Increased post-tonsillectomy secondary haemorrhage with disposable instruments: an audit cycle

The objective of the audit was to examine the increased morbidity associated with elective tonsillectomy with single-use instruments in a district general hospital in England. Retrospective audit of consecutive case notes of 145 patients who underwent tonsillectomy in a 6-week period after the introduction of single-use instruments was carried out. The main outcome measure was incidence of secondary haemorrhage. In total, 9.5% of patients required re-admission indicated by secondary haemorrhage, 4% required emergency surgery and 43% of the total group had haemostasis achieved with ties. None of these was re-admitted. Out of the total group, 57% had haemostasis achieved with single-use bipolar forceps; 16.8% of these patients were re-admitted, with 7% of this group requiring emergency surgery to control the haemorrhage. Animal tissue experiments and design analysis of the single-use bipolar diathermy highlighted the deficiencies of the initial single-use bipolar diathermy. This was replaced by a new design of single-use diathermy forceps. A second audit was performed which revealed a significant reduction in postoperative morbidity. Complications associated with the introduction of new instruments can be identified by repeated audit cycles.     

The admission of patients with peri‐tonsillar abscess to a general ENT ward and its influence on secondary post‐tonsillectomy haemorrhage

The admission of patients with peri‐tonsillar abscess to a general ENT ward and its influence on secondary post‐tonsillectomy haemorrhage Patients with peri‐tonsillar abscess require hospitalization. The aim of this prospective study was to determine whether the admission of patients with peri‐tonsillar abscess to the same ward as those undergoing tonsillectomy influences the incidence of secondary post‐tonsillectomy haemorrhage. We included all adult patients undergoing in‐patient tonsillectomy (n = 183) and all patients with proven peri‐tonsillar abscess (n = 46) over a 1‐year period. Both patient groups were nursed in the same general otolaryngology ward. The operation dates of those patients who developed secondary post‐tonsillectomy haemorrhage were matched to the dates when patients with peri‐tonsillar abscess were admitted. Out of the 71 patients who had tonsillectomy on days when patients with peri‐tonsillar abscess were admitted, 10 developed secondary haemorrhage. Out of the 112 patients who had tonsillectomy on days when no one in the ward had peri‐tonsillar abscess, 16 developed secondary haemorrhage. No difference was demonstrated (χ² = 0.0014, P > 0.05). In this study, admission of patients with peri‐tonsillar abscess to a general otolaryngology ward does not influence the incidence of secondary post‐tonsillectomy haemorrhage in patients undergoing elective surgery.     

A completed audit cycle on post-tonsillectomy haemorrhage rate: Coblation versus standard tonsillectomy

Conclusion. A significant reduction in post-tonsillectomy secondary haemorrhage rate was observed after coblation tonsillectomy was abandoned in our department. Objective. Comparison of the postoperative haemorrhage rate following coblation tonsillectomy and routine dissection tonsillectomy. Patients and methods. This was a retrospective study. In the first audit period, 441 sequential tonsillectomies between January and September 2002 were reviewed. Coblation was compared with cold steel and diathermy dissection with either ties and/or diathermy used for haemostasis. Coblation tonsillectomy was subsequently abandoned in our unit and, in the second audit period, all tonsillectomies (n=416) between July 2003 and August 2004 were included. Statistical analysis was performed using the χ² test. Results. The overall primary haemorrhage rate in the first audit cycle was 1.8% (8/441). In the second cycle with no coblation procedures, 1.4% of patients (6/416) suffered from primary haemorrhage (c.f. 8/441 (1.8%) in the first cycle, p=0.666). Secondary haemorrhage, was seen among 15.4% of patients (68/441) in the first audit cycle. In the second cycle, after coblation was discontinued, the secondary haemorrhage rate fell significantly (p<0.001) to 5.8% (24/416). A breakdown of the results of cold steel/diathermy and coblation techniques in both adults and children is also presented.     

Assessment of secondary haemorrhage rates following adult tonsillectomy – a telephone survey and literature review

Assessment of secondary haemorrhage rates following adult tonsillectomy – a telephone survey and literature review Many previous studies have considered patient re‐admission rates alone as the true rate of secondary haemorrhage following adult tonsillectomy. We aimed to determine the true rate of secondary haemorrhage following tonsillectomy in adults by performing a telephone interview with 60 consecutive patients. Whilst 40% (n = 24) of our patients reported a significant episode of bleeding (blood actively flowing from their mouth for more than 1 min) following discharge, only 8% (n = 5) were re‐admitted and only 3% (n = 2) required return to theatre. Review of the current literature suggests that return‐to‐theatre rates are more consistent than hospital re‐admission rates in large studies. We would suggest that although secondary haemorrhage can occasionally be very serious, the majority is minor, and it would therefore be more useful when comparing different techniques for tonsillectomy to consider numbers of patients returning to theatre rather than re‐admission rates.     

Post-tonsillectomy haemorrhage: reusable and disposable instruments compared

The aim of this study was to determine if the introduction of disposable instruments for tonsillectomy resulted in a significant change in post-tonsillectomy haemorrhage rates. This is a prospective comparative study of haemorrhage rates for cold dissection (CD) tonsillectomy in adults using reusable instruments during 1999–2000 (n=83) and disposable instruments between August and December 2001 (n=111). Haemorrhage rates in children with reusable instruments (n=156) and disposable instruments (n=115) were also compared. Confidence intervals were established for the differences between study groups along with exact levels of significance. No difference was found in the overall reactionary haemorrhage rate [P=0.32, Diff 0.9% (95% CI; –3.2 to +0.4)] or secondary haemorrhage rate [P=1.00, Diff 3.4% (95% CI; –0.09 to +0.01)] between reusable and disposable instruments. The introduction of disposable instruments has not produced a statistically significant increase in post-tonsillectomy haemorrhage rates in our centre.This paper was presented at the ORS Spring Meeting, Manchester Royal Infirmary, April 2002.     

Post-tonsillectomy haemorrhage: A retrospective comparison of abscess- and elective tonsillectomy

Conclusion. There is no increased risk of postoperative haemorrhage for abscess tonsillectomies in comparison to elective tonsillectomies. Objective. There is still controversy as regards the optimal management of peritonsillar abscess. Opponents of tonsillectomy à chaud cite an increased postoperative bleeding risk. Most authors who compared the risks of postoperative haemorrhage after tonsillectomy à chaud and tonsillectomy à froid did not take into consideration criteria such as the age and gender of the patients or the experience of the surgeon. We aimed to eliminate this bias by performing a retrospective study in which a large series of abscess tonsillectomies were compared with an age- and gender-matched group of elective tonsillectomies. Material and methods. All patients had been operated on at the Department of Otorhinolaryngology, University of Duisburg-Essen between March 1994 and August 2000. There were 350 patients in the abscess tonsillectomy group (61% male, 39% female; mean age 31.8 years; range 3–88 years) and 311 in the elective tonsillectomy comparison group (61% male, 39% female; mean age 30.0 years; range 2–83 years). Results. In the abscess tonsillectomy group, 9 patients (2.6%; confidence level 1.1–4.8%) had postoperative haemorrhages which required treatment under general anaesthesia, compared to 17 (5.5%; confidence level 3.2–8.6%) in the age- and gender-matched group of “selected” elective tonsillectomies. The difference between these two rates was not significant (p=0.056). The fairly high rate of haemorrhages in the elective tonsillectomy group was mainly due to the effect of the age-matching procedure, which excluded a considerable number of usually unproblematic tonsillectomies for tonsillar hyperplasia in young children. Moreover, our results show that there is a learning curve for surgeons performing tonsillectomies with regard to postoperative haemorrhages.     

Analgesia in tonsillectomy: a double-blind study on pre and post-operative treatment with diclofenac

The efficacy and tolerability of diclofenac suppositories given pre and/or post-operatively were investigated in a randomized double-blind study on 99 patients undergoing tonsillectomy. In one group, 50 mg diclofenac was given 1 h preoperatively, followed by 50 mg directly after the operation. In another group, diclofenac 100 mg was given only immediately post-operatively. A significantly lower consumption of rescue analgesics (paracetamol and/or pethidine) was found in the group treated preoperatively with diclofenac and the average time until first demand of rescue analgesics was significantly longer compared to the group given diclofenac post-operatively only. The tolerance was good and no serious bleeding complications occurred in either group. In the treatment of post-operative pain after tonsillectomy, the combination of pre and post-operative administration of diclofenac suppositories resulted in significantly lower consumption of rescue analgesics and is thus preferable to administration solely post-operatively.     

A randomised controlled trial of the effect of regional nerve blocks on immediate post‐tonsillectomy pain in adult patients

Post‐operative pain is the main cause of morbidity following tonsillectomy. The efficacy of glossopharyngeal and lesser palatine nerve blocks in controlling postoperative pain in adult patients was investigated prospectively. Patients 16 years and older admitted for elective tonsillectomy were randomised to one of three groups to receive a pre‐incisional oropharyngeal injection of 0.5% bupivicaine, a ‘dummy’ injection of saline or no injection. Dissection tonsillectomy and general anaesthetic techniques were standardized. Postoperative pain was monitored for 24 h. anova , χ² and Fisher's exact test were used for intergroup comparisons. Ninety‐two patients (72 women and 20 men), mean age 22 years were studied. Twenty‐nine patients received 0.5% bupivicaine, 30 saline and 33 no pre‐incisional injection. The overall mean pain scores of 2.1, 1.9 and 1.9 in the bupivicaine, saline and no injection groups were similar. Glossopharyngeal and lesser palatine 0.5% bupivicaine nerve blocks are not effective in reducing early post‐tonsillectomy pain.     

A telephone audit in parallel with the UK national tonsillectomy audit to investigate re-admission as a measure of secondary haemorrhage rate

OBJECTIVES: An audit to run in parallel with the remaining 5 months (at the time of conception) of the national tonsillectomy audit to examine the accuracy of re-admission following bleeding as a measure of secondary haemorrhage rate. METHODS: A retrospective, case series audit of all patients undergoing tonsillectomy between 29th April and 1st October 2004 at Frimley Park Hospital a UK District General Hospital. One hundred and twenty-nine patients (adults and children) undergoing tonsillectomy were contacted by telephone 2 weeks after surgery. The main outcome measures were reported bleeding and re-admission. We reviewed all studies reported in the literature investigating secondary haemorrhage rate in the community. RESULTS: This study demonstrated 19% (n=24) of patients experienced bleeding post-operatively. Ten per cent (n=13) returned to hospital for advice and were admitted. The literature review shows the variability of the proportion of patients with bleeding that are re-admitted is 33.3 standard deviations. CONCLUSIONS: There are widely different regional re-admission rates for post-tonsillectomy secondary haemorrhage. Re-admission is an unreliable measure of secondary haemorrhage. Change of practise based on conclusions drawn from re-admission rates are unsound.     

A prospective double‐blind randomized controlled trial comparing the suitability of KTP laser tonsillectomy with conventional dissection tonsillectomy for day case surgery

Tonsillectomy using a KTP laser has been performed increasingly but is not a routinely practised technique in the UK. In the USA, tonsillectomy is often performed as a day case procedure but, here in the UK, it is still standard practice to admit patients for overnight stay. We present the largest prospective double‐blind randomized controlled trial to date (151 patients) comparing KTP laser with standard dissection tonsillectomy and assess the suitability of both procedures for day case surgery. We found that there was significantly less peroperative haemorrhage if tonsillectomy was performed using the KTP laser, but it did cause more postoperative pain, more depression in mood and a higher rate of both reactionary and secondary haemorrhage, which was not significant when compared with conventional dissection. There was no difference in operating time, and over 40% of patients in each group needed overnight admission. We conclude that KTP laser tonsillectomy offers no benefit apart from less intraoperative bleeding over standard dissection tonsillectomy. Discharge from hospital after tonsillectomy was found to be unpredictable. Tonsillectomy is therefore an unsuitable procedure for planned surgery through a day unit, but approximately 58% of patients could be discharged on the same day from an extended day surgery unit, and the rest have one night in hospital.     

Meta‐analysis of the timing of haemorrhage after tonsillectomy: an important factor in determining the safety of performing tonsillectomy as a day case procedure

Objectives: To perform a meta‐analysis of studies of the timing of primary tonsillectomy haemorrhage. In particular to compare the difference in risk between 0–8 and 8–24 h; that is whether overnight inpatient tonsillectomy is required. Design: Medline search of all tonsillectomy studies to perform a meta‐analysis of the timing of primary haemorrhages. Setting: Literature‐based study. Participants: All adult and paediatric tonsillectomy studies giving the absolute number and timing of all primary haemorrhages. Main outcome measures: The overall incidence of haemorrhage occurring between 0–8 and 8–24 h. The overall incidence of haemorrhage for each of the first 24 h after operation. Compare risk of a bleed occurring 0–8, 8–24 and >24 h where data were available. Results: From a 1.4% overall risk of a primary haemorrhage only one in 14 occur after 8 h, i.e. 0.1% (95% CI = 0.08–0.16%). A total of 833 patients would require to be kept overnight in order to identify one case of bleeding after 8 h. Conclusions: Little benefit was conferred from overnight admission from the point of view of monitoring for primary haemorrhage. A case can be made for either day‐case tonsillectomy (hospital stay over the period in which 93% of primary haemorrhages would occur) or the ‘belt‐and‐braces’ approach of a 1‐week stay (during which all haemorrhages would occur) but current 24‐h admission appears illogical.