Hemorrhage following coblation tonsillectomy

OBJECTIVES: We performed a prospective study to evaluate the incidence of post-tonsillectomy hemorrhage (PTH) in adults and children who underwent Coblation tonsillectomy (CTE) under general anesthesia. METHODS: The data of 63 adults and children (mean age, 21.8 years) were analyzed. RESULTS: There were 7 episodes of considerable bleeding (11.1%) that required surgical treatment under general anesthesia in 6 patients, of whom 5 experienced secondary bleeding (>24 hours). Moreover, bleeding and massive swelling of the pharynx required surgical treatment and prolonged intubation (35 hours) in 1 patient. None of the patients received blood transfusions. There was no case with a lethal outcome. Less intense bleeding (clots; blood-tinged sputum) was observed in 17 patients (27%) who required readmission or prolonged inpatient observation, 1 of whom had previously undergone surgical treatment of PTH. However, these 17 patients had an uneventful clinical course. In total, 22 patients experienced minor or major forms of PTH (34.9%). CONCLUSIONS: At least in our hands, CTE dramatically increased the frequency of PTH. The high rate of secondary bleeding contrasts with our documented experience using conventional methods, ie, cold dissection and suture ligation, to achieve hemostasis (7.9% with CTE versus <0.8% with conventional methods). Therefore, at our institution, tonsillectomy with conventional instruments remains the method of choice.     

Excessive post-tonsillectomy hemorrhage requiring ligature of the external carotid artery

Ligature of the external carotid artery (LECA) is the method of choice in patients with excessive post-tonsillectomy hemorrhage. This retrospective study was undertaken to evaluate the incidence, characteristics and warning signs of excessive post-tonsillectomy hemorrhage. BASIC PROCEDURES: Between January 1988 and December 2000, a total of 25 patients had to be treated by LECA. Tonsillectomy had been previously performed in seven patients at our department (group A) and in 18 patients elsewhere (group B). MAIN FINDINGS: LECA was performed in most cases 6 (group A) and 11 days (group B) after tonsillectomy. There was one case with lethal outcome. A total of 12 patients (group B) had been operated by two surgeons. PRINCIPAL CONCLUSIONS: Excessive bleeding following tonsillectomy may occur as delayed bleeding, abrupt and require immediate LECA and blood transfusion. Prior recurrent episodes of bleeding can be a warning sign. Anatomical vascular abnormalities have to be considered. Inpatient policy in these underestimated cases was life-saving.     

Hemorrhage after tonsillectomy. Analysis of 229 cases

Background. In Germany a hospital stay of 6 days following tonsillectomy is recommended. Our retrospective study aimed to evaluate the incidence of hemorrhage following tonsillectomy with regard to the safety of a shorter hospital stay. Patients and methods. 5474 patients of our clinic who underwent tonsillectomy between 1988 and 1998 were enrolled in our study. Additionally, 65 patients with hemorrhage following tonsillectomy elsewhere were included. Results. Postoperative hemorrhage occured in 145 (2,65%) of our patients, 7 patients underwent recurrent treatment, in 97% suture ligation was sufficient. Primary bleeding (<24 h) occured in 79,7% of our patients. A 42-month old boy died at home due to massive bleeding 6 days following surgery. In this particular case, we strictly recommended postpone dismission because the boy had recurrent episodes of bleeding the days before. Postoperative hemorrhage after tonsillectomy performed elsewhere had to be treated in most cases 7–8 days postoperatively. Suture ligation of bleeding vessels was not sufficient in 21% and ligature of the external carotid artery mandatory. In these cases we usually found signs of deep necrosis. Conclusion. Due to the risk of life-threatening bleeding tonsillectomy should be performed as an inpatient procedure. The time of hospital stay should be related to the results obtained by self-evaluation and definition of risk factors. Readmission of patients with hemorrhage after dismission should be recommended. The follow-up has to be extended as long as the healing process continues.     

Our experience with surgical treatment of posterior epistaxis. Report of 16 cases]

Management of intractable posterior epistaxis remains a challenge to the otolaryngologist. When anterior and posterior packing techniques fail to control the hemorrhage, a surgical technique designed to interrupt the blood supply to the posterior parts of the nose is indicated. The common procedures employ ligation of the external carotid artery, of the maxillary artery and its terminal branch the sphenopalatine artery. Those procedures performed on 16 patients are clearly described and the indications for each one are established. Immediate control of bleeding was accomplished in 14 of 16 patients. Two patients had postoperatively recurrent but less severe epistaxis.     

Electrosurgery as a risk factor for secondary post-tonsillectomy hemorrhage

The literature suggests that tonsillectomy techniques are not standardized throughout the world although certain techniques were identified as risk factors for post-tonsillectomy hemorrhage (PTH). This survey was undertaken to evaluate whether surgical techniques are uniformly performed in a nation of 82 million people and if they are related to the incidence of PTH or lethal outcome. A questionnaire was sent personally to the chairmen of 156 departments of otorhinolaryngolog, yincluding 37 University Hospitals to assess the surgical training techniques of tonsil dissection and hemostasis, incidence of primary (<24 h) and secondary (>24 h) PTH, number of tonsillectomies performed in 2006 and the number of cases with lethal outcome. The responses were made anonymous for further analysis. The response rate was 88.5% (138/156). A total of 54,572 procedures were performed (mean 395.4, median 361.5, SD 199.5, range 100–975 annually per clinic). Cold dissection was the teaching method of choice (117). Hemostasis was either achieved by suture ligation or bipolar cautery in 91 departments. Secondary bleeding clearly prevailed in the responses (97). One patient experienced a fatal bleeding after tonsillectomy indicated for tumour removal. Two other cases with lethal outcome had undergone surgery elsewhere including one patient who had undergone tonsillotomy. Lethal outcome occurred with an estimated incidence of 1/75,000. The term “conventional tonsillectomy” is loosely defined and includes various surgical techniques for tonsil dissection and methods to achieve hemostasis. The incidence of secondary PTH is related to electrosurgery with statistical significance. Lethal outcome may occur, if ever, rarely but even after intracapsular tonsillectomy.     

感染性颈动脉破裂的治疗

目的　探讨感染性颈动脉破裂的治疗方法。方法 回顾性分析我科自2000～2011年所有感染性颈动脉破裂病例及同期内所有英语文献记载的病例。结果 31例患者共发生46次感染性颈动脉破裂,最常见的破裂部位为颈总动脉（33/46,71.7%）。经血管结扎治疗17次（37.8%）,血管内支架置入20次（44.4%）, 栓塞治疗7次（15.6%）。血管结扎在治疗感染性颈动脉破裂时再次出血发生率11.8%（2/17）明显低于血管内支架置入60.0%（12/20）差异有统计学意义（χ 2=4.355, P =0.037）。结论 血管结扎是感染性颈动脉破裂较好的治疗方法,它可能是防止再次出血的最好方法。但是如果结扎颈内动脉或颈总动脉,其并发症发生率可能相对较高。     

Post-tonsillectomy hemorrhage: results of a 3-month follow-up

Episodes of post-tonsillectomy hemorrhage are unpredictable and potentially life-threatening. Primary post-tonsillectomy hemorrhage (< 24 hr postoperatively) is generally considered to be more common and more serious than secondary hemorrhage (> 24 hr). Therefore, recent studies have focused on the control of primary hemorrhage in order to determine the appropriate length of postoperative observation. The issue of follow-up is becoming more important in light of the increasing popularity of outpatient tonsillectomy. We undertook a prospective study to evaluate the incidence of post-tonsillectomy hemorrhage over the short and long term (3 mo). We studied 602 patients, aged 23 months to 89 years (mean: 20.6 yr), who had undergone inpatient tonsillectomy in 1999 and who had been hospitalized for at least 5 days. Our goal was to ascertain the number of episodes of postoperative hemorrhage that required surgical treatment under general anesthesia. We were able to contact 601 of these patients (or their parents) by telephone 3 months postoperatively to inquire about any instances of delayed secondary bleeding. In all, 16 patients (2.7%) had experienced post-tonsillectomy bleeding that required surgically achieved hemostasis under general anesthesia. Of this group, 11 patients (68.8%) had experienced primary hemorrhage and were treated immediately, and five (31.3%) experienced secondary hemorrhage. One patient in the latter group experienced excessive bleeding 38 days postoperatively, which we believe is the latest episode of secondary bleeding reported to date. Based on the findings of this study, we believe that a postoperative follow-up period of 10 days is sufficient to identify all but the most rare cases of post-tonsillectomy hemorrhage.     

Lethal post-tonsillectomy hemorrhage

Background: Post-tonsillectomy hemorrhage (PTH) seems to be a rare but unavoidable complication. Due to the frequency of performed tonsillectomies, it can be estimated that a certain amount may result in a lethal outcome. This study was undertaken to evaluate the clinical features of these rare cases. Material and methods: Retrospective case series of five patients with lethal post-tonsillectomy hemorrhage are reported after they had undergone tonsillectomy by four different surgeons. The relevant literature was reviewed. Results: The youngest patient was 42 months and the oldest almost 13 years old. All patients were male. Three patients had left the hospital against surgeon’s recommendation 5 days following tonsillectomy. Preceding episodes of bleeding prior to the lethal bleeding occurred in two patients. Lethal PTH occurred in four patients within 5–9 days, the latest bleeding 39 days after surgery. In the literature, lethal PTH was described for eight patients since 1958. The youngest patient was 4 years, the oldest 18 years old (mean: 8.6 years; median: 6.5 years). In three patients, lethal PTH occurred on the day of surgery and the latest bleeding 54 days after surgery. Conclusion: Due to the paucity of reports, little reliable information can be obtained from the literature. It remains unclear, whether or not this reflects the true incidence of this complication. The experience with the five reported cases suggests, that immediate surgical treatment may have avoided lethal outcome in most cases. Therefore, a close postoperative follow-up is advisable to detect any episode of bleeding as soon as possible which should be referred to a specialist. Certainly, the collected data do not suffice to establish general guidelines, indicating that further collection of cases is required to assess characteristics of lethal PTH.     

儿童扁桃体切除术后出血率及出血程度分级的初步探讨

目的　统计儿童扁桃体切除术后出血率,根据Windfuhr分级法衡量儿童扁桃体术后出血的程度。方法 统计2010年3月～2013年3月在深圳市儿童医院行扁桃体切 除或扁桃体加腺样体切除患儿资料,统计术后出血发生率。结果　1672例患儿扁桃体切除术后出血16例,出血率为0.96%。女童术后出血率1.8%明显高于男童出血率0.53%,差异有统计学意义（χ 2=5.545,P <0.05）;原发性出血6例,继发性出血10例。出血程度1级9例,2级7例。结论 儿童扁桃体切除术后出血率很低,遇有活动性出血者应手气管插管全麻下止血。     

Saphenous vein graft for bypass of the external carotid artery to supraclinoid internal carotid artery using a modified technique: an anatomical and technical study

OBJECTIVE: To investigate the use of a saphenous vein graft for bypass of the external carotid artery (ECA) to supraclinoid internal carotid artery (ICA) when the proximal middle cerebral artery (MCA) is not suitable for a bypass procedure. MATERIAL AND METHODS: Five adult cadaver sides were used. Dissection required a frontotemporal craniotomy and a zygomatic arch osteotomy, with a hole being opened 2-3 mm lateral to the foramen rotundum extradurally. The ECA was found easily via a second incision in the cervical region. The ophthalmic segment of the ICA was exposed by removal of the anterior clinoid process intradurally. After the dura over the hole was opened, the 7-8-cm long bypass graft was passed just behind the mandibula and through the hole inside the dura to reach the ICA. The ECA was then transected proximal to the occipital artery (OA) branch and the distal side of the vein graft was anastomosed end-to-end with the ECA and end-to-side with the supraclinoid ICA. RESULTS: The mean diameter of the ECA proximal to the OA was 3.75+/-0.4 mm (range 3.35-4.15 mm) and that of the supraclinoid ICA was 3.4+/-0.5 mm (range 2.9-3.9 mm). The mean length of the venous graft was 7.5+/-0.5 cm (range 7-8 cm). CONCLUSION: When high blood flow is needed and the proximal MCA is not suitable for a bypass, the bypass described herein may be an alternative to a superficial temporal to MCA bypass as well as to extracranial carotid artery to MCA or ICA bypasses, which both need long vein grafts.     

Management of infected carotid artery rupture

Carotid artery rupture (CAR) is a life-threatening complication of head and neck cancer, and infection complicates its management. The purpose of this study was to review our experience with the treatment of infected CAR and to summarize the existing literature on this topic. We retrospectively reviewed the medical records of patients treated in our department from 2000 to 2011 and re-analyzed cases reported in the literature during the same time period. We analyzed etiology, anatomic location, treatment, and rates of recurrent hemorrhage for each case. A total of 46 episodes of infected CAR occurred in the four patients in our own records and 27 patients described in the literature. Twenty-eight patients suffered from various head and neck cancers and underwent surgical resection, and 27 of them subsequently received radiotherapy or radiotherapy combined with chemotherapy (the 28th patient died before radiotherapy due to severe blood loss). The most common site of bleeding was the common carotid artery (33/46, 71.7 %). Seventeen cases (17/45, 37.8 %) were treated with surgical ligation, 20 (44.4 %) with stent placement, and 7 (15.6 %) with embolization. Surgical ligation had a lower rate of recurrent bleeding (2/17, 11.8 %) than stent placement (12/20, 60.0 %) when used for the treatment of infected CAR (P = 0.037, Chi squared test). Our results suggest that surgical ligation is an effective option in the management of infected CAR and may be the best choice to prevent recurrent hemorrhage. The complication rates, however, may be high when the common carotid or the internal carotid arteries are ligated.     

Postoperative bleeding after laser surgery in head and neck tumors

BACKGROUND: There are different reports in the literature how often postoperative hemorrhage occurs after laser resection of head-and-neck tumours. This retrospective study investigates the frequency of postoperative hemorrhage after laser surgery of head and neck tumours. Time and extent of bleeding have been considered as well as the localization of the primary tumour and possible general risk factors. METHODS AND PATIENTS: Between 1998 and 2001, microscopic laser surgery was performed in 223 patients with previously untreated squamous cell carcinomas of the oral cavity, oropharynx, supraglottic and glottic region and the hypopharynx. In case of ultrasonographic or palpable evidence of cervical lymphadenopathy surgery included subsequent neck dissection. The mean age of the patients was 59.2 year. RESULTS: Postoperative bleeding occurred in 14 out of 223 patients (6 %). It was 9 % for oral carcinoma, patients 10 % for oropharyngeal carcinoma, 5 % for supraglottic carcinoma and none for glottic and hypopharyngeal carcinoma. 5 patients were treated conservatively, 4 patients were controlled bei cautery and ligation, 1 patient was treated with ligation of the lingual artery and in 2 cases ligation of the external carotid artery was performed. 1 patient had a fatal hemorrhage. CONCLUSIONS: Laser-surgical resection of head and neck carcinomas does not lead to a higher incidence of bleeding complications compared to ordinary surgery.     

三叉神经颅内段的血液供应

目的 本研究通过对三叉神经(颅内段)血供的观察，为与三叉神经相关的疾病的手术及术中止血提供临床解剖学资料。方法 在手术显微镜下对20侧成人尸头标本进行三叉神经颅内段的显微解剖研究。观察其血供。结果 三叉神经(颅内段)的血供来源广泛，其中三叉神经根的血供主要来源于小脑前下动脉(占70％)、脑桥上外侧动脉(占55％)、小脑上动脉(占45％)、脑桥下外侧动脉(15％)；三叉神经节的血供主要来自海绵窦下外侧动脉(占75％)，当下外侧动脉不发达或缺如时，则主要来自脑膜垂体于的外侧支(占30％)；眼神经近段血供主要来自海绵窦下外侧动脉后支(占55％)，远段主要来自海绵窦下外侧动脉前支(占75％)；上颌神经近段血供主要来自海绵窦下外侧动脉，远段来自上颌动脉的分支翼腭动脉和颞深中动脉、脑膜中动脉；下颌神经主要由颈外动脉的分支脑膜中动脉和颞深中动脉供血。结论 三叉神经根的滋养动脉主要来源于基底动脉的分支，三叉神经节和其三大分支可同时接受颈内、颈外动脉分支供血，在涉及三叉神经的手术时，既要防止损伤其滋养动脉，又要考虑病灶血供来源的复杂性。     

Aberrant internal carotid artery in the middle ear with a deficiency in the origin of the anterior cerebral artery: A case report

An aberrant internal carotid artery (ICA) in the middle ear is rare and difficult to diagnose, and may lead to severe complications. We present here a case of aberrant ICA with a deficiency in the origin of the anterior cerebral artery. The only symptom was aural fullness, and a nonpulsatile and white tympanic mass in the anteroinferior area was noted. Computed tomography (CT) and magnetic resonance angiography (MRA) are useful tools that provide excellent visualization of the temporal bone for the diagnosis of aberrant ICA by the following features: intratympanic mass, enlarged inferior tympanic canaliculus, absence of the vertical segment of the ICA canal, and absence of bone covering the tympanic portion of the ICA. In addition, in this case, a deficiency in the origin of the anterior cerebral artery on the same side was identified by MRA, and cerebral arteriography and a carotid occlusion test were performed. Because of the deficiency in the origin of the anterior cerebral artery, the ICA compression revealed that there was almost no cross flow from the other ICA. Our experience illustrates that after confirmation of the diagnosis of aberrant ICA, localized treatment and/or surgical procedures should be considered carefully.     

Angiography and Transcatheter Arterial Embolization of Vascular Injuries of the Face and Neck

The condition of patients sustaining penetrating neck trauma often appears deceptively stable, even when major structures have been injured. The clinician must identify patients who require treatment and limit invasive procedures in those without significant injuries. Angiography is often used to search for vascular damage following penetration of the neck and face. The charts of 401 hemodynamically stable patients with penetrating cervicofacial wounds who were evaluated by angiography followed, when necessary, by either transcatheter arterial embolization and observation or surgery were reviewed. One hundred twelve patients (27.9%) had 131 vascular injuries identified by angiography; 77 (68.8%) of these patients sustained injuries to zone III of the neck or the face. The most commonly injured vessels were the internal carotid artery (ICA), the vertebral artery, and the external carotid artery (ECA) system. Multiple vessel injuries were seen in 17 (15.2%) of 112 patients and were more likely in patients with wounds in zone III or above than in those wounded in zone II or below (20.8% vs. 2.9%, respectively; P<.025). Injuries to the internal maxillary artery (IMA) (60%), ECA (53.3%), and the ICA (30.8%) were also significantly more likely to be accompanied by additional vascular injuries (P<.005). No clinically significant venous injuries were missed. Complications were noted in only 4 patients, and no deaths occurred as a result of angiography. Angiography is a safe, effective modality in the head and neck trauma setting. Particular scrutiny should be given to patients with zone III or facial wounds, particularly those with documented ICA, IMA, and ECA injuries, since these patients have a higher incidence of multiple vascular injuries.     

Congenital absence or hypoplasia of the carotid artery: radioclinical issues

PURPOSE: Congenital anomaly of the carotid artery is a rare abnormality. It is usually discovered incidentally by color Doppler carotid sonography, angiography, computed tomography (CT), or magnetic resonance imaging (MRI) of the head and neck taken for some other reason. Most patients are not symptomatic because of sufficient cerebral circulation supplied to the defective area by the communicating arteries of the circle of Willis, intercavernous anastomosis, communicating arteries from external carotid artery, and by persistent embryologic arteries to the carotid artery territory. However, sometimes, this anatomic variation may eventually lead to some clinical signs and symptoms in particular circumstances in the head and neck of which surgeons are unaware. A retrospective study was designed to emphasize the characteristic radiologic and clinical picture in patients with the congenital absence (agenesis and aplasia) or hypoplasia of the carotid artery, to delineate the associated abnormalities and existing collateral vessels, and to find out its incidence. MATERIAL AND METHODS: Five thousand one hundred cerebral MRI and/or catheter angiograms performed between February 1988 and March 2002 were reviewed for carotid artery abnormality. RESULTS: Seven patients with congenital absence or hypoplasia (4 of these patients were presented with hypoplasia of internal carotid artery [ICA], 3 with absence of ICA) of ICA were identified (0.13%). The radiologic and clinical study of 5 patients with unilateral (3 of these patients were presented with hypoplasia and 2 with absence of ICA) and 2 patients with bilateral (1 was presented with absence of ICA, whereas the other was hypoplasia) congenital abnormality with absence or hypoplasia of ICA demonstrate that those patients are usually asymptomatic and they are diagnosed incidentally. CONCLUSION: It has been concluded that the combined use of magnetic resonance angiography and CT scanning of the skull base may disclose small but patent ICA. Collateral vessels seem to be usual in such cases, but they may be prominent in cases of acquired vascular occlusion, or increased hemodynamic pressure in dysplastic changes in collateral arteries are known causes of aneurysms. The main vascular supply for the brain in patients with congenitally small (hypoplasia) or absent (agenesis or aplasia) ICA is the vertebrobasilar system in bilateral cases. However, contralateral carotid vessel is the dominant arterial supply for unilateral cases, which has to be borne in mind in surgical interventions to the involved side.     

Post-tonsillectomy hemorrhage: incidence, prevention and management

Tonsillectomy (with or without adenoidectomy) continues to be a commonly performed operation in the United States. Over the years, the incidence of post-tonsillectomy hemorrhage (reported between 0% and 20%) has decreased, but continues to pose serious problems. We reviewed 1,445 tonsillectomies performed over a 2-year period to study the incidence of post-tonsillectomy hemorrhage. Thirty-eight of 1,445 children (2.62%) had postoperative bleeding. The incidence of primary hemorrhage (within 24 hours) was 0.14%. Delayed hemorrhage requiring operative intervention or observation in the hospital was 1.03% and 0.76%, respectively. Ten patients (0.69%) had delayed hemorrhage of a minor nature that had stopped by the time they reached the hospital; these children were treated with observation alone and did not require hospitalization or operative intervention. The proposed reasons for this low rate of post-tonsillectomy hemorrhage include complete preoperative coagulation screening, meticulous attention to surgical technique, use of suction-cautery to obtain hemostasis and, possibly, use of postoperative antibiotics. Management of hemorrhage is discussed with respect to observation, surgical intervention, and blood transfusion.     

Serious post-tonsillectomy hemorrhage with and without lethal outcome in children and adolescents

Background: Serious post-tonsillectomy hemorrhage (PTH) is an uncommon complication requiring immediate and adequate medical treatment. This study was undertaken to describe and evaluate the clinical data and courses of serious PTH, with and without lethal outcome in children and adolescents. Materials and methods: Bleeding episodes accompanied by hemorrhagic shock requiring resuscitation and/or major medical treatment were labeled as serious PTH, with or without lethal outcome. Personal experiences as surgeons and expert reports in connection with lawsuits and Professional Boards, as well as reports collected after a published request contributed to the data collection. Results: Thirty-one boys and 21 girls (gender not stated for three patients) younger than 18 years of age were enrolled in our study (mean: 8.47; median: 6; S.D.: 4.73 years). Thirty-three children were 8 years of age or younger (60%). Lethal outcome was reported for 19 patients of whom 11 had experienced repeated episodes of bleeding. The majority of the surviving children experienced serious PTH without remaining sequelae (32), however, four children suffered from remaining sequelae. Forty-three children experienced repeated episodes of PTH. The first episode of PTH occurred either at home (32) or in the hospital (22; location not stated for one child). Primary hemorrhage (<24h) was reported for three, secondary bleeding (>24h) for 52 children (94.5%). A total of 169 bleeding episodes was reported of whom 149 were specified as massive (56), major (31), minor (15), diffuse (12), with spontaneous cessation (19) or vomiting of considerable amounts of blood (16). Aspiration was confirmed at the autopsy of seven patients. Ligature of greater arteries in the neck was performed in 35 cases, suturing of the faucal pillars in four and packing of the oropharynx in six patients. Twenty-four children received blood transfusions. Resuscitation was performed in 17 cases but remained ineffective in seven patients. Conclusion: Repeated episodes of bleeding should be considered as a warning sign of serious PTH. Inpatient observation does not eliminate the risk of lethal outcome. Children up to 8 years of age seem to be more susceptible to serious PTH, whereas gender remained irrelevant as a contributing risk factor. Life-threatening PTH is likely to occur as secondary PTH.     

Ligation of the external carotid artery for severe epistaxis.

Epistaxis which is not controlled by anterior and posterior nasal packing is usually treated by ligation or embolization of the arterial supply to the nose. Transantral ligation of the maxillary artery, or embolization of its branches, have recently been considered the treatments of choice. Ligation of the external carotid artery has the advantage of being a short procedure which can be readily performed under local anesthesia, and does not require particular surgical expertise or the use of specialized equipment. This procedure, in combination with ligation of the ipsilateral anterior ethmoidal artery, controlled the bleeding in 14 of 15 patients over a nine-year period. There were no deaths and no significant complications. Although ligation and embolization of the maxillary artery are of proven efficacy, ligation of the external carotid artery is similarly effective and its simplicity may still make it the procedure of choice in some situations.     

Effect of changing postoperative pain management on bleeding rates in tonsillectomy patients

Purpose

To review rates of post-tonsillectomy hemorrhage (PTH) at a quaternary medical center, including the impact of narcotic versus nonsteroidal anti-inflammatory drug (NSAID) postoperative pain management.