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Posttonsillectomy Hemorrhage
What Is It and What Should Be Recorded?
James H. Liu, MD;
Kristofer E. Anderson, MD;
J. Paul Willging, MD;
Charles M. Myer III, MD;
Sally R. Shott, MD;
Glenn O. Bratcher, MD;
Robin T. Cotton, MD
Arch Otolaryngol Head Neck Surg. 2001;127:1271-1275.
ABSTRACT
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Objectives To report on our incidence of posttonsillectomy hemorrhage and to define
what constituted posttonsillectomy bleeding.
Design Retrospective study.
Setting Tertiary care children's hospital and a local satellite facility.
Patients A series of 1438 consecutive patients who had undergone either tonsillectomy
or adenotonsillectomy between January 1, 1999, and December 31, 1999.
Intervention During this period, parents were instructed to return with their children
for clinical evaluation if any blood was seen in the postoperative period.
Main Outcome Measures Postoperative day of evaluation, age, sex, location of bleeding, management
strategy, length of hospital admission, and any bleeding disorders were noted
for each patient.
Results A total of 112 patients underwent evaluation 134 times. Of these patients,
96 required only 1 evaluation and 16 required more than 1 evaluation. All
patients who had more than 1 evaluation required intervention. The total number
of children requiring intervention for posttonsillectomy hemorrhage was 51
(3.5%) of the 1438 patients. Female patients were more likely than male patients
to return for evaluation. Patients who were 12 years and older were the most
likely and those 3 years and younger were the least likely to have posttonsillectomy
hemorrhage. The most common time from surgery to initial evaluation for hemorrhage
was 6 days.
Conclusions By reviewing our own criteria for defining and recording posttonsillectomy
hemorrhage, we conclude that posttonsillectomy hemorrhage is defined differently
in the literature. This supports the need for a standard definition to allow
for direct comparisons.
INTRODUCTION
TONSILLECTOMY with and without adenoidectomy is one of the most common
surgical procedures performed by otolaryngologists in the United States.1 Recurrent tonsillitis, obstructive sleep apnea, and
peritonsillar abscess are the most common indications.2
The most frequent serious complication of tonsillectomy is posttonsillectomy
hemorrhage, occurring at a rate between 0.28% and 20%.2-13
This wide range of posttonsillectomy hemorrhage rates reflects the diversity
in the otolaryngological community on how to properly define significant posttonsillectomy
hemorrhage. In this study, we report a widely inclusive definition of posttonsillectomy
hemorrhage. A review of reporting criteria in the literature is described
and a plea for consistency in reporting is made for defining significant posttonsillectomy
hemorrhage to allow comparisons between medical centers and to allow assessment
of one's own performance improvement.
MATERIALS AND METHODS
A retrospective medical record review was undertaken on a series of
1438 consecutive patients who had undergone either tonsillectomy or adenotonsillectomy
between January 1, 1999, and December 31, 1999, at Children's Hospital Medical
Center, University of Cincinnati Medical Center, Cincinnati, Ohio, a tertiary
care children's hospital, or at Children's Outpatient Services, Mason, Ohio,
a local satellite facility. All surgical procedures were performed by 1 of
5 otolaryngology staff (J.P.W., C.M.M., S.R.S., G.O.B., or R.T.C.) or by otolaryngology
residents and pediatric otolaryngology fellows under the direct supervision
of staff. All surgeons used a similar surgical procedure. Patients received
general endotracheal anesthesia with tonsillar exposure provided by a Crowe-Davis
mouth gag. Examination for a submucous cleft palate and prominent vessels
was undertaken prior to the initiation of surgery. Surgical procedures were
then performed using the technique of electrocautery dissection of the tonsils
followed by suction electrocautery for adenoid removal and for final hemostatic
control of the tonsillar fossa. Prior to anesthetic reversal, all patients
received gastric and oropharyngeal suction and the tonsillar fossa and adenoid
beds were reexamined for bleeding.
Using hospital and otolaryngology departmental records, all postoperative
tonsillectomy hemorrhage incidents were identified. Patient ages, sex, concurrent
bleeding disorders, and postoperative day of bleeding evaluation were noted.
In addition, the location of hemorrhage from the tonsillar fossa (diffuse,
superior pole, middle pole, or inferior pole) was recorded if identified.
Location of evaluation (emergency department, inpatient ward, or operating
room) and management strategy (no therapy, clot suction, direct pressure,
or cautery) were identified. A significant posttonsillectomy hemorrhage was
defined as a patient requiring intervention in the form of either direct pressure
or cautery regardless of the location of evaluation. Hospital admissions and
duration of hospital stays were noted.
To determine statistical significance,  2 analysis was
performed. Statistical significance was set at P<.05.
RESULTS
A total of 1438 patients were identified from our computerized billing
database. The age distribution of patients was as follows: 317 (22.0%) between
0 and 3 years old, 969 (67.4%) between 4 and 11 years old, and 152 (10.6%)
12 years old or older. The oldest patient to undergo surgery was 20 years
old, the youngest 2.5 months. Overall, 706 (49.1%) of the patients were female
and 732 (50.9%) were male.
One hundred twelve (7.8%) of the 1438 patients returned for posttonsillectomy
hemorrhage evaluation when the caregiver saw blood of any volume. No patients
required a blood transfusion. Ninety-six patients were evaluated once for
hemorrhage and 16 patients were evaluated multiple times for bleeding; 11
had 2 evaluations, 4 had 3 evaluations, and 1 had 4 evaluations. This resulted
in 134 total posttonsillectomy hemorrhage evaluations. Of the 134 bleeding
evaluations, 9 (6.7%) were primary or within 24 hours of surgery and 125 (93.3%)
were secondary or longer than 24 hours after tonsillectomy. The most common
time for posttonsillectomy hemorrhage evaluation was postoperative day 6 (Figure 1). Of the 134 evaluations, 51 were
on the right side (5 in the upper pole, 7 in the middle pole, 16 in the lower
pole; 8 were diffuse and 15 were unspecified) and 57 were on the left side
(7 in the upper pole, 6 in the middle pole, 14 in the lower pole; 11 were
diffuse and 19 were unspecified).
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Postoperative day for the evaluation of hemorrhage after tonsillectomy.
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The age distribution for the 112 patients who presented for posttonsillectomy
hemorrhage evaluation(s) was as follows: 13 children between 0 and 3 years
old (4.1% of the 0- to 3-year-olds undergoing operation), 78 children between
4 and 11 years old (8.0% of the 4- to 11-year-olds undergoing operation),
and 21 children 12 years old and older (13.8% of the  12-year-olds undergoing
operation). Using 2 analysis, the difference in the percentage
of the age groups who presented for evaluation is statistically significant
(P = .001). The percentage for the 3 age groups relative
to the hemorrhage evaluation cohort of 112 patients is 12% or 13 of the 0-
to 3-year-olds; 70% or 78 of the 4- to 11-year-olds; and 19% or 21 of those
12-year-olds and older. Sixty-eight (9.6% of all female patients) of the patients
evaluated for bleeding were female, and 44 were male (6.0% of all male patients).
The difference in the sex of the patients who presented for evaluation is
statistically significant (P = .01). Females made
up 61% (68 patients) and males made up 39% (44 patients) of the posttonsillectomy
hemorrhage evaluation cohort of 112 patients.
Of 112 patients who presented for postoperative evaluation, 51 (46%)
required intervention. Thus, our significant posttonsillectomy bleeding rate
was considered to be 51 (3.5%) of the 1438 patients. These children were considered
to be our patients who had had an actual posttonsillectomy hemorrhage because
they had bleeding to a degree that some form of intervention was deemed necessary.
Of the 51 patients, 31 had intervention in the emergency department and 20
had intervention in the operating room. All 16 patients who presented for
multiple hemorrhage evaluations required intervention. Six were managed in
the emergency department and 10 required intervention in the operating room.
The age distribution of our significant bleedings was as follows: 3
children between 0 and 3 years old (0.9% of the 0- to 3-year-olds who were
operated on), 34 children between 4 and 11 years old (3.5% of the 4- to 11-year-olds
who were operated on), and 14 children 12 years old and older (9.2% of the 12-year-olds
who were operated on). The differences between age groups with posttonsillectomy
hemorrhage requiring intervention is statistically significant (P<.001). The percentage of significant bleeding for the 3 age groups
relative to the hemorrhage evaluation cohort of 112 patients is 3% (3 patients)
for those 0 to 3 years old; 30% (34 patients) for those 4 to 11 years old;
and 13% (14 patients) for those 12 years old and older. Twenty-nine of the
51 patients with significant bleeding were female (4.1% of all female patients),
and 22 were male (3.0% of all male patients). The differences between the
sex of the patients with significant bleeding is not statistically significant
(P = .26). Of those who had significant bleeding,
females make up 57% (29 of the 51 patients) and males 43% (22 of the 51 patients).
For the 61 patients who were evaluated but required no intervention,
32 were discharged home from the hospital after undergoing clinical examination.
Twenty-nine patients were admitted to the hospital for observation. If a patient
was admitted to the hospital either after intervention or for observation,
the average length of stay was 1.2 days.
Three patients with bleeding disorders were identified in this study.
Two were diagnosed before surgery as having a nonspecific anticoagulant disorder
with prolonged partial thromboplastin time. One patient was diagnosed postoperatively
as having a platelet disorder resulting in a prolonged bleeding time.
COMMENT
In the last 30 years, a multitude of researchers have investigated the
cause, incidence, and management of posttonsillectomy hemorrhage, yielding
hemorrhage rates between 0.28% and 20%.2-13
Primary hemorrhage is defined as bleeding that occurs in the first 24 postoperative
hours. Secondary hemorrhage, or postoperative bleeding after 24 hours, has
as its origin the sloughing of eschar, trauma secondary to solid food ingestion,
tonsil bed infection, postoperative nonsteroidal anti-inflammatory drug usage,
or idiopathic causes.3-5
Studies investigating the effect of the age and sex of the patient, indication
for surgery, and surgical method have demonstrated variable results, while
other factors, including the surgeon's operative experience, show no effect
on hemorrhage rates.2, 5-6
Despite this wealth of data, great differences exist in the reported incidence
of posttonsillectomy hemorrhage, recommended management, and the very definition
of what constitutes significant posttonsillectomy hemorrhage.
How a study defines posttonsillectomy hemorrhage directly affects the
recorded incidence rate. For example, several early posttonsillectomy bleeding
studies noted incidence rates of 0.46%, 0.8%, and 1% following cold knife
tonsillectomies with study inclusion criteria primarily based on the need
for operative therapy.7-9
Maniglia et al10 reported a hemorrhage rate
of 0.28%, with 2 primary and 2 secondary hemorrhages, in a study of 1428 cases
of cold knife tonsillectomies with bismuth subgallate hemostasis. Study inclusion
required "significant bleeding" defined as hemorrhage requiring emergency
department or operating room intervention for control. In comparison, in a
study of 1445 cold knife tonsillectomies, Handler et al11
reported a postoperative hemorrhage rate of 2.62%. This value reflects the
inclusion of not only operative candidates but also primary and secondary
hemorrhages that required only hospital admission and observation and those
reported by parents at clinic follow-up appointments. Using the criteria of
Maniglia et al, Handler et al would have a hemorrhage rate of only 1.03%.
In a similar study using the criteria of Handler et al, Conley and Ellison5 reported hemorrhage rates of 1.1% (n = 705) and 4.1%
(n = 581), or 2.5% total, in a cohort of 1286 patients undergoing standardized
cold knife tonsillectomies comparing the utility with and without a 3-minute
retraction relaxation and bismuth subgallate intraoperatively for bleeding
control. Their total rate would be only 1.4% by the criteria of Maniglia et
al; Kristensen and Tveteras,3 in a study of
1150 cold knife tonsillectomies, found a 2.8% postoperative hemorrhage rate
by including only those bleedings requiring operative intervention using criteria
similar to Maniglia et al. Gabalski et al12
retrospectively reviewed the medical records of 534 patients by examining
the time course of postoperative hemorrhage and reported a hemorrhage rate
of 0.37% using reporting criteria similar to Maniglia et al. Weimert et al13 who reviewed 2431 electrocautery dissection tonsillectomies
reported a hemorrhage rate of 1.2%; it was 0.58% if only operative candidates
were counted. Irani and Berkowitz,6 in a review
of posttonsillectomy hemorrhage studies included only patients requiring hospital
admission for bleeding, resulting in only 163 patients in the 12 years reviewed.
Their 13% rate of major interventions (operative control or transfusion) cannot
be compared with the studies by Kristensen and Tveteras,3
Conley and Ellison,5 Maniglia et al,10 Handler et al,11 or
Weimert et al13 because a total case number
is not provided. These examples illustrate how different authors use variations
in the definition of "significant" posttonsillectomy hemorrhage as functions
of the goals of their individual studies, all producing results that are not
directly comparable.
Despite the acceptance of electrocautery for the control of postoperative
bleeding, few studies have examined the effect of electrocautery dissection
on postoperative tonsillectomy hemorrhage. The prospective study of Weimert
et al13 compared cold knife and electrocautery
dissection tonsillectomies and concluded that electrocautery dissection was
more rapid, decreased blood loss, and significantly decreased primary hemorrhage
rates, the most frequent cause of posttonsillectomy mortality. Weimert et
al reported a postoperative hemorrhage rate of 1.2% for electrocautery dissection.
Szeremeta et al,2 in a retrospective comparison
of cold knife and electrocautery dissection techniques, found hemorrhage rates
of 3.9% and 2.9%, respectively, excluding patients with a history of peritonsillar
abscess, which dramatically increased cold knife tonsillectomy hemorrhage
rates. All patients in our study underwent electrocautery dissection and suction
electrocautery for hemostasis.
In this study, we defined evaluation for posttonsillectomy hemorrhage
as any bleeding incident that results in clinical evaluation of the patient,
whether in the clinic, emergency department, or operating room. This inclusive
definition allows all subclassifications of hemorrhages to be compared from
a known baseline. Like Handler et al,11 we
include all bleedings reported by parents and hospital staff, regardless of
examination findings or eventual management and, thus, can assess all bleeding
incidents whether managed without intervention or hospital admission, hospital
admission for 23-hour observation, emergency department intervention, or operative
evaluation and intervention. It is important to include patients with benign
examination and those patients who require neither hospital admission nor
intervention because of these incidents, while not emergency situations, are
stressful for the affected child and family and require a considerable commitment
of time and resources from the medical system. Parents in our practice are
informed to return to the emergency department for any postoperative hemorrhage,
the severity of which cannot be determined without clinical evaluation. Not
only those patients who are seen with frank hemorrhage, but also those who
report blood-tinged sputum and vomitus should be included for these are among
the more common posttonsillectomy hemorrhage presentations. Overall, our study
produced a total posttonsillectomy hemorrhage evaluation rate of 7.8%. Our
primary hemorrhage evaluation rate, or evaluation rate for bleeding within
the first 24 hours after surgery, was 0.6%, which is comparable to previously
quoted rates of 0.14% to 1.5%.4-5,8-10
Thirty-two patients (28.6%) of those who presented for evaluation required
no intervention or hospital admission; 29 patients (25.9%) were managed with
hospital admission and observation; 31 patients (27.7%) received intervention
in the emergency department; and 20 patients (17.9%) required return to the
operating room for definitive treatment. Operative intervention was definitive
in all but 1 of the total of 20 patients requiring surgical control; the 1
patient who returned for further evaluation required no intervention. If reporting
only those patients requiring intervention in any clinical location, our significant
bleeding rate is 3.5%.
This study also identified hemorrhage rates and management issues in
patients who presented with multiple bleeding episodes. Sixteen of the 112
patients had more than 1 evaluation for hemorrhage; 11 had 2 episodes, 4 had
3, and 1 had 4. All eventually required emergency department (6 patients)
or operative (10 patients) intervention. Thus, it is reasonable to return
to the operating room for evaluation and intervention on the second presentation.
A return to the operating room also can be justified if the patient is too
uncooperative to allow a thorough examination in the emergency department.1 No prior studies of multiple bleedings could be identified
for comparison.
A significantly greater number of female patients (9.6%) presented for
hemorrhage evaluation compared with males (6.0%). However, although the percentage
of female patients with significant bleeding events was higher than that of
males (4.1%-3.0%, respectively), this difference is not statistically significant.
This value contradicts the findings of Kristensen and Tveteras3
that males have a greater hemorrhage rate but agrees with the study findings
by Breson and Diepeveen8 and Carmody et al.9 In our study, patients who were 12 years old and older
were much more likely to have posttonsillectomy bleeding. Those children who
were 3 years old or younger in our study were the least likely to have posttonsillectomy
bleeding. This is consistent with previous studies that show that older patients
are more likely to bleed than younger ones.3, 8-9
In evaluating a patient who reports posttonsillectomy hemorrhage, certain
historical facts must be established. Whether adenoidectomy was included with
tonsillectomy, operative complications, and previous bleedings, and/or postoperative
complications must be elicited. The postoperative day should be determined.
Primary hemorrhages tend to occur prior to postoperative discharge, but secondary
hemorrhage has been reported up to 21 days after surgery.4
The presentation of the hemorrhage at home is also important in estimating
the degree of blood loss and for identifying signs of hypotension. A history
of frank hemorrhage does not always correlate with examination findings. On
physical examination, vital signs, presence of frank bleeding, oozing, clot,
and eschar (including position on tonsillar fossa) should be recorded. In
our study, the inferior tonsillar pole was found to be the most likely location
of a posttonsillectomy hemorrhage, unlike the findings of Conley and Ellison5 that the superior pole was most likely to bleed. Coagulation
studies, including bleeding time, and a complete blood cell count, should
be obtained with hematologic consultation if study results are abnormal. All
patients should receive intravenous fluid hydration while being evaluated.
We recommend adhering to the strategy elucidated by Cressman and Myer1 in a survey of pediatric otolaryngology fellowship
programs in determining the need for hospital admission. If only a stable
eschar is seen on examination, without clot or active bleeding, and the patient
is hemodynamically stable with an otherwise normal recovery course, then discharge
home is acceptable. Clot requiring suctioning, frank bleeding or oozing requiring
emergency department or operative intervention, or a history of dehydration
or poor recovery necessitates hospital admission. Clot suctioning, silver
nitrate cautery, or direct pressure hemorrhage control in the emergency department
generally requires hospital observation, although the clinical situation determines
when discharge is appropriate. This time course often applies to operative
candidates as well.
Traditionally, diagnosis of a bleeding disorder has been a relative
contraindication for tonsillectomy. The use of electrocautery and laser tonsillectomy
has begun to challenge this position.4, 11
Our institution does not routinely conduct preoperative coagulation studies
on patients without a personal or family history of bleeding problems. Of
the 112 patients who presented with hemorrhage, 2 received a preoperative
hematologic diagnosis of a nonspecific anticoagulant characterized by a prolonged
partial thromboplastin time; one required direct pressure in the emergency
department for hemostasis and the other was evaluated and discharged home.
Both patients had a family history of bleeding disorders. A third patient
was found to have a prolonged bleeding time in posthemorrhage coagulation
studies. Hematologic evaluation diagnosed a non–von Willebrand platelet
disorder with normal prothrombin time, partial thromboplastin time, and fibrinogen
level. This patient had 2 bleeding episodes—the first required silver
nitrate cautery in the emergency department on postoperative day 7 and the
second on postoperative day 9 required silver nitrate cautery followed by
definitive operative electrocautery. Therefore, 3 (0.2%) of the 1438 patients
undergoing either tonsillectomy or adenotonsillectomy or 3 (2.7%) of the 112
patients who returned for hemorrhage evaluations had a bleeding disorder.
Two of the 3 patients had family histories that would warrant preoperative
evaluation. This illustrates the lack of cost-effectiveness for screening
all patients undergoing tonsillectomy or adenotonsillectomy preoperatively
with laboratory studies to ascertain the existence of bleeding disorders.
CONCLUSIONS
We have presented criteria for reporting posttonsillectomy hemorrhage
rates that are inclusive of all hemorrhage evaluations, whether or not there
is a final diagnosis of actual or significant bleeding. Knowing the number
of patients who are evaluated but do not require intervention places the actual
hemorrhage rate in perspective compared with the incidence of patient presentations
for evaluation. This definition provides a baseline against which actual hemorrhage
rates and intervention modalities can be compared between researchers.
All patients who report any bleeding after tonsillectomy should return
for clinical evaluation. A patient who requires intervention with direct pressure
or electrocautery in the clinic, emergency room, or operating room should
be recorded as having a significant posttonsillectomy hemorrhage. Patients
who are female and/or 12 years old and older are the most likely to be evaluated
for posttonsillectomy bleeding. Patients 12 years old and older, regardless
of the sex, are the most likely to have significant posttonsillectomy bleeding.
Admission to the hospital for observation is suggested and evaluation in the
operating room may be warranted when patients present more than once for evaluation
of posttonsillectomy hemorrhage.
AUTHOR INFORMATION
Accepted for publication May 16, 2001.
Presented at the 28th Annual Conference of the Society for Ear, Nose,
and Throat Advances in Children, Chicago, Ill, October 27, 2000.
We thank Theodore F. Herschede for assistance in collecting and maintaining
our database and Judy A. Bean, PhD, for assistance in statistical analysis.
Corresponding author: James H. Liu, MD, Texas ENT Specialists, PA,
17070 Red Oak Dr, Suite 205, Houston, TX 77090 (e-mail: liuent{at}msn.com).
From the Department of Pediatric Otolaryngology–Head and Neck
Surgery, Children's Hospital Medical Center, the University of Cincinnati
Medical Center, Cincinnati, Ohio. Dr Liu is now in private practice with Texas
ENT Specialists, PA, Houston.
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