Postoperative Bleeding and Associated Utilization following Tonsillectomy in Children: A Systematic Review and Meta‐analysis

Abstract

Objective To assess post-tonsillectomy hemorrhage (PTH), associated non-operative readmissions/revisits, and reoperations in children. Data Sources MEDLINE, EMBASE, and the Cochrane Library. Review Methods Two investigators independently screened studies against predetermined criteria and extracted key data. Investigators independently assessed study risk of bias and the strength of the evidence of the body of literature. We calculated unadjusted pooled estimates of PTH frequency and also conducted a Bayesian meta-analysis to estimate frequency of primary and secondary PTH and PTH-associated reoperation and revisits/readmissions by partial and total tonsillectomy and surgical approach. Results In meta-analysis, the frequency of primary and secondary PTH associated with total and partial tonsillectomy was below 4% for any technique and with overlapping confidence bounds. Pooled frequencies of PTH were also below 5% overall (4.2% for total tonsillectomy; 1.5% for partial tonsillectomy) in comparative studies. Fewer PTH occurred with tonsillectomy for obstructive sleep-disordered breathing than throat infection. In meta-analysis, frequency of PTH-associated non-operative revisits/readmission or reoperation ranged from 0.2% to 5.7% for total tonsillectomy and from 0.1% to 3.7% for partial tonsillectomy. At least four deaths were reported in case series including 1,778,342 children. Conclusions PTH occurred in roughly 4% of tonsillectomies in studies included in this review. Though studies typically did not report bleeding severity or amount, relatively few episodes of PTH necessitated reoperation for hemostasis. Nonetheless, tonsillectomy is not without risk of harm. Frequency of PTH across techniques was similar; thus we cannot conclude that a given technique is superior.

Correlation between clinical grading of adenoid or tonsil hypertrophy and adenoid or tonsil volume post adenotonsillectomy: a prospective cohort study

“…[23][24][25] Unfortunately, these procedures are performed as first line surgical operations in the paediatric population who are the susceptible age-group for obstructive adenoidal and or tonsillar disease which are located amongst the highly vascularized and difficult for surgical access regions of the upper aerodigestive tract. 26,27 This was confirmed in this cohort where 86.5% were ≤18 years who were majorly ≤4 years with 63.5%; the age-group with up to 4-5 risks of developing serious to life-threatening airway and post tonsillectomy bleeding complications of the procedure. 26,28 We recorded 81.2% of our cohort with grades III and IV adenoid/tonsil hypertrophy who had adenoidectomy, tonsillectomy or both as similarly reported by other researchers.…”

Patient reported pain-related outcome measures after tonsil surgery: an analysis of 32,225 children from the National Tonsil Surgery Register in Sweden 2009–2016

“…In a recent review, the risk of postoperative bleeding after TE was assessed, estimating the bleeding frequency after TE (again performed on indication OSA) in children to be 0.3% primary bleeding and 2.2% secondary bleeding, with a re-operation rate of 1.3%. This is approximately twice as high as the figures presented after TT; 1.3% primary bleeding and 0.3% secondary bleeding, with 0.6% re-operation rate [ 11 ]. The risk of bleeding seems to increase with age [ 19 ].…”

“…Tonsil surgery is a painful childhood surgical procedure that causes moderate to severe pain many days after the surgery [ 7 – 10 ]. When the risk for postoperative hemorrhage and infection is also included [ 11 , 12 ], tonsil surgery can be considered to cause significant morbidity during recovery. In many countries, a majority of tonsil surgery procedures are performed in outpatient settings [ 1 , 6 ].…”

Clinical Practice Guideline: Tonsillectomy in Children (Update)

“…Two recent meta-analyses determined that frequencies of PTB were similar between cold dissection (3.8%) and coblation (3.3%). 29,258 In a systematic Cochrane review of 9 trials that compared coblation and other techniques for tonsillectomy, there was no significant difference between techniques with respect to PTB rates. 263 A case series of 1997 children undergoing coblation tonsillectomy from January 2000 to June 2004 showed similar rates of primary and secondary bleeding as compared with electrocautery tonsillectomy.…”