Postoperative Challenges in Tonsillectomy: Focus on Secondary Hemorrhage

Post-Tonsillectomy Hemorrhage: Factors Influencing Risk and Management Strategies

Background

A tonsillectomy is defined by the American Academy of Otolaryngology-Head andNeck Surgery as "a surgical procedure in which the tonsils, including their capsule, are completely removed by cutting the peritonsillar space between the tonsillar capsule (around the palatine tonsils) and the muscle wall" (1). Although tonsillectomy is an old and established procedure, it remains one of children's most common major surgeries. One of the most popular surgical procedures in the US is tonsillectomy. In the US, more than 500,000 procedures are carried out yearly on children under 15 years old (2). This incidence rate decreased compared to the 2009 National Health Stat Report, which noted over 530,000 tonsillectomies in children younger than 15 years of age (1). Recurrent pharyngeal infections and sleep-disordered breathing (SDB) are two common causes of

this surgery. Bleeding, velopharyngeal insufficiency, and dehydration are known complications of tonsillectomy (3). Depending on the procedure, tonsillectomy requires different equipment. Intracapsular tonsillectomy (partial tonsillectomy) and extracapsular tonsillectomy (complete tonsillectomy) are the two fundamental types of tonsillectomy (4). Extracapsular techniques that are most frequently applied include harmonic scalpel, bipolar cautery (also known as bipolar scissors), "cold" knife (sharp incision), and monopolar electrocautery. Microdebriders, carbon dioxide lasers, and bipolar radiofrequency ablation (potentially removing the tonsils entirely) are examples of intracapsular techniques that can be applied (5). An extracapsular or intracapsular tonsillectomy may be used for pediatric patients with obstructive sleep apnea. However, only extracapsular operations should be done for children who need a tonsillectomy due to peritonsillar abscess or tonsillitis (4, 5).

Epidemiology of Tonsillectomy and Postoperative Complications

The prevalence of Tonsillectomy procedures worldwide varies based on various factors, including patient demographics, healthcare systems, geography, and recommended treatments. A 15-year longitudinal study of the Welsh population was evaluated from 1999 to 2014. During this period, 48,505 tonsillectomies were performed, along with 67,205 hospital admissions for tonsillitis, 8,567 for peritonsillar abscess, and 187 for retropharyngeal or parapharyngeal abscess. Tonsillectomy procedure rates vary widely, in 1998, the rate was 11.8 per child in Northern Ireland and 1.9 per 1000 children in Canada. Additionally, A retrospective analysis was performed at the Otorhinolaryngology Department of the Miguel Servais University Hospital from January 2006 to December 2014. A total of 326 surgeries were performed, of which 39.88% (130) were performed on men and 60.12% (196) on women. The most common presentation was recurrent tonsillitis, accounting for 74.85% of cases, a much higher percentage than other causes. The second most common indications were recurrent tonsillitis with abscess/phlegm and recurrent peritonsillar abscess/phlegm or parapharyngeal abscess/phlegm. While tonsillectomy rates are much lower in Spain, Italy, and Poland, in Belgium, Finland, and Norway they are twice as high as in the UK. Childhood tonsillectomy rates are three times higher in the US than in the UK. The difference is four times higher in New England and seven times higher in England (UK). In a study conducted between 2005 and 2016, almost four out of every 1,000 children experienced a sore throat severe enough to fulfill the evidence-based criteria for a tonsillectomy, and only about one in seven children in the UK got the surgery. This means that no tonsillectomy was ever necessary. Two to three kids out of every 1,000 underwent tonsil removal annually during that time. Out of them, one in eight satisfied the standards based on evidence. This is equivalent to about 32,500 unnecessary tonsillectomies, which come at a yearly cost to the UK of £36.9 million.

There are also geographical differences in the indications for tonsillectomy: in Western countries, obstructive sleep apnea has emerged as a major indicator, especially among adolescents, whereas in developing countries tonsillectomy remains most commonly performed for recurrent or chronic tonsillitis. The researchers identified the following indications for a children's tonsillectomy, a sore throat (78.5%), obstructive symptoms (16.2%), and peritonsillar abscess (0.5%).

Anatomy and Physiology of the Tonsils

The palatine tonsils, or "tonsils," and the pharyngeal tonsils, or "adenoids," are the two basic types of tonsils (6). The pharyngeal tonsils are also situated in the midline of the posterior wall and roof of the nasopharynx. The palatine tonsils are located along the lateral wall of the oropharynx between the anterior and posterior tonsillar pillars (6, 7).  The main artery of the tonsil is the tonsillar branch of the facial artery. It penetrates the superior constrictor muscle just above the styloglossus muscle and then penetrates around the inferior pole of the tonsil (8). The tonsillar branch of the glossopharyngeal nerve and the lesser palatine nerve provide sensory input to the palatine tonsil and tonsillar fossa and arise from the second division (V2) of the trigeminal nerve. Patients with tonsillar disease or who have recently had a tonsillectomy may complain of ear-referred pain because the glossopharyngeal nerve also supplies sensation to the middle ear via a branch of the tympanic nerve (7, 8).

The main role of the tonsils is to protect against food-borne infections. The immediate submucosal region of these lymphoid organs contains germinal centers where B and T cells reside. Mostly composed of B cells, they secrete IgG and IgA (9). Thus, exposure to allergens in the upper respiratory tract enhances both local and systemic immunity. Recurrent tonsillitis may indicate an underlying immune system problem in the patient or the tonsils themselves. In children with recurrent tonsillitis, the levels of IgA synthesis in tonsillar B cells were significantly reduced (9, 10).

Postoperative Complications of Tonsillectomy

A tonsillectomy is a standard procedure, although there are some associated risks. Although tonsillectomy is generally considered a minor surgery, however, it has more frequent and sometimes serious consequences than other similar surgeries. Postoperative complications might arise sooner or later, and they can range in severity from minor discomfort to potentially fatal diseases (11). More complications occur from pediatric tonsillectomy than from any other major surgical procedure. These are the two forms of bleeding. These are the two forms of bleeding, Primary bleeding happens 24 hours after surgery, while secondary bleeding happens a few days later (typically 5 to 10 days). Recent studies have shown that the rate varies widely in the general population (2.61% to 15%) but is approximately 4% in children who suffer from postoperative bleeding (12).  A study revealed that 2.7% of children are returned to the hospital within 30 days, while 12.4% of children are brought to the emergency room due to bleeding. The most common complication of tonsillectomy is delayed bleeding, occurring in 2-4% of cases (11). Remarkably, bleeding after surgery is more frequent and might be brought on by fibrin clots that were forced loose at the operative site. Depending on the type of operation, postoperative bleeding has been observed to occur 1–10% of the time (13). For instance, compared to cold steel dissection, bipolar cautery is associated with a reduced bleeding rate. A study included 694 patients who underwent tonsillectomy (TE) with or without adenoidectomy at the Otolaryngology Department of Yokohama Minami Kyosai Hospital. This study's post-tonsillectomy hemorrhage (PTH) risk was 11.6%, with a primary PTH rate of 1.6% and a secondary PTH rate of 10.0%. The reoperation rate was 2.6%.  Furthermore, another study results show that Bleeding after tonsillectomy occurred in 1.83% of cases. Primary bleeding occurred in 33.70% of patients, and secondary bleeding occurred in 66.30% (14). The reoperation rate due to bleeding in all patients was 0.92% and 0.88% of patients were rehospitalization due to bleeding. Multiple hemostatic procedures were performed in 6.52% of patients (14). Unexpected, life-threatening bleeding after tonsillectomy requires immediate and appropriate medical attention. Patients with a higher incidence of tonsillitis are thought to have more complex anatomy and larger scars in the tonsillar bed, which increases the risk of bleeding after surgery (15). The main causes of secondary bleeding were the underlying muscle or artery visible after removal of the initial scab or infection at the site (16). After surgery, the fibrin clot often detaches from the tonsillar fossa on the fifth or seventh day, leaving behind a thin layer of newly formed stroma and epithelium. This is the point at which the risk of significant bleeding is highest, and also the point at which the venous bed is relatively exposed (17). As an indicator of quality and safety, it is important to consider the frequency of postoperative bleeding after tonsillectomy. Analysis of primary and secondary bleeding after tonsillectomy should be performed annually (16).

Another typical consequence after surgery is pain. Symptoms can range from mild to severe and usually last for 7-10 days. It is often thought that some patients need to be readmitted to the hospital to treat dehydration and relieve symptoms caused by insufficient oral fluid intake (18). There is disagreement on the relationship between the risk of bleeding and the surgical indication. Tolska et al. and Seshamani et al. observed a greater risk of bleeding in individuals whose first diagnosis was recurrent tonsillitis, however, this link might not be statistically significant (19). According to recent research by Betancourt et al., bleeding is more frequently associated with a history of peritonsillar abscess. The long-term impact of tonsillectomy may include altered sensitivity to allergies, infections, and respiratory disorders (18). The healing of wounds following tonsillectomy is an area that has received little research, with little published papers in this field (20). Hence, there is little data available to doctors to guide dissection techniques in a way that promotes healing following tonsillectomy. Enhanced comprehension of this field might result in better assessment of surgical methods and the recovery period (16, 20).

Risking of Secondary Hemorrhage

Older age has been linked as a possible risk factor for secondary PTB in earlier research. Male sex and increasing age Two independent risk factors for repeat visits owing to bleeding were found in large database research of 35,085 tonsillectomies conducted in hospital outpatient and inpatient settings (21). There is debate on the intrinsic risk of PTB when stratified by surgical indication. According to some writers, children who have tonsillectomies due to sleep apnea may be more likely to experience bleeding than children who have chronic tonsillitis (22). Because sleep apnea is obstructive, it is thought to increase the risk of bleeding throughout the healing phase by creating a larger negative pressure gradient in the throat. according to a database analysis of over 138,998 procedures performed in California, Obesity and old age are risk factors for post-tonsillar bleeding (PTB), but sleep apnea is not (22, 23). According to Tomkinson et al., patients aged 12 years or older had a 1.5- to 3-fold higher incidence of postoperative bleeding (primary or secondary) requiring surgery compared with children younger than 12 years (24). Furthermore, some have reported that those with chronic tonsillitis have a higher chance of bleeding. A study by Ikoma Ryo et al., revealed that male sex, age, and surgeon competency were clinical risk variables for category III post-tonsillectomy hemorrhage (PTH) (23). Additionally, Yoshiaki Inuzuka et al. found that the taking of non-steroidal anti-inflammatory drugs before surgery, male sex, and current smoking status were the main risk factors for overall post-tonsillectomy bleeding (21).

Surgical Techniques: Bipolar Cautery in Tonsillectomy

About 2,000 years ago, the Roman physician Celsus wrote the first report on tonsillectomy. From this, it is clear that people were already aware of the importance of postoperative bleeding (25). Since then, physicians have been searching for strategies to reduce both intraoperative and postoperative bleeding. A study result shows that the tonsillectomy technique and the surgeon's experience seem to be largely associated with primary bleeding (26). However, it is also believed that differences in the surgeon's expertise and specific temperatures for incision and coagulation settings may affect the outcome of surgery. One study found that there is a significant difference in the familiarity of surgical techniques and the anatomy of the peritonsillar space between junior surgeons (<5 years of experience) and experienced surgeons (>5 years of experience) (14). Furthermore, it has been found that different temperatures are much more likely to cause bleeding, especially in warmer seasons. Monopolar electrocautery appears to have reduced the rate of initial bleeding and intraoperative blood loss (27). According to Raut et al., depending on whether hot homeostasis or cold dissection was used as the primary treatment, secondary bleeding occurred in 15.76% of cases and primary bleeding occurred in 5.55% of cases. Meanwhile, primary bleeding occurred in 3.14% of cases and secondary bleeding occurred in 12.5%. This may be attributed to the use of hot dissection and cold homeostasis as the only methods (28). Retrospective medical record analysis of tonsillectomies performed by cold dissection using bipolar cautery for hemostasis purposes between January 1, 2016, and June 30, 2017 (29), and the number of post-tonsillectomy bleedings that occurred during this period, 119 patients who underwent tonsillectomy, 15 patients (12.6%) experienced bleeding after tonsillectomy between the 5th and 12th postoperative days (29). This may explain the fact that in studies where suction cautery is routinely used to control bleeding, even in “cold knife” tonsillectomy, the rate of major bleeding is low, even lower than the rebleeding rate (30). The opposite seems to be true when suture ligation is used to stop bleeding during tonsillectomy. Electrocautery, especially bipolar coagulation, is considered the most commonly used method for tonsillectomy (26).

Depending on the method, several studies have found varying rates of both primary and secondary tonsillar hemorrhage, Comparative literature reviews on bleeding incidence often focus on surgical methods, ligation, bipolar-monopolar cautery, and chemical agents (e.g., Ankaferd Blood Stopper) (31). The most common of these techniques is bipolar cautery. Every approach has benefits and drawbacks of its own. However, the primary goal is to develop a technique that may shorten the duration of the procedure, minimize the danger of bleeding during and after the procedure, lower the number of problems, and improve the patient's comfort after the procedure (32). Although some authors have reported that the tonsillar fossa healed faster using the CD technique, Pizzuto et al. showed there was no difference in the healing period of tonsillar fossae between electrosurgical and conventional dissection tonsillectomy (32, 33).

Although Coblation tonsillectomy is becoming more common in modern practice, bipolar electrocautery tonsillectomy has long been the procedure of choice for many otologists (34). Two groups of equal size were randomly selected from 120 patients. Throughout the observation period, the mean pain score associated with Coblation tonsillectomy was significantly lower than that of bipolar electrocautery (p < 0.001)  (35). The difference in pain duration was statistically longer in the bipolar group. The incidence of secondary and reactive postoperative bleeding was significantly higher in the bipolar group (36). It has been demonstrated that recovery time is significantly reduced when tonsillectomy is done by the coblation technique. Additionally, to investigate the difference in post-tonsillectomy bleeding between the cold steel technique and bipolar diathermy for tonsillectomy. 102 patients undergoing tonsillectomy participated in a randomized controlled trial (37). When evaluating bipolar diathermy and suturing techniques, Sharif M. et al. found that 1% of both groups experienced regular bleeding (38).In a comparative study of 180 patients, Khan AR et al. found that the frequency of rebleeding differed between patients who used suturing (4.16%) and those who used diathermy (13.33%) (39). The frequency of secondary bleeding with the cold steel technique was measured to be 1.96%, whereas the frequency with bipolar diathermy was 11.76%. The study found that those who received bipolar diathermy therapy were more likely to experience bleeding after tonsillectomy than those who received the cold steel technique (37). Similarly, when bipolar cautery and ligation were compared for hemostasis following tonsillectomy, Malik MK et al. discovered that the incidence of secondary bleeding was 1.3% in the bipolar cautery group and 0.7% in the ligation group. surprisingly, bipolar cautery shortened the duration of the procedure overall, but it also caused more postoperative pain, such as sore throat (40). Iqbal SM et al. compared the results of diathermy coagulation with the suturing technique to evaluate hemorrhage after tonsillectomy. The study found that secondary bleeding occurred in 5% of cases after suturing method and 12% after diathermy (33). Though warm dissection is linked to increased subsequent bleeding, some professionals still choose cold dissection in cases of bleeding patients due to its effectiveness and reduced postoperative morbidity (41). According to these specialists, using heated dissection during a tonsillectomy raises the risk of morbidity throughout the healing process, particularly following hospital discharge (42).

Clinical Importance of Monitoring Secondary Hemorrhage

Up to 50% of patients who report postoperative bleeding will not experience rebleeding, and bleeding can be managed conservatively (43). Approximately 90% of patients who undergo reoperation for hemostasis will have successful cessation of bleeding. In a retrospective analysis of 209 patients who bled after tonsillectomy requiring surgery, the success rate dropped to 50-67% (21, 43). Burton et al. conducted recent research and concluded that no proof using antibiotics after a tonsillectomy reduces discomfort or bleeding. Patients who had bleeding episodes were kept in the hospital for 24 hours under proper surveillance and hydration and electrolyte replacement (44).  Negum et al. discovered that conservative care alone was necessary in almost 90% of group B patients. Only (10%) needed to be operated on again, and general anesthesia was used to stop the bleeding (45).

 

Objectives:

The main objective of this study is to evaluate the incidence and risk factors of secondary hemorrhage after tonsillectomy using bipolar cautery. Special attention will be paid to identifying patient characteristics, surgical methods, and postoperative care that may impact the development of this complication.
1. To assess the overall incidence of bipolar cautery-induced subsequent bleeding following tonsillectomy.

2. To examine when subsequent bleeding occurs, especially in the five-to-ten-day postoperative interval.
3. To look at the relationship between patient-related variables (such as age, gender, and comorbidities) and subsequent bleeding after tonsillectomy.
4. Using the body of available research as a basis, evaluate the frequency of subsequent bleeding between conventional tonsillectomy procedures and bipolar cautery.
5. To determine how well bipolar cautery works in comparison to alternative techniques for reducing intraoperative and postoperative bleeding.
6. To offer suggestions for clinical supervision and care to lower the chance of bleeding in patients having bipolar cautery performed during tonsillectomy.

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