Primary and secondary postoperative hemorrhage in pediatric tonsillectomy

Abstract

Background: Tonsillectomy is the most common procedure for treatment of pediatric recurrent acute tonsillitis and tonsillar enlargement that contributes to obstructive sleep apnea hypopnea syndrome. Postoperative hemorrhage of tonsillectomy is a life-threatening complication.

Aim: To identify the risk factors that may contribute to primary and secondary post-operative hemorrhage in pediatric tonsillectomy.

Methods: The clinical data from 5015 children, 3443 males and 1572 females, aged 1.92-17.08 years, with recurrent tonsillitis and/or tonsil hypertrophy who underwent tonsillectomy in our hospital from January 2009 to December 2018 were retrospectively collected. The variables including sex, age, time of onset, diagnosis, method of tonsillectomy, experience of surgeon, time when the surgery started and monthly average air temperature were abstracted. The patients with postoperative hemorrhage were classified into two groups, the primary bleeding group and the secondary bleeding group, and their characteristics were compared with those of the nonbleeding group separately. Statistical analysis was performed by chi-square test with SPSS 20.

Results: Ninety-two patients had post-tonsillectomy hemorrhage, and the incidence rate of post-tonsillectomy hemorrhage was 1.83%. The mean age was 5.75 years. Cases of primary hemorrhage accounted for approximately 33.70% (31/92), and cases of secondary hemorrhage occurred in 66.30% (61/92). The rate of reoperation for bleeding was 0.92%, and the rate of rehospitalization for bleeding was 0.88% in all patients. Multiple hemostasis surgery was performed in 6.52% (3/46) of patients. The method of tonsillectomy (coblation tonsillectomy) and experience of the surgeon (junior surgeon with less than 5 years of experience) were significantly associated with primary hemorrhage (χ ² = 5.830, P = 0.016, χ ²= 6.621, P = 0.010, respectively). Age (over 6 years old) and time of onset (more than a 1-year history) were significantly associated with secondary hemorrhage (χ ²= 15.242, P = 0.000, χ ²=4.293, P = 0.038, respectively). There was no significant difference in sex, diagnosis, time when the surgery started or monthly average air temperature. There was a significant difference in the intervention measures between the primary bleeding group and the secondary bleeding group (χ ²= 10.947, P = 0.001). The lower pole and middle portion were the common bleeding sites, followed by the upper pole and palatoglossal arch.

Conclusion: The incidence rate of post-tonsillectomy hemorrhage is low. Coblation tonsillectomy and less than 5 years' experience of surgeon contribute to the tendency for primary hemorrhage. Age and time of onset are responsible for secondary hemorrhage.

Keywords: Child; Obstructive; Postoperative hemorrhage; Sleep apnea; Tonsillectomy; Tonsillitis.

Figure 1

Postoperative pathology results. Hemangioma tissue composed of capillaries with red blood cells in the lumen was found in the basal part of the left tonsil (hematoxylin-eosin staining, × 50).

Figure 2

Digital subtraction angiography. A mass of abnormal vessels with random distribution was mainly supplied by branches of the left maxillary artery and partly supplied by the left facial artery, ascending cervical artery and branches of the right facial artery.

Figure 3

Post-tonsillectomy hemorrhage in the right tonsillar fossa of a 5-year-old boy on the 6^th d after tonsillectomy. A: The right tonsillar fossa was covered by clot formation and without continued bleeding before treatment; B: Arterial hemorrhage was detected while removing the clot; C: Bleeding was stopped after electrocoagulation.