Background Tonsillectomy is a commonly performed surgery in the world. The common indicators of tonsillectomy include recurrent tonsillitis, recurrent peritonsillar abscess, and obstructive sleep apnea. Tonsillectomy may be followed by many complications like dehydration, vomiting, nausea, bleeding, pain, and infections, among which bleeding is the most serious complication.
Objective The study aimed to evaluate the incidence and possible risk factors post-tonsillectomy hemorrhage.
Methods This prospective descriptive study included 100 patients (54 females and 46 males) aged between 5-30 years from the otolaryngology unit in Ad-Diwaniah hospital, Ad-Diwania governorate, Iraq, between May 2017 and October 2019. T Inclusion criteria: recurrent tonsillitis, tonsillar enlargement affecting sleep pattern, obstructive sleep apnea syndrome, and immunoglobulin-A nephropathy. Post-tonsillectomy, the hemorrhage was classified based on the bleeding time postsurgery. If bleeding occurred on the first day (24 hours) after operation, it was called primary post- tonsillectomy bleeding, and post that, it was termed secondary post-tonsillectomy bleeding.
Results Of 100 patients, only 11 developed post-tonsillectomy hemorrhage (11%). Primary post-tonsillectomy bleeding occurred in eight patients, whereas secondary post- tonsillectomy bleeding occurred in three patients. Nine male and two female patients developed post-tonsillectomy hemorrhage. Primary post-tonsillectomy hemorrhage occurred in those with obstructive sleep apnea, recurrent tonsillitis, and history of non-steroidal anti-inflammatory drug use, smoking, and obesity and secondary posttonsillectomy hemorrhage occurred in those with smoking history, obesity, obstructive sleep apnea, and recurrent tonsillitis.
Conclusion Older age group, male sex, recurrent tonsillitis, and smoking history are pivotal factors of post tonsillectomy hemorrhage.
Key words: tonsillitis, tonsillectomy, post-tonsillectomy hemorrhage
*Corresponding author: Mazin Rajeh Jaber, Department of Surgery, College of Medicine, University of Al-Qadisiyah, Diwaniyah City, Iraq. Email: mazin.alzubaidi@qu.edu.iq
Submitted: 21 May 2021; Accepted: 25 July 2021; Published: 1 September 2021
©2021 Mazin Rajeh Jaber
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International (CC BY-NC-SA 4.0). License (http://creativecommons.org/licenses/by-nc-sa/4.0/)
Tonsillectomy is a commonly performed surgery around the world. The symptoms of tonsillectomy include recurrent tonsillar infection, recurrent peritonsillar abscess, and obstructive sleep apnea.1–3 Recurrent tonsillitis and disturbed sleep (obstructive sleep apnea due to bilateral tonsillar hypertrophy), and chronic tonsillitis are the commonest indications for tonsillectomy in children and adults, respectively.4–6. Other complications post-tonsillectomy include dehydration, vomiting, nausea, bleeding, pain, and infections, of which bleeding is the most serious complication.7,8 Post-tonsillectomy hemorrhage (PTH) is classified based on the bleeding time after surgery.9,10 Factors affecting post-tonsillectomy bleeding include nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen and aging. The surgeon’s experience was also related to post-tonsillectomy bleeding.11 Post-tonsillectomy bleeding is higher in those with diathermy tonsillectomy than the dissection method.12
This study aimed to evaluate the incidence and possible risk factors of PTH.
This prospective descriptive study included 100 patients (54 females and 46 males) aged between 5–30 years from the otolaryngology unit in Ad-Diwaniah hospital, Ad-Diwania governorate, Iraq, between May 2017 and October 2019. The inclusion criteria were recurrent tonsillitis (defined by SIGN criteria), tonsillar hypertrophy interfere with a sleeping pattern, obstructive sleep apnea, and immunoglobulin A nephropathy.
Recurrent tonsillitis defined by SIGN criteria included:
Tonsillitis causing sore throats.
The sore throat interference with normal life functioning.
Greater than seven severe episodes of sore throats in the last year, or five or more episodes in each of the last 2 years, or more than three episodes in each of the last 3 years.13,14 ,15
Tonsillectomies were performed under general anesthesia with endotracheal intubation and pharyngeal pack, Crowe-Davis mouth gag was inserted. The cold steel tonsillectomy method was employed in this study. Here the tonsil is dragged to the mid-line, and the mucosa was incised to expose the capsule. The dissection was performed through the loose areolar tissue plane between the tonsil and the pharyngeal muscles for the complete tonsil excision. Ligatures were used to cover bleeding vessels as required.13 PTH was classified according to the bleeding time after surgery. If bleeding began within the first 24 hours after the operation, it was termed primary post-tonsillectomy bleeding, and post that, was secondary post-tonsillectomy bleeding.
PTH was classified into five grades according to Windfuhr’s study16:
1st grade: bleeding stopped spontaneously.
2nd grade: bleeding ceased under local anesthesia.
3rd grade: bleeding stopped under general anesthesia.
4th grade: bleeding ceased by ligation of the external carotid artery.
5th grade: death of the patient.
The sex, age, obesity, operative time, smoking status, antibiotics use, and perioperative NSAIDs were recorded.
The study included 100 patients (54 females and 46 males). Table 1 shows the indications and sex distribution of the study population. Among 100 patients, only 11 patients developed post-tonsillectomy hemorrhage (11%). Primary PTH was recorded in eight patients, whereas secondary PTH occurred in three patients. Males (9 patients) developed PTH more than females (2 patients). Table 2 shows the PTH type and patients sex distribution.
TABLE 1. The Indications and Sex Distribution of the Study Population.
| Indication | Male | Female | Total |
|---|---|---|---|
| Recurrent tonsillitis | 24 | 33 | 57 |
| Tonsil enlargement impairing sleep | 6 | 11 | 17 |
| Obstructive sleep apnea syndrome | 14 | 9 | 23 |
| Immunoglobulin A nephropathy | 2 | 1 | 3 |
| Total | 46 | 54 | 100 |
TABLE 2. Post-tonsillectomy Hemorrhage Type and Sex Distribution of the Patients.
| Type of post-tonsillectomy hemorrhage | Male | Female | Total |
|---|---|---|---|
| Primary post-tonsillectomy bleeding | 7 | 1 | 8 |
| Secondary post-tonsillectomy bleeding | 2 | 1 | 3 |
| Total | 9 | 2 | 11 |
The PTH increased with age (Table 3).
TABLE 3. Post-tonsillectomy Hemorrhage in Relation to Age Groups.
| Age (years) | Primary post- tonsillectomy bleeding | Secondary post-tonsillectomy bleeding | Total |
|---|---|---|---|
| 5–10 | 1 | 0 | 1 |
| 11–20 | 2 | 0 | 2 |
| 20–30 | 5 | 3 | 8 |
| Total | 8 | 3 | 11 |
Primary PTH occurred in patients with recurrent tonsillitis (6 patients) and obstructive sleep apnea syndrome (2 patients). Secondary PTH also occurred in patients with recurrent tonsillitis (2 patients) and obstructive sleep apnea syndrome (1 patient), as shown in Table 4.
TABLE 4. Post-tonsillectomy Hemorrhage in Relation to Indications of Surgery.
| Indication | Primary post- tonsillectomy bleeding | Secondary post-tonsillectomy bleeding | Total |
|---|---|---|---|
| Recurrent tonsillitis | 6 | 2 | 8 |
| Tonsil enlargement impairing sleep | 0 | 0 | 0 |
| Obstructive sleep apnea syndrome | 2 | 1 | 3 |
| Immunoglobulin A nephropathy | 0 | 0 | 0 |
| Total | 8 | 3 | 11 |
Primary PTH was reported in smokers (6 patients), perioperative non-steroidal anti-inflammatory drug use (1 patient), and obesity (1 patient). Secondary PTH occurred in those with a smoking history (2 patients) and obesity (1 patient), as shown in Table 5.
TABLE 5. Post-tonsillectomy Hemorrhage in Relation to Risk Factors.
| Risk factor | Primary post- tonsillectomy bleeding | Secondary post-tonsillectomy bleeding | Total |
|---|---|---|---|
| History of smoking | 6 | 2 | 8 |
| History of nonsteroidal anti-inflammatory drugs | 1 | 0 | 1 |
| Obesity (body mass index ≥ 25) | 1 | 1 | 2 |
| Antibiotics after surgery | 0 | 0 | 0 |
| Total | 8 | 3 | 11 |
According to Windfuhr’s grading nine patients were in grade 1, two in grade 2, as shown in Table 6.
TABLE 6. Post-tonsillectomy Hemorrhage According to Windfuhr’s Grading System.
| Windfuhr’s grades | Number of patients |
|---|---|
| Grade 1 | 9 |
| Grade 2 | 0 |
| Grade 3 | 2 |
| Grade 4 | 0 |
| Grade 5 | 0 |
In our study, 11 patients developed PTH (11%). Primary PTH was reported in eight patients, and secondary PTH occurred in three. Of those patients with PTH, the majority (8 patients) were in the older age group (20–30 years). Previous studies showed that age was an important factor in PTH.12,17–19 Children above 11 years of age showed more chances of post-tonsillectomy bleeding.20,21 One study also suggested that age was not an important risk factor,22 as increasing age may cause fragile vessels.20 In this study, males (9 patients) developed PTH more than females (2 patients). Primary post-tonsillectomy bleeding was higher (7 patients) than secondary post-tonsillectomy bleeding (2 patients) in males. The study by Yoshiaki et al.23 suggested that the sex male was a risk factor for secondary PTH, which may be because of the interference of the estrogen hormone in wound healing.24 In children, sex was not a critical factor for PTH.20,25 One study showed that the risk of bleeding was higher in males than females,26 and another showed that the risk is equal for both sexes.27 In patients with recurrent tonsillitis, primary post-tonsillectomy bleeding occurred in six patients and secondary post-tonsillectomy bleeding occurred in two.
Spektor et al.20 reported that the incidence of PTH was higher in recurrent tonsillitis. Two patients with obstructive sleep apnea syndrome developed primary PTH, and secondary PTH was observed in one patient. Previous studies revealed that obstructive sleep apnea was an important risk factor of PTH.28,29 Smoking history was recorded in eight patients (6 in the primary- and two in secondary post-tonsillectomy bleeding. Some studies also reported that smoking was a critical risk factor for hemorrhage in adult patients.30–32 Smoking may increase the risk for inflammation, infection and impair wound healing after surgery, enhancing the possibility of post-tonsillectomy bleeding.33 Yamashita et al.34 showed that smokers could have an increased sputum production compared with nonsmokers and this may cause excessive cough after surgery leading to bleeding. In this study, primary post-tonsillectomy bleeding occurred in one patient with ibuprofen use. Perioperative use of the nonsteroidal anti-inflammatory drug could increase the risk for PTH because of the antiplatelet function of the cyclooxygenase inhibition.35
Previous studies claimed that non-steroidal anti-inflammatory drugs use enhances the risk for PTH,36–39 which was disagreed by the study of Riggin et al.40–42 In this study, two obese patients developed PTH. Kshirsagar et al.43,44 claimed that the chance of bleeding was 2.3 times higher in obese children than nonobese, but the cause was unclear. Yoshiaki et al.45 showed that obesity was not a significant risk for PTH.
This study shows that the male sex, increasing age, and recurrent tonsillitis are suspected risk factors for PTH.
Ethical clearance was obtained from Diwaniyah teaching hospital’s ethical committee.
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