Risk Factors For Post-Tonsillectomy Hemorrhage

Tonsillectomy is one of the most widely recognized surgeries for tonsillitis. It is the default surgery option for obstructive sleep apnea, recurrent tonsillitis, and recurrent peritonsillar abscess. However, there are limited risk factor analyses in Saudi Arabia related to tonsillectomy. The goal of study is to evaluate and analyze the risk factors for secondary post-tonsillectomy bleeding in Saudi Arabia. This retrospective review study was directed at King Abdullah Specialized Children's Hospital, Riyadh, Saudi Arabia. Univariate and multivariate investigations were performed to decide the risk factors. A total of 713 children were included. Post-tonsillectomy bleeding occurred in only 5.3% of tonsillectomies. There was no seasonal variation impact on post-tonsillectomy bleeding rate (P = .8). The multivariate analysis showed a significant association between post-tonsillectomy bleeding and both age (odds ratio [OR] = 1.156; 95% CI: 1.007-1.326; P = .039) and sleep disorder breathing/obstructive sleep apnea (OR = 3.581; 95% CI: 1.454-8.820; P = .006). This study revealed that age, sleep disorder/obstructive sleep apnea, and longer hospital stay after tonsillectomy are significant risk factors for post-tonsillectomy bleeding. This study provides an important baseline for further local studies in the future.

Background: Tonsillectomy, with or without adenoidectomy, is well recognized as one of the most often done surgical procedures in the field of pediatrics. It is commonly recommended for many reasons, such as repeated episodes of adenotonsillitis, obstructive sleep apnea, and peritonsillar abscesses. The aim of this study was to evaluate and assess the significance of the possible risk factors for secondary post tonsillectomy haemorrhage in children. Methods: This prospective study was carried out on 70 patients aged from 3 to18 years old, both sexes, presented with secondary post tonsillectomy haemorrhage. Complete otorhinolaryngological clinical examination to detect tonsillar bed infection (purulent exudate from tonsillar bed, fever, sore throat with bad odor of the mouth) and severity of hemorrhage which is either minimal hemorrhage stopped spontaneously are assessed to all patients. Results: Young age (3-5 years), female sex, number of attacks/ year and postoperative hemoglobin (Hb) level, cold season, Hot techniques of tonsillectomy (unipolar tonsillectomy), and analgesic (ibuprofen) were significant predictors of secondary post tonsillectomy hemorrhage (PTH) requiring management either conservative or second surgical intervention whereas other parameters were insignificant predictors. Conclusions: There are numerous risk factors associated with secondary post-tonsillectomy bleeding in children. Analgesic (ibuprofen) were significant predictors of secondary PTH requiring management either conservative or second surgical intervention whereas other parameters were insignificant predictors.

To review our experience on post-tonsillectomy and/or adenoidectomy hemorrhage (PTAH) at a tertiary pediatric referral hospital and to evaluate the management and risk factors for recurrent postoperative hemorrhage and for delayed bleeding after day 14. A retrospective chart review was performed for all pediatric patients admitted to The Children's Hospital at Westmead for PTAH between July 01, 2014, and June 30, 2019. Patients with recurrent hemorrhage and those with bleeding after day 14 were selected for subanalysis. Of the 291 patients admitted for PTAH, 31 (11%) patients had recurrent postoperative hemorrhage, and 11 (4%) patients had delayed bleeding after day 14. Surgical intervention for cessation of hemorrhage was required in 88 (30%) patients, including 2 patients who required return to the theater more than once. Nine (3%) patients received blood transfusions. The average number of days between bleeding episodes was 4 days. Recurrent postoperative hemorrhage occurred in 8.5% of patients who were managed operatively at their first presentation compared to 11.4% of patients who were managed nonoperatively (odds ratio: 1.1; 95% confidence interval 0.43-2.8). No association was found between abnormal coagulation profile, surgical indication, and risk of delayed postoperative hemorrhage. Recurrent or delayed postoperative hemorrhage represents a small proportion of children with postoperative bleeding and cannot be reliably predicted. Management of first presentations with either a conservative or a surgical approach is reasonable since the risk of recurrent of PTAH may be unrelated to the choice of management at initial presentation. Careful preoperative counseling of patients and their families is important to help set expectations in the event of PTAH.

Post-tonsillectomy haemorrhage—Do coagulation tests and coagulopathy history have predictive value?

Aim The United Kingdom was affected by the COVID-19 pandemic with the reduction of many services within the NHS, including suspension of elective surgical procedures from March 2020. We hypothesised that delayed surgery caused by the pandemic may increase the risk of post-tonsillectomy haemorrhage due to increased episodes of tonsillitis. The aims of this review were to investigate the relationship between prolonged waiting times and post-tonsillectomy haemorrhage. Method We performed a single-site, retrospective review from March 2019 to August 2023, with data collected from electronic hospital records. Both adults and children were included in the analysis and only procedures performed for recurrent tonsillitis were included. Results We identified 234 cases: 184 adeno/tonsillectomies in the pre-COVID (March 2019-20) and 50 in the post-COVID (August 2020-21) cohort. In the pre-COVID cohort, 7.6% (n=14) experienced a post-tonsillectomy haemorrhage, with 1.1% (n=2) experiencing a primary haemorrhage and 6.5% (n=12) experiencing secondary haemorrhage. The return to theatre rate was 2.2% (n=4). Median waiting time for surgery was 78 days. In the post-COVID cohort, secondary haemorrhage occurred in 6.0% (n=3). No patients experienced a primary haemorrhage and return to theatre rate was 0%. Median waiting time was 345 days. Simple logistic regression was performed which showed no significant association between waiting times and post-tonsillectomy haemorrhage across the whole (p = 0.90, 95% CI [-0.0002, 0.0002]) cohort. Conclusions Our cohort demonstrated no significant relationship between prolonged waiting times and post-tonsillectomy haemorrhage. Small sample size was a significant limitation; we recommend a larger scale, multi-centre study to investigate this further.

Background: Tonsillectomy is a common procedure in otolaryngology and currently, there are limited multivariable analyses regarding factors associated with secondary post-tonsillectomy haemorrhage (PTH) in an Australian metropolitan setting. This study aims to provide further analysis of various factors associated with secondary PTH in an Australian metropolitan health service. Methods: A retrospective review was conducted for all elective tonsillectomies performed at Western Health, Australia between December 2011 and December 2015. Multivariable logistic regression analyses were performed. Results: A total of 1,257 tonsillectomies were included. Secondary PTH was observed in 87 (6.9%) patients with 35 (2.8%) returning to theatre. No differences in PTH were found between surgical techniques, month of tonsillectomy, same day discharge and surgeon experience. Multivariable analysis showed that patients receiving ibuprofen (OR =2.07; 95% CI =1.08, 3.99), as well as a 1-year increase in age (OR =1.03; 95% CI =1.01, 1.05) were associated with significantly increased odds of PTH. Conclusions: Tonsillectomy is a common procedure in otolaryngology and this study provides updated local data for a more accurate comparison of surgical outcome.

Post-tonsillectomy bleeding in children with von Willebrand disease: A single-institution experience

Posttonsillectomy hemorrhage (PTH) is a common and potentially life-threatening complication in pediatric tonsillectomy. Early identification and prediction of PTH are of great significance. Currently, there are very few tools available for clinicians to accurately assess the risk of PTH. This study aimed to develop and validate a predictive model for secondary PTH. A retrospective analysis was conducted on 492 individuals who underwent tonsillectomy or tonsillotomy in Children's Hospital of Soochow University from July 1st, 2015 to December 31th, 2023. The study population was randomly divided into the training set and the validation set at a ratio of 7:3. Univariate logistic regression analysis was used to screen features. Multivariate logistic regression and seven machine learning algorithms were used to construct predictive models. Discrimination, calibration, and clinical utility were used to compare the predictive performance. The SHapley Additive exPlanation (SHAP) method was used to interpret the results of the best-performing model. One multivariate logistic regression model and seven machine learning models were constructed. The XGBoost model yielded the best performance in the validation set. The SHAP method ranked the features of the XGBoost model based on their importance and provided both global and local explanations of the model. This study established a machine learning-based predictive model for secondary PTH, which may enable clinicians to accurately assess the risk of secondary PTH in children. 4.

Genetically predicted leukocyte telomere length (LTL) has been evaluated in a number of studies of childhood and adult cancer, with evidence that longer predicted LTL is associated with increased cancer risk. We use Mendelian Randomization (MR) to test whether genetically predicted LTL is associated with germ cell tumors (GCT) in pediatric, adolescent, and adult cases using six SNPs that are validated predictors of LTL. A seventh SNP in the validated genetic predictor of LTL, rs2736100, a variant on TERT, is associated with adult testicular GCT (TGCT); therefore, in our overall analysis, we removed this SNP to avoid violating MR assumptions. Pediatric GCT samples were obtained from a Children's Oncology Group study and state biobank programs in Michigan and California. Genotyping array data were generated using the Illumina HumanCoreExome Beadchip. For each SNP, we estimated main effects for pediatric GCT within 610 complete case-parent trios using the transmission disequilibrium test. We did the same in an independent case-control dataset of 803 pediatric cases and 1,022 controls stratified by ancestry using multivariable logistic regression adjusted for sex, ancestry-specific principal components (PCs), and study site. Effect estimates were meta-analyzed and used to perform the MR analyses. In a separate sample of 396 cases and 1,589 matched controls from the UK Biobank, genotyping array data was used to evaluate the association between a polygenic risk score capturing genetically predicted LTL and TGCT in men <50 years old using multivariable logistic regression adjusted for global ancestry PCs (PC1-10). We observed a positive association between LTL and overall risk of GCT in both the pediatric cases (OR [95% CI] = 2.52 [1.19, 5.34] per kb of LTL; p=0.016) and the adult TGCT cases (OR [95% CI] = 1.94 [0.60, 6.28] per kb of LTL; p=0.266). Subgroup analyses in our pediatric GCT cases show consistent findings of longer LTL and risk across subgroups, with the exception of teratomas. Additionally, we evaluated the individual SNP effect of TERT/rs2736100-A and observed a significant association in pediatric GCT (OR [95% CI] = 1.21 [1.09, 1.35]; p =0.0003) which is driven by male cases diagnosed in adolescence (age at dx 11-19 years). A significant association was also observed between TERT/rs2736100-A and adult TGCT (OR [95% CI] = 1.25 [1.07, 1.46]; p=0.005). Similar to analyses of other childhood and adult cancers, our results indicate that longer telomere length is associated with an increased risk of GCT in pediatric, adolescent, and adult GCT. We also observed a strong association between pediatric GCT and TERT and confirmed previous findings with adult TGCT. These results indicate further analyses of variants in genes relevant for telomere function and maintenance are warranted. Citation Format: Shannon S. Cigan, Ava C. Kelley, John J. Meredith, Erica K. Langer, Anthony J. Hooten, John A. Lane, Benjamin R. Cole, Nathan Pankratz, Jenny Poynter. Predicted leukocyte telomere length and risk of germ cell tumors [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 874.

The Epstein-Barr virus (EBV) is thought to be involved in the pathogenesis of some Hodgkin disease (HD) cases. EBV may be associated particularly with childhood HD, a disease rare in the West compared with developing countries. In this study, a large series of Chinese pediatric HD cases has been examined to determine the age-specific prevalence of EBV. Paraffin sections from 104 pediatric and 52 adult Chinese HD cases were examined for EBV-RNA (EBERs) and EBV latent membrane protein-1. Most pediatric cases arose in boys and showed an histology of mixed cellularity. Prominent interfollicular involvement was seen frequently in the childhood cases. EBV was identified in tumor cells in 113 of 156 (72%) HD cases but was more frequent in pediatric cases (93 of 104; 89%) compared with adult cases (20 of 52; 38%) (P < 0.01; chi-square test). EBV was found in 86 out of 91 (95%) cases in children aged 3-10 years and in 7 out of 13 (54%) cases in children aged 11-14 years (P < 0.01; chi-square test). The virus was less frequent in cases in young adults than in old adults, although this trend was not significant (P > 0.05; chi-square test). Pediatric HD was associated with EBV irrespective of histologic subtype. In adults, EBV was associated more frequently with mixed cellularity than with other subtypes. To the authors' knowledge, this is to date the largest series of pediatric HD cases studied for EBV. Study findings provided further evidence that HD is etiologically heterogeneous. The authors believe that pediatric HD now should be regarded as a distinctive EBV-related lymphoma.

Effect of changing postoperative pain management on bleeding rates in tonsillectomy patients

Epithelial Proliferation in Cholesteatoma

We conducted a retrospective study of 4,848 patients to evaluate the age-specific incidence of post-tonsillectomy hemorrhage that required surgical treatment. We reviewed the charts of 2,567 patients younger than 15 years (pediatric group) and 2,281 patients aged 15 years and older (adult group) who had undergone tonsillectomy with or without adenoidectomy. We found that post-tonsillectomy hemorrhage occurred significantly more often in the adult group (3.9 vs 1.6%; p < 0.001). Moreover, primary hemorrhage (< 24 hr postoperatively) was also significantly more common in the adult group than in the pediatric group (82.9 vs 65.9%, p = 0.023). Analysis of other parameters revealed that post-tonsillectomy hemorrhage was significantly more common in males and in patients who had a history of chronic or recurrent throat infection. Awareness of these risk factors should help improve patient care and outcomes.

Although postoperative bleeding after tonsillectomy is rare, it is potentially life-threatening. The association between steroid administration and postoperative bleeding remains controversial. The findings of previous studies were limited by small sample sizes. To examine the impact of intravenous steroid administration on posttonsillectomy bleeding requiring reoperation in children and adults. Retrospective cohort study of 61 430 patients from 718 hospitals who underwent tonsillectomy between 2007 and 2013, using the Diagnosis Procedure Combination database in Japan. Intravenous steroid administration on the day of tonsillectomy. The main outcome measure was reoperation for hemostasis under general anesthesia. Patient characteristics (age, sex, comorbidities) and steroid use were examined. Patients were classified as children (age ≤15 years, n = 31 934) and adults (age >15 years, n = 29 496), and subclassified into those who received intravenous steroid therapy on the day of tonsillectomy (steroid group) and those who did not (control group). Multivariable logistic regression analysis was performed to analyze the association between steroid use and posttonsillectomy bleeding with adjustment for patient characteristics. The rate of reoperation was significantly higher in the steroid group than in the control group for children (1.2% vs 0.5%) (P < .001) but not for adults (1.7% vs 1.4%) (P = .14). Reoperation was most frequently performed at about 7 days after tonsillectomy. After adjusting for patient characteristics, we found a significant increase in the rate of reoperation in the steroid group in children (adjusted odds ratio [OR], 2.50 [95% CI, 1.47-4.23]) (P = .001) but not in adults (OR, 1.18 [95% CI, 0.85-1.64]) (P = .31). Intravenous steroid administration on the day of tonsillectomy in children was an independent risk factor for severe bleeding requiring reoperation.

Hemorrhages are main complications after tonsillectomy, whatever technique is used. This prospective study aimed at revealing pros and cons associated with monopolar electrodissection tonsillectomy. A prospective study. A prospective study on all patients undergoing tonsillectomy or adenotonsillectomy in Central Hospital of Central Finland in 1997. Operation time and bleeding, as well as perioperative and postoperative complications, were recorded. Inpatient tonsillectomy was performed in 440 patients (mean age, 17.9 y). Primary post-tonsillectomy hemorrhage (within 24 h) occurred in 2.3%. A total of 15.9% of patients searched for medical help because of secondary post-tonsillectomy hemorrhage, 7.7% receiving active treatment and 8.2% not. Post-tonsillectomy hemorrhages proved to be most common in older patients and when peritonsillar abscess was in patient history. Monopolar electrodissection tonsillectomy was fast and resulted in little intraoperative bleeding. However, postoperative hemorrhages were common, and the mean use of analgesics was for more than 10 days. Preoperative counseling must be thorough and realistic. Our results indicate that better methods for tonsillectomy still need to be developed.