Various Factors Impact Bleeding Following Tonsil Surgery

What are the risk factors for the frequency and severity of bleeding episodes following tonsillectomy (TE), tonsillotomy (TO) or adenoidectomy (AE)?

Background: TE, TO and AE are the most frequent surgeries in the field of otorhinolaryngology. A variety of studies have dealt with post-operative hemorrhage as the most serious complication of tonsil surgeries. Yet there are varying definitions of what is considered a post-operative bleeding episode, and there are differences in study designs, reported hemorrhage rates and their risk factors in various studies.

Study design: Prospective, multi-center cohort study.

Setting: Department of General Otorhinolaryngology-Head and Neck Surgery, Medical University of Graz, Austria; Department of Mathematics, University Klagenfurt, Austria.

Synopsis: A total of 9,405 patients undergoing TE, TO and AE from October 1, 2009 through June 30, 2010 were studied in Austria. The hemorrhage rate was 15 percent for TE + AE, 2.3 percent for TO + AE and 0.8 percent for AE. Minor bleeding episodes increased the risk of a subsequent severe bleeding episode. Elevated hemorrhage rates were observed for adults, TE + AE and cold steel dissection combined with bipolar diathermy. There was a significantly higher risk of severe bleeding for children aged 6 to 15 years, males and all bipolar operation techniques. Although more than half of all surgeries were AE and TO, only 5 percent of all bleeding episodes were recorded for these types. For TE, the risk factors of patient age (primarily older patients), patient gender (male), indication for surgery (recurrent tonsillitis, tonsillar hypertrophy, obstructive sleep apnea, abscess), grade of surgeon (registrars in training versus consultants) and operation techniques (bipolar techniques and coblation) influenced both the frequency and severity of hemorrhage significantly. Patients with a minor post-operative bleeding episode showed a dramatically higher risk of a second severe bleeding episode. The authors found the post-TE hemorrhage rate to be 15 percent, with 4.6 percent of all patients having to return to the operating room. A limitation of the study was a methodologic bias in that the severity of bleeding episodes was measured according to the medical treatment and not according to the actual intensity of bleeding.

Bottom line: Intensity of bleeding episodes is a crucial aspect of the investigation of post-operative hemorrhage, and a classification of the severity of post-operative bleeding along objective medical criteria is very useful. Because the occurrence of minor bleeding doubles the risk of a second, more severe bleed, the authors suggest readmission to a hospital for minor bleeding.