Ear, Nose & Throat Journal2023, Vol. 102(4) 244–250© The Author(s) 2021Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/0145561321999594journals.sagepub.com/home/ear
Objective: 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. Methods: 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. Results: 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. Conclusions: 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.
Keywordstonsillectomy, adenoidectomy, recurrent, postoperative complication, delayed hemorrhage
Post-tonsillectomy and/or adenoidectomy hemorrhage (PTAH) is one of the most common complications requiring admission for management in otolaryngology. Several factors such as patient’s age, gender, surgical indication, surgical technique, and choice of postoperative analgesia agent have been associated with increased rates of PTAH.1-6 Up to 7.5% of pediatric patients undergoing tonsillectomy and/or adenoidectomy will experience postoperative bleeding.7-9 However, few studies have reviewed the management and outcomes of children who have recurrent PTAH or those who have bleeding beyond the expected 2-week recovery period.
The aim of our study was to review our experience on PTAH at a tertiary pediatric referral hospital and to identify factors that may increase the risk of recurrent PTAH or for delayed bleeding beyond 2 weeks postoperatively.
A retrospective review was conducted on all patients admitted to The Children’s Hospital at Westmead, Sydney, Australia, for PTAH between July 01, 2014, and June 30, 2019. Patients with PTAH were included, and those with hemorrhage from other sources (eg, inferior turbinate or septum) were excluded. Recurrent PTAH was defined as 2 or more episodes of PTAH. Delayed presentation was defined as any bleeding after postoperative day 14.
It is a standard practice at our institution to admit all patients who present to the emergency department with PTAH for a period of observation. Patients were taken to theater if they had active bleeding as evidenced by fresh blood on oropharyngeal examination or if there were concerns for significant blood loss based on history, hemoglobin concentration, hemodynamic changes, and age of the patient. Patients were transfused if their hemoglobin was ×70g/L or if there was significant ongoing blood loss or hemodynamic instability. Coagulation studies (prothrombin time [PT], activated partial thromboplastin time [APTT], international normalized ratio [INR], and fibrinogen) were routinely performed on children who were admitted with PTAH.
Deidentified data were collected on patient demographics including gender and age, indication for initial operation, hemoglobin concentration, coagulation profile, appearance of oropharynx (normal oropharynx, clots, and fresh blood) at time of presentation, and postoperative day of bleeding. Requirement for blood transfusion or return to theater and length of stay were also recorded.
Ethics approval was obtained from the Sydney Children’s Hospital Network Human Research Ethics Committee (2020/ETH00143). Statistical analysis was performed using SPSS (Version 23; IMB Corp).
During the 5-year period, 291 children (118 females and 173 males) were admitted with PTAH. Age at presentation ranged from 12 months to 17.2 years (mean: 6.9 years). Only 61 (21%) of the children had their surgery at our facility, while the rest (79%) had their initial operation at other public and private hospitals. Data on the operative technique used were therefore not available for most patients. Indication for tonsillectomy and/or adenoidectomy was available for 197 (68%) children (Table 1).
Day of presentation for bleeding ranged from postoperative day 0 (primary hemorrhage) to postoperative day 28 (median: postoperative day 7; Figure 1).
Delayed presentations after day 14 occurred in 11 (4%) children, with one child presenting twice after day 14. Five (45%) of these children required surgical management, while 3 (27%) required a blood transfusion (hemoglobin ranged from 55 g/L to 81 g/L). Three (27%) had presented on more than one occasion, and all 3 of these patients required operative intervention after day 14.
Routine coagulation studies were normal in 10 of 11 children with delayed PTAH. One child’s results were not found. On further hematological investigations, one child had a low vitamin C level which may have partially contributed to the bleeding risk; another child had a mildly raised protein S of unclear significance (Table 2).
Twenty children were admitted to our hospital more than once for PTAH, while another 11 children were discharged from another hospital for PTAH before re-presenting to our hospital. In total, 31 (11%) of children had recurrent PTAH.
The day of presentation for the first episode of bleeding ranged from 4 to 21 days (mean: day 8), while the second presentation ranged from days 6 to 28 (mean: day 12). The mean number of days between the first and the second admission was 3.8 days (range: 0-9 days).
Of the 31 children who had recurrent PTAH, 17 (55%) children required operative management, while 4 (13%) required a blood transfusion. For these patients with multiple presentations, the odds of requiring a return to theater was 3.6 (95% confidence interval [CI]: 1.7-7.8), while the odds of requiring a transfusion was 7.5 (95%CI: 1.9-29.9).
For patients with recurrent PTAH, 45% patients had a repeat bleed from the same side, while 15% bled from the contralateral side. Three patients had bleeding from the adenoidectomy site of which one bled from the adenoid bed on both admissions. The remaining patients had a normal oropharyngeal examination on at least one occasion.
Mean hemoglobin on initial presentation was 118 g/L (range: 92-153 g/L), while the hemoglobin at their repeat presentation was 102 g/L (range: 55-136 g/L); there was an average hemoglobin drop of 16.6g/L (range: 0-43 g/L) between presentations. Coagulation studies were available for 28 (90%) patients: 36% of patients had a prolonged PT, while 3.6% had a prolonged APTT. One patient was diagnosed with factor XIII deficiency; their PT and APTT were both normal. No other patient was diagnosed with a coagulation disorder postoperatively (Table 3).
There was no association between hemoglobin levels, platelet count, PT, APTT, age, gender, appearance of oropharynx, and the risk of recurrent PTAH on regression analysis.
Eighty-eight (30%) children required operative management for cessation of hemorrhage, including 2 children who required return to the theater twice. Nine (3%) children received blood transfusions, with a mean hemoglobin of 81 g/L (range: 55-104 g/L). Seven of the 9 (77%) children undergoing transfusions required a return to theater at the same time.
Patients who had a hemoglobin < 100g/L were more likely to return to theater (odds ratio [OR] 3.2; 95%CI: 1.8-5.7) as were patients who had clots on examination of their oropharynx (OR 8.2; 95%CI: 3.9-17.2). There were no deaths related to PTAH in this cohort.
Of the 71 children who were taken to theatre at their initial presentation, 6 (8.5%) subsequently went on to have another episode of bleeding, while 25 (11.4%) of the 220 children managed nonoperatively had recurrent PTAH (Figure 2). The rate of recurrent PTAH was not statistically different between those managed operatively compared to those managed conservatively at their initial presentation (OR 1.1; 95%CI: 0.43-2.8). The need for operative management at subsequent presentations was also not statistically significant between those managed operatively versus those managed conservatively at their first presentation (OR 3.6; 95%CI: 0.48-27.1).
Length of stay ranged from 9 hours to 8.8 days (mean: 1.6 days). The child who stayed nearly 9 days had factor XIII deficiency diagnosed postoperatively. Patients who had recurrent PTAH had a trend toward a longer length of stay compared to those who presented only once (mean 43 hours vs 36 hours, P = .05).
Postoperative hemorrhage is a potentially serious complication following tonsillectomy and/or adenoidectomy, occurring in up to 7.5% of patients undergoing surgery.7-9 Although children with delayed or recurrent PTAH represent only a small proportion of those who present with PTAH, bleeding beyond the expected 2-week postoperative recovery period can be distressing for patients and their families, and repeated admissions for PTAH can create a significant burden on not only the families but also on the health care system.
Our study showed that 11% of children experienced recurrent PTAH, and 4% of children presented with delayed PTAH beyond day 14. This is consistent with previous studies in the literature which report a rebleeding rate of between 4% and 17.5% for children following their initial PTAH.10-12
In our cohort, children with recurrent PTAH were 4 times more likely to require surgical management and 8 times more likely to undergo a blood transfusion compared to those who present only once. This may reflect the lower threshold for operative intervention for children with recurrent PTAH, as well as the lower hemoglobin concentrations following recurrent PTAH, with children in our cohort having a mean hemoglobin drop of 16.6 g/L between presentations. Children who had recurrent PTAH also had a trend toward a longer length of stay compared to those who presented only once, which may be a consequence of a longer period of observation in hospital following recurrent PTAH.
Previous studies have suggested that older patients, those with recurrent tonsillitis, and those with a higher body mass index were more likely to have recurrent PTAH.13,14 However, this was not reflected in our study, with no association found between age, gender, appearance of oropharynx, and recurrent PTAH. In addition, we did not find any association between abnormalities in hemoglobin concentrations and coagulation profile and risk of multiple bleeding episodes. This is consistent with a study by van der Meer et al which also failed to find an association between abnormal coagulation and recurrent bleeding in children with recurrent post-tonsillectomy bleeding.12 Furthermore, choice of surgical technique, severity of first bleed, and NSAIDs use have not been found to increase the risk of recurrent PTAH.12,14 The risk of recurrent PTAH is therefore difficult to predict for any given child.
We found that the proportion of patients who went on to have recurrent PTAH was similar between those who were managed conservatively at the first presentation compared to those who were managed surgically (11.4% vs 8.5%, respectively). This suggests that there is a risk of rebleeding regardless of choice of management at first presentation. It would therefore be reasonable to manage the child with either approach, depending on their clinical presentation. However, given the limited number of recurrent PTAH in our cohort, care must be taken in interpreting the impact of surgical versus conservative management based on our study alone.
It is interesting to note that the 2 patients with recurrent PTAH and required operative management on both occasions had relied upon diathermy alone for hemostatic control during their first return to theater; however, statistical analysis did not find any difference between risk of recurrent PTAH based on whether or not the tonsil pillars were sutured at the time of return to theatre for hemostasis.
Overall, our study showed that children with a first episode of PTAH have a 10% risk of having a second episode of bleeding. On average, the second bleeding episode occurred 4 days after the initial bleed, with nearly all recurrent bleeding occurring within 7 days. This information is useful for both parents and clinicians when planning to discharge a child after the first postoperative bleeding episode.
Delayed bleeding beyond the expected recovery period may also cause significant distress for patients and their families. While it is widely accepted that PTAH can occur up to 14 days after the initial operation, previous studies have found that postoperative hemorrhage most commonly occurred between 5 and 10 days after the initial operation.11,15-18
Our study found that 18% of our cohort had postoperative bleeding after day 10, and 4% presented after day 14. Few studies report on these delayed presentations, particularly the delayed PTAH of 14 to 28 days. In our study, over half the patients with delayed presentations had clear evidence of bleeding with either fresh blood or clot on examination. Over 40% of the patients presenting after day 14 required surgical intervention, while just over a quarter underwent a blood transfusion. Visualization of the adenoid bed of these delayed presenters is recommended in view of our findings that a small but significant proportion (18%) had bleeding from their adenoidectomy site as confirmed intraoperatively.
The coagulation profiles were normal in these children with delayed presentations, which is unsurprising, since previous studies have suggested that unidentified coagulation disorders were found in <1% of patients with post-tonsillectomy hemorrhage.19,20 Furthermore, despite other studies suggesting that patients with recurrent tonsillitis were at an increased risk of postoperative bleeding,3,4,19 none of the children with delayed presentations in our study had recurrent tonsillitis as the indication for their original operation. This difficulty in identifying risk factors for delayed bleeding beyond day 14 emphasizes the importance of preoperative counseling of patients and their families, especially those who live remotely without ready access to hospital facilities.
Our study identified 1 patient with vitamin C deficiency who presented with both recurrent and delayed PTAH, with the second episode occurring on day 16. It is well recognized that vitamin C deficiency can result in decreased collagen synthesis, increased capillary fragility, and impaired wound healing.21 Diffuse postoperative hemorrhage secondary to vitamin C deficiency have been reported in adult patients undergoing abdominal, cardiothoracic, and neurosurgical operations.22 However, the incidence of vitamin C deficiency in our cohort remains unknown, as vitamin C levels were not routinely performed in patients who present with PTAH. Nutritional deficiencies, although uncommon, should therefore be considered in patients who present with recurrent or delayed PTAH.
Previous studies have also reported higher rates of postoperative bleeding in patients with hemophilia and von Willebrand disease, with secondary PTAH rates of up to 10% to 20%.23-25 However, it is unclear whether these patients are more likely to have recurrent or delayed hemorrhage. Our cohort included one child with hemophilia diagnosed preoperatively who had a single episode of PTAH at day 11, and none of the children in our study were diagnosed with von Willebrand disease following admission for recurrent or delayed PTAH. Nevertheless, investigation for an underlying coagulation disorder should still be undertaken for children who present with delayed or recurrent PTAH.
The limitations of our retrospective study include the possibility of missed patients due to the absence of specific search codes for recurrent or delayed PTAH. Our study did not take into account patients who may have presented to other hospitals for subsequent episodes of bleeding; the true incidence of recurrent PTAH may therefore be underestimated. Also, the majority of our patients had their initial operation performed at various hospitals across the state; thus, surgical technique and indications for surgery were not available in all patients. In addition, the number of patients with a bleeding disorder may be underestimated in our cohort, as further hematological investigations were generally only performed on patients with abnormal coagulation profiles. Finally, the relatively small number of cases made assessment of the data’s significance more difficult. Future multicenter studies may help us to further evaluate risk factors responsible for recurrent or delayed PTAH, and further studies on the impact of agents such as tranexamic may help us better manage this subgroup of patients.
Children who have an initial episode of PTAH have a 10% risk of having a subsequent episode of bleeding. Although patients who have recurrent PTAH were more likely to require return to theater and blood transfusions, management of first presentation with either a conservative or a surgical approach is reasonable, since there is a risk of recurrent PTAH irrespective of choice of management at initial presentation.
Children who have recurrent or delayed PTAH beyond day 14 represent only a small proportion of those with PTAH. However, it is difficult to predict those who will fall into these subgroups. In view of this, careful preoperative counseling is important to help set expectations in the event of post tonsillectomy and/or adenoidectomy hemorrhage.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Phylannie K. F. Cheung https://orcid.org/0000-0002-7939-1942
1 Department of Paediatric Otolaryngology, The Children’s Hospital at Westmead, New South Wales, Australia
2 Discipline of Paediatric and Adolescent Health, Sydney Medical School, University of Sydney, New South Wales, Australia
3 Faculty of Medicine and Health Sciences, Macquarie University, Macquarie, New South Wales, Australia
Received: December 29, 2020; revised: December 29, 2020; accepted: January 07, 2021
Corresponding Author:Phylannie K. F. Cheung, MBBS, MS, Department of Paediatric Otolaryngology, The Children’s Hospital at Westmead. Locked Bag 4001, Westmead, New South Wales 2145, Australia.Email: pche6046@uni.sydney.edu.au
