Bankstown Hospital - Grand Rounds - Further Reading

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Benchmarking post-tonsillectomy haemorrhage rates –

Findings from a 20-year analysis

Ikoma, R., et al. (2014). "Risk factors for post-tonsillectomy hemorrhage." Auris Nasus Larynx 41(4): 376-379. https://www.sciencedirect.com/science/article/pii/S0385814614000352 REQUEST ARTICLE

       Objective The aim of the present study was to investigate the rate of post-tonsillectomy hemorrhage (PTH) in a single institution and to evaluate the clinical risk factors for PTH. Methods We reviewed the records of 692 patients who underwent tonsillectomy (TE) at Yokohama Minami Kyosai Hospital in Japan. PTH grades were grouped into three categories according to the severity of the hemorrhagic episode: (I) minimal hemorrhage that stopped after noninvasive treatment, (II) hemorrhage requiring treatment with local anesthesia, and (III) hemorrhage requiring reoperation under general anesthesia in the operating room. Clinical risk factors such as sex, age (adults vs. children), TE indication, surgeon's skill level, operative time, ligature type, and duration of antibiotic administration for PTH were investigated. Results Among the 692 patients, 80 (11.6%) showed PTH, with primary and secondary hemorrhage accounting for 1.6% and 10.0%, respectively. A category III PTH was observed in 18 patients; thus, the overall risk of reoperation was 2.6%. The PTH episode most frequently occurred on postoperative days 5 and 6. The frequency of PTH was significantly higher in male patients and in adults (P<0.01, for both factors). Surgeon's skill was also associated with PTH rate. A stepwise multivariate logistic regression revealed that adult age (odds ratio [OR]=18.9) and male gender (OR=3.78) were the clinical risk factors for PTH. It also revealed that male gender (OR=82065335), adult age (OR=10.6), and surgeon's skill level (OR=7.50) were the clinical risk factors for the category III PTH. Conclusions The risk of PTH was higher in this report compared with previous reports, which may be associated with the definition of PTH. Clinical risk factors for PTH were adult age and male gender. The surgeon's skill level was an additional risk factor for category III PTH.

Jacobson, A., et al. (2024). "Incidence of Surgically Managed Post-Tonsillectomy Hemorrhage Associated With NSAID Prescribing for Postoperative Pain Management." Military Medicine 189(9-10): e1955-e1959. https://academic.oup.com/milmed/article-abstract/189/9-10/e1955/7675950?redirectedFrom=fulltext REQUEST ARTICLE

                Tonsillectomy ranks high among the most common pediatric surgical procedures in the United States. Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), such as ibuprofen, are routinely prescribed to manage post-tonsillectomy pain, but may carry the risk of hemorrhage. This retrospective, longitudinal, secondary-data analysis study compared the incidence of surgically managed post-tonsillectomy hemorrhage (sPTH) in pediatric patients prescribed ibuprofen at Brooke Army Medical Center (BAMC) after tonsillectomy compared to a similar cohort of pediatric patients at the Children’s Hospital of Philadelphia (CHOP) not prescribed ibuprofen. Additional regression analysis examined predictors of sPTH at BAMC.The odds of sPTH was lower in patients who were prescribed ibuprofen at BAMC, relative to patients who were not at CHOP (OR 0.57, 95% CI, 0.37, 0.87; P &lt; 0.01). In a generalized linear model evaluating BAMC patient data, there was a lack of a relationship between reason for tonsillectomy (tonsillitis versus tonsillar obstruction), primary procedure (tonsillectomy-only versus tonsillectomy with adenoidectomy), and presence of a co-occurring procedure.Post-tonsillectomy ibuprofen prescribing practices were not associated with an elevated risk of sPTH, relative to patients at CHOP not exposed to ibuprofen.

Kværner, et al. (2009). "Benchmarking surgery: secondary post-tonsillectomy hemorrhage 1999–2005." Acta Oto-Laryngologica 129(2): 195-198. https://www.tandfonline.com/doi/full/10.1080/00016480802078101 REQUEST ARTICLE

                Conclusions. We found no evidence that the reported increase in otolaryngologic surgery in Norway in recent years has affected post-tonsillectomy hemorrhage rates, and suggest that the latter is a valuable benchmark for the quality of the tonsillectomies and adenotonsillectomies nationwide. Objectives. To estimate the incidence of post-tonsillectomy hemorrhage and assess the distribution of hospitalizations for post-hemorrhage bleeding and surgery. Materials and methods. This was a national study using data from the Norwegian Patient Registry 1999?2005 with complete information on the incidence of post-hemorrhage hospitalizations, rebleeding surgery, and (adeno)tonsillectomy rates. Results. One patient per 200 tonsillectomies was hospitalized and 1 per 1000 operated for post-tonsillectomy hemorrhage during the study period. Of the 328 patients hospitalized, 64 (20%) required surgery under general anesthesia. Peak age was 5?9 years; 194 (59%) with post-tonsillectomy hemorrhage were males. The mean rebleeding rate was 0.5% (confidence interval (CI)=0.5?0.6) when secondary rebleeding was estimated as the proportion of all tonsillectomies. While tonsillar surgery was more frequent in the non-adult population, post-tonsillectomy surgery was equally common in the ages below and above 16 years. Seasonal variation in post-tonsillectomy hemorrhages was not found.

Li, J. C., et al. (2022). "Reference rate for post-tonsillectomy haemorrhage in Australia—A 2000–2020 national hospital morbidity database analysis." PLoS One 17(8): e0273320. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0273320 REQUEST ARTICLE

                This study aims to provide a national benchmark rate of post-tonsillectomy haemorrhage (PTH) in Australia. Using data from Australia’s National Hospital Morbidity Database (NHMD) from 1 July 2000 to 30 June 2020, we have conducted a nation-wide population-based study to estimate a reference rate of PTH. Outcomes of interest included the overall rate and time-trend of PTH, the relationship between PTH rates with age and gender as well as the epidemiology of tonsillectomy procedures. A total of 941,557 tonsillectomy procedures and 15,391 PTH episodes were recorded for the study period. Whilst the incidence of tonsillectomy procedures and the number of day-stay tonsillectomy procedures have increased substantially over time, the overall rate of PTH for all ages has remained relatively constant (1.6% [95% CI: 1.61 to 1.66]) with no significant association observed between the annual rates of PTH and time (year) (Spearman correlation coefficient, Rs = 0.24 (95% CI: -0.22 to 0.61), P = 0.3). However, the rate of PTH in adults (aged 15 years and over) experienced a statistically significant mild to moderate upward association with time (year) Rs = 0.64 (95% CI: 0.28 to 0.84), P = 0.003. Analysis of the odds of PTH using the risk factors of increasing age and male gender showed a unique age and gender risk pattern for PTH where males aged 20 to 24 years had the highest risk of PTH odds ratio 7.3 (95% CI: 6.7 to 7.8) compared to patients aged 1 to 4 years. Clinicians should be mindful of the greater risk of PTH in male adolescents and young adults. The NHMD datasets can be continually used to evaluate the benchmark PTH rate in Australia and to facilitate tonsillectomy surgical audit activities and quality improvement programs on a national basis.

ENT research review. [online resource] 2021 -

This Review features key medical articles from global journals with commentary from Professor Richard  J Harvey and Dr Cara Morris. The Review covers topics such as chronic rhinosinusitis,obstructive sleep apnoea, endoscopic sinus surgery, and epistaxis. It includes information on conference reviews, relevant articles, expert writers, podcasts and related website links. https://www.researchreview.com.au/au/Clinical-Area/Surgery/ENT.aspx