What lessons can be learned from the Austrian events?

INTRODUCTION: The death of 5 children in Austria below the age of 6 years due to posttonsillectomy haemorrhage in 2006 and 2007 led to an intensive discussion on the potential life-threatening risks of tonsil surgery. On this occasion, a consensus paper with clear recommendations for tonsil surgery was released by the Austrian Societies of Otorhinolaryngology, Head and Neck Surgery and Paediatrics followed by a nationwide multicentre study. METHODS: All consecutive tonsillectomies, tonsillotomies and adenoidectomies performed in public hospitals in Austria within 9 months were assessed. Data on all participating patients were collected via an online questionnaire requesting patient characteristics, surgery details and postoperative haemorrhage. A strict definition for postoperative bleeding episodes with 7 severity grades was applied. Every bleeding episode after extubation was counted as postoperative bleeding event. RESULTS: The study population - all younger than 18 years of age - consisted of 6,765 patients (tonsillectomy 2,080, 31%; tonsillotomy 1,292, 19%; adenoidectomy 3,393, 50%). Postoperative haemorrhage episodes were reported in 15% after tonsillectomy and in 2.3% after tonsillotomy, with the risk increasing parallel to age. Multiple bleeding episodes were recorded in one fourth of all tonsillectomy bleedings, but were rare after tonsillotomy. Surgical revision under general anaesthesia was necessary in 4.2% after tonsillectomy and in 0.9% after tonsillotomy. DISCUSSION: As the incidence of tonsillectomy in children younger than 6 years has declined following the recommendations of the consensus paper issued in 2007, tonsillotomy has become more frequent in this age group. Overnight hospital admission and observation is suggested for all patients experiencing postoperative haemorrhage, as the occurrence of one minor bleeding doubled the risk of a second severe bleeding.

Preoperative coagulation screening prior to tonsillectomy in adults: current practice and recommendations.

The hypotheses of the study are: (1) a positive history of coagulopathy predicts a higher postoperative haemorrhage risk, (2) a positive laboratory screening for coagulopathy can forecast a higher haemorrhage risk and (3) the haemorrhage risk in patients with known bleeding disorder is elevated. In a multicentre study information on 3,041 tonsillectomies in adults over 9 months, from 1st October 2009 until 30th June 2010, was evaluated. The outcome variables were patient characteristics, postoperative haemorrhage, history of coagulopathy and laboratory screening for coagulopathy. A history of coagulopathy and laboratory screening for coagulopathy were performed in almost all patients (98.6 %, 2,998/3,041). The overall haemorrhage rate was 16 %, including all bleeding episodes after extubation, with 4.8 % returning to theatre. A positive history was reported in 2 % (55/3,041) and a positive laboratory screening in 3 % (94/3,041) of all patients. A positive history is significantly associated with a higher risk of postoperative haemorrhage (31 %, 17/55, p < 0.002) compared to patients with a negative history (16 %, 387/2,497). A positive laboratory for coagulopathy was not significantly associated with an increased haemorrhage risk (20 %, 19/94, p < 0.235) compared to patients with a negative laboratory (16 %, 390/2,249). The haemorrhage risk for adults with a bleeding disorder is twice as high (31 %, 17/55) as for adults without bleeding disorder (16 %, 476/2,973). In conclusion, an adult patient's history of coagulopathy should be taken prior to tonsillectomy as a positive history doubles the haemorrhage risk while a laboratory screening for coagulopathy has no significant power to predict an elevated haemorrhage risk. Bleeding disorders double the risk of postoperative haemorrhage.

Significant post-tonsillectomy pain is associated with increased risk of hemorrhage.

OBJECTIVES: In this study, we set out to assess the association of postoperative pain types with the risk of hemorrhage after tonsillectomy. METHODS: The questionnaire-based study was conducted on 335 patients who had undergone tonsillectomy. Hemorrhage risk and postoperative pain were evaluated retrospectively with use of a visual analog scale for 5 time periods (day 1, days 2 to 3, days 4 to 7, days 7 to 14, and later). RESULTS: Five pain types were identified by a cluster analysis. The most frequent pain types, I (24.8%; 83 patients) and II (50.8%; 170 patients), show decreasing pain, with pain type II starting on a higher level than pain type I. Pain types III (10.7%; 36 patients) and IV (1.2%; 4 patients) start at a low level with increasing pain for the first few days. In type III, pain decreases after 1 week, whereas type IV consists of a high level of pain for more than 2 weeks. Pain type V (12.5%; 42 patients) involves a very high level of pain from the beginning, which decreases only gradually. Pain type I is associated with a low hemorrhage rate. Patients with increasing pain (types III and IV) and pain type V show a significantly higher hemorrhage risk. CONCLUSIONS: Patients who have severe or increasing pain in the first few days after tonsillectomy have a significantly higher risk of hemorrhage.

Hemorrhage following tonsil surgery: a multicenter prospective study.

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 hemorrhage, 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 ± AE was 15.0%, for TO ± AE was 2.3%, and for AE was 0.8%. Rate of return to the operating room for TE ± AE was 4.6%, for TO ± 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 ± AE (P < .001), and cold steel dissection combined with bipolar diathermy (P = .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 = .007), males (P = .02), and all bipolar operation techniques (P = .005). CONCLUSIONS: The occurrence of a postoperative minor bleeding episode increases the risk of a subsequent severe bleeding episode.

Tonsilar haemorrhage and re-admission: a questionnaire based study.

The aim of our study was to investigate the accuracy of haemorrhage rate in the community (i.e., actual rate versus hospital recorded rate) for tonsil operations. Bleeding episodes were investigated for 695 consecutive patients undergoing tonsillectomy, adenotonsillectomy and tonsillotomy at the Department of ORL, H&NS, MU of Graz, Austria, between January 1 2007 and June 30 2008 by questionnaire. Main purposes of our study were the evaluation of the incidence of postoperative haemorrhage, need for revision surgery, medical care of patients experiencing postoperative bleeding and multiple bleeding episodes. Haemorrhage was defined as any bleeding, be it minimal or significant, after extubation. The study group comprised 407 patients who answered the questionnaire: 61.7% adults, 22.1% school children between 6 and 15 years and 16.2% children aged less than 6 years. Exactly 100 patients (24.6% of 407) showed some kind of postoperative bleeding, but only 79 of them (19.4% of 407) were recorded at hospital. A return to theatre due to haemorrhage was required in 4.7% of all 407 cases. Combining hospital records and data from the questionnaire allowed us to estimate an overall haemorrhage rate of 21.4% for all 695 patients. Every fifth patient experiencing postoperative haemorrhage did not return to the hospital he or she was operated in. We would have missed 21.0% of all bleeding episodes by assessing re-admitting patients suffering postoperative bleeding only. We conclude that haemorrhage rate is considerably higher than assumed by investigating hospital records only and strongly related to the definition of postoperative bleeding and to the study design.