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DOCTORAL THESIS
MULTICENTRE PROSPECTIVE STUDY ON ALL
PATIENTS UNDERGOING TONSILLECTOMY,
TONSILLOTOMY OR ADENOIDECTOMY IN AUSTRIA
IN 2009 AND 2010
Submitted by
Dr. med. univ. Stephanie Angelika Sarny
Mat.Nr.: 0433093
Attending the Academic Degree
Doctor Scientiae Medicae
Dr. scient. med. (“PhD equivalent”)
At the
Medical University of Graz
Conducted at the
Department of General Otorhinolaryngology, Head and Neck Surgery,
Graz, Austria
Supervized by
Univ.-Prof. Dr. Heinz Stammberger
Univ.-Doz. Mag. DDr. Walter Habermann
Ao.Univ.-Prof. Mag. Dr. Guenther Ossimitz
II
Affidavit
I, hereby, declare that the following doctoral thesis has been written only by the
undersigned and without any assistance from third parties. Furthermore, I confirm
that no sources have been used in the preparation of this thesis other than those
indicated in the thesis itself.
Dr.med.univ. Stephanie Sarny Graz, 20th December 2011
III
Acknowledgements
It is an honour for me to thank Univ.-Prof. Dr. Heinz Stammberger, head of the
Department of General Otorhinolaryngology, Head and Neck Surgery, Graz, Austria,
for giving me the opportunity to work on this project and for supporting me with his
expertise.
I am very grateful to Ao.Univ.-Prof. Mag. Dr. Guenther Ossimitz, who assisted me
with statistical advices and encouraged me with his confidence.
I am also very thankful to Univ.-Doz. Mag. DDr. Walter Habermann who constantly
supported me in my work.
It was only possible to realize this project with the help of all the contributors named
below. I would especially like to thank them for their assistance.
Stephanie Sarny, M.D.
Project team: Dr. Stephanie Sarny, M.D., Ao.Univ.-Prof. Mag. Dr. Guenther Ossimitz,
Ph.D, Univ.-Doz. Mag. DDr. Walter Habermann, M.D. Ph.D, Univ.-Prof. Dr.
Stammberger Heinz, M.D. FRCS
The project team would like to express their gratitude to the Austrian Society of Oto-
Rhino-Laryngology, Head and Neck Surgery, who provided funding for the project.
Special thanks go to the chairpersons of Austria´s ENT departments (in 2009):
Univ.-Prof. Dr. Wolfgang Gstöttner Head of the Austrian Society of ORL
Univ.-Prof. Dr. Wolfgang Anderhuber Leoben Hospital
Univ.-Prof. Dr. Wolfgang Biegenzahn Medical University of Vienna
Univ.-Prof. Dr. Klaus Böheim St. Pölten Hospital
Univ.-Doz. Dr. Monika Cartellieri Kaiser Franz Josef Hospital, Vienna
Univ.-Prof. Dr. Hans Edmund Eckel Klagenfurt Hospital
Univ.-Prof. Dr. Wolfgang Elsässer Feldkirch Hospital
Univ.-Prof. Dr. Peter Franz Rudolfstiftung Hospital, Vienna
Univ.-Prof. Dr. Gerhard Friedrich Medical University of Graz
Univ.-Prof. Dr. Werner Habicher Barmherzige Schwestern Hospital, Ried
Univ.-Prof. Dr. Wolfgang Gstöttner Medical University of Vienna
Univ.-Prof. Dr. Floris Heger Elisabethinen Linz Hospital
OA Dr. Gerhard Herzog Zell am See Hospital
Univ.-Doz. Dr. Heribert Höfler Barmherzigen Brüder Hospital, Vienna
Univ.-Prof. Dr. Heinz Jünger Krems Hospital
IV
Univ.-Prof. Dr. Christoph Karas Schwarzach im Pongau Hospital
Univ.-Prof. Dr. Tilman Keck Elisabethinen Hospital, Graz
Univ.-Prof. Dr. Antonius Kierner Barmherzigen Brüder Hospital, Eisenstadt
OA Dr. Hannes Kirschner Lienz Hospital
Univ.-Prof. Dr. Josef Meindl Barmherzigen Schwestern Hospital, Linz
Univ.-Prof. Dr. Antal Mink Steyr Hospital
Univ.-Prof. Dr. Michael Moser Medical University of Graz
Univ.-Doz. Dr. Csilla Neuchrist Weinviertel Hospital, Mistelbach
OA Dr. Johannes Neumüller Vöcklabruck Hospital
Univ.-Prof. Dr. Peter Ostertag Kufstein Hospital
OA Dr. Robert Panholzer Braunau am Inn Hospital
Univ.-Prof. Dr. Robert Pavelka Wiener Neustadt Hospital
OA Dr. Richard Pauer St. Vinzenz Hospital
OA Dr. Hannes Picker Schwaz Hospital
Univ.-Prof. Dr. Gerd Rasp Medical University of Salzburg
Univ.-Prof. Dr. Christoph Reisser Hanusch Hospital, Vienna
Univ.-Prof. Dr. Ernst Richter Linz Hospital
Univ.-Prof. Dr. Herbert Riechelmann Medical University of Innsbruck
Univ.-Prof. Dr. Heinz Stammberger Medical University of Graz
Univ.-Prof. Dr. Herwig Swoboda Hietzing Hospital, Vienna
Univ.-Prof. Dr. Patrick Zorowka Medical University of Innsbruck
The project team would like to thank all contributors for their cooperation and
diligence, which provided us with data of remarkable quality.
The authors would especially like to thank all hospital staff who contributed surgery
data to the study: Doris Aichinger M.D., Ulrich Amann M.D., Anna Aszmayr M.D.,
Birte Bender M.D., Elisabeth Blassnigg M.D., Christoph Brand M.D., Elisabeth Brand
M.D., Otto Braumandl M.D., Martin Bruch M.D., Christoph Flux M.D., Margit Gombotz
M.D., Matthias Grabner M.D., Stefan Hoier M.D., Franjo Juric M.D., Joachim
Kronberger M.D., Thomas Kunst M.D., Christoph Matscheko M.D., Hermine Mayr
M.D., Magdalena Necek M.D., Johannes Neumüller M.D., Anita Neuwirth M.D.,
Robert Panholzer M.D., Richard Pauer M.D., Christof Pauli M.D., Hannes Picker
M.D., Robert Pinnitsch M.D., Julia Rechenmacher M.D., Andreas Riedler M.D., Kyros
Sabbas M.D., Michael Safar M.D., Claus Schleinzer M.D., Barbara Schubert M.D.,
Johannes Schwarzer M.D., Anahid Seraydarian M.D., Andreas Strobl M.D., Beatrix
Thalhammer M.D., Sandra Waltenberger M.D., Anette Wenzel M.D., Martin Wernig
M.D., Claudia Winter M.D., Thomas Wöllner M.D., Gabriella Zahratka M.D., Michaela
Zumtobel M.D. We would like to thank David Prodinger for creating the web-based
data entry system. Finally, thanks to everybody else who has remained unnamed.
V
Abstract
Background Postoperative haemorrhage as a serious complication after
tonsillectomy (TE), tonsillotomy (TO) or adenoidectomy (AE) is covered in many
studies, using rather inconsistent measurement methods. We introduce a new
classification for the severity of postoperative hemorrhage and investigate risk factors
for both the frequency and severity of bleeding episodes.
Methods Our study is based on a prospective census recording all TE, TO and AE
from 1 October 2009 to 30 June 2010 in Austria. Information was collected
concerning indications for surgery, grade of surgeon, operation technique and
postoperative haemorrhage, classified as any bleeding episode after extubation
according to severity,.
Results A total of 9,405 patients were included. The haemorrhage rate for TE with or
without (±) AE was 15.0%, for TO±AE 2.3% and for AE 0.8%. The return to theatre
rate for TE±AE was 4.6%, for TO±AE 0.9% and for AE 0.3%. Minor bleeding
episodes doubled the risk of a subsequent severe bleeding episode (p<0.001).
Elevated haemorrhage rates were observed for adults (p<0.001), TE±AE (p<0.001)
and cold steel dissection combined with bipolar diathermy (p=0.05). A multivariate
logistic regression model for the frequency of post-tonsillectomy haemorrhage
showed significant odds ratios for males, children aged under six, children aged 6-15,
abscess TE and cold steel combined with bipolar diathermy. Additionally we found a
significantly higher risk of severe bleeding episodes in children aged 6-15 (p=0.007),
males (p=0.02) and for all bipolar operation techniques (p=0.005). Intraoperative
blood loss of more than 110 ml indicated a significantly higher postoperative
haemorrhage risk, while a blood loss lower than 30 ml was associated with fewer
postoperative bleeding episodes. Finally, a positive coagulation history predicted an
elevated haemorrhage rate (p<0.001) better than any result of the coagulation test.
Conclusions The occurrence of a minor postoperative bleeding episode increases
the risk of a subsequent severe bleeding episode.
Funding Austrian Society of Oto-Rhino-Laryngology, Head and Neck Surgery
Key words: tonsillectomy, tonsillotomy, adenoidectomy, postoperative haemorrhage,
bleeding episode, risk factor, coagulation
VI
Table of Contents
Acknowledgements…………………………………………………………III
Abstract………………………………………………………………………..V
Table of Contents…………………………………………………………...VI
List of Figures…………………………….……………………………..…..IX
List of Tables………………………………………………………………...XI
1. INTRODUCTION………………………………………………………….14
1.1. Background to the study ............................................................................................. 14
1.2. Aim of the “Austrian Tonsil Study 2010” ...................................................................... 16
1.3. Anatomical background .............................................................................................. 17
1.4. Historical background ................................................................................................. 18
1.5. Histological background .............................................................................................. 19
1.6. Type of surgery ........................................................................................................... 20
1.6.1. Tonsillectomy (TE) ................................................................................................ 20
1.6.2. Tonsillotomy (TO) ................................................................................................. 20
1.6.3. Adenoidectomy (AE) ............................................................................................. 20
1.7. Inpatient versus outpatient surgery ............................................................................. 21
1.8. Indications for tonsil surgery ....................................................................................... 23
1.8.1. Acute recurrent or chronic tonsillitis ...................................................................... 24
1.8.2. Tonsillar hypertrophy/obstructive sleep apnoea-syndrome (OSAS) ...................... 26
1.8.3. Peritonsillar abscess ............................................................................................. 28
1.8.4. Tonsil cancer ........................................................................................................ 29
1.9. Indications for adenoidectomy .................................................................................... 30
1.9.1. Adenoid hypertrophy and persistent ear infection ................................................. 30
1.9.2. Recurrent rhinosinusitis ........................................................................................ 30
1.9.3. Obstructive sleep apnoea-syndrome (OSAS) ....................................................... 30
1.10. Complications of tonsil and adenoid surgery ............................................................. 31
1.10.1.1 Postoperative haemorrhage rates in the literature ............................................ 32
1.10.1.2. Risk factors for postoperative haemorrhage .................................................... 35
1.10.1.2.1. Type of surgery ............................................................................................. 35
1.10.1.2.2. Patients´ age................................................................................................. 35
1.10.1.2.3. Patients´ sex ................................................................................................. 35
1.10.1.2.4. Indication for surgery .................................................................................... 35
1.10.1.2.5. Operation techniques .................................................................................... 36
1.10.1.2.6. Abnormal coagulation tests ........................................................................... 36
1.10.1.2.7. Postoperative infection of tonsillar fossa ....................................................... 38
1.10.1.3. Timing of postoperative haemorrhage ............................................................. 39
1.10.2 Postoperative pain ............................................................................................... 40
VII
1.10.3 Intraoperative complications ................................................................................ 42
1.10.3.1. Anaesthetic complications ............................................................................... 42
1.10.3.2. Excessive intraoperative haemorrhage ............................................................ 42
1.10.4. Immediate complications .................................................................................... 44
1.10.4.1. Nausea, vomiting and dehydration ................................................................... 44
1.10.5. Delayed complications ........................................................................................ 45
1.10.5.1. Velopharyngeal insufficiency (VPI) .................................................................. 45
1.10.5.2. Nasopharyngeal stenosis ................................................................................. 45
1.11. Operation techniques for tonsil surgery ..................................................................... 47
1.11.1. Cold steel dissection ........................................................................................... 48
1.11.2. Electrocautery dissection .................................................................................... 48
1.11.3. Harmonic scalpel (HS) ........................................................................................ 49
1.11.5. Argon-plasma-coagulation (APC) ....................................................................... 50
1.11.7. Coblation ............................................................................................................ 50
1.11.8. Colorado-needle ................................................................................................. 51
1.11.9. Radiofrequency technique (RF) .......................................................................... 52
1.12. Operation techniques for adenoidectomy .................................................................. 53
1.12.1. Curettage adenoidectomy ................................................................................... 53
1.12.2. Electrocautery ..................................................................................................... 53
1.12.3. Power-assisted adenoidectomy .......................................................................... 54
1.12.4. Coblation ............................................................................................................ 54
2. MATERIAL AND METHODS…………………………………………….55
2.1. Study organization ...................................................................................................... 55
2.2 Study period ................................................................................................................. 55
2.3. Patient selection ......................................................................................................... 56
2.4. Data collection and management of data submission ................................................. 56
2.5. Study design ............................................................................................................... 60
2.6. Definition and Classification of Postoperative Haemorrhage ....................................... 60
2.7. Statistical analyses ..................................................................................................... 62
3. RESULTS………………………………………………………………….63
3.1. DESCRIPTIVE RESULTS........................................................................................... 63
3.1.1 Participating hospitals ............................................................................................ 63
3.1.3 Patient characteristics ............................................................................................ 64
3.1.4 Tonsillectomy ......................................................................................................... 67
3.1.5 Tonsillotomy .......................................................................................................... 70
3.1.6 Adenoidectomy ...................................................................................................... 73
3.1.7 Age distribution for all types of surgeries ............................................................... 76
3.2. POSTOPERATIVE HAEMORRHAGE ........................................................................ 77
3.2.1 Tonsillectomy ......................................................................................................... 77
3.2.2 Tonsillotomy .......................................................................................................... 79
VIII
3.2.3 Adenoidectomy ...................................................................................................... 81
3.3.1 Overview for all types of surgeries ............................................................................ 82
3.3.2 Tonsillectomy ......................................................................................................... 83
3.3.3 Tonsillotomy .......................................................................................................... 85
3.3.4 Adenoidectomy ...................................................................................................... 86
3.3.5 Distribution of postoperative haemorrhage by days ............................................... 87
3.4.1. Risk model for postoperative haemorrhage after tonsillectomy ............................. 88
3.4.2. Risk model for the return-to-theatre rate after tonsillectomy ................................. 90
3.5. MULTIPLE BLEEDING EPISODES ............................................................................ 92
3.6. HOSPITAL PERFORMANCE ..................................................................................... 94
3.6.1. Overview ............................................................................................................... 95
3.6.2. Frequency of haemorrhage and number of bleeding episodes ............................. 96
3.6.3. Indication for tonsil surgery (TE and TO) .............................................................. 97
3.6.4. Postoperative haemorrhage by indication for tonsil surgery .................................. 98
3.6.5. Operation technique for tonsillectomy ................................................................... 99
3.6.6. Operation technique for tonsillotomy................................................................... 100
3.6.7. Operation technique for adenoidectomy ............................................................. 101
3.7. INTRAOPERATIVE BLOOD LOSS ........................................................................... 102
3.7.1 Patient characteristics .......................................................................................... 102
3.7.2. Amount of intraoperative blood loss .................................................................... 103
3.7.3.Association between intraoperative blood loss and other factors ......................... 104
3.8. PREOPERATIVE COAGULATION ........................................................................... 110
3.8.1. Population description ........................................................................................ 110
3.8.2. Preoperative screening practice in Austria .......................................................... 110
3.8.3. Postoperative haemorrhage ................................................................................ 111
3.8.4. Bleeding disorders .............................................................................................. 114
4. DISCUSSION…………………………………………………………….115
5. FINAL STATEMENTS AND RECOMMENDATIONS……………….119
6. REFERENCES…………………………………………………………..122
7. APPENDIX……………………………………………………………….141
7.1. Questionnaires .......................................................................................................... 141
7.2. Curriculum vitae ........................................................................................................ 150
7.3. International Publications .......................................................................................... 152
IX
List of Figures
Figure 1.1 Tonsillar tissue
(http://www.lab.anhb.uwa.edu.au/mb140/corepages/Lymphoid2/lymph2.htm#Tonsils)
Figure 1.2 Normal tonsils (Benjamin B, Bingham B, Hawke M, Stammberger H. Farbatlas
der Hals-Nasen-Ohren-Heilkunde. Deutscher Ärzte Verlag: Köln, 1995. p.215)
Figure 1.3 Acute tonsillitis (Benjamin B, Bingham B, Hawke M, Stammberger H. Farbatlas
der Hals-Nasen-Ohren-Heilkunde. Deutscher Ärzte Verlag: Köln, 1995. p.216)
Figure 1.4 Tonsillar hypertrophy (Benjamin B, Bingham B, Hawke M, Stammberger H.
Farbatlas der Hals-Nasen-Ohren-Heilkunde. Deutscher Ärzte Verlag: Köln, 1995. p.216)
Figure 1.5 Peritonsillar abscess (Benjamin B, Bingham B, Hawke M, Stammberger H.
Farbatlas der Hals-Nasen-Ohren-Heilkunde. Deutscher Ärzte Verlag: Köln, 1995. p.217)
Figure 1.6 Squamous cell carcinoma of the tonsil (Benjamin B, Bingham B, Hawke M,
Stammberger H. Farbatlas der Hals-Nasen-Ohren-Heilkunde. Deutscher Ärzte Verlag: Köln,
1995. p.220)
Figure 2.1 Homepage: www.tonsil-evaluation.org
Figure 2.2 Homepage: after login
Figure 2.3 Homepage: first admission for primary operation
Figure 2.4 Homepage: admission for postoperative haemorrhage in the hospital
where primary surgery was undertaken
Figure 2.5 Homepage: admission for postoperative bleeding episode in unknown
hospital
Figure 2.6 Classification of postoperative haemorrhage (German version)
Figure 3.1 Tonsillectomy: duration of hospitalization by age group
Figure 3.2 Tonsillotomy: duration of hospitalization by age group
Figure 3.3 Adenoidectomy: duration of hospitalization
Figure 3.4 Age distribution for all surgeries
X
Figure 3.5 Age distribution for surgeries with or without adenoidectomy
Figure 3.6 Tonsillectomy (±AE): distribution of bleeding grades for postoperative
days
Figure 3.7 Distribution of frequency of surgeries (TE±AE, TO±AE, AE) by department
Figure 3.8 Distribution of intraoperative blood loss (ml) by age group
Figure 3.9 Mean of intraoperative blood loss for indication of surgery by age group
Figure 3.10 Mean of relative intraoperative blood loss for indication of surgery by age
group
Figure 3.11 Intraoperative blood loss by operation technique
Figure 3.12 Bleeding disorders for patients undergoing tonsillectomy or
adenotonsillectomy
Figure 7.1 First hospital admission or admission due to postoperative haemorrhage
Figure 7.2 Questionnaire for first hospital admission (1)
Figure 7.3 Questionnaire for first hospital admission (2)
Figure 7.4 Questionnaire for first hospital admission (3)
Figure 7.5 Questionnaire for hospital admission due to postoperative
haemorrhage(1)
Figure 7.6 Questionnaire for hospital admission due to postoperative
haemorrhage(2)
Figure 7.7 Questionnaire for hospital admission due to postoperative
haemorrhage(3)
Figure 7.8 Questionnaire for hospital admission due to postoperative haemorrhage
for a patient who was operated in a different hospital (1)
Figure 7.9 Questionnaire for hospital admission due to postoperative haemorrhage
for a patient who was operated in a different hospital (2)
XI
List of Tables
Table 1.1 Recommendations for tonsillectomy in patients with recurrent tonsillitis
Table 1.2 Complications of tonsil and adenoid surgery
Table 1.3 Definition of “postoperative haemorrhage”
Table 1.4 Literature review of studies examining the efficacy of preoperative
coagulation history and tests
Table 1.5 Operation techniques: overview
Table 2.1 Classification of postoperative haemorrhage (English version)
Table 2.2 Regression models
Table 3.1 Number of entries in central database
Table 3.2 Age-sex distribution of patients
Table 3.3 Distribution of type of surgery by age group
Table 3.4 Tonsillectomy (±AE): patients´ characteristics
Table 3.5 Intraoperative haemostasis for tonsillectomy
Table 3.6 Tonsillotomy (±AE): patients´ characteristics
Table 3.7 Intraoperative haemostasis for tonsillotomy
Table 3.8 Adenoidectomy: patients´ characteristics
Table 3.9 Intraoperative haemostasis for adenoidectomy
Table 3.10 Tonsillectomy (±AE): patient characteristics and postoperative
haemorrhage rates
Table 3.11 Tonsillotomy (±AE): patient characteristics and postoperative
haemorrhage rates
Table 3.12 Adenoidectomy (AE): patient characteristics and postoperative
haemorrhage rates
Table 3.13 Number of bleeding episodes for all types of surgery
XII
Table 3.14 Tonsillectomy (±AE): patient characteristics for all haemorrhage grades
Table 3.15 Tonsillotomy (±AE): patient characteristics for all haemorrhage grades
Table 3.16 Adenoidectomy: patient characteristics for all haemorrhage grades
Table 3.17 Logistic regression analysis: model testing 1
Table 3.18 Tonsillectomy with or without adenoidectomy: binary logistic regression
model for postoperative haemorrhage
Table 3.19 Logistic regression analysis: model testing 2
Table 3.20 Tonsillectomy with or without adenoidectomy: binary logistic regression
model for return-to theatre
Table 3.21 Multiple bleeding episodes after tonsillectomy (±AE) per patient by age
group
Table 3.22 Patients with multiple bleeding episodes after tonsillectomy (with or
without adenoidectomy)
Table 3.23 Hospital performance: overview
Table 3.24 Hospital performance: frequency of haemorrhage (yes/no) and number of
bleeding episodes
Table 3.25 Hospital performance: indications for tonsil surgery (TE and TO)
Table 3.26 Hospital performance: postoperative haemorrhage by indication for tonsil
surgery
Table 3.27 Hospital performance: operation technique for tonsillectomy
Table 3.28 Hospital performance: operation technique for tonsillotomy
Table 3.29 Hospital performance: operation technique for adenoidectomy
Table 3.30 Patient characteristics: intraoperative blood loss
Table 3.31 Patient characteristics for six groups categorized by intraoperative blood
loss in ml
Table 3.32 Preoperative coagulation history and tests performed nationwide
XIII
Table 3.33 Outcome of coagulation history and tests
Table 3.34 Tonsillectomy procedures: distribution of positive and negative
coagulation history and tests
INTRODUCTION
14
1. INTRODUCTION
1.1. Background to the study
Tonsillectomy, tonsillotomy and adenoidectomy are the most frequently undertaken
surgeries in the field of otorhinolaryngology. In the United States about 536,000
tonsillectomies with or without adenoidectomies were carried out in 2006.1 These
surgeries are considered to be safe procedures with low complication rates and are
often performed in combination with each other. However, they can lead to severe
postoperative haemorrhage, sometimes fatal,2,3 and excessive pain4 has been
reported, along with minor complications like difficulty in swallowing, vomiting and
dehydration.5
Many studies deal with postoperative haemorrhage as the most serious complication
of tonsil surgeries. It is commonly accepted that bleeding episodes can be classified
into primary haemorrhage, within the first 24 hours of surgery, and secondary
haemorrhage, after the first 24 hours of surgery.6-11 Furthermore, authors often
differentiate between haemorrhage requiring surgical treatment and minor
haemorrhage.9,12 Due to varying definitions of what is considered a postoperative
bleeding episode and due to differences in study designs the reported haemorrhage
rates and their risk factors vary considerably between different studies, such that
haemorrhage rates ranging from 0.1% to 40.0% are reported in the literature.6
The Austrian Tonsil Study 2010 was set up as a multicentre prospective full census
to investigate the overall incidence of surgeries performed in one country along with
their risk factors for postoperative haemorrhage. Before the nationwide study was
initiated, a lively discussion about post-tonsillectomy haemorrhage had been ongoing
since 2006 and 2007, when five children under the age of six died due to massive
postoperative bleeding after a tonsillectomy. As a result the Austrian Society of
Otorhinolaryngology, Head and Neck Surgery and the Austrian Society of Paediatrics
issued a joint consensus paper in late 2007 about the indications and complications
of tonsillectomy.13 Tonsillectomy, for instance, should not be performed in children
under the age of six with very few exceptions; tonsillotomy should be favoured in this
age group. For children aged six and above the consensus paper recommends
INTRODUCTION
15
tonsillectomy in cases with seven or more tonsil infections in one year or five tonsil
infections in each of two consecutive years.
On behalf of the Austrian Society of Otorhinolaryngology, Head and Neck Surgery all
public ENT departments in Austria were invited to participate in the study. Data from
all consecutive patients operated from October 2009 to June 2010 were entered
electronically. Postoperative bleeding episodes were defined precisely and a
standardized classification considering the severity of bleeding episodes and
subsequent medical treatment was set up. For the first time both the frequency of
postoperative haemorrhage (with the number of operated patients as a basis) and
the severity of bleeding episodes (with the number of bleeding episodes as a basis)
could be evaluated.
INTRODUCTION
16
1.2. Aim of the “Austrian Tonsil Study 2010”
The overall aim of the study was to assess postoperative haemorrhage associated
with different risk factors for tonsillectomy, tonsillotomy and adenoidectomy.
The specific aims of the study were the following:
o to carry out a census with a complete prospective survey nationwide for
tonsillectomy, tonsillotomy and adenoidectomy in order to obtain demographic
data for tonsil and adenoid surgery;
o to collect patient characteristics (age, sex) undergoing tonsil or adenoid
surgery;
o to assess the distribution of indications for surgery;
o to measure the duration of hospitalization;
o to evaluate operation techniques and methods of intraoperative haemostasis;
o to record the grad of surgeon;
o to introduce a new classification for bleeding episodes;
o to determine the incidence of severe and possibly fatal postoperative
haemorrhage;
o to verify risk factors for the frequency of postoperative haemorrhage;
o to explore the distribution of the severity of bleeding episodes;
o to evaluate risk factors for severe postoperative haemorrhage;
o to assess practical guidelines for determining increased haemorrhage risk.
INTRODUCTION
17
1.3. Anatomical background
The tonsils are also known as “Waldeyer´s Tonsillar Ring” and are located in the
pharynx. Depending on their localization, four types of tonsils are described:14-17
The pharyngeal tonsils, called the adenoids, are located in the superior portion of the
pharynx, the nasopharynx. It lies posterior to the nasal cavity and extends
downwards to the soft palate. The posterior wall contains the adenoids, which can be
enlarged especially in early childhood.
The palatine tonsils are the largest components of Waldeyer´s Ring and lie in the
oropharynx, which is located posterior to the oral cavity extending from the soft palate
to the hydroid bone. They are paired, each of the tonsils lying in the tonsillar fossa.
This fossa is bounded by the anterior tonsillar pillar, formed by the palatoglossus
muscle, and the posterior tonsillar pillar, built by the palatopharyngeal muscle. The
pharyngeal constrictor builds the base of the fossa and covers the glossopharyngeal
nerve and the nerval structures of the carotid sheath. When placing sutures or
dissecting too deeply, these structures can be harmed. The nerve supply of the
palatine tonsil comes from the glossopharyngeal nerve and the maxillar nerve. The
major blood supply comes from the facial artery, which arises from the external
carotid artery. Together with the dorsal lingual artery the ascending branch of the
palatine artery (arising from the facial artery) and the tonsillar branch of the facial
artery supply the inferior pole of the tonsil while the superior pole receives branches
from the ascending pharyngeal artery. Venous drainage is more diffuse, with a
venous plexus draining into the lingual and pharyngeal veins, which run into the
internal jugular vein.
The lingual tonsils are situated at the base and posterior region of the tongue.
The tubal tonsils are close to the orifice of the pharyngealtympanic tube. They lie
posterior to the opening of the tube into the nasopharynx.18
INTRODUCTION
18
1.4. Historical background
The first removal of the tonsils was described in the first century A.D. by Cornelius
Celsus in Rome. He used his bare fingers to grasp hold of the tonsil and remove it. If
the tonsil was covered by a membrane, he used a scalpel to cut through it.
Afterwards vinegar and a painted medication were used to achieve haemostasis.19
The lack of adequate anaesthesia prevented the breakthrough of adenoid and tonsil
surgeries until 1846 when the first narcosis was demonstrated by William Morton.
Before the discovery of anaesthesia, the removal of the tonsils had to be fast and
was, therefore, performed with a “guillotine”. The guillotine was originally designed for
cutting oedemas uvulas and was then subject to many modifications for use on
tonsillar tissue.20 Instruments for tonsillotomy in particular are meant to be based on
modifications of the guillotine.21
In 1917 Crowe was the first to describe sharp dissection of the tonsils. He examined
1000 tonsillectomies performed in Johns Hopkins Hospital, Baltimore, USA, between
1911 and 1917 and monitored the patients postoperatively for emerging
complications. Furthermore, he described the Crowe-Davis mouth gag, which is still
in use.21 Other surgical techniques, like tonsillar forceps and scissors, as well as
sutures and cautery for haemostasis, were described later on.
Removal of the adenoids was first described by Meyer in 1858 using a ring knife
inserted through the nasal cavity.19
At the beginning, tonsillectomy procedures fell in the domain of general surgeons, but
the difficulty of visualizing the tonsils made this type of surgery a specialization of
otorhinolaryngology.
Since the discovery of antibiotics in around 1930, the incidence of adenoid and tonsil
surgeries has declined strongly. In the past recurrent tonsillitis was the most frequent
indication for tonsil surgery, whereas nowadays the number of surgeries performed
due to hypertrophy and obstructive sleep apnoea syndrome has increased22 and both
became an indication for tonsillotomy in childhood.
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1.5. Histological background
The tonsils are lymphoepithelial tissue, also known as the pharyngeal lymphoid ring.
The tissue contains B-cell lymphocytes, T-cell lymphocytes and plasma cells which
activate secretory immunity.
From the epithelium of the tonsils, crypts extend deep into the tonsillar tissue in order
to enlarge the surface of the tonsils. These crypts contain dentritus, comprising dead
cells, and can harbour bacteria. Direct antigen uptake into the tissue allows
immediate activation of the immune system. The palatine tonsils are additionally
surrounded by a capsule of connective tissue, which separates the lymphatic tissue
from the pharyngeal muscle lying underneath the tonsil.23
The tonsil tissue is most active from the age of four to ten and tends to regress
afterwards. The secretory immune function still remains, but becomes less active.
Figure 1.1 Tonsillar tissue
Figure 1 shows the epithelium covering the lymphoid tissue and the tonsillar crypts.
On the surface of the tonsils, the epithelium looks like stratified squamous epithelium,
whereas inside the crypts the epithelium is invaded by lymphoid cells.
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1.6. Type of surgery
1.6.1. Tonsillectomy (TE)
Removal of the palatine tonsils together the surrounding capsule is known as
“tonsillectomy”. It is one of the procedures performed most frequently by
otorhinolaryngologists all over the world. The oldest – and still the gold standard –
method is cold steel dissection. For haemostasis, bipolar diathermy or ligatures are
frequently used. After surgery the tonsillar fossa is covered by a white coat of
fibrinous exudate. Tonsillectomy procedures are often combined with removal of the
adenoids and can additionally be combined with nasal surgery without increasing the
risk of haemorrhage.24
1.6.2. Tonsillotomy (TO)
The term “tonsillotomy” denotes incomplete removal of the palatine tonsils. Also
known as “intracapsular tonsillectomy”, most of the lymphoid tissue is removed but
the capsule is left behind. The method is described as being less invasive with lower
complication rates: postoperative haemorrhage rates are lower, postoperative pain is
less intense and a return to normal activity and diet is achieved earlier than after
tonsillectomy. The main indications are enlarged tonsils in early childhood.
1.6.3. Adenoidectomy (AE)
Removal of the pharyngeal tonsil is called adenoidectomy and it is commonly
performed in paediatric patients. An adenoidectomy is often combined with a
tonsillectomy and it is then called an “adenotonsillectomy” (TE+AE). Nearly 30% of
children under the age of two undergoing an adenoidectomy will undergo a
tonsillectomy within the next five years.25 Valtonen et al.26 cautions against a routine
adenoidectomy when performing a tonsillectomy, especially in children under the age
of ten.
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1.7. Inpatient versus outpatient surgery
A review of the literature reveals that many studies have been published on the
question of performing ENT surgeries as inpatient or outpatient procedures. Over the
past century, there has been a dramatic increase in the performance of tonsillectomy
as day-case surgery. Whereas ambulatory tonsillectomy is commonly performed in
the United States and the United Kingdom, inpatient surgery is favoured in Central
Europe whereby the length of hospitalization differs from country to country. In
Germany a hospital stay of one week is recommended while in Austria the preferred
duration of hospitalization is two nights after surgery. Adenoidectomy is performed in
an ambulatory setting for the majority of patients in the United States and the United
Kingdom, but debate still continues about the best strategies for managing this type
of surgery in German-speaking countries. One German expert in the field of tonsil
and adenoid surgery suggests performing an adenoidectomy as inpatient surgery
when other general diseases of the individual patient are known.27
Several attempts have been made to examine the safety of ambulatory tonsillectomy.
In an audit carried out by the Royal College of Surgeons UK, Brown et al.28 reported
that the main reason for admission after ambulatory tonsillectomy are vomiting (in
30% of cases), prolonged recovery from anaesthesia (22%) and haemorrhage (20%).
A recent review published by Brigger and Brietzke in 200629 analysed 17 reports,
concluding that paediatric tonsillectomy as a day-case surgery is a safe procedure,
although tonsillectomy in children bellow the age of four was related to a higher rate
of early complications. This finding was supported by Mitchell et al.,30 who reviewed
102 children under three years of age, and judged adenotonsillectomy to be a safe
ambulatory surgery. Ross et al.31 recommended planning overnight admission only
for infants of eighteen months or less and found children with upper airway
obstruction to be at higher risk of postoperative complications than children with other
indications for surgery. The same result was published by Holzmann et al.32 at
University Hospital Zurich who reported higher complication rates in children with
severe obstructive symptoms than in children with recurrent tonsillitis. Tonsillectomy
was suggested as a safe outpatient surgery regardless of the patients´ age,
indication of surgery or type of surgery by studies conducted in the USA29-31 and
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Israel.33 A study carried out in Spain34 confirmed the safety of tonsillectomies in
children, although they reported an overall complication rate of 9.3% (116 out of 1243
patients) as well as primary and secondary haemorrhage rates of 6.27% (n=78) and
0.48% (n=6). Authors from Belgium35 assessed nearly 2000 outpatient
tonsillectomies and found low haemorrhage and complication rates. Finally, in New
Zealand paediatric ambulatory tonsillectomy is described as being safe as long as
overnight observation is possible and trained hospital staff are available.36
Another major issue in the literature concerns the question of costs. Ambulatory
surgery is less expensive than inpatient surgery and is therefore, often favoured over
any inpatient procedure.37 Since costs in national health systems are increasing
dramatically, there is a concerted attempt in many countries to minimize the costs of
specific surgeries. As a result, ENT surgeries in particular are performed more and
more frequently as day-case surgeries.1
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1.8. Indications for tonsil surgery
Tonsillectomy or tonsillotomy is indicated in cases of
o acute recurrent or chronic tonsillitis,
o tonsillar hypertrophy/ obstructive sleep apnoea syndrome (OSAS),
o peritonsillar abscess and
o tonsil cancer.
Figure 1.2 Normal tonsils
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1.8.1. Acute recurrent or chronic tonsillitis
The term “tonsillitis” describes an acute infection of the palatine tonsil and is most
frequent in childhood. Two third of infections are due to viruses, typically adeno- and
parainfluenza viruses, and one third is caused by group A β-haemolytic streptococci
requiring antibiotic treatment. The infection is usually accompanied by fever, throat
and sometimes ear pain while swallowing and swollen lymph nodes. Diagnosis
involves inspection of the tonsils, and sometimes a blood count with inflammation
parameters and a rapid streptococcal test. This test verifies the presence of
streptococci and helps doctors decide whether treatment with antibiotics is necessary
or not. Infectious mononucleosis, diphtheria and agranulocytosis must always be
borne in mind as alternative diagnoses. Complications of streptococcal tonsillitis are
delayed antigen-antibody reactions that can result in acute glomerulonephritis, acute
rheumatic fever or rheumatic endocarditis. The term “chronic tonsillitis” is poorly
defined in the literature but is reported as a sore throat with tonsillar inflammation
lasting for at least three months by one author.38
Figure 1.3 Acute tonsillitis
For the indication “recurrent tonsillitis” several international recommendations exist
for the performance of surgery which are based on one randomized clinical trial by
Paradise et al.39,40 The Mayo Clinic,41 and the Austrian Society of Oto-Rhino-
Laryngology, Head and Neck Surgery and the Austrian Society of Paediatrics13 has
issued guidelines for tonsillectomy (table 1.1).
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Table 1.1 Recommendations for tonsillectomy in patients with recurrent tonsillitis
Frequency of tonsil infections:
a. Seven or more tonsil infections in one year
b. Five or more tonsil infections in each of two consecutive years
c. Four or more tonsil infections in each of three consecutive years
Additional criteria:
a. Oral temperature above 38.3°C
b. Cervical lymphadenopathy greater than 2 cm
c. Tonsillar exudate or positive Group A β-haemolytic streptococcus
In Belgium a survey among ENT specialists reported that the majority of doctors
performed a tonsillectomy if the patient suffered three to four episodes of tonsillitis in
one year and that the decision was influenced by the ENT training of the doctor.42
Paradise et al.39 reported that tonsillectomy in children statistically significantly lowers
the incidence of “sore throats” in the first two years of follow-up. This finding is
supported by other studies evaluating both paediatric and adolescent patients.43-49
However, an additional adenoidectomy did not improve the outcome.39 In contrast
with these studies, van Staaij50 argued that adenotonsillectomy has no benefits over
“watchful waiting” in children with mild symptoms of throat infection.
Kasenom et al.51 calculated an “index of tonsillitis” by multiplying the frequency of
tonsil infections per year with by the duration of illness. A score of 36 was suggested
by the authors to be an optimal cut-off for the sclerotic level of the tonsil. In a prior
study Kasenom et al.52 found an association between the sclerotic process and
diminished tonsillar defence as the count of neutrophils is lower, which consequently
increases the risk of bacteraemia after surgery. Having a score of more than 36
indicates that the patients´ tonsils should be removed.
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1.8.2. Tonsillar hypertrophy/obstructive sleep apnoea-syndrome (OSAS)
In early childhood the palatine tonsils and the adenoids can grow as a response to
the immune system. The symptoms caused by hyperplasia of the lymphoid tissue
can either be mild and not even recognized or severe enough to require surgery.
Extreme hypertrophy of the tonsils is called “kissing tonsils” as they touch each other
in the midline of the mouth.
The obstructive sleep apnoea-syndrome (OSAS) is a sleep-related disorder. During
sleep, the muscles of the velum, oropharynx and hypopharynx tend to collapse and
narrow the airway. The symptoms are snoring, periods of apnoea during sleep
followed by “gasping”, restless sleep with morning lethargy and daytime sleepiness
accompanied by poor concentration, headaches and changes in behaviour.
OSAS is more frequent in obese children and those with a history of allergic rhinitis.
Almost three percent of children suffer from OSAS, but only nine percent of snoring
children develop OSAS. The standard diagnostic examination is a polysomnography,
which is not necessary when the clinical presentation of the patient is obvious.53 Over
the past 35 years, the incidence of enlarged and obstructing tonsils has risen while
the incidence of recurrent infection has decreased.54 Authors still recommend
tonsillectomy for the treatment of OSAS55,56 although tonsillotomy should be favoured
over tonsillectomy as postoperative pain and the risk of haemorrhage are lower.57
Furthermore, tonsillotomy has no disadvantages over tonsillectomy in terms of re-
enlargement of the tonsils or snoring.58 Intracapsular tonsillectomy significantly
improved the quality of life for children suffering from OSAS.59
Tonsillar hypertrophy is the most frequent indication in childhood.60 The Austrian
Society of Oto-Rhino-Laryngology, Head and Neck Surgery strongly recommends the
tonsillotomy procedure for tonsillar hypertrophy, especially in children below the age
of six.
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Figure 1.4 Tonsillar hypertrophy
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1.8.3. Peritonsillar abscess
An abscess is a unilateral collection of pus and is not only restricted to the tonsillar
tissue but also extends to the connective tissue near the tonsil. It is usually located at
the upper pole of the tonsil or retro-, para- and subtonsillar. Symptoms are unilateral
redness, a swollen soft palate and uvular oedema. The abscess can be treated either
by needle aspiration, incision, drainage or immediate (“quinsy”) tonsillectomy.61-63
There are controversial opinions about the efficiency of immediate and elective
tonsillectomy. Some authors do not describe differences in postoperative
haemorrhage risks,64-67 while others calculated a higher haemorrhage risk for
abscess tonsillectomy.68 In a retrospective review of 102 young patients, Blotter et
al.69 found that medication for treatment of a peritonsillar abscess in children is a
good method and suggested surgical treatment only for patients who do not respond
to drugs. Compared to older children, for children under the age of six, medical
therapy was more successful. However, the study fails to explain the treatment
applied. Suzuki et al.70 proposed immediate abscess tonsillectomy as being a safe
surgery without complications. Herzon recommended that a peritonsillar abscess
should first be treated with needle aspiration. However, in cases with a history of
more than two episodes of acute tonsillitis in the year before the peritonsillar
abscess, an immediate tonsillectomy should be performed.71
Figure 1.5 Peritonsillar abscess
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1.8.4. Tonsil cancer
Most malignant tumours of the oropharynx are lymphoma and squamous cell
carcinomas located in 80 percent of all cases in the palatine tonsil or tongue base.
They may present as an asymmetric hyperplasia of the tonsil with additional
symptoms like fever, night sweats and dysphagia.72 However, most cases of
unilateral tonsil enlargement are not due to malignant cancer.73
Figure 1.6 Squamous cell carcinoma of the tonsil
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1.9. Indications for adenoidectomy
Adenoidectomy is indicated in cases of
o Adenoid hypertrophy and persistent ear infection,
o Recurrent rhinosinusitis and
o Obstructive sleep apnoea-syndrome (OSAS).
1.9.1. Adenoid hypertrophy and persistent ear infection
Hypertrophy of the adenoids is a very common situation in paediatric patients aged
three to six years. However, surgical treatment is recommended only when the
symptoms cause health problems. Common symptoms are difficulty in breathing,
resulting in “breathing through the mouth”, nasal discharge (a ”runny nose”) and
rhinophonia clausa (hyponasal voice), which is often combined with recurrent
infections of the upper airway and the middle ear. As the adenoids are near the
opening of the eustachian tube, the increase in lymphatic tissue can result in
compression of the tube and subsequent dysfunction. Inflammation of the middle ear
persists and recurrent otitis media results. Adenoidectomy is then usually performed
in combination with myringotomy.74 A review describes a significant benefit for
adenoidectomy in children with middle ear infections.75 After performing a
myringotomy, a subsequent adenoidectomy reduces the risk of a further necessary
myringotomy.76 Permanent symptoms following non-treatment of adenoid
hypertrophy are hearing loss, delayed language development and deformity of the
maxillar.
1.9.2. Recurrent rhinosinusitis
Some authors suggest an adenoidectomy in children with persistent or recurrent
sinusitis, even if the adenoids are not enlarged, before performing a FESS.77,78
1.9.3. Obstructive sleep apnoea-syndrome (OSAS)
In conjunction with hypertrophy of the tonsils, the adenoids might also be enlarged.
An adenotonsillectomy will then be undertaken in children suffering from OSAS.
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1.10. Complications of tonsil and adenoid surgery
Postoperative complications of tonsillectomy, tonsillotomy and adenoidectomy vary in
their occurrence and frequencies. Table 1.2 gives an overview of complications
described in the literature. They will be discussed in the following chapter starting
with postoperative haemorrhage and pain, as they are the most frequent
complications.
Table 1.2 Complications of tonsil and adenoid surgery (in relation to Johnson5, Randall79)
Intraoperative complications Anaesthetic complication
Excessive intraoperative haemorrhage
Immediate complications Nausea, vomiting, dehydration
Sore throat, otalgia, eustachian tube injury
Fever
Postoperative pain
Postoperative haemorrhage
Delayed complications Velopharyngeal insufficiency
Postoperative haemorrhage
Long-term complications Nasopharyngeal stenosis
Eagle syndrome
Regrowth of the lymphoid tissue
Immunological changes
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1.10.1 Postoperative haemorrhage
1.10.1.1 Postoperative haemorrhage rates in the literature
Postoperative haemorrhage is one of the most serious complications following tonsil
or adenoid surgery. It may occur any time up to three weeks after surgery and can be
minimal or severe; even fatal outcomes are described in the literature.2,80 It is
commonly accepted that bleeding episodes can be classified into primary
haemorrhage, within the first 24 hours of surgery, and secondary haemorrhage, after
the first 24 hours of surgery.6-12 Furthermore, most authors differentiate between
postoperative haemorrhage requiring surgical re-admission and minor bleeding
without imperative treatment under general anaesthesia.9 Classifications of
postoperative haemorrhage are rare in the literature; one has been published by
Windfuhr and Seehafter81 assessing the necessary treatment for any bleeding
episodes.
In relation to tonsillectomy, the haemorrhage risks vary between 1.5%7 and 40.0%.82
Blakley analysed 63 reports on post-tonsillectomy haemorrhage and described a
mean haemorrhage rate of 4.5% with a standard deviation of 9.4%. He suggested a
maximum expected haemorrhage rate of 13.9%.83 The largest study on post-
tonsillectomy haemorrhage was the prospective National Tonsil Audit in the UK
carried out by Lowe et al.12 in 2007 and covering about 34,000 patients undergoing
tonsillectomy. They reported a postoperative hemorrhage rate of 3.5% covering
bleeding occuring during hospitalization and bleeding leading to re-admission; 0.9%
of all patients were returned to theatre. Using data from the same study, van der
Meulen et al. found that postoperative hemorrhage after tonsillectomy with bipolar
methods or coblation is three times higher compared to cold steel tonsillectomy
alone.84 A retrospective study by Windfuhr et al. conducted on 15,218 patients in
Germany in 2005 found a return-to-theatre rate of 2.86% for tonsillectomy and 0.25%
for adenoidectomy.7 A meta-analysis by Krishna and Lee reported a haemorrhage
rate of 3.3% after tonsillectomy for patients with normal coagulation tests.85 A recent
prospective multicentre study published by Tomkinson et al. in 2011 evaluating about
17,500 tonsillectomies with or without adenoidectomy in Wales found a “primary
minor haemorrhage” of 0.1% (within the first 24 hours after surgery, no return to
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theatre), a “secondary minor haemorrhage” of 1.8% (after 24 hours of surgery,
readmission to hospital, no return to theatre) and a return to theatre rate of 1.5%. The
authors admitted that minor bleeding was poorly recorded in their multicentre
observational study.9 Attner et al. reported a haemorrhage rate of 7.5% in a
prospective study covering 2,800 cases in 2009.10 One study from in 1984 evaluating
20,000 patients after adenotonsillectomy reported that not one patient required a
return to theatre due to haemorrhage on the day of surgery.86 Bhattacharyya87
reported on 685 tonsillectomies in adults and found a postoperative haemorrhage
rate of 5.1%. A notably higher haemorrhage risk after monopolar tonsillectomy was
described by Blomgren et al.88 at the Central Hospital in Finland: 15.9% of operated
patients visited hospital again due to postoperative secondary haemorrhage; the
primary haemorrhage rate was 2.3%. In 1984 records from 1,150 tonsillectomies
were evaluated, revealing that the return-to-theatre rate was 2.8%, with young men
and patients with a peritonsillar abscess being at a higher risk of haemorrhage.89 In
1887 Tami et al.90 described an immediate postoperative haemorrhage rate of 2.7%
(21 out of 775 consecutive patients) in one English hospital. They additionally
admitted that patients with an abnormal coagulation test were more likely to suffer
from postoperative bleedings.
For tonsillotomies and adenoidectomies, haemorrhage rates have not been invested
in as much detail as for tonsillectomies. There is one study which predicted a
bleeding rate of 0.08% after adenoidectomy91 while another study found a return-to-
theatre rate of 0.35% for adenoidectomy compared to 1.78% for tonsillectomy.92 The
highest haemorrhage rate for adenoidectomy after surgical treatment was 0.43%.27
No investigation of haemorrhage rates for tonsillotomy was found in the literature.
Major reasons for the great disparity in haemorrhage rates, especially for
tonsillectomy procedures, are varying definitions of “postoperative bleeding” and the
way in which bleeding episodes are assessed. First, different definitions of
“postoperative haemorrhage” lead to a wide range of haemorrhage rates (table 1.3).
Second, study designs vary strongly. The majority of authors recorded hospital re-
admission as a benchmark for post-tonsillectomy haemorrhage rates. Only a few
authors examined patients after discharge to ascertain whether haemorrhage
occurred or not by sending a questionnaire or calling patients postoperatively.82,93-97
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These authors generally report a higher haemorrhage rate starting at 11.0%,97
12.8%,95 15.7%,96 19.0%,93 and increasing up to 40.0%.82 Third, another reason for
not being able to compare bleeding rates is the different age distribution. Authors
examining only adults, for example Bhattacharyya87, generally report a higher
haemorrhage rate than authors analysing children.
Liu et al.98, Mink et al.99 and Sarny et al.100 concluded that standardized definitions
and guidelines for study designs are required to enable comparison between studies.
Table 1.3 Definition of “postoperative haemorrhage”
Definition of “postoperative haemorrhage” Haemorrhage
Haemorrhage leading to hospital re-admission12 3.5%
Haemorrhage requiring surgical treatment under general anaesthesia7 1.5%
Any blood noted on sheets, pillows, blood-tinged sputum or nasal discharge95 12.8%
Blood actively flowing from the mouth82 40.0%
Any kind of bleeding episode93 19.0%
No definition101
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1.10.1.2. Risk factors for postoperative haemorrhage
Results concerning risk factors for postoperative haemorrhage are controversially
discussed in the published literature.7-9,12,102 One major reason might be the
application of different statistical methods for analysis which result in varying
outcomes. Most authors test for proportions in order to compare a specific subgroup
with the whole population. Only a few authors use multivariate logistic regression for
testing all risk factors in one model at the same time.9,12 This offers a far more
precise picture of the influence of multiple factors at one time.
The risk factors type pertaining to the type of surgery, the patients´ age and sex,
indication for surgery, operation technique, abnormal coagulation tests and
postoperative infection of the tonsillar fossa will be described in the following.
1.10.1.2.1. Type of surgery
It is well known that bleeding rates are strongly related to the type of surgery.
Tonsillectomy shows higher postoperative haemorrhage rates than the less invasive
methods of tonsillotomy and adenoidectomy.7
1.10.1.2.2. Patients´ age
The age of patients has consistently been described as being a major risk factor for
the occurrence of haemorrhage with older patients being at higher risk.7-9,12
1.10.1.2.3. Patients´ sex
There is a discrepancy concerning sex as a risk factor for postoperative
haemorrhage. Some authors found a positive correlation for males being at higher
risk7,9 and others did not.8,12
1.10.1.2.4. Indication for surgery
Regarding the indication for surgery, tonsillar hypertrophy is supposed to show a
lower haemorrhage rate than other indications.12 Differing rates are described for
tonsillectomy due to peritonsillar abscess. Some authors report higher rates for
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immediate abscess tonsillectomy compared to elective tonsillectomy,65,68 but others
do not.64,66
1.10.1.2.5. Operation techniques
In recent years, operation techniques have been investigated in more detail, showing
statistically significantly higher or lower postoperative haemorrhage rates for certain
operation techniques, for example: bipolar diathermy for tonsillectomy shows higher
haemorrhage rates compared to cold steel dissection tonsillectomy11,84 as does
monopolar diathermy.103 A literature review on the coblation technique reports a
higher postoperative haemorrhage rate compared to other techniques for
tonsillectomy.104 Lowe et al. supports this finding.12,84 However, one study conducted
on 1600 patients described a lower risk for secondary haemorrhage in patients
undergoing coblation tonsillectomy.104
1.10.1.2.6. Abnormal coagulation tests
Debate continues as to the best strategy for managing of possible bleeding disorders
in patients undergoing surgery.105 Questions have been raised about the
effectiveness of preoperative coagulation tests.
A meta-analysis from 2001 evaluating coagulation studies revealed that the
postoperative haemorrhage risk is not elevated in patients with abnormal coagulation
tests.106 With the help of the German Surveillance Unit for Rare Paediatric Disorders,
Bidlingmaier et al.107 argued that bleeding episodes were not predictable although
coagulation tests were done for most patients undergoing ENT surgery. They even
reported two deaths after adenoidectomy. Prim et al.108 analysed 1,516 cases with a
normal coagulation test preoperatively and found that one half of the patients with
postoperative haemorrhage had an undetected coagulation disorder (mostly von
Willebrand's disease).
Bolger et al.109 could not detect bleeding disorders by examining patients´ clinical
history in detail. This finding was supported by others.110-114 Cooper et al.115 do not
recommend preoperative coagulation tests either, arguing that routine use is too
expensive. Likewise, in their analysis of about 1,350 children, Schwab et al.116 do not
recommend blood tests prior to surgery, but tests should be performed in children
with a history of abnormal bleeding. Licameli et al.117 published a questionnaire for
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the preoperative screening of patients at risk of postoperative haemorrhage. A
detailed overview of the literature is given in table 1.4.
Guidelines have been issued which basically give similar recommendations. The
American Academy of Otolaryngology, Head- and Neck Surgery suggested a
preoperative coagulation work-up only “if an abnormality is suspected by history or if
genetic information is not available” in a consensus statement in the Clinical
Indicators Compendium of 1999.118 However, a recent survey showed a discrepancy
between current practice and the recommendations, as 40 percentage of
practitioners performed coagulation screening preoperatively although the patient´s
and family history were negative.105 The British Committee for Standards in
Haematology recommended taking bleeding history prior to surgery with detailed
information on family history, previous excessive postsurgical or posttraumatic
bleeding and intake of anticoagulant drugs. Coagulation tests should not be routinely
performed in unselected patients and should only be ordered in patients with positive
bleeding history.119 The German Society of Oto-Rhino-Laryngology, Head and Neck
Surgery published a questionnaire for taking a standardized coagulation history for
each patient, but did not recommend the routine performance of coagulation
screenings.120
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Table 1.4 Literature review of studies examining the efficacy of preoperative coagulation history and tests
Authors Patients Findings and recommendation
Asaf et al.121 416 <18 years No coagulation test; except for patients with a positive history
Bidlingmaier107 1,068 <16 years No coagulation test
Bolger et al.109 52 patients No clear recommendation; 11.5% had abnormal coagulation
test; history detected no coagulation disorder
Burk et al.122 1,603 children No coagulation test; except for patients with a positive history
Close et al.110 96 patients No coagulation test, no coagulation history
Cooper et al.115 review No coagulation test is most cost effective
Eberl et al.112 702 children No coagulation test; except for patients with a positive history
Eisert et al.113 148 <14 years No coagulation test; except for patients with a positive history
Gabriel et al.114 1,706 <15 years No coagulation test, no coagulation history
Howells et al.123 382 <12 years No coagulation test; except for patients with a positive history
Licameli et al.117 7,730 children Questionnaire on coagulation history; coagulation test yes
Schmidt et al.124 91 patients Coagulation tests should be performed
Schwaab et al.116 1,137 children,AE No coagulation test; except for patients with a positive history
Tami et al.90 775 patients Coagulation tests should be performed
Zwack, Derkay125 4,373 children No coagulation test
1.10.1.2.7. Postoperative infection of tonsillar fossa
A study from 2007 showed that postoperative infection of the tonsillar fossa is no risk
factor for secondary haemorrhage126 while another study described a positive
relationship between preoperative bacterial colonization of the tonsillar fossa and
postoperative haemorrhage, recommending antibiotics.127 However, prescribed
antibiotics did not reduce the risk of post-tonsillectomy haemorrhage in general.128,129
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1.10.1.3. Timing of postoperative haemorrhage
In terms of when postoperative haemorrhage occure, there was a tendency for higher
haemorrhage rates on the day of surgery as well as days five to eight after
surgery.130
Deitmar and Neuwirth131 conducted a study on 105 patients undergoing tonsillectomy
and identified 11 patients with bleeding on the day of surgery, 16 on day five, 24 on
day six, 12 on day seven and 11 on day eight.
In a multicentre study Windfuhr7 claimed that 80 percent of patients had their
bleeding episode on the day of surgery and that on day five and six only 5 percent
each experienced any bleeding.
Wei8 reported a postoperative haemorrhage for only one out of 90 patients on the
day of surgery with the majority of patients experiencing bleeding on postoperative
day five (13 out of 90), six (16 out of 90) and seven (12 out of 90).
It is obvious that the rate of primary haemorrhage relative to secondary haemorrhage
varies strongly among studies. Some authors report a high haemorrhage rate on the
day of surgery7 and some do not.8 One major reason is the loss of follow-up as some
patients do not visit hospital when they experience a bleeding episode. A study by
Sarny et al.100 interviewing patients by means of a postoperative questionnaire found
twice as high a secondary haemorrhage rate compared to the primary haemorrhage
rate (9.1% versus 21.9%). As follow-up could be monitored by interviewing all
patients and not only reviewing their medical hospital charts, these results are
reliable. However, it has to be borne in mind that haemorrhage rates always vary
according to the definition of postoperative bleedings.
Another major reason for the importance of the timing of haemorrhages is the
commonly raised concern of the length of hospitalization. The authors of a meta-
analysis claim that bleeding episodes on the day of surgery will be recognized when
performing day-case surgery. Therefore, patients do not need to stay overnight. They
suggest either performing an ambulatory tonsillectomy or hospitalization of one week
to cover secondary bleeds (which occur between postoperative day five and
seven).132
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1.10.2 Postoperative pain
Postoperative pain occurs in the majority of operated patients with differing intensities
over time and between individuals.
Warnock and Lander4 discovered a significant decrease in postoperative pain for 129
children aged 5 to 16 years over an evaluation period of one week. Lavy133 discussed
postoperative pain after tonsillectomy in 50 patients divided into two age groups. He
claimed that the mean pain in patients aged ten years and above stayed constant
over nine days, whereas the average level of pain in younger patients decreased
after the second postoperative day.
The reasons for different pain progressions are controversial in the literature. Some
studies have investigated antibiotic intake and other medication for the reduction of
postoperative pain while others have documented the intensity of pain relating to
operation techniques.
Antibiotic therapy after surgery did not decrease postoperative pain, but enabled an
earlier return to normal diet and normal activity.128,129,134,135 A single intravenous dose
of corticosteroids during the tonsillectomy procedure is said to decrease pain on
postoperative day one in a meta-analysis dating from 2006.136 Local anaesthetics are
recommended for pain control in children after a tonsillectomy when applied once
after surgery for five minutes.137 This result was supported by a literature review
published by Grainger and Saravanappa.138
No differences in postoperative pain were found in relation to surgical techniques
such as electrocautery dissection, coblation and microdebridement139 compared to
cold steel dissection,140 or bipolar scissors tonsillectomy141 and monopolar cautery
compared to harmonic scalpel tonsillectomy.142 However, lower pain levels were
described using ligature tonsillectomy compared to cold steel tonsillectomy.143 A
prospective single-blinded and randomized clinical trial found a significantly higher
intake of analgesic postoperatively and a longer time to areturn to normal diet for
paediatric patients undergoing bipolar diathermy tonsillectomy compared to cold steel
dissection tonsillectomy.144
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As for surgery types, tonsillotomy is well known to be less painful than tonsillectomy,
as described in two recent studies by Ericsson and Hultcrantz145 and Hultcrantz et
al.146 Cohen et al.59 compared pain courses for intra- and extracapsular tonsillectomy
in 43 patients by creating mean pain levels for the first ten postoperative days, finding
that pain after intracapsular tonsillectomy is significantly less severe. These results
were consistent with other studies.147,148 Microdebrider tonsillotomy is less painful in
children with obstructive tonsillar hypertrophy compared to electrosurgical
tonsillectomy.149 Equally, post-tonsillectomy pain is said to be lower when the
preoperative fasting time of the child is shorter.150
One study reported that for the parents of operated children, adult patients and
doctors the control of postoperative pain is slightly more important than better control
of postoperative haemorrhage.151
Although several studies have evaluated the intensity of postoperative pain, the
relationship between postoperative pain and haemorrhage has not yet been
investigated empirically in the literature.4,94 In order to evaluate such a relationship, a
study conducted by Sarny et al. described post-tonsillectomy pain types, including
the association of pain and postoperative haemorrhage and the relationship of pain
with age, gender and indication for surgery. Patients suffering from severe or
increasing pain for the first three post-tonsillectomy days are at a notably higher risk
of haemorrhage than other patients.
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1.10.3 Intraoperative complications
1.10.3.1. Anaesthetic complications
Anaesthesia for tonsil and adenoid surgery is complicated as the endotracheal tube
for the airway flow is in the surgical field. The tube can accidently be cut or kinked
and, especially when electrocautery is used, burning can arise. As these surgeries
are mostly common in childhood while children are often infected, the endotracheal
mucosa is thin and likely to be hypersensitive. Another complication arising due to
blood in the hypopharynx is laryngospasm or aspiration of blood. Moreover, loss of
teeth should be avoided by careful placement of the mouth gag. For these reasons
anaesthesia in ENT patients should be performed by a well experienced
anaesthetist.
In patients with a severe postoperative haemorrhage requiring surgical treatment, a
so called “crush intubation” has to be arranged as the patients are hardly fasting, in
which case possible high blood loss prior to surgery has to be kept in mind.
1.10.3.2. Excessive intraoperative haemorrhage
Articles covering intraoperative blood loss during tonsillectomy are rare in the
international literature. Authors describe intraoperative blood loss as varying strongly
from 7.8 ml26 to 115 ml.152 Blood loss of about 70 ml for both tonsillectomy and
adenotonsillectomy was reported by Carithas et al.153. In contrast, Valtonen et al.26
described blood loss five times higher caused by adenoidectomy compared to
tonsillectomy alone.
A few studies looked at the association between age and intraoperative blood loss.
All authors evaluated the absolute blood loss in children up to 19 years of age but
reported differing results. Both Gabriel et al.114 and Valtonen et al.26 described a
significant increase in intraoperative blood loss with age while Nguyen et al.154
claimed to find no differences in the amount of intraoperative bleeding related to age.
Connections between indications for surgery and intraoperative blood loss are hardly
covered in the literature. Valtonen et al.26 and Nguyen et al.154 both described no
significant difference between the amount of intraoperative blood loss during surgery
for enlarged tonsils and surgery due to recurrent tonsillitis.
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In recent years, intraoperative blood loss in association with a specific operation
technique has been investigated in increasing number of studies, evaluating in
addition the duration of surgery, postoperative pain and the return to normal diet.
Bipolar diathermy is said to lower intraoperative blood loss when compared to cold
steel dissection,152,155-158 but increases the risk of postoperative haemorrhage.84 The
mean blood loss for bipolar diathermy was 30 ml versus a mean blood loss of 60 ml
during cold steel dissection. Silveira et al.155 (enrolling 60 children) and Szeremeta et
al.158 (484 patients) found a reduction in blood loss for bipolar diathermy (30 ml)
compared to cold steel dissection (100 ml). A lower median intraoperative blood loss
for bipolar scissors (5 ml) compared to cold dissection tonsillectomy (115 ml) was
described by Raut et al.152 in connection with 200 cases. Coblation technique by
comparison with cold steel dissection is associated with less intraoperative blood
loss.159-162
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1.10.4. Immediate complications
1.10.4.1. Nausea, vomiting and dehydration
Immediately after surgery, many patients experience nausea and vomiting which is
often due to swallowed blood and prescribed narcotic and pain medication. The
patient´s refusal to eat and drink might lead to dehydration, which is quite often
poorly managed. Special attention has to be drawn to children, who have a lower
volume of blood, and therefore become dehydrated faster than adults. One study
reports a faster return to a normal diet when a single dose of steroids is administered
during surgery.163
1.10.4.2. Sore throat, otalgia and eustachian tube injury
A sore throat is experienced by nearly all patients and is often accompanied by
otalgia. Otalgia is due to accidentally injury to the opening of the eustachian tube and
can be followed by middle ear infections.
1.10.4.3. Fever
Fever in the first 18 to 36 hours after surgery is caused by anaesthetic effects, stress
and bacteraemia.79 Crysdale and Russel164 found that 2.6% (245 out of 9,409) of
paediatric patients had a temperature higher than 38.5°C.
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1.10.5. Delayed complications
1.10.5.1. Velopharyngeal insufficiency (VPI)
Velopharyngeal insufficiency causes hypernasal speech and nasal regurgitation due
to an inability of the valve to separate the oral and the nasal cavity from each other.
This is primarily caused by adenoidectomy as the nasopharyngeal airway might be
enlarged during surgery. However, this condition does not last more than a few
months.6
1.10.5.2. Nasopharyngeal stenosis
Nasopharyngeal stenosis can appear after adenotonsillectomy, when the mucosa
was excessively injured and scars arise. The scar contracture causes a narrowing of
the nasopharynx, called a “stenosis”. Symptoms are snoring, dysphagia and difficulty
in breathing. Surgical treatment of this very rare complication of adenotonsillectomy
is difficult. Toh et al.165 described the use of a bivalve palatal transposition flap and
Cotton166 reports on a laterally based pharyngeal flap. The use of a CO2 – laser is
introduced by Jones et al.167
1.10.5.3. Eagle syndrome
The eagle syndrome is due to ossification of the stylohyoid ligament or an elongated
processus styloideus and is known to be a very uncommon complication. It was
described by Weiss168 who noticed that patients with the symptoms of an eagle
syndrome, like a unilateral sore throat and dysphagia, had undergone tonsillectomy
in the past.
1.10.5.4. Re-growth of the lymphoid tissue
Re-growth of the tonsillar tissue can be associated with a partial tonsillectomy. It is
described for 16.6% of children who underwent a partial tonsillectomy using the
radiofrequency technique.169 This effect is supposed to be age related and most
likely in children aged seven years and above.170 Another investigation concerning
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adenoid re-growth reported more frequent occurrence in children treated with
repeated courses of antibiotics postoperatively.171
1.10.5.5. Immunological changes
Varying opinions exist concerning the influence of tonsillectomy and adenoidectomy
on the immune system.172 One study showed that tonsillectomy has an influence on
the immune system (lower IgA levels were found in children after tonsillectomy), but
without any statistical significance.173
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1.11. Operation techniques for tonsil surgery
New methods for tonsil surgery are continually being introduced in the international
literature with some of them being associated with lower morbidity rates and some
not.174 Table 1.5 gives an overview of the operation techniques currently in use.
Tonsillectomy is mainly performed under general endotracheal anaesthesia and only
in rare cases is it performed under local anaesthetic. General anaesthesia is advised
for children up to fourteen years, abscess tonsillectomy, adults suffering from
epilepsy and patients with an abnormal blood count for more precise intraoperative
haemostasis.175
In recent years, due to the occurrence of Creuzfeld-Jacob-disease, a broad
discussion has taken place in the UK as to whether single-use surgical instruments
can be used instead of reusable instruments. A multicentre audit in UK hospitals
demonstrated that single-use instruments are as effective as reusable instruments
and might even be cheaper.176
Table 1.5 Operation techniques: overview
(according to Stuck et al. “Tonsillectomy in Children”, Deutsches Ärzteblatt) 177
Non–heat generating Scissors, raspatory, loop (disposable instrument)
Hydro-Jet (disposable instrument)
Heat generating Monopolar cauterizing needle
Bipolar forceps/ scissors
KTP/holmium laser
CO2 laser
Suction coagulation (disposable instrument)
Argon plasma
Ultrasonic knife (disposable instrument)
Coblation
Colorado Micro Needle (disposable instrument)
Microneedle (disposable instrument)
Frequently used types of operation techniques are described in the following chapter.
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1.11.1. Cold steel dissection
Cold steel dissection tonsillectomy has been performed for many years now and still
remains the gold standard.21
After the patient has been prepared for surgery, the first tonsil is grasped with forceps
and pulled into the midline in order to identify the anterior palatine arch. The mucous
membrane is incized and the tonsils capsule identified. After the incision at the
anterior palatine arch, the upper tonsil pole is exposed and the base removed with
the raspatory. The tonsil is gently removed from the fossa by cutting its lower pole.
Haemostasis is usually obtained with packs, electrocautery, suture ligature or other
methods.
1.11.2. Electrocautery dissection
Electrocautery dissection has been used for about 20 years. The surgical instruments
are heated to very high temperatures (approximately 400-600 °C) and are applied to
the tissue, which is burned and subsequently removed.
Two methods of electrocautery dissection exist: monopolar and bipolar
electrocautery. When using monopolar electrocautery, a single electrode (called a
grounding pad) is placed on one part of the patient´s body, often the patient´s thigh.
The other electrode is used by the surgeon to apply heat to cut the tissue. The
bipolar electrocautery method uses two electrodes which are both placed in one pair
of forceps or scissors.178
Monopolar diathermy is the most frequently used tonsillectomy method in Australia
179 while in the UK bipolar diathermy and cold steel dissection are the most common
techniques for tonsillectomy.180 A study conducted in Chicago, USA, reported that
monopolar electrocautery was the most frequently used technique for paediatric
adenotonsillectomy and coblation the second most frequent.181
Controversy exists concerning intraoperative blood loss, surgical time, rate of
postoperative haemorrhage, postoperative pain levels and the time of recovery after
surgery when applying electrocautery as compared to cold steel dissection.
A shorter surgical time and decreased intraoperative blood loss are described by
some authors.152,156 Another study evaluating the overall cost of surgical techniques
stated a lower price and less intraoperative blood loss for mixed tonsillectomy (cold
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steel and bipolar diathermy) when compared with cold steel dissection alone.182
Postoperative haemorrhage rates were said to be three times higher with bipolar
diathermy compared to cold steel dissection alone in a large audit performed in the
UK evaluating 13,500 surgeries.84 One investigation on 200 consenting patients
undergoing tonsillectomy ether with bipolar scissors or cold steel dissection did not
find statistically significant differences in the postoperative haemorrhage rates or pain
scores. Blomgren et al.88 demonstrated that after monopolar electrocautery
tonsillectomy, 15.9% of operated patients saw a doctor because of postoperative
bleeding. Johnston et al.183 found no significant difference between intracapsular
tonsillectomy and monopolar tonsillectomy for the outcome variables postoperative
haemorrhage, dehydration and postoperative tonsillitis. In large studies9,84 or a meta-
analysis,184 electrocautery for tonsillectomy, whether monopolar or bipolar, was
associated with an increased risk of postoperative haemorrhage compared to cold
steel dissection.
1.11.3. Harmonic scalpel (HS)
The harmonic scalpel is an ultrasonic dissection coagulator (Ethicon Endo-Surgery
Inc, Cincinnati, Ohio). The method is a recent medical invention, similar to
electrocautery and coblation, but uses lower temperatures (50-100°C) to remove the
tissue. Instead of heat produced by electricity, heat is produced by mechanical
energy and high-frequency vibration motion at 55 KHz per second. This leads to
coagulation and cutting of the tissue. So far the method has only been used for 2% of
tonsillectomies.185
Several advantages of the HS technique have been reported in the literature
including lower intraoperative blood loss and less postoperative pain.186,187
Postoperative haemorrhage rates are described as being significantly lower with the
use of HS compared with other methods for tonsillectomy.188 Other studies focusing
on the HS technique do not report on less pain189. However, some studies are
underpowered to perceive a significant difference in haemorrhage rates.190
1.11.4. Laser
For tonsillectomy three lasers are used: the carbon dioxide (CO2) laser, which is most
commonly used, the Nd:YAG laser and the KTP-laser. Coagulating and cutting the
tissue as well as coagulating vessels up to 0.5 mm can be performed by laser
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tonsillectomy.191 For larger vessels bipolar diathermy is necessary.
The main advantages for laser use are less intraoperative blood loss, lower
postoperative pain192 and more precise cutting, especially when using a microscope.
Yet some important disadvantages are known, like longer surgery time and the need
to protect the endotracheal tubus from injury. CO2-laser tonsillotomy has been
described by Unkel et al. for 109 children with tonsillar hyperplasia resulting in a good
and long lasting outcome.193
1.11.5. Argon-plasma-coagulation (APC)
The APC is a high frequency monopolar technique performed with a special
instrument called a “Raspatorium nach Bergler”. The technique was first introduced in
2000 by Dr. Bergler from Germany.194 Without direct tissue contact, electric current is
applied through ionized argon gas in order to coagulate and dissect.195 The
technique is known as the “hot” technique. Intraoperative haemostasis and surgical
time is reduced by using the APC, whereas pain and haemorrhage risk remains the
same.196,197 APC is described as being more effective at achieving haemostasis than
electrocautery.198
1.11.6. Microdebridement
The microdebrider is a surgical blade rotating at high speed to cut the tissue. It is
used for intracapsular tonsillectomy, where the tonsil is mechanically shaved out of
the fossa, leaving the capsule behind. As heat is not needed, the procedure is safe in
terms of postoperative bleeding, pain and infection.139,199 Prolonged surgical time and
slightly higher blood loss is described compared to monopolar diathermy.200 The
main indication for intracapsular tonsillectomy is tonsillar hypertrophy rather than
recurrent infections.201
1.11.7. Coblation
Coblation uses radiofrequency energy for cutting the tissue, similar to electrocautery,
but at lower temperatures (40-70°C). A conductive medium, such as a saline
solution, is needed to create a plasma field in order to destroy the tissue. The
intracellular bonds are cracked by free sodium ions resulting from a reaction between
the achieved temperatures and the saline solution. The byproducts, like oxygen and
carbon dioxide, eliminated by continuous lavation of the operation field. Coblation
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was devised by ArthroCare Corporation, Sunnyvale, CA, USA.
Controversy still remains as to the effects on intraoperative blood loss, postoperative
pain and haemorrhage after coblation tonsillectomy in contrast to other methods.
Intraoperative blood loss is described as being equivalent to other surgery
methods.202 In a study by Belloso et al.104 the coblation technique was associated
with a lower incidence of postoperative haemorrhage, lower pain levels and an earlier
return to normal diet and activity. Noordzij and Affleck160 supported these findings. No
statistical differences in pain scores were found by Arya et al.203 when comparing
coblation tonsillectomy and coblation tonsillotomy. Focusing on the same operation
techniques, Chang et al.204 described improved postoperative recovery after
coblation tonsillotomy.
However, disadvantages of the coblation technique have also been described in the
literature. One author reports a five time higher haemorrhage risk for coblation when
compared with cold steel dissection.205 A meta-analysis in German by Mösges et
al.206 reported a similar bleeding rate for coblation and cold dissection tonsillectomy
while Glade et al.207 found similar haemorrhage rates for coblation and electrocautery
tonsillectomy and a lower incidence of postoperative dehydration after coblation
tonsillectomy. One large audit performed by Lowe and his study team12 reports a 3-
fold increase in postoperative haemorrhage risk after coblation tonsillectomy in
comparison to cold steel tonsillectomy. In conclusion, further research should be
carried out to investigate the coblation technique, including large, randomized control
trials.208
1.11.8. Colorado-needle
The Colorado-needle is a microdissection needle with a monopolar electrode. The
needle tip has a sharp point containing tungsten, a heavy metal which has the
highest melting point of all non-alloyed metals. This makes precise cutting of the
tissue possible. In Austria the Colorado-needle is mostly used for tonsillotomy.
The microdissection needle is rarely described in the literature and only a few articles
are available.209 In a pilot study, lower postoperative pain levels were described when
using the Colorado-needle for tonsillectomy.210
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1.11.9. Radiofrequency technique (RF)
The RF-technique is a new method applied especially in the paediatric population
when tonsils are enlarged. A tonsillotomy with RF is performed with the Ellman 4.0
Mhz Surgitron Dual Radiowave Unit, which is connected to a neutral electrode that is
placed under the patient´s shoulder. Using a monopolar needle tip, the tonsil tissue is
cut and the vessels are coagulated. To protect the posterior pillar, a gauze strip is
placed at the back of the tonsils.211 The technique is described as having the same
beneficial long-term effects as tonsillectomy in children with recurrent tonsillitis or
obstructive symptoms.212 Forty adult patients were randomly assigned to either
tonsillectomy using the RF-technique or traditional cold steel tonsillectomy. The
results showed no significant differences in postoperative morbidity.213 Ericsson et
al.214 described less pain after intracapsular RF-tonsillectomy (tonsillotomy)
compared to traditional tonsillectomy. These findings have been supported by other
studies.215 In a recent study, one patient´s tonsil was removed using the RF-
technique and the other using the monopolar electrocautery technique. The authors
reported benefits in favour of the RF-technique in terms of wound healing after
surgery; postoperative pain scores were comparable between the two groups.216
Nemati et al.217 compared RF-tonsillotomy to cold steel tonsillectomy and reported a
better outcome for former in terms of the duration of surgery, intraoperative blood
loss, pain and postoperative recovery. RF-tonsillotomy was not associated with
increased pain compared to laser tonsillotomy.218
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1.12. Operation techniques for adenoidectomy
For the removal of the adenoids the conventional procedure is still the curettage
adenoidectomy.185,219 This technique has been well discussed in the literature and
some modifications have been introduced.220 Several instruments exist which use
ether indirect vision of the adenoids or endoscopic control as a relatively new
method.
1.12.1. Curettage adenoidectomy
After finger palpation of the soft palate, the adenoids are shaved from the
nasopharyngeal wall with the curette in one movement. Under indirect vision with a
laryngeal mirror, possible remnants will are identified and again removed with the
curette. The use of the “Adenoid curette by Beckmann” is quite widespread. Diverse
sizes exist with different cutting edges. The “Adenotom by La Force” is also used
frequently. After removal of the tissue, a gauze pack is inserted in the nasopharynx
for some minutes in order to achieve haemostasis.
In recent years, endoscopic-assisted curettage has appeared. It has the advantage
of direct vision of the adenoids and therefore, complete removal is more likely to be
achieved.221 There is some controversy about the effectiveness of the method. It has
been proved to significantly reduce the rate of re-enlargement of the adenoid tissue
without significant extra time or costs.222 However, another study reveals no
differences between the gold standard curettage adenoidectomy and endoscopic-
assisted adenoidectomy.223
1.12.2. Electrocautery
The use of eletrocautery for adenoidectomy is similar to the electrocautery method
used when removing tonsil tissue. Ablation of the tissue is achieved by a curved
Frazier-type suction system or a disposable hand-switching suction coagulator. The
adenoid pad is cauterized with care so as not to injure the soft plate, the opening of
the eustachian tubes or other structures. Compared to curettage adenoidectomy,
electrocautery is described as a safe procedure with no significant differences in
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postoperative outcomes but lower intraoperative blood loss 224-227 and shorter
operating time.226,228
1.12.3. Power-assisted adenoidectomy
This method is similar to electrocautery, but it utilizes an endoscopic shaver to
remove the tissue. It is reported that this method is faster229 and results in a better
postoperative outcome compared to curettage adenoidectomy.230
1.12.4. Coblation
Coblation, as described above, has many advantages and is therefore, another
method of choice for adenoidectomy. Less postoperative neck pain is reported for
patients undergoing coblation adenoidectomy compared to curettage or cautery
methods.207 In addition, it appears to involve minimal intraoperative blood loss and
faster postoperative recovery.
MATERIAL AND METHODS
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2. MATERIAL AND METHODS
2.1. Study organization
The study was designed as a collaboration between Austria´s ENT departments and
was funded by the Austrian Society of Oto-Rhino-Laryngology, Head and Neck
Surgery. It was set up in order to evaluate the frequency of all tonsillectomies,
tonsillotomies and adenoidectomies performed by ENT-departments. Data were
collected prospectively via an online form.
Prior to the start of the study, its concept was presented at the national meeting of
the Austrian Society of Oto-Rhino-Laryngology, Head and Neck Surgery. In
September 2009 representatives of each of the ENT departments in Austria were
given detailed instructions about the project and introduced to the procedure of
submitting patients' data in the online questionnaire. The representatives were
responsible for providing continuous and accurate information about the cases in
their departments. The details were entered after the patients' surgery, on the day
they were discharged and whenever haemorrhage occurred. It was each ENT
department's responsibility to obtain informed consent from patients before
submitting their data to the central database. Further correspondents were organized
by e-mail and telephone. Each month every department received a summary report
of the data submitted.
2.2 Study period
The study population consisted of all patients operated between 1st October 2009
and 30th June 2010, so that a full coverage of tonsil operations in Austria for a period
of nine months is given. The period of data entry lasted for nine months but remained
open until the end of August 2010 so as to allow enough time to include all relevant
postoperative bleedings.
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2.3. Patient selection
All patients, both children and adults, operated in participating national hospitals were
eligible for inclusion if operated during the evaluation period.
They included patients who underwent
tonsillectomy with adenoidectomy (TE+AE),
tonsillectomy without adenoidectomy (TE),
tonsillotomy with adenoidectomy (TO+AE),
tonsillotomy without adenoidectomy (TO),
adenoidectomy (AE)
and excluded patients who underwent a
tonsillar biopsy,
tonsillectomy due to cancer and
non-consenting patients.
The study was approved by the Ethics Committee of the Medical University of Graz,
Austria (number 21-072 ex 09/10).
2.4. Data collection and management of data submission
The data were collected electronically and entered locally at each hospital. A
password-protected account was created for every clinic in order to ensure secure
data entry. All cases were submitted via the website of the Austrian Tonsil Study
2010 (www.tonsil-evaluation.org, figure 2.1). The data were stored in a secure central
database; every clinic was able to revise their submitted information. All information
was also stored on a central server located in Vienna. This procedure worked very
well and can be recommended for studies of this size.
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Figure 2.1 Homepage: www.tonsil-evaluation.org
The procedure to submit data was rather straightforward: after login, either a list of
already entered cases could be opened or a single case (new or existing) for direct
editing. Cases were identified by the patient's date of birth and date of surgery.
Entering dates was facilitated by a built-in calendar function (figure 2.2).
Figure 2.2 Homepage: after login
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58
For each individual case, a web form was presented for editing which contained data
entered in earlier sessions. If there were no earlier sessions, an empty form was
presented. When a new case was created, the form was empty and had to be filled
with data about surgery. The data sets could be edited for all entries until 30th August
2010 (two months after the last surgery).
During the entry procedure, two different possibilities were distinguished: new
patients versus patients returning to hospital due to some haemorrhage. For patients
returning to hospital, a further distinction was made between patients who returned to
the hospital they were operated in and patients who were originally operated in
another hospital.
Patients were classified as follows:
patients in hospital for the primary operation (figure 2.3);
patients returning to the same hospital as they were operated in due to
postoperative bleeding (figure 2.4) and
patients with a postoperative bleeding episode who were originally operated in
a different hospital (figure 2.5).
Figure 2.3 Homepage: first admission for primary operation
Figure 2.4 Homepage: admission for postoperative haemorrhage in the hospital where
primary surgery was undertaken
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Figure 2.5 Homepage: admission for postoperative bleeding episode in unknown
hospital
For the group of patients who were admitted for postoperative haemorrhage to a
different hospital than the one they had been operated in, a shortened data set was
collected about surgery. Wherever possible, persons who were operated in hospital A
and who returned to hospital B due to bleeding were matched in the database by
manually combining the surgery data of hospital A with the haemorrhage data of
hospital B. If hospital A was not taking part in the study or the operation time was
outside the study period, the case was excluded from further analysis. This was
necessary for 48 out of the 9,621 entries in the database. By removing such cases, it
was possible to ensure that no single person was represented in the database by
more than one entry.
Once the study had started, submission was monitored by the project team and
hospital representatives were contacted if information details were missing or
submission seemed to be slow. The project team was not involved in submitting the
data. Every month each department received a report of the cases submitted by them
in the previous month (see Appendix). Within the study period, about 200 requests
for help were answered regarding data submission, about three quarters by e-mail
and the rest by telephone.
In September 2010 the data were presented at the annual meeting of the Austrian
Society of Oto-Rhino-Laryngology, Head and Neck Surgery, Salzburg, Austria. Every
department received a statistical analysis about 50 pages in length concerning their
submitted patients. More detailed questions were answered by e-mail afterwards.
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2.5. Study design
The study is a prospective multicentre cohort study. The data were entered
prospectively during the study period of nine months, plus two extra months follow-up
time. Information was collected about the patient's age, sex, weight, date of birth,
date of surgery and date of hospital discharge as well as their red blood count and
coagulation tests. Operation details included the indication for surgery, operation
technique, intraoperative blood loss, grade of surgeon, and anaesthesia-related
details. Details on postoperative haemorrhage included the day, grade and located
side of the bleeding episode. A copy of the questionnaire is attached at the end of
this thesis (see Appendix).
2.6. Definition and Classification of Postoperative Haemorrhage
Postoperative haemorrhage was defined and classified rigorously. Any bleeding
episode after extubation was included to calculate the postoperative haemorrhage
rate. Operated patients were asked to return to hospital immediately if any amount of
blood was spotted in the sputum. Bleeding episodes were recorded according to a
classification of postoperative haemorrhage (figure 2.5 and 2.6) which quantified
severity according to the necessary medical treatment. Grade A consists of bleedings
that were just recorded anamnestically, which means that bleeding had stopped
before re-entering the hospital. Grade B consists of minor bleedings under
examination which could be stopped with non-invasive treatment. Grade C consists
of bleedings that require a return to theatre or medical treatment under general
anaesthesia. Grade D are dramatic bleedings that require a blood transfusion.
Fortunately grade E (exitus after fatal bleeding) did not occur in our study.
MATERIAL AND METHODS
61
Figure 2.6: Classification of postoperative haemorrhage (German version)
Table 2.1: Classification of postoperative haemorrhage (English version)
DAY OF BLEEDING EPISODE
T0 Day of surgery until midnight T1 Midnight of day of surgery until next midnight (24 hours) T2 Second day after surgery from midnight to midnight T3 Third day after surgery from midnight to midnight Tx etc.
T21 21st day after surgery from midnight to midnight
SEVERITY OF BLEEDING EPISODE
A Anamnestically recorded blood-tinged sputum A1 Wound is and stays dry, no coagulum upon inspection A2 Coagulum upon inspection, dry wound after removal
B Bleeding actively under examination, treatment necessary, dry wound afterwards, blood count in normal range, no shock
B1 Minimal haemorrhage, stops after non-invasive treatment (e.g. adrenalin sponge)
B2 Haemorrhage requiring treatment under local anaesthetic
C SurgiCal treatment with general anaesthesia, blood count still in normal range, no shock
D Dramatic haemorrhage, haemoglobin decreased, blood transfusion required, difficult surgical treatment, intensive care may be necessary
E Exitus due to haemorrhage or haemorrhage-related complications
EXAMPLES
T1A2 Coagulum upon inspection without haemorrhage on the first postoperative day, dry wound after removal
T2A2 and T5C
Coagulum upon inspection without haemorrhage on the second postoperative day, dry wound after removal. Second postoperative haemorrhage on day five requiring surgical treatment under general anaesthesia
MATERIAL AND METHODS
62
2.7. Statistical analyses
Statistical analyses were performed using PASW 18.0 (SPSS Inc., Chicago, IL,
USA). Figures were created with Microsoft Excel 2007.
Descriptive statistics were used to show the patients´ characteristics. The results
were expressed in absolute numbers and as a percentage.
Dependencies of categorized parametric data were analysed using chi-square
independence tests for cross-tabulations. Deviations for proportions in the subgroups
were tested two-sided with tests for proportions. The P value was tested two sided; P
values of less than 0.05 were considered significant, p<0.01 highly significant and
p<0.001 extremely significant. Multivariate logistic regression was performed to
explore the potential risk factors related to postoperative haemorrhage.
For the analyses of not normally distributed variables (tested with the Kolmogorov-
Smirnoff-Test) non-parametric methods were used. The Mann-Whitney-U-Test was
applied for independent variables with two values and the Kruskal-Wallis-Test for
independent variables with more than two possible values.
As different logistic regression models are available, they are listed in table 2.2 along
with information on when to choose which model.
Table 2.2 Regression models
Regression models Independent variable Dependent variable
Binary logistic regression categorical (=nominal or
ordinal)
OR metric
dichotomous
Multinominal logistic
regression
categorical (=nominal or
ordinal)
categorical (=nominal or
ordinal)
Ordinal logistic regression categorical (=nominal or
ordinal)
ordinal
RESULTS
63
3. RESULTS
3.1. DESCRIPTIVE RESULTS
3.1.1 Participating hospitals
Patients were recruited from 32 clinics from all over Austria with the number of cases
per hospital ranging from 26 to 765 entries. A total of 9,621 cases were entered in
the central database by the time entries were closed in August 2010. This number
included some double entries relating to the same person being operated in hospital
A and going to hospital B due to some haemorrhage. Removing these double entries
reduced the number of valid cases in the database by 48. Another reason for
excluding entries in the database was missing data concerning the variables "date of
birth", "date of surgery" or "type of surgery", which happened for 168 cases.
Altogether 216 of the 9,621 primary entries in the database could not be used for
further analysis. Table 3.1 gives an overview.
Table 3.1 Number of entries in central database
total % of total
Entries submitted 9621 100.0
Cases included for analysis 9405 97.8
Entries not included – missing data 168 1.7
Entries not included – other hospitals 48 0.5
3.1.2 Demographic Data
The overall number of patients operated in nine months allows an estimate of about
12,830 surgeries in one year. In relation to Austria´s population of 8.4 million, the
overall annual operation rate is 1 per 655 persons per year.
RESULTS
64
3.1.3 Patient characteristics
Of the 9,405 patients who could be included for analysis, 5,476 (58.2%) were males
and 3,929 (41.8%) were females (table 3.2). Young children had been predominantly
males.
The entire study cohort composed 3,474 (36.9%) children under the age of six, 2,424
(25.8%) school children aged six to fifteen and 3,507 (37.3%) adults aged fifteen and
older (table 3.2). One third each were children younger than six years and adults
older than fifteen years.
Table 3.2 Age-sex distribution of patients
Age group Male Female Total
< 6 years 2,257 (65%) 1,217 (35%) 3,474 (100%)
6 - 15 years 1,439 (59%) 985 (41%) 2,424 (100%)
> 15 years 1,780 (51%) 1,727 (49%) 3,507 (100%)
Total 5,476 (58%) 3,929 (42%) 9,405 (100%)
Regarding the type of surgery, adenoidectomies (37.1%, 3,492) and tonsillectomies
(36.8%, 3,459) were performed most frequently. A tonsillotomy with adenoidectomy
was performed in 13.0% (1,221 patients), a tonsillectomy with adenoidectomy in
12.1% (1,135 patients) and a tonsillotomy without adenoidectomy in 1.0% (98
patients).
RESULTS
65
Type of surgery and age group (years)
< 6
6 - 15
> 15
Total
TE
% of surgery type
1.5%
11.9%
86.6%
100%
Number of patients 51
413
2,995
3,459
% of age group 1.5% 17.0% 85.4% 36.8%
TE+AE
% of surgery type
15.8%
58.1%
26.1%
100%
Number of patients 179
660
296
1,135
% of age group 5.2% 27.2% 8.4% 12.1%
TO±AE
% of surgery type
75.1%
22.2%
2.7%
100%
Number of patients 991
293
35
1,319
% of age group 28.5% 12.1% 1.0% 14.0%
AE
% of surgery type
64.5%
30.3%
5,2%
100%
Number of patients 2,253
1,058
181
3,492
% of age group 64.9% 43.6% 5.2% 37.1%
Total
% of surgery type
36.9%
25.8%
37.3%
100%
Number of patients 3,474
2,424
3,507
9,405
% of age group 100% 100% 100% 100%
Table 3.3 Distribution of type of surgery by age group (total number and % of row and column sum) TE = tonsillectomy, TE+AE = adenotonsillectomy, TO±AE = tonsillotomy or adenotonsillotomy,
AE = adenoidectomy
Table 3.3 allows a comparison of the type of surgery by age group. Depending on the
intended total – either the sum of a row or the sum of a column – either the
percentage of the type of surgery or the percentage of the age group is given. For
example, the value of 413 children aged six to fifteen with TE is 11.9% of all TE
surgeries (row sum: 3,459); at the same time, 17.0% of all surgeries performed in this
age group are of type TE (column sum: 2,424). In terms of age group, children aged
less than six years underwent tonsillectomy ±AE in only 5.2% of cases while the
majority underwent AE (64.9%). In school children aged six to fifteen, AE was less
frequent, but still displayed the most frequent surgery type (43.6%). Adults underwent
almost solely TE (85.4%); TO was performed in only 1% of all adults. In terms of the
type of surgery, TE without AE was performed most frequently in adults (85.4%) and
TE with AE most frequently in school children (58.1%). TO was carried out mainly in
children (75.1%) with a decreasing rate as age increased. AE was most commonly
performed in children (64.5%).
RESULTS
66
For the following analyses, the types of surgery have been grouped into tonsillectomy
(TE) with or without (±) adenoidectomy, tonsillotomy (TO) ± adenoidectomy and
adenoidectomy (AE).
RESULTS
67
3.1.4 Tonsillectomy
Table 3.4 Tonsillectomy (±AE): patients´ characteristic
Number of patients % of total
Total 4,594 100.0
Sex Male 2,384 51.9
Female 2,210 48.1
Age group <6 years 230 5.0
6-15 years 1,073 23.4
>15 years 3,291 71.6
Indication for surgery RT (single answer) 3,367 73.3
TH (single answer) 51 1.1
OSAS (single answer) 73 1.6
Immediate abscess (single answer) 448 9.8
Elective abscess (single answer) 81 1.8
TH + OSAS 27 0.6
RT + TH 208 4.5
RT + OSAS 62 1.3
RT + OSAS + TH 27 0.6
Immediate abscess + RT 19 0.4
Elective abscess + RT 46 1.0
Not specified 185 4.0
Grade of surgeon Consultant 2,448 53.3
Specialist registrar 1,994 43.4
Not specified 152 3.3
Operation technique Cold steel 4,012 87.3
Cold steel + bipolar forceps 210 4.6
Cold steel + bipolar scissors 27 0.6
Bipolar forceps 34 0.7
Bipolar scissors 64 1.4
Bipolar forceps and scissors 35 0.8
Coblation 51 1.1
Laser 4 0.1
Not specified 157 3.4
RT = recurrent tonsillitis, TH = tonsillar hypertrophy, OSAS = obstructive sleep apnoea-syndrome
RESULTS
68
Of the 4,594 patients who underwent TE±AE, the distribution of male and female
patients was almost equal. The indications for surgery among the patients were
unevenly distributed. Recurrent tonsillitis as a single answer was by far the most
common indication, followed by peritonsillar abscess operated immediately after
diagnosis. A peritonsillar abscess was preferred to be operated immediately when
diagnosed instead of delaying the operation until after healing. However, a delayed
elective operation was preferred when the peritonsillar abscess appeared along with
recurrent tonsillitis. Interestingly enough, tonsillar hypertrophy appeared more often
combined with recurrent tonsillitis than without (table 3.4). More than half of all TE
were operated by consultants and the most common surgical technique was cold
steel dissection. The second most frequent surgical technique was cold steel
dissection combined with bipolar diathermy. Laser was not employed as a routinely
used operation instrument for TE in Austria (table 3.4).
Table 3.5 illustrates the management of intraoperative haemostasis in patients
undergoing TE. Packs and bipolar diathermy were most frequently used for
intraoperative haemostasis. Packs with adrenalin, a circular suture and antifibrinolytic
substances were used more often than coblation, closure suture of the palatine arch,
local anaesthetic or monopolar diathermy.
Table 3.5 Intraoperative haemostasis for tonsillectomy
Intraoperative haemostasis (multiple answers allowed)
Used % of used Not used
Packs 3,503 37.6 1,091
Adrenalin packs 456 4.9 4,138
Bipolar diathermy 4,286 46.0 308
Monopolar diathermy 13 0.1 4,581
Coblation 46 0.5 4,548
Circular suture 584 6.3 4,010
Closure suture of palatine arch 28 0.3 4,566
Antifibrinolytic substance 351 3.8 4,243
Local anaesthetics 28 0.3 4,566
Haemostyptics 27 0.3 4,567
Total 9,322 100.0
RESULTS
69
Mean overnight stay after TE was 2.9 nights with a standard deviation of 1.5 nights.
Outpatient TE was hardly performed and most patients left hospital after two nights.
Only 6% of all patients left hospital after one night and 1.5% stayed in hospital for
more than one week (figure 3.1).
Figure 3.1 Tonsillectomy: duration of hospitalization by age group
0 9
95 53
20 15 5 7 2 5 58
473
279
89 45
5 12 9 12
171
1100
914
419
184
52 47 49
0
200
400
600
800
1000
1200
Nu
mb
er o
f p
atie
nts
Postoperative night
< 6 years
6 - 15 years
>15 years
0 1 2 3 4 5 6 7 > 7
RESULTS
70
3.1.5 Tonsillotomy
Table 3.6 Tonsillotomy (±AE) patient´ characteristics
Number of patients % of total
Total 1,319 100.0
Sex Male 863 65.4
Female 456 34.6
Age group <6 years 991 75.1
6-15 years 293 22.2
>15 years 35 2.7
Indication for surgery RT (single answer) 59 4.5
TH (single answer) 680 51.6
OSAS (single answer) 87 6.6
TH + OSAS 319 24.2
RT + TH 59 4.5
RT + OSAS 23 1.7
RT + OSAS + TH 33 2.5
Not specified 59 4.5
Grade of surgeon Consultant 731 55.4
Specialist registrar 563 42.7
Not specified 25 1.9
Operation technique Colorado-needle 627 47.5
Coblation 346 26.2
CO2 laser 169 12.8
Bipolar technique 69 5.2
Radiofrequency-technique 25 1.9
Other 36 2.7
Not specified 47 3.6
RT = recurrent tonsillitis, TH = tonsillar hypertrophy, OSAS = obstructive sleep apnoea syndrome
RESULTS
71
Of the 1,319 patients undergoing TO±AE, two thirds were males and three quarters
were younger than six (table 3.6). The most common indication was tonsillar
hypertrophy in half of all patients, followed by tonsillar hypertrophy combined with
OSAS. Slightly more than half of the patients were operated by consultants. The
most frequently used operation technique was the Colorado-needle in nearly half of
all cases. Coblation was used in 26% of cases, followed by the CO2 laser in 13%.
Radiofrequency technique was only used in 2% of all cases.
Table 3.7 shows the methods used to achieve intraoperative haemostasis. Packs and
bipolar diathermy were utilized frequently and the coblation technique was applied in
10% of cases.
Table 3.7 Intraoperative haemostasis for tonsillotomy
Intraoperative haemostasis (multiple answers allowed)
Used % of used Not used
Packs 1,086 43.9 233
Adrenalin packs 93 3.8 1,226
Bipolar diathermy 963 38.9 356
Monopolar diathermy 17 0.7 1,302
Coblation 225 9.1 1,094
Circular suture 9 0.4 1,310
Closure suture of palatine arch 0 0.0 1,319
Antifibrinolytic substance 80 3.2 1,239
Local anaesthetic 0 0.0 1,319
Haemostyptics 0 0.0 1,319
Total 2,473 100.0
RESULTS
72
Mean overnight stay after TO was 2.1 nights with a standard deviation of 1.2 nights.
Patients undergoing TO left hospital earlier compared to patients undergoing TE. TO
on an outpatient basis was performed in only in 1% of cases and only 1% of patients
stayed in hospital for more than five days (figure 3.2).
Figure 3.2 Tonsillotomy: duration of hospitalization by age group
10
256
400
164
43
15 6 1 3 2
81
126
43
6 8 0 0 0 0 4 10 7 1 0 2 0 3 0
50
100
150
200
250
300
350
400
450
Nu
mb
er o
f p
atie
nts
Postoperative day
< 6 years
6 - 15 years
> 15 years
0 1 2 3 4 5 6 7 > 7
RESULTS
73
3.1.6 Adenoidectomy
Table 3.8 Adenoidectomy: patient´ characteristics
Number of patients % of total
Total 3,492 100.0
Sex Male 2,229 63.8
Female 1,263 36.2
Age group <6 years 2,253 64.5
6-15 years 1,058 30.3
>15 years 181 5.2
Indication for surgery RT (single answer) 719 20.6
DET (single answer) 727 20.8
OSAS (single answer) 282 8.1
RT + DET 849 24.3
RT + OSAS 191 5.5
DET + OSAS 175 5.0
RT + OSAS + DET 134 3.8
Not specified 415 11.9
Grade of surgeon Consultant 1,983 56.8
Specialist registrar 1,435 41.1
Not specified 74 2.1
Operation technique Adenoid curette by Beckmann 1,322 37.9
Coblation 27 0.8
Adenotome by La Force 117 3.4
Adenoid curette + endoscopic control +/- pharyngeal mirror
1,229 35.2
Other 4 0.1
Not specified 793 22.7
OSAS = obstructive sleep apnoea syndrome, RT = recurrent infections, DET = dysfunction of eustachian tubes
RESULTS
74
AE was performed in 3,492 patients, a majority of them male. Two thirds were
children under the age of six and one third was school children aged six to fifteen.
Recurrent infections, a dysfunction of the eustachian tubes and a combination
thereof were the indications in most cases. Again AE was performed by consultants
for more than half of all cases. The prevalent operation technique was the adenoid
curette by Beckmann with or without endoscopic control or pharyngeal mirror (Table
3.8) while the most frequent intraoperative haemostasis methods were bipolar
diathermy, packs and antifibrinolytic substances in 8% (table 3.9).
Table 3.9 Intraoperative haemostasis for adenoidectomy
Intraoperative haemostasis (multiple answers allowed)
Used % of used Not used
Packs 2,861 58.8 631
Adrenalin packs 371 7.6 3,121
Bipolar diathermy 1,328 27.3 2,164
Monopolar diathermy 4 0.1 3,488
Coblation 25 0.5 3,467
Circular suture 0 0.0 3,492
Closure suture of palatine arch 0 0.0 3,492
Antifibrinolytic substance 277 5.7 3,215
Local anaesthetic 0 0.0 3,492
Haemostyptics 0 0.0 3,492
Total 4,866 100.0
RESULTS
75
Mean overnight stay after AE was one night. Day-case AE was performed in 46% of
all patients and 20% stayed two postoperative nights in hospital (figure 3.3).
Figure 3.3 Adenoidectomy: duration of hospitalization
989
1638
421
43 26 8 3 2 11 0
200
400
600
800
1000
1200
1400
1600
1800
Nu
mb
er o
f p
atie
nts
Postoperative day
0 1 2 3 4 5 6 7 > 7
RESULTS
76
3.1.7 Age distribution for all types of surgeries
Figure 3.4 Age distribution for all surgeries
Figure 3.5 Age distribution for surgeries with or without adenoidectomy
0
200
400
600
800
1000
1200
0 5 10 15 20 25 30 35 40 45 50
Nu
mb
er o
f p
atie
nts
Age
AE only
TO+/-AE
TE+/-AE
0
200
400
600
800
1000
1200
0 5 10 15 20 25 30 35 40 45 50
Nu
mb
er o
f p
atie
nts
Age
All without AE
All with AE
RESULTS
77
3.2. POSTOPERATIVE HAEMORRHAGE
3.2.1 Tonsillectomy
Table 3.10 Tonsillectomy (±AE): patient characteristics and postoperative haemorrhage rates
Number of patients
Total without
haemorrhage with
haemorrhage p-value* RR
All consenting patients (TE ± AE) 4,594 (100.0%) 3,905 (85.0%) 689 (15.0%)
Sex Male 2,384 (51.1%) 1,994 (83.6%) 390 (16.4%) =0.063 1.0
Female 2,210 (48.9%) 1,911 (86.5%) 299 (13.5%) =0.053 0.8
Age (years)
<6 230 (5.0%) 214 (93.0%) 16 (7.0%) <0.001 1.0
6 - 15 1,073 (23.4%) 961 (89.6%) 112 (10.4%) <0.001 1.49
>15 3,291 (71.6%) 2,730 (83.0%) 561 (17.0%) <0.001 2.43
Indication for surgery
RT (single answer) 3,367 (73.3%) 2,868 (85.2%) 527 (14.8%) =0.304 1.0
TH (single answer) 51 (1.1%) 46 (90.2%) 5 (9.8%) =0.299 0.63
OSAS (single answer) 73 (1.6%) 60 (82.2%) 13 (17.8%) =0.501 1.15
Immediate abscess (single answer) 448 (9.8%) 387 (86.4%) 61 (13.6%) =0.331 0.86
Elective abscess (single answer) 81 (1.8%) 65 (80.2%) 16 (19.8%) =0.231 1.28
TH + OSAS 27 (0.6%) 24 (88.9%) 3 (11.1%) =0.572 0.72
RT + TH 208 (4.5%) 177 (85.1%) 31 (14.9%) =0.969 0.96
RT + OSAS 62 (1.3%) 55 (88.7%) 7 (11.3%) =0.414 0.73
RT + OSAS+ TH 27 (0.6%) 24 (88.9%) 3 (11.1%) =0.572 0.72
Immediate abscess + RT 19 (0.4%) 18 (94.7%) 1 (5.3%) =0.235 0.34
Elective abscess + RT 46 (1.0%) 43 (93.5%) 3 (6.5%) =0.107 0.42
Others and not specified 185 (4.0%)
Grade of surgeon
Consultant 2,448 (53.3%) 2,069 (84.5%) 379 (15.5%) =0.502 1.0
Specialist registrar 1,994 (43.4%) 1,733 (86.9%) 261 (13.1%) =0.017 0.85
Not specified 152 (3.3%)
Operation technique
Cold steel (CS) 4,012 (87.3%) 3,450 (86.0%) 562 (14.0%) ** 1.0
CS + bipolar forceps ± scissors 237 (5.2%) 193 (81.4%) 44 (18.6%) =0.05 1.33
Bipolar forceps ± scissors (no CS) 133 (2.9%) 115 (86.5%) 18 (13.5%) =0.877 0.96
Coblation 55 (1.2%) 42 (76.4%) 13 (23.6%) =0.042 1.69
Others and not specified 157 (3.4%)
* Total number as the baseline category, ** cold steel as the baseline category, RR = relative risk (95% CI) RT = recurrent tonsillitis, TH = tonsillar hypertrophy, OSAS = obstructive sleep apnoea syndrome
RESULTS
78
Among the 4,594 patients undergoing TE during the evaluation period, 689 (15.0%)
patients experienced some form of postoperative haemorrhage. The most vulnerable
group for suffering postoperative haemorrhage were adults (17.0%). Fortunately
children up to the age of fifteen had highly significantly fewer bleeding episodes than
adults (10.9% vs. 20.6%). On the whole, surgical revision of a postoperative
haemorrhage was necessary in 4.9% of all patients undergoing TE. Again children
under six had a lower return-to-theatre rate than school children and adults (1.3% vs.
4.7% and 5.3%). Age influenced the rate of postoperative haemorrhage significantly
for all age groups (table 3.10).
Table 3.10 shows that patients with elective abscess TE and obstructive sleep
apnoea syndrome had the highest postoperative haemorrhage rate while
haemorrhage rates for tonsillar hypertrophy were comparably low. Immediate
abscess TE showed a lower risk for haemorrhage than elective abscess TE. The
indication did not influence the postoperative haemorrhage rate significantly.
There was a significant difference relating to the expertise of the surgeon. On
average, patients operated by registrars in training experienced fewer postoperative
haemorrhages.
In relation to operation techniques for TE, the study found significant differences in
the haemorrhage rates when comparing cold steel dissection with other operation
techniques. Contrary to expectations, haemorrhage rates were not elevated when
only bipolar techniques were used. In contrast, cold steel dissection in combination
with bipolar diathermy revealed a significantly higher haemorrhage rate. A more
significant haemorrhage rate was found for the coblation technique in comparison
with cold steel dissection (table 3.10).
RESULTS
79
3.2.2 Tonsillotomy
Table 3.11 Tonsillotomy (±AE): patient characteristics and postoperative haemorrhage rates
Number of patients
Total without
haemorrhage with
haemorrhage p-value* RR
All consenting patients (TO ± AE) 1,319 (100.0%) 1,289 (97.7%) 30 (2.3%)
Sex Male 863 (65.4%) 846 (98.0%) 17 (2.0%) =0.581 1.0
Female 456 (34.6%) 443 (97.1%) 13 (2.9%) =0.386 1.45
Age (years) <6 991 (75.1%) 970 (97.9%) 21 (2.1%) =0.743 1.0
6 - 15 293 (22.2%) 286 (97.6%) 7 (2.4%) =0.895 1.14
>15 35 (2.7%) 33 (94.3%) 2 (5.7%) =0.172 2.7
Indication for surgery
RT (single answer) 59 (4.5%) 58 (98.3%) 1 (1.7%) =0.743 1.0
TH (single answer) 680 (51.6%) 662 (97.4%) 18 (2.6%) =0.515 1.53
OSAS (single answer) 87 (6.6%) 87 (100.0%) 0 (0.0%) =0.135 0
TH + OSAS 319 (24.2%) 315 (98.1%) 6 (1.9%) =0.410 1.12
RT + TH 59 (4.5%) 59 (100.0%) 0 (0.0%) =0.257 0
RT + OSAS 23 (1.7%) 22 (95.7%) 1 (4.3%) =0.412 2.53
RT + OSAS + TH 33 (2.5%) 33 (100.0%) 0 (0.0%) =0.468 0
Others and not specified 59 (4.5%)
Grade of surgeon
Consultant 731 (55.4%) 711 (97.3%) 20 (2.7%) =0.403 1.0
Specialist registrar 563 (42.7%) 555 (98.6%) 8 (1.4%) =0.174 0.52
Not specified 25 (1.9%)
Operation technique
Colorado-needle 627 (47.5%) 614 (97.9%) 13 (2.1%) =0.736 1.0
Coblation 346 (26.2%) 339 (98.0%) 7 (2.0%) =0.534 0.95
CO2 laser 169 (12.8%) 167 (98.8%) 2 (1.2%) =0.295 0.57
Bipolar technique 69 (5.2%) 69 (100.0%) 0 (0.0%) =0.224 0
Radiofrequency-technique 25 (1.9%) 22 (88.0%) 3 (12.0%) =0.002 5.71
Others and not specified 83 (6.3%) 78 (94.0%) 5 (6.0%)
* Total number as the baseline category, RR = relative risk (95% CI) RT = recurrent tonsillitis, TH = tonsillar hypertrophy, OSAS = obstructive sleep apnoea syndrome
RESULTS
80
Of the 1,319 patients undergoing TO, 2.3% experienced postoperative haemorrhage,
of whom one third needed surgical revision (0.8%). Although age had not been a
significant risk factor for postoperative haemorrhage, a tendency for a higher
haemorrhage rate was established for increasing age. In contrast to TE, there was a
slight preponderance for females to suffer haemorrhage (table 3.11).
Haemorrhage occurred in patients undergoing surgery due to tonsillar hypertrophy
and/or obstructive sleep apnoea syndrome. There was no elevated risk for patients
with recurrent tonsillitis. The grade of surgery did not affect the haemorrhage rate
significantly, but again registrars in training had a lower rate than consultants.
It is interesting to note that using the radiofrequency technique proved to have a 5.7
higher risk of postoperative haemorrhage than the “Colorado-needle”. The bipolar
technique did not result in any bleeding. Employment of the CO2 laser showed a
lower high haemorrhage rate when compared to coblation, the Colorado-needle and
other monopolar techniques (table 3.11).
RESULTS
81
3.2.3 Adenoidectomy
Table 3.12 Adenoidectomy (AE): patient characteristics and postoperative haemorrhage rates
Number of patients
Total without
haemorrhage with
haemorrhage p-value* RR
All consenting patients (AE) 3,492 (100.0%) 3,464 (99.2%) 28 (0.8%)
Sex Male 2,229 (63.8%) 2,210 (99.1%) 19 (0.9%) =0.789 1.0
Female 1,263 (36.2%) 1,254 (99.3%) 9 (0.7%) =0.722 0.77
Age (years)
<6 2,253 (64.5%) 2,240 (99.4%) 13 (0.6%) =0.232 1.0
6 - 15 1,058 (30.3%) 1,048 (99.1%) 10 (0.9%) =0.766 1.5
>15 181 (5.2%) 176 (97.2%) 5 (2.8%) =0.016 4.67
Indication for surgery
RT (single answer) 719 (20.6%) 711 (98.9%) 8 (1.1%) =0.224 1.0
DET (single answer) 727 (20.8%) 724 (99.6%) 3 (0.4%) =0.166 0.36
OSAS (single answer) 282 (8.1%) 279 (98.9%) 3 (1.1%) =0.394 0.96
RT + DET 849 (24.3%) 846 (99.6%) 3 (0.4%) =0.091 0.36
RT + OSAS 191 (5.5%) 189 (99.0%) 2 (1.0%) =0.453 0.91
DET + OSAS 175 (5.0%) 172 (98.3%) 3 (1.7%) =0.166 1.55
RT + OSAS + DET 134 (3.8%) 133 (99.3%) 1 (0.7%) =0.659 0.64
Others and not specified 415 (11.9%)
Grade of surgeon
Consultant 1,983 (56.8%) 1,969 (99.3%) 14 (0.7%) =0.63 1.0
Specialist registrar 1,435 (41.1%) 1,424 (99.2%) 11 (0.8%) =0.88 1.14
Not specified 74 (2.1%)
Operation technique
Adenoid curette by Beckmann
1,322 (37.9%) 1,313 (99.3%) 9 (0.7%) =0.622 1.0
Coblation 27 (0.8%) 27 (100.0%) 0 (0.0%) =0.804 0
Adenotome by La Force 117 (3.4%) 116 (99.1%) 1 (0.9%) =0.61 1.29
Adenoid curette + endoscopic control +/- pharyngeal mirror
1,229 (35.2%) 1,223 (99.5%) 6 (0.5%) =0.218 0.71
Laser 4 (0.1%) 4 (100.0%) 0 (0.0%) =0.968 0
Others and not specified 793 (22.7%)
* Total number as the baseline category, RR = relative risk (95% CI) OSAS=obstructive sleep apnoea syndrome, RT=recurrent infections, DET=dysfunction of eustachian tubes
Patients undergoing AE had a postoperative haemorrhage rate of 0.8% with a return-
to-theatre rate of 0.3%. The variety of risk factors did not reveal any significance.
Interestingly, increasing age went along with higher haemorrhage rates (table 3.12).
RESULTS
82
3.3. GRADES OF BLEEDING EPISODES
For measurement of the severity of postoperative haemorrhage, the bleeding
episodes have been assigned to one of the grades from A to E. For detailed
information about the classification of postoperative bleeding episodes see chapter
“Material and Methods”.
3.3.1 Overview for all types of surgeries
Table 3.13 Number of bleeding episodes for all types of surgery
TE±AE TO±AE AE Total
Grade of bleeding episode A1 157 (18%) 7 (20%) 7 (24%) 171 (18%)
A2 300 (34%) 15 (43%) 5 (17%) 320 (34%) B1 112 (13%) 1 (3%) 4 (14%) 117 (12%) B2 71 (8%) 0 (0%) 1 (3%) 72 (8%)
C 241 (27%) 12 (34%) 11 (38%) 264 (28%)
D 8 (1%) 0 (0%) 1 (3%) 9 (1%)
E 0 (0%) 0 (0%) 0 (0%) 0 (0%)
Total 889 (100%) 35 (100%) 29 (100%) 953 (100%)
Of the patients analysed, 747 (7.9%) experienced at least one postoperative bleeding
episode resulting in a totality of 953 bleeding episodes. Multiple bleeding episodes
occurred in 156 patients with 39 patients bleeding more than two times after surgery.
From table 3.13 it is apparent that nearly 30 per cent of bleeding episodes had to be
treated under general anaesthesia. Interestingly, bleeding episodes of grade C
occurred more frequently after AE than after TE±AE or TO±AE (38% vs. 27% and
34%) in relation to grade A and B bleeding episodes.
Both grade A1 and A2 bleeding episodes occurred much more often than the other
grades for all types of surgery; however the type of surgery did not influence the
severity of haemorrhage significantly (p=0.163).
The tables below illustrate the main characteristics of the patients by grade of
bleeding episode for TE, TO and AE.
RESULTS
83
3.3.2 Tonsillectomy
Table 3.14 Tonsillectomy (±AE): patients characteristics for all haemorrhage grades
Total A1 A2 B1 B2 C D
Total number of bleeding episodes 889(100%) 157(18%) 300(34%) 112(13%) 71(8%) 241(27%) 8(1%)
Age (years)
< 6 19(100%) 9(47%) 5(26%) 2(11%) 0(0%) 3(16%) 0(0%)
6 - 15 138(100%) 20(14%) 51(37%) 13(9%) 0(0%) 52(38%) 2(1%)
> 15 732(100%) 128(17%) 244(33%) 97(13%) 71(10%) 186(25%) 6(1%)
Gender Female 368(100%) 75(20%) 134(36%) 34(9%) 30(8%) 89(24%) 6(2%)
Male 521(100%) 82(15.5%) 166(32%) 78(15%) 41(8%) 152(29%) 2(0.5%)
Indication for surgery
RT (single answer) 642(100%) 115(18%) 217(34%) 84(13%) 49(8%) 171(27%) 6(1%)
TH +/- OSAS 28(100%) 1(4%) 13(46%) 2(7%) 5(18%) 7(25%) 0(0%)
RT + OSAS +/- TH 54(100%) 10(19%) 19(35%) 8(15%) 3(6%) 13(24%) 1(2%)
Abscess(elective/immediate) 108(100%) 18(17%) 34(31%) 13(12%) 11(10%) 32(30%) 0(0%)
Others and not specified 57(100%) 13(23%) 17(30%) 5(9%) 3(5%) 18(32%) 1(2%)
Grade of surgeon
Consultant 484(100%) 69(14%) 179(37%) 57(12%) 45(9%) 130(27%) 4(1%)
Specialist registrar 341(100%) 70(21%) 101(30%) 50(15%) 22(6%) 94(28%) 4(1%)
Not specified 64(100%) 18(28%) 20(31%) 5(08%) 4(06%) 17(27%) 0(0%)
Operation technique
Cold steel (CS) 717(100%) 124(17%) 239(33%) 97(14%) 63(9%) 186(26%) 8(1%)
CS+bipolar forceps/scissors 61(100%) 11(18.0%) 21(34.4%) 4(6.6%) 1(1.6%) 24(39.3%) 0(0%)
Bipolar forceps±scissors 27(100%) 8(29.6%) 9(33.3%) 1(3.7%) 1(3.7%) 8(29.6%) 0(0%)
Coblation 16(100%) 1(6%) 9(56%) 3(19%) 0(0%) 3(19%) 0(0%)
Others and not specified 68(100%) 13(19%) 22(32%) 7(10%) 6(9%) 20(29%) 0(0%)
RT = recurrent tonsillitis, TH = tonsillar hypertrophy, OSAS = obstructive sleep apnoea-syndrome, CS = cold steel
For analysis of table 3.14 haemorrhage grades A1 and A2, B1 and B2, C and D have
each been grouped. The severity of post-tonsillectomy haemorrhage depended
significantly on the patients´ age, sex and operation technique.
A strong relationship between age and the severity of bleeding episodes was at
significant level (p=0.03). Children under the age of six had significantly (p<0.04)
more minor bleeding episodes (grades A1 and A2) compared to the study population.
Minor bleeding episodes occurred in school children or adults with no significant
differences in the total number of bleeding episodes (p=0.99; p=0.75). Different
RESULTS
84
outcomes for severe bleeding episodes were observed. School children were at a
highly significant (p=0.004) risk for grade C bleedings compared to the study
population, whereas children under six and adults were not found to be significantly
at risk (p=0.07; p=0.28).
Another significant factor affecting the severity of bleeding episodes was the patient´s
sex. Males experienced grade C bleeding episodes significantly more often than
females (p=0.021). However, life-threatening grade D haemorrhages occurred first
and foremost in females (6 out of 8 patients).
The indication of surgery was grouped into four categories, revealing no significant
differences for the haemorrhage grades (p=0.99).
Findings obtained from correlating operation technique and haemorrhage grade
suggest that methods employing bipolar techniques lead to more severe bleeding
episodes than cold steel dissection (p=0.005). In addition, the coblation technique is
associated with a significantly higher risk for grade C haemorrhages (p=0.031, table
3.14).
RESULTS
85
3.3.3 Tonsillotomy
Table 3.15 Tonsillotomy (±AE): patient characteristics for all haemorrhage grades
Total A1 A2 B1 B2 C D
Total number of bleeding episodes 35 (100%) 7 (20%) 15 (43%) 1 (03%) 0 (0%) 12 (34%) 0 (0%)
Age (years)
< 6 22 (100%) 3 (14%) 9 (41%) 0 (0%) 0 (0%) 10 (45%) 0 (0%)
6 – 15 11 (100%) 3 (27%) 5 (45%) 1 (09%) 0 (0%) 2 (18%) 0 (0%)
> 15 2 (100%) 1 (50%) 1 (50%) 0 (0%) 0 (0%) 0 (00%) 0 (0%)
Gender Female 17 (100%) 2 (12%) 8 (47%) 1 (06%) 0 (0%) 6 (35%) 0 (0%)
Male 18 (100%) 5 (28%) 7 (39%) 0 (0%) 0 (0%) 6 (33%) 0 (0%)
Indication for surgery
RT (single answer) 1 (100%) 0 (0%) 1 (100%) 0 (0%) 0 (0%) 0 (0%) 0 (0%)
TH +/- OSAS 29 (100%) 5 (17%) 11 (38%) 1 (03%) 0 (0%) 12 (41%) 0 (0%)
RT + OSAS +/- TH 1 (100%) 0 (0%) 1 (100%) 0 (00%) 0 (0%) 0 (0%) 0 (0%)
Others and not specified 4 (100%) 2 (50%) 2 (50%) 0 (0%) 0 (0%) 0 (0%) 0 (0%)
Grade of surgeon
Consultant 22 (100%) 3 (14%) 8 (36%) 0 (0%) 0 (0%) 11 (50%) 0 (0%)
Specialist registrar 11 (100%) 3 (27%) 6 (55%) 1 (09%) 0 (0%) 1 (09%) 0 (0%)
Not specified 2 (100%) 1 (50%) 1 (50%) 0 (0%) 0 (0%) 0 (00%) 0 (0%)
Operation technique
Coblation 8 (100%) 2 (25%) 3 (38%) 0 (0%) 0 (0%) 3 (38%) 0 (0%)
Colorado needle 17 (100%) 3 (18%) 8 (47%) 1 (6%) 0 (0%) 5 (29%) 0 (0%)
CO2 - laser 2 (100%) 0 (0%) 1 (50%) 0 (0%) 0 (0%) 1 (50%) 0 (0%)
Bipolar technique 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%)
Radiofrequency technique 3 (100%) 0 (0%) 1 (33%) 0 (0%) 0 (0%) 2 (67%) 0 (0%)
Other 2 (100%) 0 (0%) 1 (50%) 0 (0%) 0 (0%) 1 (50%) 0 (0%)
Not specified 3 (100%) 2 (67%) 1 (33%) 0 (0%) 0 (0%) 0 (0%) 0 (0%)
RT = recurrent tonsillitis, TH = tonsilar hypertrophy, OSAS = obstructive sleep apnoea-syndrome
Bleeding episodes for TO are rather rare and minor bleeding episodes are more
frequent than severe bleeding episodes. Grade A bleeding episodes were nearly
twice as frequent as grade C while bleeding episodes of grade B rarely occurred.
Generally speaking, the haemorrhage rate observed for TO was low and hardly any
statistically significant effects considering risk factors were found (table 3.15).
RESULTS
86
3.3.4 Adenoidectomy
Table 3.16 Adenoidectomy: patient characteristics for all haemorrhage grades
Total A1 A2 B1 B2 C D
Total number of bleeding episodes 29 (100%) 7 (24%) 5 (17%) 4 (14%) 1 (3%) 11 (38%) 1 (3%)
Age (years)
< 6 13 (100%) 6 (46%) 2 (15%) 2 (15%) 0 (0%) 3 (23%) 0 (0%)
6 – 15 11 (100%) 1 (9%) 3 (27%) 2 (18%) 1 (9%) 3 (27%) 1 (9%)
> 15 5 (100%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 5 (100%) 0 (0%)
Gender Female 9 (100%) 1 (11%) 0 (0%) 3 (33%) 0 (0%) 5 (56%) 0 (0%)
Male 20 (100%) 6 (30%) 5 (25%) 1 (5%) 1 (5%) 6 (30%) 1 (5%)
Indication for surgery
RT (single answer) 9 (100%) 0 (0%) 1 (11%) 1 (11%) 1 (11%) 6 (67%) 0 (0%)
DET (single answer) 3 (100%) 1 (33%) 1 (33%) 1 (33%) 0 (0%) 0 (0%) 0 (0%)
OSAS (single answer) 3 (100%) 1 (33%) 0 (0%) 0 (0%) 0 (0%) 1 (33%) 1 (33%)
RT + DET 3 (100%) 2 (67%) 0 (0%) 0 (0%) 0 (0%) 1 (33%) 0 (0%)
RT + OSAS 2 (100%) 1 (50%) 1 (50%) 0 (0%) 0 (0%) 0 (0%) 0 (0%)
DET + OSAS 3 (100%) 0 (0%) 1 (33%) 2 (67%) 0 (0%) 0 (0%) 0 (0%)
RT + OSAS + DET 1 (100%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 1 (100%) 0 (0%)
Others and not specified 5 (100%) 2 (40%) 1 (20%) 0 (0%) 0 (0%) 2 (40%) 0 (0%)
Grade of surgeon
Consultant 14 (100%) 2 (14%) 2 (14%) 4 (29%) 1 (7%) 5 (36%) 0 (0%)
Specialist registrar 12 (100%) 4 (33%) 2 (17%) 0 (0%) 0 (0%) 5 (42%) 1 (8%)
Not specified 3 (100%) 1 (33%) 1 (33%) 0 (0%) 0 (0%) 1 (33%) 0 (0%)
Operation technique
Adenoid curette by Beckmann 9 (100%) 2 (22%) 1 (11%) 2 (22%) 1 (11%) 3 (33%) 0 (0%)
Coblation 0 (100%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%)
Adenotome by La Force 1 (100%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 1 (100%) 0 (0%)
Adenoid curette+ Endoscopic control± Pharyngeal mirror 7 (100%) 1 (14%) 3 (43%) 0 (0%) 0 (0%) 3 (43%) 0 (0%)
Other 0 (100%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%)
Not specified 12 (100%) 4 (33%) 1 (8%) 2 (17%) 0 (0%) 4 (33%) 1 (8%)
RT = recurrent infections, DET = dysfunction of eustachian tubes, OSAS = obstructive sleep apnoea syndrome
Bleeding episodes for AE were infrequent; however grade C bleeding episodes
emerged comparatively often. A tendency towards grade C bleeding episodes was
observed in particular for the indication “recurrent infections” and rose with increasing
age (table 3.16).
RESULTS
87
3.3.5 Distribution of postoperative haemorrhage by days
Postoperative haemorrhage for tonsillectomy occurred most frequently on the day of
surgery and at days four, five and six. No differences were established for the
bleeding grades relating to the day of the haemorrhage (Figure 3.6).
Figure 3.6 Tonsillectomy (±AE): distribution of bleeding grades for postoperative days
0
10
20
30
40
50
60
70
80
90
100
110
120
Gra
de o
f b
leed
ing
ep
iso
de
Day
A1
A2
B1
B2
C
D
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
RESULTS
88
3.4. RISK MODELS FOR POSTOPERATIVE HAEMORRHAGE
3.4.1. Risk model for postoperative haemorrhage after tonsillectomy
Table 3.17 illustrates the risk for postoperative haemorrhage using a logistic
regression model. The binary logistic model was applied as the outcome variable
“haemorrhage yes or no” is dichotomous. Many variables which may contribute as
risk factors to the occurrence of postoperative haemorrhage have been incorporated.
The likelihood of each single variable contributing to a higher risk of haemorrhage
when influenced by all other variables was tested. Dummy variables were created for
each category with the first category being the reference category.
Goodness of fit was measured by the Hosmer-Lemeshow-test giving a significance
level of 0.18. As the significance level is greater than 0.05, a well-fitted model was
created. In addition the Omnibus test for model coefficients showed an adequate fit
of the model to the data at a significant level (p<0.001). Cox & Snell R-squared and
Nagelkerkes R-squared are attempts to interpret the R2 of the linear regression model
for a logistic regression model. Nagelkerkes R-squared is the corrected version of the
Cox & Snell R-squared and describes the variance of 4.2%. According to Peng et al.
there is a lack of standards for the reporting of logistic regression models. Table 3.17
below was created in the style Peng et al. suggest.231
Table 3.17 Logistic regression analysis: model testing 1
Goodness-of-fit-tests
Test Chi-Square df p-value
Likelihood test 3771.1
Homser-Lemeshow test 11.407 8 0.180
Omnibus test 112.404 13 < 0.001
R2-type Indices
Cox & Snell R-squared 0.024
Nagelkerkes R-squared 0.042
df = degrees of freedom
RESULTS
89
Table 3.18 gives the odds ratios, confidence intervals and p-values for each factor
contributing to the risk of postoperative haemorrhage.
Table 3.18 Tonsillectomy with or without adenoidectomy: binary logistic regression model for postoperative haemorrhage
Risk factor Adjusted
Odds Ratio
95% Confidence
Interval
P Value
Age (years) > 15 1.0
6 – 15 0.54 0.43 0.67 <0.001
< 6 0.32 0.19 0.54 <0.001
Sex Female 1.0
Male 1.32 1.12 1.56 =0.001
Indication for surgery
RT (single answer) 1.0
TH +/- OSAS 0.85 0.52 1.38 =0.51
RT + OSAS +/- TH 1.08 0.76 1.54 =0.67
Abscess (elective/immediate)
0.75 0.58 0.97 =0.03
Not specified 0.99 0.65 1.53 =0.99
Grade of surgeon
Consultant 1.0
Specialist registrar 0.82 0.68 0.97 =0.022
Not specified 1.58 0.99 2.5 =0.054
Operation technique
Cold steel (CS) 1.0
CS+ bipolar forceps/scissors
1.44 1.022 2.04 =0.037
Bipolar forceps ± scissors 0.88 0.53 1.46 =0.615
Coblation 1.63 0.86 3.08 =0.137
Not specified 2.39 1.54 3.72 <0.001
RT = recurrent tonsillitis, TH = tonsillar hypertrophy, OSAS = obstructive sleep apnoea-syndrome, CS = cold steel
After adjusting for confounders by logistic regression analysis, the significance of
association for postoperative haemorrhage was established for the following risk
factors. Children under six were three times less likely to experience postoperative
haemorrhage (Odds Ratio [OR] 0.32; 95% CI, 0.19-0.54) and school children were
twice less likely to do so (OR 0.54; 95% CI, 0.43-0.67). An increase in risk of one
third was accounted for in males (OR 1.32; 95% CI, 1.12-1.56). A significant result
was obtained for abscess TE (p<0.03) with an OR of 0.75 (CI 0.58-0.97) compared to
recurrent infection as an indication. The operation technique “cold steel and bipolar
RESULTS
90
scissor/forceps” showed a significantly higher OR (OR 1.44, CI 1.022-2.04).
Operations performed by registrars rather than by consultants were less likely to be
followed by postoperative haemorrhage (OR 0.82, CI 0.68-0.97).
3.4.2. Risk model for the return-to-theatre rate after tonsillectomy
The logistic regression model was used to test the risk of the return-to-theatre rate of
patients undergoing tonsillectomy with or without an adenoidectomy. The goodness-
of-fit tests indicate a well-fitting model (table 3.19).
Table 3.19 Logistic regression analysis: model testing 2
Goodness-of-fit-tests
Test Chi-Square df p-value
Likelihood test 1773.584
Homser-Lemeshow test 7.515 7 0.377
Omnibus test 40.35 13 <0.001
R2-type Indices
Cox & Snell R-squared 0.009
Nagelkerkes R-squared 0.027
df = degrees of freedom
Table 3.20 shows the risk factors for the return-to-theatre rate after adjustment. In
contrast with the previous risk model for postoperative haemorrhage, the risk model
for the return-to-theatre revealed different levels of significance for different variables.
Children under six were significantly (p=0.009) less likely to return to theatre due to
postoperative haemorrhage than other age groups. The OR for children was 0.215
(CI 0.068-0.684) with adults being the reference category. In other words, the risk for
adults returning to theatre was a five times higher risk than for children. The age
group from six to fifteen years showed an OR of 0.834 (CI 0.599-1.161) indicating
nearly the same risk as adults. Nearly double the risk for a return to theatre was
observed for males (OR 1.48, CI 1.12-1.95). The indication for TE±AE did not affect
the need for revision surgery. In contrast to the earlier regression model for
postoperative haemorrhage, the expertise of the surgeon did not significantly
influence the risk of revision surgery. The operation technique “cold steel and bipolar
RESULTS
91
scissor/forceps” achieved a significantly (p<0.001) higher OR when compared to the
reference category “cold steel” dissection.
Table 3.20 Tonsillectomy with or without adenoidectomy: binary logistic regression model for return-to theatre
Risk factor Adjusted
Odds Ratio
95% Confidence
Interval
P Value
Age (years) > 15 1.0
6 – 15 0.834 0.599 1.161 =0.282
< 6 0.215 0.068 0.684 =0.009
Sex Female 1.0
Male 1.481 1.123 1.953 =0.005
Indication for surgery
RT (single answer) 1.0
TH ± OSAS 0.836 0.379 1.844 =0.657
RT + OSAS ± TH 0.852 0.464 1.564 =0.606
Abscess (elective/immediate)
0.8 0.525 1.217 =0.297
Not specified 0.925 0.458 1.868 =0.828
Grade of surgeon
Consultant 1.0
Specialist registrar 0.891 0.669 1.188 =0.432
Not specified 1.508 0.721 3.57 =0.275
Operation technique
Cold steel (CS) 1.0
CS+ bipolar forceps/scissors
1.099 0.501 2.409 =0.814
Bipolar forceps ± scissors 2.224 1.391 3.556 <0.001
Coblation 0.769 0.184 3.213 =0.719
Not specified 2.093 1.044 4.194 =0.037
RT = recurrent tonsillitis, TH = tonsillar hypertrophy, OSAS = obstructive sleep apnoea-syndrome, CS = cold steel
RESULTS
92
3.5. MULTIPLE BLEEDING EPISODES
The occurrence of more than one postoperative bleeding episode is of special
interest to the surgeon as well as to the patient. In Austria the Austrian Society of
Oto-Rhino-Laryngology, Head and Neck Surgery recommends overnight observation
for patients experiencing a postoperative bleeding episode. Patients are routinely re-
admitted to hospital for one night no matter whether the bleeding episode was
minimal or severe. The following results only consider tonsillectomy procedures (with
or without adenoidectomy) as most bleeding episodes occurred after this type of
surgery.
Table 3.21 Multiple bleeding episodes after tonsillectomy (±AE) per patient by age group
Haemorrhage Total # of patients Children < 6 Children 6-15 Adults > 15
No episode 3,905(85.0%) 214(93.0%) 961(89.6%) 2,730(83.0%)
One episode 538(11.7%) 15(6.5%) 92(8.6%) 431(13.1%)
Two episodes 113(2.5%) 0(0%) 16(1.5%) 97(2.9%)
Three episodes 29(0.6%) 0(0%) 2(0.2%) 27(0.8%)
Four episodes 7(0.2%) 1(0.4%) 2(0.2%) 4(0.1%)
Five episodes 2(0%) 0(0%) 0(0%) 2(0.1%)
Total # of patients 4,594(100.0%) 230(100.0%) 1,073(100.0%) 3,291(100.0%)
Table 3.21 depicts the frequency of bleeding episodes per operated patient and split
by age group. A preponderance of multiple bleeding episodes is observed in the
adult population. About 3.9% of all operated adults, or 23.2% (130 of 561) adults
suffering postoperative haemorrhage, which is almost every fourth patient, had more
than one bleeding episode. In early childhood, multiple bleedings occurred less
frequently although one child under six and two children under fifteen had four
episodes of bleedings.
RESULTS
93
Table 3.22 Patients with multiple bleeding episodes after tonsillectomy (with or without adenoidectomy)
Number
of cases
% of all
patients
n=4594
% of patients w.
haemorrhage
n=689
% of first
bleeding
is minor
n=532
% of
severe
bleeding
n=239
% of
multiple
hem.
n=156
All patients 4,594 100%
Patients with haemorrhage* 689 15.0% 100.0%
Minor bleeding(s)* (grades A+B) 556 12.1% 80.7%
First bleeding is minor* 532 11.6% 77.2% 100.0%
Only minor bleeding(s)* 478 10.4% 69.4% 89.8%
Severe bleeding(s)* (grades C+D) 239 5.2% 34.7% n.a. 100.0%
Only severe bleeding(s)* 161 3.5% 23.4% n.a. 67.4%
Patients with multiple bleedings 151 3.3% 21.9% n.a. n.a. 100.0%
Severe bleeding after minor bleeding 54 1.2% 7.8% 10.2% 22.6% 35.8%
Minor bleeding after severe bleeding 24 0.5% 3.5% n.a. 10.0% 15.9%
* single and multiple bleeding(s), n.a. = not applicable
Multiple bleeding episodes were recorded for one in thirty patients (3.3%) which is
nearly one in four patients with a haemorrhage (21.9%, table 3.22). This table
indicates that multiple bleeding is of considerable relevance when studying
postoperative haemorrhage after TE. The sequence of severity for multiple bleeding
episodes is of special interest. We assume that the occurrence of a light bleeding is
an indicator for a second severe bleeding. Testing this question we found that one in
ten patients who experienced minor postoperative bleeding had a second severe
bleeding (10.2%). Comparing this with the overall risk of severe bleeding after TE of
5.2% yields an extremely significant result (p<0.001). This allows us to conclude that
evidence of minor bleeding (even of only an anamnestic nature) increases the risk of
a second severe bleeding episode by a factor of two above and beyond the overall
risk of severe bleeding (5.2% 10.2%). A major result of assessing the severity of
multiple bleeding episodes was that the occurrence of a minor bleeding episode
doubles the risk of a second severe bleeding episode.
RESULTS
94
3.6. HOSPITAL PERFORMANCE
A total of 32 ENT-departments participated in the Austrian Tonsil Study. The
performance of the individual departments is listed below for diverse outcome
variables. Both absolute numbers and percentages in brackets are given.
Figure 3.7 Distribution of frequency of surgeries (TE±AE, TO±AE, AE) by department
The following tables give an overview of the individual statistics for the participating
ENT departments. The frequency of surgeries performed within the study period
ranged from 26 to 765 patients (figure 3.7).
0
50
100
150
200
250
300
350
400
450
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
freq
uen
cy o
f su
rger
ies
department
TE+/-AE TO+/-AE AE
RESULTS
95
3.6.1. Overview
Table 3.23 Hospital performance: overview
Surgery Age group (years) Sex
DEP. Total (%) TE±AE TO±AE AE <6 6-15 >15 male female
Total 9,405(100) 4,594(49) 1,319(14) 3,492(37) 3,474(37) 2,424(26) 3,507(37) 5,476(58) 3,929(42)
1 288(100) 182(63) 34(12) 72(25) 91(32) 71(25) 126(44) 176(61) 112(39)
2 159(100) 101(64) 7(4) 51(32) 34(21) 43(27) 82(52) 100(63) 59(37)
3 308(100) 188(61) 18(6) 102(33) 106(34) 67(22) 135(44) 177(57) 131(43)
4 26(100) 0(0) 4(15) 22(85) 16(62) 10(38) 0(0) 17(65) 9(35)
5 135(100) 60(44) 21(16) 54(40) 55(41) 28(21) 52(39) 87(64) 48(36)
6 49(100) 16(33) 4(8) 29(59) 14(29) 18(37) 17(35) 26(53) 23(47)
7 230(100) 124(54) 20(9) 86(37) 79(34) 52(23) 99(43) 122(53) 108(47)
8 217(100) 144(66) 31(14) 42(19) 47(22) 54(25) 116(53) 117(54) 100(46)
9 200(100) 85(43) 29(15) 86(43) 79(40) 59(30) 62(31) 115(58) 85(43)
10 267(100) 200(75) 11(4) 56(21) 77(29) 79(30) 111(42) 154(58) 113(42)
11 208(100) 142(68) 18(9) 48(23) 42(20) 49(24) 117(56) 112(54) 96(46)
12 106(100) 17(16) 22(21) 67(63) 53(50) 29(27) 24(23) 65(61) 41(39)
13 530(100) 200(38) 94(18) 236(45) 252(48) 130(25) 148(28) 314(59) 216(41)
14 250(100) 135(54) 23(9) 92(37) 81(32) 61(24) 108(43) 148(59) 102(41)
15 765(100) 388(51) 75(10) 302(39) 251(33) 200(26) 314(41) 383(50) 382(50)
16 115(100) 67(58) 15(13) 33(29) 31(27) 25(22) 59(51) 63(55) 52(45)
17 304(100) 107(35) 63(21) 134(44) 142(47) 106(35) 56(18) 199(65) 105(35)
18 201(100) 74(37) 56(28) 71(35) 107(53) 46(23) 48(24) 113(56) 88(44)
19 274(100) 100(36) 81(30) 93(34) 128(47) 69(25) 77(28) 176(64) 98(36)
20 44(100) 20(45) 1(2) 23(52) 19(43) 11(25) 14(32) 28(64) 16(36)
21 352(100) 157(45) 30(9) 165(47) 141(40) 68(19) 143(41) 180(51) 172(49)
22 342(100) 181(53) 50(15) 111(32) 139(41) 76(22) 127(37) 176(51) 166(49)
23 505(100) 221(44) 61(12) 223(44) 200(40) 131(26) 174(34) 300(59) 205(41)
24 120(100) 69(58) 21(18) 30(25) 33(28) 31(26) 56(47) 69(58) 51(43)
25 223(100) 89(40) 23(10) 111(50) 102(46) 52(23) 69(31) 121(54) 102(46)
26 338(100) 182(54) 37(11) 119(35) 107(32) 78(23) 153(45) 200(59) 138(41)
27 620(100) 314(51) 135(22) 171(28) 211(34) 135(22) 274(44) 401(65) 219(35)
28 462(100) 221(48) 74(16) 167(36) 191(41) 135(29) 136(29) 277(60) 185(40)
29 303(100) 124(41) 37(12) 142(47) 135(45) 88(29) 80(26) 163(54) 140(46)
30 404(100) 172(43) 37(9) 195(48) 143(35) 109(27) 152(38) 225(56) 179(44)
31 494(100) 225(46) 106(21) 163(33) 191(39) 136(28) 167(34) 322(65) 172(35)
32 566(100) 289(51) 81(14) 196(35) 177(31) 178(31) 211(37) 350(62) 216(38)
DEP. = department, TE±AE = tonsillectomy with or without (±) adenoidectomy, TO+AE = tonsillotomy ± adenoidectomy, AE = adenoidectomy
RESULTS
96
3.6.2. Frequency of haemorrhage and number of bleeding episodes
Table 3.24 Hospital performance: frequency of haemorrhage (yes/no) and number of bleeding episodes
Haemorrhage Bleeding episodes
DEP Total(%) TE±AE TO±AE AE Total(%) A1 A2 B1 B2 C D E
Total 747(8) 689(7) 30(0) 28(0) 953(100) 170(18) 322(34) 116(12) 73(8) 263(28) 9(1) 0(0)
1 33(11) 31(11) 1(0) 1(0) 44(100) 6(14) 11(25) 10(23) 7(16) 10(23) 0(0) 0(0)
2 21(13) 21(13) 0(0) 0(0) 27(100) 5(19) 7(26) 5(19) 4(15) 6(22) 0(0) 0(0)
3 35(11) 35(11) 0(0) 0(0) 48(100) 4(8) 16(33) 12(25) 2(4) 14(29) 0(0) 0(0)
4 6(23) 6(23) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0)
5 5(4) 5(4) 0(0) 0(0) 9(100) 0(0) 2(22) 3(33) 2(22) 2(22) 0(0) 0(0)
6 14(29) 13(27) 0(0) 1(2) 5(100) 0(0) 4(80) 0(0) 0(0) 1(20) 0(0) 0(0)
7 33(14) 29(13) 2(1) 2(1) 18(100) 1(6) 4(22) 1(6) 5(28) 7(39) 0(0) 0(0)
8 20(9) 18(8) 2(1) 0(0) 44(100) 5(11) 22(50) 8(18) 0(0) 8(18) 1(2) 0(0)
9 20(10) 20(10) 0(0) 0(0) 27(100) 2(7) 9(33) 5(19) 2(7) 9(33) 0(0) 0(0)
10 22(8) 21(8) 1(0) 0(0) 26(100) 3(12) 13(50) 0(0) 1(4) 9(35) 0(0) 0(0)
11 2(1) 2(1) 0(0) 0(0) 32(100) 6(19) 13(41) 3(9) 5(16) 5(16) 0(0) 0(0)
12 39(37) 33(31) 5(5) 1(1) 2(100) 1(50) 0(0) 0(0) 1(50) 0(0) 0(0) 0(0)
13 8(2) 6(1) 0(0) 2(0) 41(100) 5(12) 18(44) 1(2) 1(2) 15(37) 1(2) 0(0)
14 42(17) 39(16) 0(0) 3(1) 12(100) 1(8) 5(42) 0(0) 0(0) 6(50) 0(0) 0(0)
15 11(1) 11(1) 0(0) 0(0) 54(100) 8(15) 19(35) 14(26) 1(2) 12(22) 0(0) 0(0)
16 22(19) 21(18) 1(1) 0(0) 14(100) 0(0) 9(64) 2(14) 0(0) 3(21) 0(0) 0(0)
17 14(5) 8(3) 3(1) 3(1) 28(100) 4(14) 12(43) 1(4) 2(7) 9(32) 0(0) 0(0)
18 17(8) 16(8) 1(0) 0(0) 14(100) 0(0) 4(29) 0(0) 2(14) 6(43) 2(14) 0(0)
19 2(1) 1(0) 0(0) 1(0) 19(100) 3(16) 4(21) 2(11) 3(16) 7(37) 0(0) 0(0)
20 19(43) 17(39) 0(0) 2(5) 3(100) 0(0) 0(0) 1(33) 0(0) 2(67) 0(0) 0(0)
21 18(5) 16(5) 1(0) 1(0) 21(100) 3(14) 7(33) 0(0) 1(5) 9(43) 1(5) 0(0)
22 31(9) 28(8) 1(0) 2(1) 24(100) 14(58) 3(13) 5(21) 0(0) 2(8) 0(0) 0(0)
23 7(1) 7(1) 0(0) 0(0) 38(100) 5(13) 13(34) 3(8) 2(5) 14(37) 1(3) 0(0)
24 19(16) 19(16) 0(0) 0(0) 10(100) 3(30) 3(30) 0(0) 0(0) 4(40) 0(0) 0(0)
25 40(18) 37(17) 1(0) 2(1) 26(100) 14(54) 7(27) 1(4) 0(0) 4(15) 0(0) 0(0)
26 69(20) 64(19) 3(1) 2(1) 51(100) 11(22) 15(29) 2(4) 8(16) 14(27) 1(2) 0(0)
27 33(5) 33(5) 0(0) 0(0) 80(100) 13(16) 15(19) 15(19) 14(18) 22(28) 1(1) 0(0)
28 22(5) 21(5) 1(0) 0(0) 44(100) 10(23) 22(50) 1(2) 0(0) 11(25) 0(0) 0(0)
29 22(7) 20(7) 0(0) 2(1) 33(100) 5(15) 14(42) 1(3) 1(3) 12(36) 0(0) 0(0)
30 56(14) 49(12) 4(1) 3(1) 26(100) 4(15) 6(23) 3(12) 0(0) 13(50) 0(0) 0(0)
31 45(9) 42(9) 3(1) 0(0) 75(100) 23(31) 28(37) 8(11) 4(5) 11(15) 1(1) 0(0)
32 0(0) 0(0) 0(0) 0(0) 58(100) 11(19) 17(29) 9(16) 5(9) 16(28) 0(0) 0(0)
DEP = department, TE±AE = tonsillectomy with or without (±) adenoidectomy, TO+AE = tonsillotomy ± adenoidectomy, AE = adenoidectomy
RESULTS
97
3.6.3. Indication for tonsil surgery (TE and TO)
Table 3.25 Hospital performance: indications for tonsil surgery (TE and TO)
DEP
RT TH±OSAS TH±OSAS+RT Abscess Not specified
Total(%) <15 >15 <15 >15 <15 >15 <15 >15 <15 >15
9,405(100) 1,025(11) 2,404(26) 1,139(12) 102(1) 284(3) 130(1) 58(1) 536(6) 3,392(36) 335(4)
1 288(100) 55(19) 106(37) 30(10) 7(2) 1(0) 0(0) 4(1) 13(5) 72(25) 0(0)
2 159(100) 20(13) 58(36) 7(4) 0(0) 2(1) 1(1) 0(0) 17(11) 48(30) 6(4)
3 308(100) 39(13) 95(31) 16(5) 4(1) 8(3) 3(1) 5(2) 28(9) 105(34) 5(2)
4 26(100) 0(0) 0(0) 3(12) 0(0) 1(4) 0(0) 0(0) 0(0) 22(85) 0(0)
5 135(100) 5(4) 19(14) 24(18) 2(1) 5(4) 10(7) 0(0) 16(12) 49(36) 5(4)
6 49(100) 5(10) 9(18) 1(2) 2(4) 0(0) 0(0) 0(0) 3(6) 26(53) 3(6)
7 230(100) 29(13) 83(36) 19(8) 4(2) 0(0) 2(1) 0(0) 3(1) 83(36) 7(3)
8 217(100) 32(15) 81(37) 13(6) 3(1) 19(9) 4(2) 0(0) 16(7) 37(17) 12(6)
9 200(100) 19(10) 41(21) 19(10) 1(1) 9(5) 1(1) 2(1) 16(8) 89(45) 3(2)
10 267(100) 76(28) 79(30) 9(3) 1(0) 13(5) 9(3) 0(0) 20(7) 58(22) 2(1)
11 208(100) 22(11) 89(43) 18(9) 9(4) 2(1) 8(4) 0(0) 5(2) 49(24) 6(3)
12 106(100) 3(3) 1(1) 6(6) 2(2) 7(7) 2(2) 1(1) 15(14) 65(61) 4(4)
13 530(100) 58(11) 103(19) 71(13) 5(1) 13(2) 6(1) 4(1) 29(5) 236(45) 5(1)
14 250(100) 30(12) 67(27) 31(12) 4(2) 0(0) 1(0) 1(0) 19(8) 80(32) 17(7)
15 765(100) 52(7) 238(31) 53(7) 2(0) 63(8) 33(4) 4(1) 11(1) 279(36) 30(4)
16 115(100) 5(4) 45(39) 16(14) 1(1) 4(3) 4(3) 0(0) 6(5) 31(27) 3(3)
17 304(100) 42(14) 34(11) 50(16) 2(1) 21(7) 5(2) 1(0) 8(3) 134(44) 7(2)
18 201(100) 34(17) 36(18) 20(10) 4(2) 28(14) 2(1) 1(0) 5(2) 70(35) 1(0)
19 274(100) 28(10) 58(21) 73(27) 1(0) 0(0) 0(0) 4(1) 10(4) 92(34) 8(3)
20 44(100) 1(2) 9(20) 3(7) 1(2) 2(5) 2(5) 0(0) 1(2) 24(55) 1(2)
21 352(100) 13(4) 95(27) 31(9) 5(1) 9(3) 2(1) 4(1) 19(5) 152(43) 22(6)
22 342(100) 58(17) 108(32) 48(14) 2(1) 0(0) 0(0) 0(0) 3(1) 109(32) 14(4)
23 505(100) 49(10) 126(25) 57(11) 3(1) 8(2) 4(1) 2(0) 16(3) 215(43) 25(5)
24 120(100) 16(13) 42(35) 19(16) 1(1) 4(3) 5(4) 0(0) 0(0) 25(21) 8(7)
25 223(100) 18(8) 43(19) 20(9) 5(2) 8(4) 5(2) 0(0) 8(4) 108(48) 8(4)
26 338(100) 17(5) 70(21) 39(12) 4(1) 5(1) 3(1) 6(2) 57(17) 118(35) 19(6)
27 620(100) 40(6) 174(28) 124(20) 6(1) 12(2) 4(1) 4(1) 56(9) 166(27) 34(5)
28 462(100) 77(17) 122(26) 65(14) 0(0) 14(3) 3(1) 1(0) 8(2) 169(37) 3(1)
29 303(100) 36(12) 52(17) 41(14) 2(1) 3(1) 1(0) 2(1) 23(8) 141(47) 2(1)
30 404(100) 28(7) 85(21) 35(9) 1(0) 3(1) 3(1) 1(0) 39(10) 185(46) 24(6)
31 494(100) 56(11) 100(20) 107(22) 10(2) 5(1) 4(1) 7(1) 37(7) 152(31) 16(3)
32 566(100) 62(11) 136(24) 71(13) 8(1) 15(3) 3(1) 4(1) 29(5) 203(36) 35(6)
DEP. = department, RT = recurrent tonsillitis, TH = tonsillar hypertrophy, OSAS = obstructive sleep apnoea-syndrome
RESULTS
98
3.6.4. Postoperative haemorrhage by indication for tonsil surgery
Table 3.26 Hospital performance: postoperative haemorrhage by indication for tonsil surgery
DEP
RT TH±OSAS TH±OSAS+RT Abscess Not specified
Total(%) <15 >15 <15 >15 <15 >15 <15 >15 <15 >15
Total 747(100) 92(12) 408(55) 28(4) 17(2) 21(3) 21(3) 5(1) 76(10) 33(4) 46(6)
1 33(100) 2(6) 24(73) 0(0) 3(9) 0(0) 0(0) 0(0) 3(9) 1(3) 0(0)
2 21(100) 2(10) 15(71) 0(0) 0(0) 0(0) 0(0) 0(0) 2(10) 1(5) 1(5)
3 35(100) 8(23) 17(49) 0(0) 1(3) 2(6) 1(3) 2(6) 1(3) 0(0) 3(9)
4 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0)
5 6(100) 0(0) 3(50) 0(0) 1(17) 0(0) 0(0) 0(0) 2(33) 0(0) 0(0)
6 5(100) 0(0) 4(80) 0(0) 0(0) 0(0) 0(0) 0(0) 1(20) 0(0) 0(0)
7 14(100) 1(7) 9(64) 0(0) 0(0) 0(0) 1(7) 0(0) 0(0) 1(7) 2(14)
8 33(100) 3(9) 21(64) 1(3) 0(0) 2(6) 1(3) 0(0) 2(6) 2(6) 1(3)
9 20(100) 2(10) 13(65) 1(5) 0(0) 0(0) 1(5) 0(0) 1(5) 1(5) 1(5)
10 20(100) 3(15) 11(55) 0(0) 0(0) 2(10) 2(10) 0(0) 1(5) 0(0) 1(5)
11 22(100) 1(5) 17(77) 1(5) 1(5) 0(0) 0(0) 0(0) 1(5) 0(0) 1(5)
12 2(100) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 2(100) 0(0) 0(0)
13 39(100) 6(15) 21(54) 5(13) 0(0) 0(0) 0(0) 0(0) 4(10) 2(5) 1(3)
14 8(100) 2(25) 3(38) 1(13) 0(0) 0(0) 0(0) 0(0) 0(0) 2(25) 0(0)
15 42(100) 6(14) 26(62) 0(0) 0(0) 1(2) 6(14) 0(0) 0(0) 2(5) 1(2)
16 11(100) 0(0) 8(73) 0(0) 0(0) 2(18) 0(0) 0(0) 1(9) 0(0) 0(0)
17 22(100) 4(18) 8(36) 0(0) 2(9) 3(14) 1(5) 0(0) 4(18) 0(0) 0(0)
18 14(100) 2(14) 5(36) 3(21) 0(0) 0(0) 1(7) 0(0) 0(0) 3(21) 0(0)
19 17(100) 3(18) 8(47) 1(6) 0(0) 0(0) 0(0) 1(6) 3(18) 0(0) 1(6)
20 2(100) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 1(50) 1(50)
21 19(100) 1(5) 11(58) 1(5) 2(11) 0(0) 0(0) 0(0) 1(5) 2(11) 1(5)
22 18(100) 2(11) 12(67) 1(6) 0(0) 0(0) 0(0) 0(0) 0(0) 1(6) 2(11)
23 31(100) 6(19) 19(61) 0(0) 0(0) 0(0) 0(0) 0(0) 1(3) 2(6) 3(10)
24 7(100) 1(14) 6(86) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0)
25 19(100) 4(21) 6(32) 0(0) 0(0) 1(5) 1(5) 0(0) 3(16) 0(0) 4(21)
26 40(100) 0(0) 19(48) 2(5) 0(0) 1(3) 0(0) 0(0) 12(30) 2(5) 4(10)
27 69(100) 6(9) 38(55) 4(6) 3(4) 0(0) 1(1) 0(0) 10(14) 2(3) 5(7)
28 33(100) 6(18) 23(70) 0(0) 0(0) 1(3) 0(0) 0(0) 3(9) 0(0) 0(0)
29 22(100) 8(36) 4(18) 1(5) 1(5) 1(5) 1(5) 0(0) 5(23) 1(5) 0(0)
30 22(100) 1(5) 13(59) 0(0) 0(0) 0(0) 1(5) 0(0) 2(9) 1(5) 4(18)
31 56(100) 8(14) 21(38) 5(9) 2(4) 3(5) 2(4) 2(4) 8(14) 3(5) 2(4)
32 45(100) 4(9) 23(51) 1(2) 1(2) 2(4) 1(2) 0(0) 3(7) 3(7) 7(16)
DEP. = department, RT = recurrent tonsillitis, TH = tonsillar hypertrophy, OSAS = obstructive sleep apnoea-syndrome
RESULTS
99
3.6.5. Operation technique for tonsillectomy
Table 3.27 Hospital performance: operation technique for tonsillectomy
DEP Total (%) CS CS+BF CS+BF BF BS BF+BS Co La n.sp.
Total
4,012(87) 210(5) 27(1) 34(1) 64(1) 35(1) 51(1) 4(0) 157(3)
1 182(100) 179(98) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 3(2)
2 101(100) 80(79) 14(14) 1(1) 1(1) 0(0) 0(0) 0(0) 0(0) 5(5)
3 188(100) 155(82) 1(1) 0(0) 0(0) 2(1) 0(0) 0(0) 0(0) 30(16)
4 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0)
5 60(100) 45(75) 4(7) 0(0) 2(3) 7(12) 0(0) 0(0) 0(0) 2(3)
6 16(100) 12(75) 3(19) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 1(6)
7 124(100) 118(95) 2(2) 0(0) 1(1) 0(0) 0(0) 0(0) 0(0) 3(2)
8 144(100) 130(90) 0(0) 1(1) 0(0) 3(2) 0(0) 8(6) 0(0) 2(1)
9 85(100) 76(89) 6(7) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 3(4)
10 200(100) 182(91) 11(6) 1(1) 0(0) 0(0) 0(0) 0(0) 0(0) 6(3)
11 142(100) 139(98) 1(1) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 2(1)
12 17(100) 17(100) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0)
13 200(100) 149(75) 47(24) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 4(2)
14 135(100) 97(72) 0(0) 2(1) 0(0) 30(22) 0(0) 1(1) 0(0) 5(4)
15 388(100) 383(99) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 5(1)
16 67(100) 26(39) 0(0) 0(0) 0(0) 0(0) 0(0) 40(60) 0(0) 1(1)
17 107(100) 89(83) 12(11) 0(0) 2(2) 0(0) 0(0) 0(0) 4(4) 0(0)
18 74(100) 71(96) 0(0) 0(0) 1(1) 0(0) 0(0) 0(0) 0(0) 2(3)
19 100(100) 98(98) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 2(2)
20 20(100) 20(100) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0)
21 157(100) 152(97) 3(2) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 2(1)
22 181(100) 169(93) 0(0) 0(0) 9(5) 0(0) 0(0) 0(0) 0(0) 3(2)
23 221(100) 211(95) 0(0) 1(0) 0(0) 0(0) 0(0) 0(0) 0(0) 9(4)
24 69(100) 69(100) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0)
25 89(100) 0(0) 4(4) 21(24) 2(2) 22(25) 35(39) 0(0) 0(0) 5(6)
26 182(100) 172(95) 1(1) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 9(5)
27 314(100) 300(96) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 14(4)
28 221(100) 218(99) 1(0) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 2(1)
29 124(100) 23(19) 92(74) 0(0) 8(6) 0(0) 0(0) 0(0) 0(0) 1(1)
30 172(100) 165(96) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 7(4)
31 225(100) 219(97) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0) 6(3)
32 289(100) 248(86) 8(3) 0(0) 8(3) 0(0) 0(0) 2(1) 0(0) 23(8)
DEP. = department, CS = cold steel, BF = bipolar forceps, BS = bipolar scissors, Co = coblation, La = laser, n.sp. = not specified
RESULTS
100
3.6.6. Operation technique for tonsillotomy
Table 3.28 Hospital performance: operation technique for tonsillotomy
DEP Total (%) Co CN La BT MT RF n.sp.
Total
346(27) 433(34) 169(13) 69(5) 194(15) 25(2) 47(4)
1 34(100) 0(0) 27(79) 0(0) 0(0) 0(0) 0(0) 7(21)
2 7(100) 0(0) 6(86) 0(0) 0(0) 0(0) 0(0) 1(14)
3 18(100) 0(0) 16(89) 0(0) 1(6) 0(0) 0(0) 1(6)
4 4(100) 0(0) 3(75) 0(0) 1(25) 0(0) 0(0) 0(0)
5 21(100) 3(14) 18(86) 0(0) 0(0) 0(0) 0(0) 0(0)
6 4(100) 4(100) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0)
7 20(100) 20(100) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0)
8 31(100) 0(0) 24(77) 0(0) 0(0) 7(23) 0(0) 0(0)
9 29(100) 1(3) 0(0) 0(0) 0(0) 0(0) 24(83) 4(14)
10 11(100) 2(18) 1(9) 0(0) 3(27) 3(27) 0(0) 2(18)
11 18(100) 0(0) 0(0) 18(100) 0(0) 0(0) 0(0) 0(0)
12 19(100) 0(0) 0(0) 0(0) 0(0) 19(100) 0(0) 0(0)
13 94(100) 92(98) 0(0) 0(0) 0(0) 0(0) 0(0) 2(2)
14 18(100) 2(11) 4(22) 0(0) 11(61) 0(0) 0(0) 1(6)
15 75(100) 1(1) 73(97) 0(0) 0(0) 0(0) 0(0) 1(1)
16 15(100) 15(100) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0)
17 38(100) 0(0) 2(5) 1(3) 11(29) 22(58) 0(0) 2(5)
18 56(100) 0(0) 50(89) 0(0) 3(5) 0(0) 0(0) 3(5)
19 81(100) 0(0) 0(0) 79(98) 0(0) 0(0) 0(0) 2(2)
20 1(100) 1(100) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0)
21 30(100) 0(0) 0(0) 0(0) 28(93) 0(0) 0(0) 2(7)
22 50(100) 50(100) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0)
23 61(100) 60(98) 0(0) 0(0) 0(0) 0(0) 0(0) 1(2)
24 21(100) 21(100) 0(0) 0(0) 0(0) 0(0) 0(0) 0(0)
25 23(100) 0(0) 8(35) 0(0) 3(13) 12(52) 0(0) 0(0)
26 37(100) 1(3) 34(92) 0(0) 1(3) 0(0) 0(0) 1(3)
27 135(100) 0(0) 126(93) 0(0) 0(0) 0(0) 1(1) 8(6)
28 74(100) 0(0) 0(0) 71(96) 3(4) 0(0) 0(0) 0(0)
29 37(100) 0(0) 8(22) 0(0) 3(8) 26(70) 0(0) 0(0)
30 37(100) 0(0) 31(84) 0(0) 0(0) 4(11) 0(0) 2(5)
31 103(100) 0(0) 2(2) 0(0) 0(0) 101(98) 0(0) 0(0)
32 81(100) 73(90) 0(0) 0(0) 1(1) 0(0) 0(0) 7(9)
DEP. = department, Co = coblation, CN = Colorado-needle, La = laser, BT = bipolar technique, MT = other monopolar technique, RF = radiofrequency
technique, n.sp. = not specified
RESULTS
101
3.6.7. Operation technique for adenoidectomy
Table 3.29 Hospital performance: operation technique for adenoidectomy
DEP. Total (%) Co AB AF Cu+EC O n.sp.
Total 1,406(100) 96(7) 2,142(152) 192(14) 2,005(143) 7(0) 1,406(100)
1 30(100) 0(0) 87(290) 33(110) 1(3) 0(0) 30(100)
2 4(100) 0(0) 8(200) 0(0) 52(1300) 0(0) 4(100)
3 37(100) 0(0) 37(100) 0(0) 59(159) 1(3) 37(100)
4 4(100) 0(0) 3(75) 0(0) 19(475) 0(0) 4(100)
5 8(100) 0(0) 15(188) 0(0) 68(850) 0(0) 8(100)
6 5(100) 0(0) 22(440) 0(0) 5(100) 0(0) 5(100)
7 29(100) 0(0) 80(276) 4(14) 1(3) 0(0) 29(100)
8 31(100) 0(0) 48(155) 0(0) 39(126) 1(3) 31(100)
9 33(100) 0(0) 85(258) 10(30) 4(12) 0(0) 33(100)
10 51(100) 0(0) 83(163) 1(2) 6(12) 0(0) 51(100)
11 31(100) 0(0) 22(71) 0(0) 34(110) 0(0) 31(100)
12 18(100) 0(0) 60(333) 0(0) 0(0) 0(0) 18(100)
13 62(100) 2(3) 109(176) 0(0) 188(303) 1(2) 62(100)
14 48(100) 2(4) 123(256) 0(0) 0(0) 0(0) 48(100)
15 139(100) 0(0) 3(2) 0(0) 408(294) 0(0) 139(100)
16 22(100) 28(127) 2(9) 0(0) 19(86) 0(0) 22(100)
17 52(100) 1(2) 186(358) 0(0) 0(0) 0(0) 52(100)
18 30(100) 0(0) 41(137) 1(3) 77(257) 0(0) 30(100)
19 39(100) 0(0) 18(46) 4(10) 128(328) 0(0) 39(100)
20 8(100) 0(0) 14(175) 0(0) 4(50) 0(0) 8(100)
21 32(100) 0(0) 163(509) 0(0) 5(16) 0(0) 32(100)
22 55(100) 0(0) 0(0) 0(0) 145(264) 0(0) 55(100)
23 106(100) 0(0) 70(66) 7(7) 151(142) 1(1) 106(100)
24 19(100) 0(0) 46(242) 0(0) 0(0) 0(0) 19(100)
25 26(100) 0(0) 7(27) 1(4) 116(446) 1(4) 26(100)
26 53(100) 0(0) 75(142) 15(28) 36(68) 0(0) 53(100)
27 17(100) 0(0) 303(1782) 0(0) 0(0) 0(0) 17(100)
28 60(100) 0(0) 94(157) 67(112) 101(168) 0(0) 60(100)
29 75(100) 0(0) 148(197) 0(0) 3(4) 0(0) 75(100)
30 95(100) 0(0) 115(121) 49(52) 2(2) 0(0) 95(100)
31 84(100) 0(0) 1(1) 0(0) 239(285) 1(1) 84(100)
32 103(100) 63(61) 74(72) 0(0) 95(92) 1(1) 103(100)
DEP. = department, Co =Coblation, AB = Adenoid curette by Beckmann, AF = Adenotome by La Force, EC = endoscopic control +/- pharyngeal mirror,
O = others, n.sp. = not specified
RESULTS
102
3.7. INTRAOPERATIVE BLOOD LOSS
When analysing intraoperative blood loss, only patients undergoing tonsillectomy or
adenotonsillectomy who were operated with cold steel dissection, bipolar diathermy
or a combination thereof were taken into consideration (table 3.30).
3.7.1 Patient characteristics
At 12 ENT departments 864 patients, both children and adults, underwent surgery.
Tonsillectomy (TE) was performed in 69% of cases (596 patients) and
adenotonsillectomy (TE+AE) in 31% (268 patients). There were slightly more males
than females. Patients aged 12 and above represented 73% (628 patients) of the
study population and children younger than 12 years of age constituted 27% (236
patients). The most common indication for surgery in both groups was recurrent
tonsillitis and the most frequent operation technique was cold steel dissection with
bipolar diathermy for haemostasis (table 3.30).
Postoperative haemorrhage occurred in 13.1% (113 patients) of the study group, but
only one in four (27.5%) was of a severe quality. The postoperative haemorrhage
rate differed according to age: for children, bleeding episodes were reported in 11.9%
cases (28 patients) and 13.5% for adults (85 patients). By type of surgery the
haemorrhage rates were equal. A return to theatre due to severe bleeding episodes
was necessary in 4.7% (41 patients) of operated patients, with slightly more children
operated under full anaesthetic (5.5% vs. 4.5%, table 3.30).
RESULTS
103
Table 3.30 Patient characteristics: intraoperative blood loss
Characteristic Total Children <12 Adults >12
Total 864(100%) 236(27.3%) 628(72.7%)
Type of surgery TE 672(100%) 68(10.1%) 604(89.9%)
TE + AE 282(100%) 192(68.1%) 90(31.9%)
Sex Male 475(100%) 138(29.1%) 337(70.9%)
Female 389(100%) 98(25.2%) 291(74.8%)
Coagulation history Negative 760(100%) 203(26.7%) 557(73.3%)
Positive 26(100%) 11(42.3%) 15(57.7%)
Not specified 78(100%) 22(28.2%) 56(71.8%)
Coagulation test Negative 658(100%) 174(26.4%) 484(73.6%)
Positive 24(100%) 5(20.8%) 19(79.2%)
Not specified 182(100%) 57(31.3%) 125(68.7%)
Indication for surgery
RT (single answer) 655(100%) 189(28.9%) 466(71.1%)
TH±OSAS 30(100%) 14(46.7%) 16(53.3%)
RT + OSAS±TH 57(100%) 26(45.6%) 31(54.4%)
Abscess 99(100%) 3(3.0%) 96(97.0%)
Other 23(100%) 4(17.4%) 19(82.6%)
Operation technique Cold steel (CS) 41(100%) 10(24.4%) 31(75.6%)
Bipolar diathermy 61(100%) 19(31.1%) 42(68.9%)
CS + bipolar d. haem. 682(100%) 184(27.0%) 498(73.0%)
CS + bipolar d. 80(100%) 23(28.8%) 57(71.3%)
Postoperative
haemorrhage
No 751(100%) 208(27.7%) 543(72.3%)
Minor 72(100%) 15(20.8%) 57(79.2%)
Return to theatre 41(100%) 13(31.7%) 28(68.3%)
TE = tonsillectomy, TE+AE = adenotonsillectomy, RT = recurrent tonsillitis, TH = tonsillar
hypertrophy, OSAS = obstructive sleep apnoea syndrome, CS = cold steel dissection, bipolar d. =
bipolar diathermy, bipolar d. haem. = bipolar diathermy haemostasis
3.7.2. Amount of intraoperative blood loss
The mean intraoperative blood loss among all 864 patients analysed was 63.5 ml
(S.D. 61.4) with a maximum of 775 ml. The mean intraoperative blood loss for TE
was 64.1 ml (S.D. 64.6 ml) and 62.0 ml for TE+AE (S.D. 54.6 ml). Figure 3.8 shows
the distribution of intraoperative blood loss by age group, with blood loss decreasing
exponentially.
RESULTS
104
Figure 3.8 Distribution of intraoperative blood loss (ml) by age group
3.7.3. Association between intraoperative blood loss and other factors
The associations between intraoperative blood loss and the patients' age, sex,
coagulation disorder, indication for surgery, operation technique and postoperative
haemorrhage are discussed below.
The patients' age had no significant impact on absolute intraoperative blood loss
(p=0.18 Mann-Whitney-U test). However, a tendency towards higher intraoperative
blood loss in adults was noticed, with a highly significant result for patients with more
than 100 ml blood loss (p<0.004, Chi-squared test, table 3.31). This result is obvious
in figure 3.8 showing the distribution of intraoperative blood loss by age group with
blood loss decreasing exponentially. When analysing relative intraoperative blood
loss, the result was statistically extremely significant (p<0.001, Mann-Whitney-U test)
but differed from the results obtained for absolute blood loss. The mean
intraoperative blood loss for children under 12 was 2.32% of the circulated blood
volume and 1.55% for adults. Children therefore have a higher, relative intraoperative
blood loss than adults. No statistically significant difference was noted for the
patients' sex (p=0.103, Mann-Whitney-U test).
RESULTS
105
Coagulation disorders did not affect the amount of intraoperative blood loss. Patients
with a history of coagulation disorders showed no elevated intraoperative blood loss
(p=0.065, Mann-Whitney-U test). Positive preoperative coagulation tests could not
predict a higher intraoperative blood loss (p=0.282, Mann-Whitney-U test).
The indication for surgery presents significant results for both absolute and relative
intraoperative blood loss (p=0.002 and p=0.001, Kruskal-Wallis test). The mean
intraoperative blood loss for all operated patients was highest for the indication
peritonsillar abscess (79 ml), followed in decreasing order by recurrent tonsillitis with
tonsillar hypertrophy (73ml), recurrent tonsillitis (62 ml) and tonsillar hypertrophy (35
ml). In children, absolute and the relative blood loss depended extremely significantly
on the indication for surgery (p<0.001, Kruskal-Wallis test). No significant differences
were achieved in the adult population (absolute blood loss p=0.403, relative blood
loss p=0.166, Kruskal-Wallis test).
RESULTS
106
Table 3.31 Patient characteristics for six groups categorized by intraoperative blood loss in ml
Total <25ml 25-50ml 50-75ml 75-100ml
100-
125ml >125 ml
Age (years) <12 236(100%) 67(28.4%) 34(14.4%) 62(26.3%) 31(13.1%) 22(9.3%) 20(8.5%)
>12 628(100%) 177(28.2%) 97(15.4%) 118(18.8%) 65(10.4%) 81(12.9%) 90(14.3%)
Sex Male 475(100%) 119(25.1%) 76(16.0%) 110(23.2%) 44(9.3%) 58(12.2%) 68(14.3%)
Female 389(100%) 125(32.1%) 55(14.1%) 70(18.0%) 52(13.4%) 45(11.6%) 42(10.8%)
Coagulation
history
Negative 1,873(100%) 944(50.4%) 237(12.7%) 265(14.1%) 163(8.7%) 130(6.9%) 134(7.2%)
Positive 70(100%) 5(7.1%) 11(15.7%) 22(31.4%) 15(21.4%) 4(5.7%) 13(18.6%)
Not specified 187(100%) 69(36.9%) 47(25.1%) 39(20.9%) 11(5.9%) 13(7.0%) 8(4.3%)
Coagulation
test
Negative 1,347(100%) 650(48.3%) 189(14.0%) 233(17.3%) 73(5.4%) 113(8.4%) 89(6.6%)
Positive 62(100%) 32(51.6%) 3(4.8%) 10(16.1%) 5(8.1%) 7(11.3%) 5(8.1%)
Not specified 721(100%) 336(46.6%) 103(14.3%) 83(11.5%) 111(15.4%) 27(3.7%) 61(8.5%)
Indication for
surgery
RT 655(100%) 187(28.5%) 103(15.7%) 130(19.8%) 76(11.6%) 83(12.7%) 76(11.6%)
TH±OSAS 30(100%) 15(50.0%) 5(16.7%) 6(20.0%) 1(3.3%) 1(3.3%) 2(6.7%)
RT + OSAS±TH 57(100%) 7(12.3%) 12(21.1%) 19(33.3%) 7(12.3%) 4(7.0%) 8(14.0%)
Abscess 99(100%) 29(29.3%) 6(6.1%) 18(18.2%) 11(11.1%) 14(14.1%) 21(21.2%)
Other 23(100%) 6(26.1%) 5(21.7%) 7(30.4%) 1(4.3%) 1(4.3%) 3(13.0%)
Operation
technique
Cold steel (CS) 41(100%) 16(39.0%) 5(12.2%) 10(24.4%) 5(12.2%) 2(4.9%) 3(7.3%)
CS + bipolar d. 80(100%) 42(52.5%) 15(18.8%) 12(15.0%) 1(1.3%) 5(6.3%) 5(6.3%)
Bipolar d. 61(100%) 41(67.2%) 10(16.4%) 5(8.2%) 0(0%) 1(1.6%) 4(6.6%)
CS+bipolar
d.haem. 682(100%) 145(21.3%) 101(14.8%) 153(22.4%) 90(13.2%) 95(13.9%) 98(14.4%)
Postoperative
haemorrhage
No 751(100%) 223(29.7%) 112(14.9%) 153(20.4%) 82(10.9%) 94(12.5%) 87(11.6%)
Minor 72(100%) 11(15.3%) 15(20.8%) 13(18.1%) 9(12.5%) 7(9.7%) 17(23.6%)
Return to
theatre 41(100%) 10(24.4%) 4(9.8%) 14(34.1%) 5(12.2%) 2(4.9%) 6(14.6%)
RT = recurrent tonsillitis, TH = tonsillar hypertrophy, OSAS = obstructive sleep apnoea syndrome, CS = cold steel
dissection, bipolar d. = bipolar diathermy, bipolar d. haem. = bipolar diathermy haemostasis
Figures 3.9 and 3.10 present line graphs of the means for absolute and relative
intraoperative blood loss by age group for the indication for surgery. Children had the
highest intraoperative blood loss when they were operated due to recurrent infections
in combination with tonsillar hypertrophy (mean 76.3 ml). The lowest blood loss was
measured during surgery for tonsillar hypertrophy (mean 16.4 ml). Adults had the
highest intraoperative blood loss after abscess tonsillectomy (mean 80.4 ml). For the
other indications, blood loss was very similar, namely between 52 and 70 ml.
RESULTS
107
Whenever recurrent infections occurred in children, intraoperative blood loss rose.
This effect did not appear in adults.Combining figures 3.9 and 3.10, it is noteworthy
that for both age groups, mean absolute blood loss is similar for the indication
recurrent infection with or without tonsillar hypertrophy, whereas relative blood loss
for both age groups is merely similar for the indication of tonsillar hypertrophy and
peritonsillar abscess.
Figure 3.9 Mean intraoperative blood loss for indication of surgery by age group
Figure 3.10 Mean of relative intraoperative blood loss for indication of surgery by age group
TH ± OSAS RT RT + OSAS ± TH abscess
Children < 12 years 16,4 56,5 76,3 33,3
Adults > 12 years 51,9 63,8 70,0 80,4
0
10
20
30
40
50
60
70
80
90
mea
n in
trao
pera
tive
bloo
d lo
ss (
ml)
TH ± OSAS RT RT + OSAS ± TH abscess
Children < 12 years 0,81 2,41 2,91 1,46
Adults > 12 years 1,01 1,55 1,50 1,75
0,0
0,5
1,0
1,5
2,0
2,5
3,0
3,5
mea
n of
rel
ativ
e in
trao
pera
tive
bloo
d lo
ss (
%)
RESULTS
108
With regard to the operation technique, intraoperative blood loss showed an
extremely significant result (p<0.001, Kruskal-Wallis test). Listed as means in
decreasing order, cold steel dissection with bipolar diathermy haemostasis showed
the highest intraoperative blood loss (mean 70 ml, 95% CI 65.3-73.9), followed by
cold steel dissection alone (mean 60 ml, 95% CI 21.7-98.0). The operation
techniques cold steel with bipolar diathermy (mean 38 ml, 95% CI 28.4-48.5) and
bipolar diathermy alone (mean 30 ml, 95% CI 16.4-44.4) showed lower intraoperative
blood loss.
Figure 3.11 depicts intraoperative blood loss for all operation techniques in
percentages of patients operated. When using bipolar diathermy as the operation
technique, intraoperative blood loss is far lower than when not using it. Intraoperative
blood loss above 60 ml was recorded for half of all patients operated with cold steel
dissection and bipolar diathermy for haemostasis. In contrast, the same amount of
blood loss was only found in 10% of all patients operated with bipolar electrocautery
alone. Persons with blood loss above 120 ml were operated with cold steel dissection
in combination with electrocautery for haemostasis twice as often compared to all
other operation methods.
Figure 3.11 Intraoperative blood loss by operation technique
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0 10 20 30 40 50 60 70 80 90 100 110 120
X: Intraoperative Blood Loss (ml)
% o
f P
atie
nts
hav
e B
loo
d L
oss
ab
ove
X
% o
f P
atie
nts
hav
e b
loo
d lo
ss le
ss t
han
X
CS + bipolar diathermy cold steel (CS)bipolar diathermy CS + bipolar diathermy haemostasis
RESULTS
109
The quantity of intraoperative blood loss was significantly related (p=0.021, Mann-
Whitney-U test) to the frequency of postoperative haemorrhage. This effect is
particularly noticeable with adults (p=0.009, Mann-Whitney-U test). We sought to
determine a clinically relevant and critical limit for intraoperative blood loss to help
predict postoperative bleeding episodes. Intraoperative blood loss could then be an
indicator for the occurrence of postoperative haemorrhage. With a chi-squared test
we found the most significant limit to be 110 ml. For patients with intraoperative blood
loss of more than 110 ml, a significant (p=0.03, Chi-squared test) risk of
postoperative haemorrhage was established as compared to patients with a blood
loss of less than 110 ml. In our study blood loss of 110 ml or more was recorded for
15.3% of operated patients (132 patients). Patients with less than 30 ml
intraoperative blood loss showed a significantly lower postoperative haemorrhage
rate (p=0.035, Chi-squared test): 31.6% (273 patients) of our participants had blood
loss lower than 30 ml. The severity of postoperative haemorrhage did not correlate
with the amount of the intraoperative blood loss (p=0.18, Mann-Whitney-U test).
RESULTS
110
3.8. PREOPERATIVE COAGULATION
3.8.1. Population description
For study purposes information on 8,161 cases collected from almost all ENT
departments nationwide was analysed: 4,286 (52.5%) of the study population
underwent tonsillectomy (with or without adenoidectomy), 1,207 (14.8%) tonsillotomy
(with or without adenoidectomy) and 2,668 (32.7%) only had an adenoidectomy.
Distribution of sexes showed a male preponderance for tonsillotomy and
adenoidectomy (two thirds of the operated patients) while distribution was equal for
tonsillectomy procedures. Paediatric patients constitute the overwhelming majority
(3,636, 94%) of patients undergoing tonsillotomies and adenoidectomies.
Tonsillectomies were mainly performed in adults (78%, 3,353). The most frequent
indication for tonsillectomy and adenoidectomy was recurrent tonsillitis (3,189, 74%
and 1,486, 32%). For tonsillotomy, hypertrophy of tonsils leading to obstructive sleep
apnoea syndrome (1,007, 83%) was the major reason for surgery.
3.8.2. Preoperative screening practice in Austria
The management of preoperative coagulation screening in the ENT departments
across Austria was evaluated as part of the study. ENT specialists were asked
whether they performed coagulation tests, including partial thromboplastin time
(PTT), prothrombine time (PT) and platelet count, or took a coagulation history.
Table 3.32 gives an overview of the distribution of patients along the variables
"patient's coagulation history (negative, positive, not evaluated)" and "coagulation
tests (negative, positive, not performed)". Both variables showed positive results in a
small proportion of cases only. A positive history was reported in 1.7% (140/8,161)
and a positive coagulation test showed up in 2.4% (193/8,161) cases. History was
not evaluated in 14.8% (1,207/8,161) cases and coagulation tests were not ordered
in 23.9% (1,949/8,161) cases. Only in 1.4% of all cases (1.19/8,161) was neither the
patient's history taken nor a coagulation test performed. This means that for 9.9%
(119/1,207) of all cases with missing patient history, a coagulation test was not
available either. Patients with a positive history have a ten-fold higher chance for a
positive coagulation test (2.4% 23% = 32/140). Only for 2.9% (4/140) of all
patients with a positive coagulation history was no coagulation test performed. In
RESULTS
111
sum, a coagulation history or a coagulation test was performed in nearly all patients
(98.6%), yielding positive results in only one in 60 patients for a positive history and
one in 40 patients for a positive test.
Table 3.32 Preoperative coagulation history and tests performed nationwide
Coagulation test
Pat.history Negative Positive Not performed Total
71% 2% 27% 100%
Negative 4,864 124 1,826 6,814
81% 64% 94% 83%
74% 23% 3% 100%
Positive 104 32 4 140
2% 17% 0% 2%
Not evaluated
87% 3% 10% 100% 1,051 37 119 1,207
17% 19% 6% 1.5% 15%
74% 2% 24% 100%
Total 6,019 193 1,949 8,161
100% 100% 100% 100% 100%
3.8.3. Postoperative haemorrhage
Postoperative haemorrhage, defined as any bleeding after extubation, was reported
over all patients at 14.2% for tonsillectomy (return-to-theatre rate 4.5%), 2.2% for
tonsillotomy (return-to-theatre rate 0.9%) and 0.6% for adenoidectomy (return-to-
theatre rate 0.3%) of all patients (8,161).
The question as to whether coagulation history or tests or both should be performed
preoperatively can be discussed based on the data in table 3.33. For tonsillectomy a
positive coagulation history is extremely significantly associated with a higher risk of
postoperative haemorrhage (p<0.001). Patients with a positive coagulation history
experienced post-tonsillectomy bleeding in 27% (21/77) of all cases compared to
patients with a negative history for whom a haemorrhage rate of 14% was recorded.
A positive coagulation test was not significantly associated with an increased risk of
haemorrhage (p<0.086) although positive screening tests increased the likelihood of
postoperative bleedings slightly compared to patients with negative screens (19%
RESULTS
112
versus 14%). For tonsillotomy and adenoidectomy, coagulation history or tests could
not predict postoperative bleeding episodes, since for both surgery types almost all
cases of postoperative haemorrhage happened to patients with both a negative
history and coagulation test. Due to the rarity of a positive history/test for TO or AE,
the absolute number of cases with a positive history/test was so low that the number
of bleedings in patients with a positive test/history was just zero or one, which is
about the same percentage as for the patients with a negative test/history. In
conclusion, neither taking the patient's history nor performing a coagulation test is of
any predictive value for TO and AE.
Table 3.33 Outcome of coagulation history and tests
TE±AE TO±AE AE
Total
No bleeding
Bleeding Total No
bleeding Bleeding
Total
No bleeding
Bleeding
Coagulation history neg. 3503 3013(86%)
490(14%) 1023 1000(98%) 23(2%)
2288 2274(99%) 14(1%)
pos. 77 56(73%) 21(27%) 23 22(96%) 1(4%) 40 40(100%) 0(0%)
p value p*<0.001 p**=0.9 p**=0.8
Coagulation test neg. 3496 3014(86%)
482(14%) 872 851(98%) 21(2%)
1651
1643(100%) 8(0%)
pos. 125 101(81%) 24(19%) 32 32(100%) 0(0%) 36 35(97%) 1(3%)
p value p*<0.086 p**=0.5 p**=0.2
TE = tonsillectomy, TO = tonsillotomy, AE = adenoidectomy, (±) = with or without, p*: chi-squared test, p**: test for proportions
RESULTS
113
Table 3.34 crosstabulates the patients' history (positive/negative) and coagulation
test (positive/negative) for tonsillectomy procedures. A positive coagulation history
predicts an elevated haemorrhage rate better than any coagulation test results.
When the coagulation history is negative, the haemorrhage rate remains nearly the
same regardless whether the result of the coagulation test is positive or negative
(15.5% and 13.8%). Likewise, when the coagulation history is positive, the
haemorrhage rate also remains nearly the same for both a positive and negative
coagulation test (29.2% and 26.4%), albeit at a higher overall rate then for a negative
coagulation history. Thus a higher haemorrhage rate is better detected by performing
a coagulation history than performing a coagulation test.
Table 3.34 Tonsillectomy procedures: distribution of positive and negative coagulation history and tests
Coagulation test
Positive Negative Total
Bleeding Total % Bleeding Total % Bleeding Total %
Positive 7 24 29.2% 14 53 26.4% 21 77 27.3%
History Negative 11 71 15.5% 392 2,835 13.8% 403 2,906 13.9%
Total 18 95 18.9% 406 2,888 14.1% 424 2,983 14.2%
RESULTS
114
3.8.4. Bleeding disorders
Bleeding disorders (figure 3.12) were reported for 140 patients who either had a
positive coagulation history or a positive coagulation test, with the bleeding disorder
reported in detail. The distribution of the type of surgery was as follows: 78
underwent TE±AE, 28 TO±AE and 34 AE. Prolonged bleedings experienced by the
patient prior to surgery were most common (52 cases), followed by a positive family
history (38 cases). Bleeding disorders, like factor deficiency (19 cases), von
Willebrand's disease (11 cases) thrombopathy (3 cases) or haemophilia (one case),
were diagnosed in 24% (34 patients). A preponderance of positive family history in
paediatric patients undergoing tonsillotomy or adenoidectomy is noteworthy (28 out
of 38 patients). The intake of anticoagulant drugs was reported only in patients prior
to tonsillectomy (16 cases). Since 20 of the 21 postoperative bleedings occurred in
patients undergoing TE, we will only describe the distribution of bleedings for TE
patients. Figure 3.12 shows that over all types of bleeding disorders, about 25% of
patients had a postoperative haemorrhage episode. The postoperative bleedings
were equally distributed among all types of bleeding disorders. The overall
haemorrhage rate for patients with a positive coagulation history is significantly
higher than for patients with negative coagulation history (26% versus 14%).
Figure 3.12 Bleeding disorders for patients undergoing tonsillectomy or adenotonsillectomy
1
1
1
2
2
5
8
2
3
5
5
10
11
22
0 5 10 15 20 25 30 35
thrombopathy
family history positive (bleeding disorder)
family history positive (prolonged bleedings)
von Willebrand´s disease
factor reduction
preoperative intake of anticoagulant drugs
patients history positive (prolonged bleeding)
postop bleeding
no bleeding
DISCUSSION
115
4. DISCUSSION
On behalf of the Austrian Society of Oto-Rhino-Laryngology, Head and Neck Surgery
the "Austrian Tonsil Study 2010" was set up to investigate the frequencies of
tonsillectomy, tonsillotomy and adenoidectomy performed in one country, namely
Austria, with a population of just over eight million. Special emphasis was put on the
incidence of postoperative haemorrhage and its risk factors. It was a full survey with
an evaluation period of nine months and for the first time a new classification of
postoperative haemorrhage was applied which allowed us to measure the severity of
bleeding episodes and the necessary medical treatment. Staff from 32 national
hospitals submitted information on cases to a central database via an online platform.
Out of the total population of Austria, 0.11% underwent tonsil and/or adenoid surgery,
divided up quite evenly by age group (around one third children under the age of six,
one third children aged six to fifteen and one third adults over the age of fifteen).
Tonsillectomy was most frequently performed in the adult population, with recurrent
tonsillitis being the most common reason and cold steel dissection the prevalent
operation technique. Tonsillotomy was performed in children under the age of six,
often when hypertrophy of the tonsils led to an obstructive sleep apnoea syndrome.
The use of the coblation technique and microdissection needles combined with
bipolar diathermy for haemostasis was preferred. An adenoidectomy alone was
carried out in young children with recurrent infections or a dysfunction of the
eustachian tubes. The adenoid curette by Beckmann was most frequently utilized
either in combination with a pharyngeal mirror or endoscopic control.
Postoperative haemorrhage occurred in 15.0% of patients undergoing tonsillectomy,
2.3% of patients undergoing tonsillotomy and 0.8% of patients undergoing
adenoidectomy. Return-to-theatre rates were 4.9% for tonsillectomy, 0.8% for
tonsillotomy and 0.3% for adenoidectomy. On the day of surgery and on days four,
five and six the highest haemorrhage rates for tonsillectomy were ascertained. A life-
threatening haemorrhage occurred in nine patients, but no fatal haemorrhage was
reported.
DISCUSSION
116
Postoperative haemorrhage was evaluated separately for the frequency and severity
of bleeding episodes. The risk factors for both are similar: the frequency of
postoperative haemorrhage depends on the type of surgery, the patient's age and
operation technique, while the severity of bleeding episodes is additionally influenced
by the patient's sex. Tonsillectomy had the highest haemorrhage rate in general.
Haemorrhage rates rose with increasing age for all types of surgery but the indication
did not show a significant correlation with an elevated haemorrhage rate. The
coblation technique was associated with a higher incidence of haemorrhage and with
more severe bleeding episodes while haemorrhage rates for bipolar techniques were
only higher when they were compared with cold steel dissection. The severity of
bleeding episodes, however, rose whenever bipolar diathermy was used.
Interestingly, the severity of bleeding episodes was additionally influenced by the sex
and age of the patients: males experienced more severe bleeding episodes than
females.
The topic of post-tonsillectomy haemorrhage is well covered in the literature and
differing haemorrhage rates have been reported.99,100 The largest study was a
prospective national tonsil audit in the UK of 34,000 patients undergoing
tonsillectomy (Lowe et al. in 2007180). They reported a postoperative haemorrhage
rate of 3.5% relating to bleedings occuring during a hospital stay and bleedings
leading to re-admission; 0.9% of all patients were returned to theatre. A retrospective
study by Windfuhr et al. (2005) conducted on 15,218 patients in Germany found a
return-to-theatre rate of 2.86% for tonsillectomy and 0.25% for adenoidectomy.232
Krishna and Lee reported a haemorrhage rate of 3.3% after tonsillectomy.233 The
latest prospective multicentre study published by Tomkinson et al. in 2011 evaluating
about 17,500 tonsillectomies with or without adenoidectomy in Wales found a primary
minor haemorrhage of 0.1%, a secondary minor haemorrhage of 1.8% and a return-
to-theatre rate of 1.5%.234 The authors admitted that minor bleedings were rarely
recorded due to the study design. A higher haemorrhage rate of 7.5% was found in a
prospective study by Attner et al. in (2009) covering 2,800 cases.10 Blakley analysed
63 reports on post-tonsillectomy haemorrhage and described a mean haemorrhage
rate of 4.5% with a standard deviation of 9.4%. He suggested a maximum expected
haemorrhage rate of 13.9%.83
DISCUSSION
117
One finding to emerge from our investigation is the elevated post-tonsillectomy
haemorrhage rate when compared with the studies discussed above. It can be
explained by the fact that minor bleeding episodes were rigorously included in the
haemorrhage count. In relation to the grades of haemorrhage that were recorded in
the study, about half of the bleeding episodes were of an anamnestic nature, just
4.1% of all patients showed at least one bleeding episode that required some kind of
treatment (grades B, C and D) and 5% of all patients with tonsillectomy had to return
to theatre.
The results concerning the risk factors of postoperative haemorrhage are a
controversial topic in other studies.8,102,180 The age of patients has consistently been
described as a major risk factor for the occurrence of haemorrhage, with older
patients being at higher risk.8,180,232,234 In support of this finding, the results of the
Austrian Tonsil Study 2010 indicate in addition that children tend to experience minor
bleedings first and foremost and that school children were more likely to experience
severe bleeding episodes. There is a discrepancy concerning sex as a risk factor as
some authors found a positive correlation for males being at higher risk232,234 and
others did not.8,180 In our study the frequency of postoperative haemorrhage does not
differ significantly for the sexes, but bleeding episodes in males are more severe than
in females. The indication for TE did not significantly influence the frequency or the
severity of haemorrhage in TE patients. The haemorrhage rate for recurrent tonsillitis
is slightly higher than for other indications, but this result is not significant. As for
operation techniques, our study confirms that coblation and bipolar techniques are
associated with a higher postoperative haemorrhage risk as described in several
other reports,11,84,208 namely bipolar techniques tended towards more severe
bleeding episodes, but not to higher haemorrhage rates in comparison to cold steel
dissection.
As ours was a multicentre study, a number of limitations must be considered. First,
the patients' data were collected by different hospital staff such that the personal
opinions as well as the expertise of the individual doctors might influence the data
entry to some extent. Second, the specific operation techniques might have been
applied in different manners by the surgeons. Third, the actual severity of
anamnestically recorded bleeding episodes could hardly be measured. Since
DISCUSSION
118
patients were asked to return to hospital immediately whenever haemorrhage
occurred, a high rate of anamnestic haemorrhage not leading to a return to theatre
could be observed. Fourth, the bleeding grade B2, standing for treatment under local
anaesthetic, was applied less frequently in children. Fifth, the study was prone to
missing values due to the multicentre study design. Although every department
received monthly reports, this factor was not completely avoidable. Sixth, operations
at private hospitals were not recorded but it is estimated that about 90% of all tonsil
and adenoid surgeries in Austria during the evaluation period were captured. Finally,
one major problem arising during the period of statistical analysis was the difficulty of
calculating the postoperative haemorrhage rate. There was much controversy as to
whether the frequency of bleeding episodes per patient (taking the number of
patients as a basis) or the bleeding episodes (also counting multiple bleeding
episodes) should be taken as a basis for further analysis. Due to the entry and
coding of the postoperative bleeding episodes, it was difficult to analyse special
issues on this topic, e.g. the number of days between the first and the second
bleeding episode.
To sum up, this has been the largest multicentre study to date in Austria's ENT
community. The findings of the study indicate that the severity of bleeding episodes is
a crucial aspect in the investigation of postoperative haemorrhage which has not
been addressed in the literature so far. By assessing differing grades of
haemorrhage, this study offers an explanation for the variety of haemorrhage rates as
reported in the literature. This study shows that a classification of the severity of
postoperative bleeding along objective medical criteria is very useful.
FINAL STATEMENTS AND RECOMMENDATIONS
119
5. FINAL STATEMENTS AND RECOMMENDATIONS
Frequency of surgery: Adenoidectomy and tonsillectomy were the most
frequently performed surgeries (both 37%), followed by adenotonsillotomy
(14%) and adenotonsillectomy (12%). The overall number of patients operated
in nine months allows us to estimate that there are probably about 12,830
surgeries in one year. Compared with Austria's population of 8.4 million, the
overall annual operation rate is 1 in 655 persons per year.
Patient characteristics: One third of all patients were under the age of six and
one third were adults over fifteen. About 60% of the children were male. In
adults the distribution of the sexes was equal.
Type of surgery: Almost 90% of all tonsillectomies were performed in adults.
Three quarters of tonsillotomies were done in children under the age of six.
Sixty percent of adenotonsillectomies were for patients aged six to fifteen. In
two thirds of the cases, adenoidectomy was performed in children under the
age of six and in one third in children aged six to fifteen.
Indication for surgery: Recurrent tonsillitis was the most common indication for
tonsillectomy (70%) and adenoidectomy (28%), while tonsillar hypertrophy
was the most common indication for tonsillotomy (52%). The obstructive sleep
apnoea syndrome (OSAS) was the main indication for children undergoing
tonsillotomy.
Duration of hospitalization: The mean overnight stay was three nights after
tonsillectomy, two nights for tonsillotomy and one night for adenoidectomy.
Haemorrhage occurred most frequently on the day of surgery and on days four
to six. As a consequence, the duration of hospitalization should either be one
night to deal with any bleeding episodes on the day of surgery or one week to
keep track of the second peak for bleeding episodes. The severity of bleeding
episodes was not influenced by the day of occurrence.
FINAL STATEMENTS AND RECOMMENDATIONS
120
Operation techniques: The most frequent operation technique for tonsillectomy
still remains cold steel dissection with bipolar haemostasis. For tonsillotomy
procedures, the Colorado needle and bipolar haemostasis were used most
often. The adenoid curette by Beckmann and bipolar haemostasis are the
methods of choice for adenoidectomy.
Grade of surgeon: All surgeries were performed by residents in training and
consultants equally often, with a slight preponderance of consultants over all
surgery types.
Classification of postoperative bleeding episodes: For the purposes of this
study, any bleeding episode after extubation was classified in grades A1, A2,
B1, B2, C, D, and E according to their severity and resulting medical
treatment. This made it possible to distinguish between the frequency of
haemorrhage (per patient) and the severity of each bleeding episode.
Frequency of haemorrhage: The postoperative haemorrhage rate was 15.0%
for tonsillectomy, 2.3% for tonsillotomy and 0.8% for adenoidectomy. The
return-to-theatre rate for severe bleedings requiring surgical treatment was
4.6%, 0.9% and 0.3% respectively. No fatal haemorrhage occurred during the
study period.
Type of surgery and haemorrhage: Bleeding episodes after adenoidectomy
hardly occurred, but if they did, they were severe. Special attention should be
paid to children undergoing adenoidectomy whenever haemorrhage appears.
Age and haemorrhage: School children aged six to fifteen are at higher risk of
suffering more severe bleeding episodes than other age groups.
Sex and haemorrhage: Bleeding episodes in males were more severe than in
females. The frequency of haemorrhage was not influenced by sex.
Indication for surgery and haemorrhage: Neither the frequency nor the severity
of postoperative haemorrhage was influenced by the indication for surgery.
FINAL STATEMENTS AND RECOMMENDATIONS
121
Grade of surgeon and haemorrhage: For residents in training a lower
haemorrhage rate was recorded which was not, however, statistically
significant.
Operation techniques for TE and haemorrhage: So called "hot" techniques –
bipolar diathermy and coblation – should be used with caution. The application
of bipolar techniques in combination with cold steel dissection proved to have
higher haemorrhage rates. More severe bleeding episodes occurred when
bipolar techniques were used. The coblation technique was found to be a risk
factor for haemorrhage and for more severe bleeding episodes in TE.
Intraoperative blood loss during TE and haemorrhage: Postoperative
haemorrhage risk rises with increasing intraoperative blood loss. An
intraoperative blood loss of more than 110 ml indicates a significantly higher
postoperative haemorrhage risk, whereas blood loss below 30 ml is
associated with fewer postoperative bleeding episodes. Blood loss depends
on age, indication for surgery and operation technique, but not on coagulation
status.
Multiple bleeding episodes after TE: The occurrence of a minor postoperative
bleeding episode increases the risk of a subsequent severe bleeding episode
by the factor of two.
Coagulation history and tests prior to TE and haemorrhage: A positive
coagulation history predicts an elevated haemorrhage rate better than any
result of the coagulation test. A positive coagulation history is extremely
significantly associated with a higher risk of postoperative haemorrhage
(p<0.001) while a positive coagulation test was not significantly associated
with an increased risk of haemorrhage (p<0.086).
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226. Wright ED, Manoukian JJ, Shapiro RS. Ablative adenoidectomy: a new
technique using simultaneous liquefaction/aspiration. J Otolaryngol 1997;
26:36-43.
227. Walker P. Pediatric adenoidectomy under vision using suction-diathermy
ablation. Laryngoscope 2001; 111:2173-2177.
228. Reed J, Sridhara S, Brietzke SE. Electrocautery adenoidectomy outcomes: a
meta-analysis. Otolaryngol Head Neck Surg 2009; 140:148-153.
229. Koltai PJ, Kalathia AS, Stanislaw P, Heras HA. Power-assisted
adenoidectomy. Arch Otolaryngol Head Neck Surg 1997; 123:685-688.
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230. Stanislaw P, Jr., Koltai PJ, Feustel PJ. Comparison of power-assisted
adenoidectomy vs adenoid curette adenoidectomy. Arch Otolaryngol Head
Neck Surg 2000; 126:845-849.
231. Sarny S, Ossimitz G, Habermann W, Stammberger H. Hemorrhage Following
Tonsil Surgery: A Multicenter Prospective Study. Laryngoscope 2011.
232. Windfuhr JP, Chen YS, Remmert S. Hemorrhage following tonsillectomy and
adenoidectomy in 15,218 patients Otolaryngol Head Neck Surg, 2005:281-
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233. Krishna P, Lee D. Post-tonsillectomy bleeding: a meta-analysis Laryngoscope,
2001:1358-1361.
234. Tomkinson A, Harrison W, Owens D, Harris S, McClure V, Temple M. Risk
factors for postoperative hemorrhage following tonsillectomy. Laryngoscope
2010.
APPENDIX
141
7. APPENDIX
7.1. Questionnaires
Figure 7.1 First hospital admission or admission due to postoperative haemorrhage
APPENDIX
142
Figure 7.2 Questionnaire for first hospital admission (1)
APPENDIX
143
Figure 7.3 Questionnaire for first hospital admission (2)
APPENDIX
144
Figure 7.4 Questionnaire for first hospital admission (3)
APPENDIX
145
Figure 7.5 Questionnaire for hospital admission due to postoperative haemorrhage (1)
APPENDIX
146
Figure 7.6 Questionnaire for hospital admission due to postoperative haemorrhage (2)
APPENDIX
147
Figure 7.7 Questionnaire for hospital admission due to postoperative haemorrhage (3)
APPENDIX
148
Figure 7.8 Questionnaire for hospital admission due to postoperative haemorrhage for a patient who
was operated in a different hospital (1)
APPENDIX
149
Figure 7.9 Questionnaire for hospital admission due to postoperative haemorrhage for a patient who
was operated in a different hospital (2)
APPENDIX
150
7.2. Curriculum vitae
International Publications:
Sarny, S.; Ossimitz, G.; Habermann, W.; Stammberger, H. “Hemorrhage following tonsil surgery: a multicenter prospective study”, The Laryngoscope, December 2011 DOI: 10.1002/lary.22347 (TOP, IF 2.096)
Sarny, S.; Habermann, W.; Ossimitz, G.; Schmid, C.; Stammberger, H. “Tonsilar
haemorrhage and readmission: A questionnaire based study“. Eur Arch
Otorhinolaryngology, March 2011 (STANDARD, IF 1.214)
Sarny S. „Detailanalyse zur Nachblutungshäufigkeit – Die Österreichische
Tonsillenstudie 2009/10“. Wiener Medizinische Wochenschrift „WMW-Skriptum“, 55.
Österreichischen HNO-Kongress, Wien, September 2011 (STANDARD)
Sarny, S.; Ossimitz, G.; Habermann, W.; Stammberger, H. „Die österreichische Tonsillenstudie 2010 – Teil 1: Statistischer Überblick”, Laryngo-rhino-otologie, January 2011 (Ahead of Print) (STANDARD, IF 0.725) Sarny, S.; Ossimitz, G.; Habermann, W.; Stammberger, H. „Österreichische Tonsillenstudie 2010 – Teil 2: Postoperative Nachblutungen“ Laryngo-rhino-otologie, February 2011 (Ahead of Print) (STANDARD, IF 0.725) Sarny, S.; Ossimitz, G.; Habermann, W.; Stammberger, H. „What lessons can be learned from the Austrian events?” ORL - Journal for Oto-Rhino-Laryngology and its related specialties, January 2011 (Ahead of Print) (STANDARD, IF 0.840) Sarny, S.; Ossimitz, G.; Habermann, W.; Stammberger, H. „Classification of post-tonsillectomy hemorrhage”, under review Sarny, S.; Ossimitz, G.; Habermann, W.; Stammberger, H. „Significant Post-Tonsillectomy Pain is Associated with Increased Risk of Haemorrhage”, under review Sarny, S.; Ossimitz, G.; Habermann, W.; Stammberger, H. „Preoperative coagulation screening before tonsil and adenoid surgery: current practise and recommendations”, under review Sarny, S.; Ossimitz, G.; Habermann, W.; Stammberger, H. „Implications of low versus high intraoperative blood loss during tonsillectomy“, under review
Abstract Publications:
Sarny, S.; Habermann, W.; Ossimitz, G.; Stammberger, H. “Nationwide Multicenter Study on Post-tonsillectomy Bleeding” AAO-HNSF Annual Meeting & OTO EXPO, 10th – 14th September 2011, San Francisco, USA Sarny, S.; Habermann, W.; Ossimitz, G.; Stammberger, H. „Classification of Post-tonsillectomy Hemorrhage“
APPENDIX
151
AAO-HNSF Annual Meeting & OTO EXPO, 10th – 14th September 2011, San Francisco, USA Sarny, S.; Habermann, W.; Ossimitz, G.; Stammberger, H. „Die Österreichische Tonisllenstudie 2010“ 82. Jahresversammlung der Deutschen Gesellschaft für Hals-Nasen-Ohren-Heilkunde, Kopf- und Hals-Chirurgie, 1st – 5th June 2011, Freiburg, Germany Sarny, S.; Habermann, W.; Schmid, C.; Ossimitz, G.; Stammberger, H. „Schmerztypen nach Tonsillektomie und assoziiertes Nachblutungsrisiko“ 81. Jahresversammlung der Deutschen Gesellschaft für Hals-Nasen-Ohren-Heilkunde, Kopf- und Hals-Chirurgie, 12th – 16th May 2010, Wiesbaden, Germany Sarny, S.; Habermann, W.; Schmid, C.; Ossimitz, G.; Stammberger, H. „Nachblutungen nach Tonsillektomie – Ergebnisse einer retrospektiven Analyse von 407 Patienten“ 80. Jahresversammlung der Deutschen Gesellschaft für Hals-Nasen-Ohren-Heilkunde, Kopf- und Hals-Chirurgie, 20th – 24th May 2009, Rostock, Germany
Oral Presentations:
Sarny, S.; Habermann, W.; Ossimitz, G.; Stammberger, H. „Die Österreichische Tonsillektomiestudie – Hintergrund und Konsequenzen“ Herbsttagung Universitäts-HNO-Klinik Regensburg. 12th November 2011, Regensburg, Germany Sarny, S.; Habermann, W.; Ossimitz, G.; Stammberger, H. „Die Österreichische Tonsillenstudie 2010, Teil II: Analysen“ 55. Österreichischer HNO – Kongress, 14th – 17th September 2011, Vienna, Austria Sarny, S.; Habermann, W.; Ossimitz, G.; Stammberger, H. “Nationwide Multicenter Study on Post-tonsillectomy Bleeding” AAO-HNSF Annual Meeting & OTO EXPO, 10th – 14th September 2011, San Francisco, USA Sarny, S.; Habermann, W.; Ossimitz, G.; Stammberger, H. „Classification of Post-tonsillectomy Hemorrhage“ AAO-HNSF Annual Meeting & OTO EXPO, 10th – 14th September 2011, San Francisco, USA Sarny, S.; Habermann, W.; Ossimitz, G.; Stammberger, H. „Die Österreichische Tonisllenstudie 2010“ 82. Jahresversammlung der Deutschen Gesellschaft für Hals-Nasen-Ohren-Heilkunde, Kopf- und Hals-Chirurgie, 1st – 5th June 2011, Freiburg, Germany Sarny, S.; Habermann, W.; Schmid, C.; Ossimitz, G.; Stammberger, H. „Schmerztypen nach Tonsillektomie und assoziiertes Nachblutungsrisiko“ 81. Jahresversammlung der Deutschen Gesellschaft für Hals-Nasen-Ohren-Heilkunde, Kopf- und Hals-Chirurgie, 12th – 16th May 2010, Wiesbaden, Germany
APPENDIX
152
Sarny, S.; Habermann, W.; Schmid, C.; Ossimitz, G.; Stammberger, H. „Nachblutungen nach Tonsillektomie – Ergebnisse einer retrospektiven Analyse von 407 Patienten“ 80. Jahresversammlung der Deutschen Gesellschaft für Hals-Nasen-Ohren-Heilkunde, Kopf- und Hals-Chirurgie, 20th – 24th May 2009, Rostock, Germany Sarny, S., Habermann, W. „Tonsillektomie – Tonsillotomie: Nachblutungsraten. Ergebnisse der Österreichischen Tonsillenstudie 2009/10 – wo stehen wir im europäischen Kontext? Vorstellung der Ergebnisse und Datenanalyse“ 54. Österreichischer HNO – Kongress, 15th – 19th September 2010, Salzburg, Austria Sarny, S.; Habermann, W.; Stammberger, H.; „Prospektive Studie zur österreichweiten Erfassung aller Tonsillektomien, Tonsillotomien und Adenotomien 2009/10“ (Projektvorstellung) 53. Österreichischer HNO-Kongress, 9th – 13th September 2009, Bregenz, Austria Sarny, S.; Habermann, W.; Schmid, C.; Ossimitz, G.; Stammberger, H. „Schmerzverläufe nach Tonsillektomie und Tonsillotomie“ 53. Österreichischer HNO-Kongress, 9th – 13th September 2009, Bregenz, Austria Awards:
Hansaton Wissenschaftspreis for the publication “Tonsilar haemorrhage and readmission: A questionnaire based study“ (2011)
Scholarship “Doctoral thesis” from the Medical University of Graz, Austria (2011)
Excellence scholarship from the Medical University of Graz, Austria (2010)
Scholarship “Multicentre prospective study on all patients undergoing tonsillectomy, tonsillotomie or adenoidectomy in Austria in 2009 and 2010 “ from the Austrian Society of Oto-Rhino-Laryngology, Head and Neck Surgery (2010)
Scholarship “Diploma thesis” from the Medical University of Graz, Austria (2009)
Foreign exchange scholarship “ENT department, Kathmandu, Nepal” from the Medical University of Graz, Austria (2008)
Foreign exchange scholarship “ENT department, Charité, Berlin, Germany” from the Medical University of Graz, Austria (2008)
7.3. International Publications
Laryngoscope 121: December 2011 Sarny et al.: Hemorrhage Following Tonsil Surgery
2553
APPENDIX
The Laryngoscope VC 2011 The American Laryngological, Rhinological and Otological Society, Inc.
Hemorrhage Following Tonsil Surgery: A Multicenter Prospective
Study
Stephanie Sarny, MD; Guenther Ossimitz, PhD; Walter Habermann, MD; Heinz Stammberger, MD
Objectives/Hypothesis: Postoperative hemorrhage as a serious complication after tonsillectomy (TE), tonsillotomy (TO), or adenoidectomy (AE) is covered in many studies, using rather inconsistent measurement methods. We introduce a new classification for the severity of postoperative hemorrhage and investigate risk factors for the frequency and severity of bleeding episodes.
Study Design: Prospective, multicenter cohort study. Methods: Our study is based on a prospective census recording all TEs, TOs, and AEs from October 1, 2009, to June 30,
2010, in Austria. Information concerning surgery indication, grade of surgeon, operation technique, and postoperative hemor- rhage, classified as any bleeding episode after extubation according to severity, were collected.
Results: A total of 9,405 patients were included. Hemorrhage rate for TE 6 AE was 15.0%, for TO 6 AE was 2.3%, and for AE was 0.8%. Rate of return to the operating room for TE 6 AE was 4.6%, for TO 6 AE was 0.9%, and for AE was 0.3%. Minor bleeding episodes increased the risk of a subsequent severe bleeding episode (P < .001). Elevated hemorrhage rates were observed for adults (P < .001), TE 6 AE (P < .001), and cold steel dissection combined with bipolar diathermy (P ¼ .05). Multivariate logistic regression model for the frequency of post-TE hemorrhage showed significant odds ratios for males, children aged <6 years, children aged 6–15 years, abscess TE, and cold steel combined with bipolar diathermy. In addition, we found a significantly higher risk of severe bleeding episodes for children aged 6–15 years (P ¼ .007), males (P ¼ .02), and all bipolar operation techniques (P ¼ .005).
Conclusions: The occurrence of a postoperative minor bleeding episode increases the risk of a subsequent severe bleeding episode.
Key Words: Tonsillectomy, tonsillotomy, adenoidectomy, postoperative hemorrhage, bleeding episode. Level of Evidence: 2c.
Laryngoscope, 121:2553–2560, 2011
INTRODUCTION
Tonsillectomy (TE), tonsillotomy (TO), and adenoidec-
tomy (AE) are the most frequent surgeries in the field of
otorhinolaryngology. The multicenter prospective Austrian
Tonsil Study 2010 was set up to investigate all surgeries
performed nationwide within 9 months, assessing operat-
ing characteristics and risk factors for the frequency and
severity of postoperative hemorrhage. In the full survey,
data from 9,621 patients of 32 ENT departments were
entered prospectively into an online database recording
about 100 variables for each patient. For the first time,
not only the frequency of hemorrhage but also the severity
of each bleeding episode was measured on a precisely
defined scale of five severity grades, A through E (Table I).
From the Department of General Otorhinolaryngology–Head and
Neck Surgery, Medical University Graz (S.S., W.H., H.S.), Austria; and the Department of Mathematics, University Klagenfurt (G.O.), Austria.
Editor ’s Note: This Manuscript was accepted for publication August 5, 2011.
The study was funded by the Austrian Society of Oto-Rhino-Laryn- gology, Head and Neck Surgery. The sponsor had no role in the study design, data collection, data analysis, data interpretation, and the writ- ing of any publication related to the study. The authors have no other funding, financial relationships, or conflicts of interest to disclose.
Send correspondence to Stephanie Sarny, MD, Auenbruggerplatz 26-28, A-8036 Graz, Austria. E-mail: [email protected]
DOI: 10.1002/lary.22347
A variety of studies have dealt with postoperative
hemorrhage as the most serious complication of tonsil
surgeries. It is commonly accepted that bleeding epi-
sodes are classified into primary hemorrhage within the
first 24 hours of surgery and secondary hemorrhage
after the first 24 hours of surgery.1–6 Furthermore,
authors often differentiate between hemorrhage requir-
ing surgical treatment and minor hemorrhage.4,7
Because of varying definitions of what is considered a
postoperative bleeding episode and differences in study
designs, the reported hemorrhage rates and their risk
factors vary considerably among studies.
In our study, we analyze both the frequency of post-
operative hemorrhage (with the number of operated
patients as a basis) and the severity of bleeding episodes
(with the number of bleeding episodes as a basis). This
double perspective allows us to take into account multi-
ple bleeding episodes and to assess risk factors for TE,
TO, and AE in an unprecedented way.
MATERIALS AND METHODS
Study Organization and Patient Selection During a period of 9 months, from October 1, 2009, to
June 30, 2010, a full survey was performed on all tonsillecto-
mies (TE), adenotonsillectomies (TEþAE), tonsillotomies (TO),
tonsillotomies with adenoidectomy (TOþAE), or merely
Laryngoscope 121: December 2011 Sarny et al.: Hemorrhage Following Tonsil Surgery
2554
APPENDIX
TABLE I.
Classification of Postoperative Bleeding Episodes.
Day of bleeding episode
T0 Day of surgery until midnight
T1 Midnight of day of surgery until next midnight (24 hr)
T2 Second day after surgery from midnight to midnight
T3 Third day after surgery from midnight to midnight
Tx Analogue
T21 21st day after surgery from midnight to midnight
Severity of bleeding episode
A Anamnestically recorded blood-tinged sputum
A1 Wound is and stays dry, no coagulum upon inspection
A2 Coagulum upon inspection, dry wound after removal
B Bleeding actively under examination, treatment necessary, dry wound afterwards, blood count in normal range, no shock
B1 Minimal hemorrhage, stops after noninvasive treatment (e.g., adrenalin sponge)
B2 Hemorrhage requiring treatment in local anesthesia
C Surgical treatment in general anesthesia, blood count still in normal range, no shock
D Dramatic hemorrhage, hemoglobin decreased, blood transfusion required, difficult surgical treatment,
intensive care may be necessary
E Exitus due to hemorrhage or hemorrhage-related complications
Examples
T1A2 Coagulum upon inspection without hemorrhage on the first postoperative day, dry wound after removal
T2A2 and T5C Coagulum upon inspection without hemorrhage on the second postoperative day, dry wound after removal.
Second postoperative hemorrhage on day 5 requiring surgical treatment in general anesthesia
adenoidectomy (AE) in Austria (population 8.4 million). All
patients, both adults and children, were recruited from 32 ENT
departments, covering urban and rural areas.
Each department was responsible for gaining patient con-
sent and entering the data of each case into a central online
database. Cases were identified only by date of birth and date
of surgery to maintain anonymity. Each participating depart-
ment was able to revise the data of their own cases and to
update these if necessary. Submission of data was monitored by
the study team, and hospitals were contacted if support seemed
to be necessary. Each month, every department received a sum-
mary report of the data being submitted.
Collected Data For each case, about 100 variables were recorded. Data on
patient characteristics, surgery type, indication for surgery,
grade of surgeon, operation technique, and postoperative hem-
orrhage were collected. Excluded from the central database
were nonconsenting patients and all patients who underwent
surgery because of tonsil cancer or underwent tonsil biopsy. The
follow-up period for monitoring postoperative hemorrhage
lasted at least 1 month after surgery. Operated patients were
asked to visit the hospital immediately if they noted any kind of
postoperative bleeding, even when it was minimal.
Postoperative hemorrhage was defined as any bleeding
episode after extubation, with the severity of bleeding episodes
recorded according to a precise classification of postoperative
hemorrhage (Table I). The hemorrhage grades have been
grouped into the five grades A through E in ascending order of
the severity of bleeding episodes: anamnestic recorded blood-
tinged sputum (grade A ¼ A1 and A2), active bleeding under
examination (grade B ¼ B1 and B2), and hemorrhage requiring
a return to the operating room (grades C and D). As no single
case of grade E (fatal bleeding) occurred, this category was not
considered further in this study. Grades A and B were counted
as minor bleeding episodes, and grades C and D were counted
as severe bleeding episodes.
Six options for the indication of surgery were defined:
recurrent infections, enlargement of the tonsils, obstructive
sleep apnea syndrome (OSAS), peritonsillar abscess operated
immediately, peritonsillar abscess operated electively, or others.
Multiple answers were allowed if required. For data analyses,
indications were grouped appropriately.
Operation techniques for TE were categorized into cold
steel dissection, bipolar scissors, bipolar forceps, coblation, laser,
or others. Laser, Colorado needle, or operation techniques other
than those listed were used only in a very few patients and
were not taken into specific consideration for statistical analy-
sis. Operation techniques for AE were categorized into adenoid
curette by Beckmann with or without endoscopic control, adeno-
tome by La Force, and coblation technique.
Database and Data Analyses Patients were excluded from analyses if essential data like
age of the patient or type of surgery were missing. Of the 9,621
cases submitted to the central database, 9,405 could be included
for further analyses. Dependencies of categorized data were
analyzed using v2 independence tests for cross-tabulations.
Deviations for proportions in subgroups were tested two-sided
with tests for proportions. P values <.05 were considered signif-
icant, P < .01 highly significant, and P < .001 extremely
significant. Multivariate logistic regression was done to explore
potential risk factors related to postoperative hemorrhage. The
study was approved by the Ethics Committee of the Medical
University Graz, Austria (21-072 ex 09/10). Statistical analysis
was performed using PASW 18.0 (SPSS, Inc., Chicago, IL). The
members of the study team were not involved in the submission
of the data.
Laryngoscope 121: December 2011 Sarny et al.: Hemorrhage Following Tonsil Surgery
2555
TABLE II.
Type of Surgery and Age Group Per Patient and Hemorrhage Grade.
No. of Patients No. of Bleeding Episodes
Total (%) Hemorrhage (%) Total (%) A1þA2 (%) B1þB2 (%) CþD (%)
Total
9,405 (100.0)
747 (7.9)
953 (100)
491 (52)
189 (20)
273 (29)
Type of surgery
TE 6 AE 4,594 (48.8) 689 (15.0) 889 (100) 457 (51) 183 (21) 249 (28)
TO 6 AE 1,319 (14.0) 30 (2.3) 35 (100) 22 (63) 1 (3) 12 (34)
AE 3,492 (37.1) 28 (0.8) 29 (100) 12 (41) 5 (17) 12 (41)
Age group, yr
<6 3,474 (36.9) 50 (1.4) 54 (100) 34 (63) 4 (7) 16 (30)
6–15 2,424 (25.8) 129 (5.3) 160 (100) 83 (52) 17 (11) 60 (38)
>15 3,507 (37.3) 568 (16.2) 739 (100) 374 (51) 168 (23) 197 (27)
TE ¼ tonsillectomy; AE ¼ adenoidectomy; TO ¼ tonsillotomy; 6 ¼ with or without.
RESULTS
Characteristics of Patients and Operations Of the 9,405 included patients, 58.2% were males.
The entire study cohort was composed of 36.9% children
aged less than 6 years and 37.3% adults older than 15
years. Among the surgery types, 48.8% were TE proce-
dures; about half of them were accompanied by AE. The
second most frequent surgery type was AE without re-
moval of the tonsils, followed by TO, which was almost
solely performed in combination with AE. For TE, the
most common indication was recurrent tonsillitis, and
the most frequently used operation technique was cold
steel dissection.
Frequency of Hemorrhage: Overview The frequency of hemorrhage differed massively for
different types of surgery and significantly for different
age groups. TE 6 AE showed with 15.0% by far the
highest hemorrhage rate of all surgery types, compared
to 2.3% for TO 6 AE and 0.8% for AE (Table II). Adults
were at a three times higher risk (568 of 3,707 [16.2%])
of postoperative hemorrhage than school children (129 of
2,424 [5.3%]).
Severity of Bleeding Episodes: Overview More than one half of all bleeding episodes (52%)
were of grade A with just anamnestic records, whereas
29% of bleeding episodes were severe and treated with
use of general anesthesia.
Surgery type seems to have an influence on the dis-
tribution of the severity of bleeding episodes, being on
the edge of statistical significance (P ¼ .059). We found
an increased relative risk of more severe bleeding epi-
sodes after AE (41% of all bleeding episodes after AE
were severe) in comparison with TE (28%) or TO (34%).
Strong evidence was established for an age-related
effect on the severity of postoperative hemorrhage (P ¼
.007). School children were at a remarkably elevated
risk of severe hemorrhage (38% of all bleeding episodes)
in comparison with adults (27%) and children younger
than 6 years (30%) (Table II).
Frequency of Hemorrhage: TE
The incidence of hemorrhage was studied sepa-
rately for TE 6 AE because TE is the type of surgery
with the highest risk of postoperative bleeding.
Patient age, grade of surgeon, and operation tech-
nique had a significant influence on the frequency of
hemorrhage after TE (Table III). Adults had the high-
est hemorrhage risk (P < .001). Surgeries performed
by registrars in training showed a lower hemorrhage
rate (P ¼ .02). Bipolar diathermy in combination with
cold steel dissection carried a higher risk compared to
cold steel alone (P < .05). The use of just electrocau-
tery for dissection (bipolar scissor and forceps) had no
significantly higher risk of hemorrhage compared
to cold steel dissection alone (P < .87). Coblation
had a higher hemorrhage rate than cold steel dissec-
tion (P < .04).
By multivariate logistic regression analysis, the fol-
lowing significant risk factors for postoperative
hemorrhage could be identified (Table IV): Children
aged younger than 6 years were three times less likely
and school children were two times less likely to experi-
ence postoperative hemorrhage. A 1.3-fold increased risk
was observed for males. A one fourth lower hemorrhage
rate was achieved for abscess TE compared to recurrent
infection. Surgeries performed by registrars (in compari-
son to consultants) were less likely to be followed by
postoperative hemorrhage. The operation technique
‘‘cold steel in combination with bipolar scissors/forceps’’
showed a 1.5-fold increased likelihood of hemorrhage
compared with cold steel alone.
Severity of Bleeding Episodes: TE About every eighth patient had a minor bleeding
episode (12.1%) after TE and every 20th patient had a
severe bleeding episode (5.2%) (Table V).
Severity of post-TE hemorrhage depended signifi-
cantly on patient age and sex and operation technique
(Table VI). For children younger than 6 years, signifi-
cantly more minor bleeding episodes were recorded
(P < 04). Males had a significantly higher rate of severe
bleeding episodes (P ¼ .021). We found no significant
Laryngoscope 121: December 2011 Sarny et al.: Hemorrhage Following Tonsil Surgery
2556
TABLE III.
Tonsillectomy With or Without Adenoidectomy: Patient Characteristics and Postoperative Hemorrhage Rates.
No. of Patients
Total (%) Without Hemorrhage (%) With Hemorrhage (%) P Value* RR
All consenting patients (TE 6 AE) 4,594 (100.0) 3,905 (85.0) 689 (15.0)
Age, yr
<6 230 (5.0) 214 (93.0) 16 (7.0) <.001 1.0
6–15 1,073 (23.4) 961 (89.6) 112 (10.4) <.001 1.49
>15 3,291 (71.6) 2,730 (83.0) 561 (17.0) <.001 2.4
Sex
Female 2,210 (48.9) 1,911 (86.5) 299 (13.5) .053 1.0
Male 2,384 (51.1) 1,994 (83.6) 390 (16.4) .063 1.22
Indication for surgery
RT (single answer) 3,367 (73.3) 2,868 (85.2) 499 (14.8) .773 1.0
TH 6 OSAS 151 (3.3) 130 (86.1) 21 (13.9) .71 0.94
RT þ OSAS 6 TH 297 (6.5) 256 (86.2) 41 (13.8) .565 0.93
Abscess (elective/immediate) 594 (12.9) 513 (86.4) 81 (13.6) .353 0.92
Others 185 (4.0)
Grade of surgeon
Consultant 2,448 (53.3) 2,069 (84.5) 379 (15.5) .502 1.0
Specialist registrar 1,994 (43.4) 1,733 (86.9) 261 (13.1) .017 0.85
Not specified 152 (3.3)
Operation technique
CS 4,012 (87.3) 3,450 (86.0) 562 (14.0) † 1.0
CS þ bipolar forceps or scissors 237 (5.2) 193 (81.4) 44 (18.6) .05 1.33
Bipolar forceps/scissors (no CS) 133 (2.9) 115 (86.5) 18 (13.5) .877 0.96
Coblation 55 (1.2) 42 (76.4) 13 (23.6) .042 1.69
Others 157 (3.4)
*Total number as the baseline category. †Cold steel as the baseline category. RR ¼ relative risk; TE ¼ tonsillectomy; AE ¼ adenoidectomy; RT ¼ recurrent tonsillitis; TH ¼ tonsillar hypertrophy; OSAS ¼ obstructive sleep apnea
syndrome; CS ¼ cold steel; 6 ¼ with or without.
difference of hemorrhage risk between various indications
for surgery (P ¼ .99). However, bleeding episodes of dra-
matic severity (grade D) occurred almost solely after TE
owing to recurrent tonsillitis. The qualification of the sur-
geon had no significant effect on the bleeding severity.
Surgery methods using bipolar diathermy had an ele-
vated risk of severe bleeding episodes in comparison to
cold steel dissection (P ¼ .005). Coblation showed a signifi-
cant tendency toward more severe bleeding episodes (P ¼
.031). Patients operated with cold steel dissection alone
experienced significantly less severe bleedings than
patients operated with any technique other than cold steel
alone (P ¼ .01).
Multiple Bleeding Episodes After TE Multiple bleeding episodes were recorded for one in
30 patients (3.3%), which is nearly one in four patients
with hemorrhage (21.9%) (Table V). This table indicates
that multiple bleeding is of considerable relevance when
studying postoperative hemorrhage after TE. The
sequence of severity for multiple bleeding episodes is of
special interest. We assume that the occurrence of light
bleeding is an indicator for a second severe bleeding epi-
sode. Testing this question, we found that one in 10
patients who experienced postoperative minor bleeding
had a second severe bleeding (54 of 532 [10.2%]).
Comparing this with the overall risk of severe bleeding
after TE of 5.2% (239 of 4,594) yields an extremely sig-
nificant result (P < .001). This allows the conclusion
that the evidence of minor bleeding (even only of anam-
nestic nature) increases the risk of a second severe
bleeding episode by the factor two above the overall risk
of a severe bleeding (5.2% ! 10.2%). Almost half of the
second severe bleeding episodes occurred on the day
after the light bleeding episode (41%).
Frequency of Hemorrhage: AE The hemorrhage rate for AE was very low at 0.8%
and did not differ statistically significant for the opera-
tion methods used (P ¼ .76). The adenoid curette by
Beckmann with or without vision control was used in
73.1%, showing a hemorrhage rate of 0.6%. The adeno-
tome by La Force applied in 3.4% had a slightly elevated
hemorrhage rate of 0.9%. Coblation technique was used
less frequently in 1.7% of all adenoidectomies with post-
operative bleeding episodes reported in 1.1%.
Laryngoscope 121: December 2011 Sarny et al.: Hemorrhage Following Tonsil Surgery
2557
RT (single answer) 1.0
TH 6 OSAS 0.85 0.52-1.38 .51
RT þ OSAS 6 TH 1.08 0.76-1.54 .67
Abscess (elective/immediate) 0.75 0.58-0.97 .03
Others 0.99 0.65-1.53 .99
TABLE IV.
Tonsillectomy With or Without Adenoidectomy: Multivariate Logis- tic Regression Model for Postoperative Hemorrhage.
than half of all surgeries were AE and TO, only 5% of
all bleeding episodes were recorded for these types. For
TE, the risk factors patient age, patient sex, indication
Risk Factor
Age (yr)
Adjusted Odds Ratio
95% Confidence Interval P Value
for surgery, grade of surgeon, and operation techniques
influenced both the frequency and severity of hemor-
rhage significantly. Patients with a minor postoperative
bleeding episode showed a dramatically higher risk of a >15 1.0
6–15 0.54 0.43-0.67 <.001
<6 0.32 0.19-0.54 <.001
Sex
Female 1.0
Male 1.32 1.12-1.56 .001
Indication for surgery
Grade of surgeon
Consultant 1.0
Specialist registrar 0.82 0.68-0.97 .022
Operation technique
CS 1.0
CS þ bipolar forceps/scissors 1.44 1.022-2.04 .037
Bipolar forceps/scissors 0.88 0.53-1.46 .615
Coblation 1.63 0.86-3.08 .137
Others 2.39 1.54-3.72 <.001
RT ¼ recurrent tonsillitis; TH ¼ tonsillar hypertrophy; OSAS ¼ obstructive sleep apnea syndrome; CS ¼ cold steel; 6 ¼ with or without.
DISCUSSION
This nationwide, multicenter, prospective study
evaluated hemorrhage rates after TE, TO, and AE for
two outcomes: the frequency and the severity of bleeding
episodes. Both the frequency and severity of postopera-
tive hemorrhage varied extremely significant for
different surgery types and age groups. Although more
second severe bleeding episode. For this reason, monitor-
ing of minor postoperative bleedings is helpful for
anticipating severe bleeding episodes.
Hemorrhage Rate After TE
The topic of post-TE hemorrhage is covered well in
the literature, and differing hemorrhage rates have been
reported. Blakley analyzed 63 reports on post-TE hemor-
rhage and described a mean hemorrhage rate of 4.5%
with a standard deviation of 9.4%. He suggested a maxi-
mum expected hemorrhage rate of 13.9%.8 The largest
study on post-TE hemorrhage was the prospective
National Tonsil Audit in the United Kingdom by Lowe
et al. in 2007 with about 34,000 patients undergoing
TE.9 They reported a postoperative hemorrhage rate of
3.5% when considering bleeding episodes occurring dur-
ing hospital stay and bleedings leading to readmission;
0.9% of all patients were returned to the operating
room. Using data from the same study, Lowe and van
der Meulen found that postoperative hemorrhage after
TE with bipolar methods or coblation is three times
higher compared to cold steel TE alone.7 A retrospective
study by Windfuhr et al. conducted on 15,218 patients in
Germany in 2005 states a rate of return to the operating
room of 2.86% for TE and 0.25% for AE.2 A meta-analy-
sis of Krishna and Lee reported a hemorrhage rate of
3.3% after TE for patients with normal coagulation
tests.10 A recent prospective multicenter study published
by Tomkinson et al. in 2011 evaluating about 17,500 ton- sillectomies with or without AE in Wales found a
‘‘primary minor hemorrhage’’ of 0.1% (within the first 24
hours after surgery, no return to operating room), a ‘‘sec-
ondary minor hemorrhage’’ of 1.8% (after 24 hours of
surgery, readmission to hospital, no return to operating
TABLE V.
Patients With Multiple Bleeding Episodes After Tonsillectomy (With or Without Adenoidectomy).
No. of Cases
% of All Patients,
n ¼ 4,594
% of Patients With Hemorrhage, n ¼
689
% of First Bleeding is
Minor, n ¼ 532
% of Severe
Bleeding, n¼239
% of Multiple Hemorrhage,
n ¼ 156
All patients
4,594
100.0
Patients with hemorrhage* 689 15.0 100.0
Minor bleeding(s) (grades AþB)* 556 12.1 80.7
First bleeding is minor* 532 11.6 77.2 100.0
Only minor bleeding(s)* 478 10.4 69.4 89.8
Severe bleeding(s)* (grades CþD) 239 5.2 34.7 NA 100.0
Only severe bleeding(s)* 161 3.5 23.4 NA 67.4
Patients with multiple bleedings 151 3.3 21.9 NA NA 100.0
Severe bleeding after minor bleeding 54 1.2 7.8 10.2 22.6 35.8
Minor bleeding after severe bleeding 24 0.5 3.5 NA 10.0 15.9
*Single and multiple bleeding(s). NA ¼ not applicable.
Laryngoscope 121: December 2011 Sarny et al.: Hemorrhage Following Tonsil Surgery
2558
Total (%) A1 (%) A2 (%) B1 (%) B2 (%) C (%) D (%)
Total no. of bleeding episodes 889 (100) 157 (18) 300 (34) 112 (13) 71 (8) 241 (27) 8 (1)
Age, yr
<6 19 (100) 9 (47) 5 (26) 2 (11) 0 (0) 3 (16) 0 (0)
6–15 138 (100) 20 (14) 51 (37) 13 (9) 0 (0) 52 (38) 2 (1)
>15 732 (100) 128 (17) 244 (33) 97 (13) 71 (10) 186 (25) 6 (1)
Sex
Female 368 (100) 75 (20) 134 (36) 34 (9) 30 (8) 89 (24) 6 (2)
Male 521 (100) 82 (15) 166 (32) 78 (15) 41 (8) 152 (29) 2 (1)
Indication for surgery
RT (single answer) 642 (100) 115 (18) 217 (34) 84 (13) 49 (8) 171 (27) 6 (1)
TH 6 OSAS 28 (100) 1 (4) 13 (46) 2 (7) 5 (18) 7 (25) 0 (0)
RT þ OSAS 6 TH 54 (100) 10 (19) 19 (35) 8 (15) 3 (6) 13 (24) 1 (2)
Abscess (elective/immediate) 108 (100) 18 (17) 34 (31) 13 (12) 11 (10) 32 (30) 0 (0)
Others 57 (100) 13 (23) 17 (30) 5 (9) 3 (5) 18 (32) 1 (2)
Grade of surgeon
Consultant 484 (100) 69 (14) 179 (37) 57 (12) 45 (9) 130 (27) 4 (1)
Specialist registrar 341 (100) 70 (21) 101 (30) 50 (15) 22 (6) 94 (28) 4 (1)
Not specified 64 (100) 18 (28) 20 (31) 5 (8) 4 (6) 17 (27) 0 (0)
Operation technique
Cold steel (CS) 717 (100) 124 (17) 239 (33) 97 (14) 63 (9) 186 (26) 8 (1)
CS þ bipolar forceps/scissors 61 (100) 11 (18) 21 (34) 4 (7) 1 (2) 24 (39) 0 (0)
Bipolar forceps/scissors 27 (100) 8 (30) 9 (33) 1 (4) 1 (4) 8 (30) 0 (0)
Coblation 16 (100) 1 (6) 9 (56) 3 (19) 0 (0) 3 (19) 0 (0)
Others 68 (100) 13 (19) 22 (32) 7 (10) 6 (9) 20 (29) 0 (0)
RT ¼ recurrent tonsillitis; TH ¼ tonsillar hypertrophy; OSAS ¼ obstructive sleep apnea syndrome; CS ¼ cold steel.
room), and a rate of return to operating room of 1.5%. The authors admitted that minor bleedings were recorded poorly in their multicenter observational
study.4 Attner et al. reported in 2009 a hemorrhage rate
of 7.5% in a prospective study covering 2,800 cases.5
In our study, the post-TE hemorrhage rate is 15.0%
(including all severity levels), and 4.6% of all patients
had to return to the operating room. These values are
considerably higher than in other studies and require
some considerations. One reason is the very strict defini-
tion of hemorrhage, which includes also anamnestically
recorded hemorrhage. A second argument is that the pri-
mary goal of our study was to investigate postoperative
hemorrhage, and thus any bleeding episode was in the
focus of all participating surgeons. Moreover, in Austria,
almost all tonsillectomies are performed as an inpatient
procedure with an average hospital stay of about 3
nights after surgery, which allows us to cover all bleed-
ing episodes happening within the first postoperative
days. Another factor to take into consideration when
comparing hemorrhage rates is the age structure of
patients. A final argument for finding elevated hemor-
rhage rates in our study is the high awareness of this
subject in the Austrian ENT community. Risks of postop-
erative hemorrhage have been discussed for years in
Austria because of several fatal postoperative bleeding
episodes in young children, which alerted the public.
Risk Factors for Post-TE Hemorrhage We analyzed the risk factors for post-TE hemor-
rhage along two different statistical methods: testing
hemorrhage rates of a specific subgroup against the
whole population (using a test for proportions) (Table
III) and a logistic regression model, which takes all risk
factors into consideration simultaneously (Table IV).
Although the plain testing of hemorrhage proportions
for specific subgroups yielded a number of significant
results, the simultaneous coverage of all influencing fac-
tors via logistic regression offers a much sharper
picture. In the literature, only a few authors used logis-
tic regression for assessing hemorrhage risk.4,7,9
Results concerning risk factors for postoperative hemorrhage are controversially discussed in other stud-
ies.2–4,7,9,11 The age of patients has consistently been described as a major risk factor for the occurrence of
hemorrhage, with older patients being at higher risk.2–4,9
Our study supports this finding. Moreover, our study
also indicates that severe bleeding episodes are extremely
rare for children younger than 6 years and that
school children are more likely to experience severe bleed-
ing episodes compared to the overall risk of severe
bleeding.
In regard to sex, some authors have found a posi- tive correlation for males being at higher risk of
hemorrhage2,4 and others have not.3,9 We found that
Laryngoscope 121: December 2011 Sarny et al.: Hemorrhage Following Tonsil Surgery
2559
bleeding episodes in males were more frequent and more
severe. In the logistic regression model, the indication
peritonsillar abscess for TE showed significantly lower
hemorrhage rates than recurrent tonsillitis, confirming
a similar result described by Lowe et al.9 In our study
the indication for surgery did not significantly affect the
severity of post-TE bleeding episodes.
Registrars in training had a lower hemorrhage rate
in our study. This might be justified, as consultants per-
form TE only in selected and more problematic cases,
whereas registrars perform surgeries routinely.
Regarding operation techniques, our study confirms
that bipolar techniques are associated with a higher
postoperative hemorrhage risk as described in several
other reports.6,7 We observed that bipolar techniques
tend toward more severe bleeding episodes but not
toward higher hemorrhage rates in comparison to cold
steel dissection. Coblation is also associated with higher
hemorrhage rates, as described in the literature.12
Hemorrhage Rate After AE For AE, hemorrhage rates were very low: only 28 of
3,495 (0.8%) patients experienced bleeding postopera-
tively. Post-AE bleeding did not differ for the operation
methods used (adenoid curette by Beckmann with or
without endoscopic control, adenotome by La Force,
coblation technique). For AE we found a tendency to-
ward more severe bleeding episodes (41% of all bleeding
episodes) in comparison to TE (28%) and TO (34%). This
may be justified by the fact that for children, mild bleed-
ing episodes may remain unnoticed because a child may
easily swallow blood and no bleeding will be recognized.
Limitations Our study was intended as a complete survey of
tonsil and adenoid surgeries performed in public hospi-
tals in Austria for a period of 9 months. Because most
surgeries were performed in public hospitals, the study
covered at least 90% of all tonsil and adenoid surgeries
performed in Austria within the study period. The collec-
tion of data worked very well owing to strict monitoring,
regular feedback to the participating departments, and
instant support in cases of problems. The database con-
tained only a few missing values of minor importance,
which did not seriously affect our investigations.
A methodologic bias of our study lies in the fact
that the severity of bleeding episodes was measured
according to the medical treatment that was applied and
not according to the actual intensity of bleeding epi-
sodes. Because young children were usually returned to
the operating room even if bleeding episodes were just
moderate, our study reports for that age group an
extremely low rate of grade B bleeding episodes and a
considerably higher rate of grade C bleeding episodes
compared to the adult age group (Table VI).
CONCLUSION
The findings of our study indicate that the intensity
of bleeding episodes is a crucial aspect of the investiga-
tion of postoperative hemorrhage, which has not been
adequately addressed in the literature so far. By assess-
ing differing grades of hemorrhage, this study offers an
explanation for the variety of hemorrhage rates being
reported in the literature. Our study shows that a classi-
fication of the severity of postoperative bleeding along
objective medical criteria (Table I) is very useful. In the
literature, postoperative hemorrhage is inconsistently
measured, which leads to a wide variety of hemorrhage
rates. Here we discuss a number of reasons for these
inconsistencies. It is very important to discern between
the frequency of hemorrhage (per patient) and the sever-
ity of each bleeding episode. Investigating the severity
allows us to assess differing severity grades and to focus
on multiple bleeding episodes. Assessing the severity
(instead of the frequency of hemorrhage) shifts the basis
of all rates from the number of operated patients to the
number of bleeding episodes, making direct comparisons
between frequencies and severity counts problematic. A
major result of assessing the severity of multiple bleed-
ing episodes was that the occurrence of a minor bleeding
episode doubles the risk of a second severe bleeding epi-
sode. Therefore, we suggest readmission to hospital for
patients experiencing a postoperative minor bleeding
episode for 1 night, as almost half of the second severe
bleedings occurred the following day after the light
bleeding episode (41%). Other mechanisms to decrease
the risk of postoperative bleeding episodes are careful
use of bipolar diathermy and physical rest.
Acknowledgments
The authors of this study thank all contributors for
their cooperation and diligence, which provided us with
data of remarkable quality. The authors thank all heads of
Austrians’ ENT-departments: Univ. Prof. Dr. Wolfgang
Gsto ttner, Univ. Prof. Dr. Wolfgang Biegenzahn, Univ.
Prof. Dr. Klaus Bo heim, Univ. Doz. Dr. Monika Cartellieri,
Univ. Prof. Dr. Hans Edmund Eckel, Univ. Prof. Dr. Wolf-
gang Elsa sser, Univ. Prof. Dr. Peter Franz, Univ. Prof. Dr.
Gerhard Friedrich, Univ. Prof. Dr. Werner Habicher, Univ.
Prof. Dr. Floris Heger, OA Dr. Gerhard Herzog, Univ. Doz.
Dr. Heribert Ho fler, Univ. Prof. Dr. Heinz Ju nger, Univ.
Prof. Dr. Christoph Karas, Univ. Prof. Dr. Tilman Keck,
Univ. Prof. Dr. Antonius Kierner, OA Dr. Hannes Kirsch-
ner, Univ. Prof. Dr. Josef Meindl, Univ. Prof. Dr. Antal
Mink, Univ. Prof. Dr. Michael Moser, Univ. Doz. Dr. Csilla
Neuchrist, OA Dr. Johannes Neumu ller, Univ. Prof. Dr. Pe-
ter Ostertag, OA Dr. Robert Panholzer, Univ. Prof. Dr. Rob-
ert Pavelka, OA Dr. Richard Pauer, OA Dr. Hannes Picker,
Univ. Prof. Dr. Gerd Rasp, Univ. Prof. Dr. Christoph
Reisser, Univ. Prof. Dr. Ernst Richter, Univ. Prof. Dr. Her-
bert Riechelmann, Univ. Prof. Dr. Herwig Swoboda, Univ.
Prof. Dr. Patrick Zorowka. The authors thank especially
all hospital staff contributing surgery data to the study:
Doris Aichinger, MD, Ulrich Amann, MD, Anna Aszmayr,
MD, Birte Bender, MD, Elisabeth Blassnigg, MD, Chris-
toph Brand, MD, Elisabeth Brand, MD, Otto Braumandl,
MD, Martin Bruch, MD, Christoph Flux, MD, Margit
Gombotz, MD, Matthias Grabner, MD, Stefan Hoier, MD,
Franjo Juric, MD, Joachim Kronberger, MD, Thomas
Kunst, MD, Christoph Matscheko, MD, Hermine Mayr,
Laryngoscope 121: December 2011 Sarny et al.: Hemorrhage Following Tonsil Surgery
2560
Anita Neuwirth, MD, Robert Panholzer, MD, Richard
Pauer, MD, Christof Pauli, MD, Hannes Picker, MD,
Robert Pinnitsch, MD, Julia Rechenmacher, MD, Andreas
Riedler, MD, Kyros Sabbas, MD, Michael Safar, MD, Claus
Schleinzer, MD, Barbara Schubert, MD, Johannes
Schwarzer, MD, Anahid Seraydarian, MD, Andreas Strobl,
MD, Beatrix Thalhammer, MD, Sandra Waltenberger,
MD, Anette Wenzel, MD, Martin Wernig, MD, Claudia
Winter, MD, Thomas Wo llner, MD, Gabriella Zahratka,
MD, and Michaela Zumtobel, MD.
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