus postoperative haemorrhage

In group A, 62 of 117 (53%) patients and in group B, 29 of53 (54.7%) patients were male (Table 2). The mean age in groups A and B was 25 (range 1–83) and 26 (range 1–76) years, respectively. The incidence of bleeding was highest within patients aged from 15 to 30 years in group A and 30 to 45 years in group B (Table 3). In group A, postoperative haemorrhage was statistically signiWcant increased in adults (97/1,123, 8.6%) compared with children (20/399, 5.0%, P = 0.02). In group B, no statistically signiWcant diVerence was found between adults (44/1,123, 3.9%) and children (9/399, 2.3%) with postoperative bleeding.

Season of operation versus postoperative haemorrhage

The incidence of postoperative bleeding in the four main seasons for both group A and B are shown in Table 4.

(P)

Eur Arch Otorhinolaryngol (2009) 266:1983– 19

Spring March–May 28/10 388 7.2/25.5Summer June–August 27/12 363 7.4/23.9Fall September–November 36/15 368 9.8/24.2

Winter December–February 26/16 403 6.5/26.5

19 Eur Arch Otorhinolaryngol (2009) 266:1983–

1212

Table 2 Gender of patients with and without postoperative Gender Patients with post-OP

haemorrhage group A/BTotal number of tonsillectomy patients

Risk for bleeding in % group A/B

haemorrhage after tonsillectomy

Male 62/29 821Female 55/24 701

Table 3 Age of patients withand without postoperative haemorrhage after tonsillectomy

Age (years) Patients with post-OPhaemorrhage group A/B

Total number of tonsillectomy patients

Risk of bleeding in % group A/B

0–15 25/11 502 4.98/2.19

15–30 57/21 467 12.20/4.49

30–45 24/16 287 8.36/5.57>45 11/5 266 4.13/1.87

Table 4 Tonsillectomy proce- dures and rates of postoperative Season Patients with post-OP

haemorrhage group A/BTotal number of tonsillectomies

Risk for bleeding in % group A/B

haemorrhages for each season

There was no statistically signiWcant diVerence in the incidence of postoperative haemorrhage in both patient groups between the four main seasons.

Postoperative bleeding with respect to time after operation, side of tonsillar fossa and type of bleeding vessel

Within group B, the mean number of days after tonsillectomy at which postoperative haemorrhage occured was5.8 § 3.4 (range 0–12 days). 24 of 53 patients (45.2%) who required operative haemostasis had haemorrhage within the Wrst Wve postoperative days (before discharge); 29 of these53 (54.8%) requiring operative haemostasis had alreadybeen discharged. 10 of 53 patients (18.9%) suVered from primary and 43 of 53 (81.1%) from secondary haemorrhage. The latter occurred most frequently within the Wrst2 days after discharge (day 6 and 7) (Fig. 1).

Based on the judgement of the treating ENT surgeon,34.6% of postoperative haemorrhage which had to be man- aged in the operating theatre was due to arterial and 65.4% due to venous bleeding. While arterial bleedings occurred within 6.3 § 2.2 days (range 3–11 days) after tonsillectomy, venous bleedings occurred within 4.8 § 3.8 days (range 0–11 days) after surgery. The side of bleeding was in 35.5%the right and in 64.5% the left tonsillar fossa.

Abscess tonsillectomy versus elective tonsillectomy

Nine of 108 patients (8.3%) undergoing abscess tonsillectomy suVered from postoperative haemorrhage and in 4

Fig. 1 Post-tonsillectomy haemorrhage: postoperative number of days

(3.7%) cases operative haemostasis was required. In contrast, 108 of 1,414 (7.6%) patients who underwent elective tonsillectomy had postoperative haemorrhage and 49 patients (3.5%) required operative haemostasis (Table 5).

Discussion

To our knowledge, this is the Wrst study assessing whether routine histologic examination of the tonsil specimen helps to identify an increased risk for postoperative haemorrhage. In our study, we found a statistically signiWcant correlation between postoperative haemorrhage and the histopathological

Eur Arch Otorhinolaryngol (2009) 266:1983– 1919 Eur Arch Otorhinolaryngol (2009) 266:1983–

1212

Table 5 Characteristicsof patients with postoperative Abscess tonsillectomy

(n = 108)Elective tonsillectomy(n = 1,414)haemorrhage receiving abscess

tonsillectomy or elective tonsillectomy Number of patients with

postoperative haemorrhageNumber of patients

receiving operative haemostasis

9 (8.3%) 108 (7.6%)

4 (3.7%) 49 (3.5%)

Gender (male/female) 65/43 (60.2)/(39.8%) 756/658 (53.5)/(46.5%) Mean age § SD 32.5 (§14.8) 26 (§19.8)

diagnosis of cryptic tonsillitis (P = 0.018) and actinomyces infection (P = 0.02). However, the odds ratio was low (1.9 and 2.0, respectively) and for both histologies the risk for postoperative haemorrhage was only slightly elevated. Therefore, the predictive value seems to be low. In our study, the overall incidence of postoperative bleeding after tonsillectomy was 7.7% (group A). 3.5% of all haemorrhages required operative haemostasis (group B). The majority of bleedings occured in the left tonsillar fossa, which might be due to the fact that left-sided tonsillectomies are more demanding for right-handed surgeons. 10 of the 53 patients of group B (18.9%) presented with primary and 43 (81.1%) with secondary haemorrhage, respectively. The main incidence of secondary haemorrhage in group B was between day 6 and 9, a time when ingestion increases as odynophagia decreases. This Wnding correlates with the retrospective study of Windfuhr et al. (15,218 tonsillectomies), who detected that secondary haemorrhage peaks at day 6 [3]. In our study, 45% of the bleedings occurred within the Wrst Wve postoperative days. Although 34% of the haemorrhages took place until day 3, merely 11% occurred within the fourth or Wfth day. This Wnding is inter- esting due to the fact that in Germany tonsillectomy patients generally remain in hospital for 5 days. Therefore, the question arises whether shorter hospitalization periods might oVer a similar safety proWle with a better cost eVec- tiveness. Some authors even support the opinion that a postoperative monitoring for 6–8 h may be suYcient to warrant safety for non-risk patients [4, 5]. In contrast, risk factors such as age <3 years, sleep apnoea, underlying dis- eases (e.g. heart disease, airway disorders), long distance to the hospital, coagulations disorders, and mental retardation [3] should rule out ambulant tonsillectomies. The reduction of hospitalization time is supported by a large retrospective study, which found that excessive post-tonsillectomy haemorrhages (8/15,218, 0.05%) took place either at the day of surgery or as secondary haemorrhage after discharge between day 5 and 10 [3].

In agreement with Breson and Diepeveen [6] our data did not show a statistically signiWcant seasonal variation of postoperative haemorrhages. In contrast, an association between postoperative haemorrhage and season has been observed with a peak of haemorrhages in summer months

[7], late summer and early autumn months [8], winter months [9] or in the winter and summer months [10]. Simi- larly, conXicting results can be found for the correlation between gender and the risk of post-tonsillectomy bleedings: In our study, gender had no inXuence on the risk for postoperative haemorrhage following tonsillectomy in agreement with data by Myssiorek and Alvi [11] or Tami et al. [11, 12]. However, other studies have shown that males have a higher incidence of haemorrhage [7, 9, 11,13–16] and one study reported that females present with a higher incidence of postoperative haemorrhage [9]. Over- all, these conXicting results point at a multifactorial aetiology rather than a direct correlation between season or gender and risk of postoperative bleeding.

Our data shows that patient age correlates with the risk for post-tonsillectomy bleeding in agreement with the pre- vious literature Wndings [3, 7, 9, 11, 13, 17]. Statistically signiWcant more postoperative haemorrhages were detected in the group of adults with a peak within patients aged 15–30 years. This age-dependence has been attributed to the fact that older patients have suVered from recurring infections of the tonsils. Myssiorek and Alvi [11] claimed that chronic infection of the tonsils leads to Wbrosis, scar- ring and neovascularization of the tonsils, which leads to an increased risk of post-tonsillectomy haemorrhage. How- ever, in our study, the postoperative haemorrhage rate decreased in patients older than 40 years. Other authors conWrmed the Wnding that mainly middle-aged patients experience a higher incidence of post-tonsillectomy haemorrhage [7, 13]. This certain age dependance might be due to the fact that patient incompliance with regard to postoperative management including dietary intake and physical rest increases in the age group between 11–40 years.

In our study, no statistical signiWcant diVerence was found between the incidence of postoperative haemorrhage after abscess tonsillectomy “en chaud” (8.3%) and elective tonsillectomy (7.7%). This supports the claim that there is no elevated risk for postoperative haemorrhage after tonsillectomy “en chaud” for peritonsillar abscess [3, 15, 18–20]. Therefore, abscess tonsillectomy seems to be economically more favourable than the alternative treatment with stab incision and elective tonsillectomy within a second hospitalization. Furthermore, the abscess tonsillectomy obviates

Eur Arch Otorhinolaryngol (2009) 266:1983– 1919 Eur Arch Otorhinolaryngol (2009) 266:1983–

1212

complications due to an incomplete drainage or haemorrhage due to injury of aberrant intratonsilar vessels during stab incision. In addition, abscess tonsillectomy detects malignancies presenting as tonsillar abscess at an earlier stage [20].

Conclusion

Our data demonstrate a signiWcant correlation between the incidence of postoperative haemorrhage and histopathological signs of cryptic tonsillitis and actinomyces infection. However, the risk for postoperative bleeding was only slightly elevated, therefore the predictive value seems to be low.

Most postoperative haemorrhages occur as primary bleeding on the day of surgery or as late second bleeding after discharge (5th postoperative day). Only few haemorrhages occurred on the fourth or Wfth day after surgery. Although gender and season of surgery were not associated with an increased rate of post-tonsillectomy haemorrhage, adult patients had signiWcantly increased risk for postoperative haemorrhage. In comparison with elective tonsillectomy abscess tonsillectomy was not associated with an increased rate of postoperative haemorrhage and therefore should be the treatment of choice. Since a multifactorial aetiology of post-tonsillectomy haemorrhage has to be assumed, large multicenter studies are necessary to evaluate the signiWcance of diVerent risk factors.

ConXict of interest statement The authors declare that they have no conXict of interest

References

1. Curtin JM (1987) The history of tonsil and adenoid surgery.Otolaryngol Clin North Am 20:415–419

2. Evans AS, Khan AM, Young D et al (2003) Assessment of secondary haemorrhage rates following adult tonsillectomy—a

telephone survey and literature review. Clin Otolaryngol AlliedSci 28:489–491

3. Windfuhr JP, Chen YS, Remmert S (2005) Hemorrhage following tonsillectomy and adenoidectomy in 15, 218 patients. Otolaryngol Head Neck Surg 132:281–286

4. Helmus C, Grin M, Westfall R (1990) Same-day-stay adenotonsil-lectomy. Laryngoscope 100:593–596

5. Guida RA, Mattucci KF (1990) Tonsillectomy and adenoidectomy: an inpatient or outpatient procedure? Laryngoscope100:491–493

6. Breson K, Diepeveen J (1969) Dissection tonsillectomy—complications and follow-up. J Laryngol Otol 83:601–608

7. Roberts C, Jayaramachandran S, Raine CH (1992) A prospective study of factors which may predispose to post-operative tonsillar fossa haemorrhage. Clin Otolaryngol Allied Sci 17:13–17

8. Williams RG (1967) Haemorrhage following tonsillectomy andadenoidectomy. (A review of 18, 184 operations). J Laryngol Otol81:805–808

9. Carmody D, Vamadevan T, Cooper SM (1982) Post tonsillectomy haemorrhage. J Laryngol Otol 96:635–638

10. Chadha NK (2007) Tonsillectomy return-to-theatre rates demon-strate a monthly and seasonal variation: an analysis of 256, 799 patients. J Laryngol Otol 121:1088–1093

11. Myssiorek D, Alvi A (1996) Post-tonsillectomy hemorrhage: an assessment of risk factors. Int J Pediatr Otorhinolaryngol 37:35–43

12. Tami TA, Parker GS, Taylor RE (1987) Post-tonsillectomy bleeding: an evaluation of risk factors. Laryngoscope 97:1307–1311

13. Kristensen S, Tveteras K (1984) Post-tonsillectomy haemorrhage.A retrospective study of 1150 operations. Clin Otolaryngol AlliedSci 9:347–350

14. Colclasure JB, Graham SS (1990) Complications of outpatient tonsillectomy and adenoidectomy: a review of 3, 340 cases. Ear Nose Throat J 69:155–160

15. Windfuhr JP, Sesterhenn K (2001) Hemorrhage after tonsillec-tomy. Analysis of 229 cases. HNO 49:706–712

16. Windfuhr JP, Ulbrich T (2001) Post-tonsillectomy hemorrhage:results of a 3-month follow-up. Ear Nose Throat J 80:790, 795–798, 800

17. Rosenfeld RM, Green RP (1990) Tonsillectomy and adenoidectomy: changing trends. Ann Otol Rhinol Laryngol 99:187–191

18. Bonding P (1973) Tonsillectomy a chaud. J Laryngol Otol87:1171–1182

19. Lockhart R, Parker GS, Tami TA (1991) Role of quinsy tonsillectomy in the management of peritonsillar abscess. Ann Otol Rhinol Laryngol 100:569–571

20. Windfuhr JP, Chen YS (2001) Immediate abscess tonsillectomy—a safe procedure? Auris Nasus Larynx 28:323–327

ebm mandiri ebm mandiri

Documents