Tonsillectomy is a commonly performed procedure with an accepted risk of posttonsillectomy hemorrhage (PTH) approaching 5%, but catastrophic effects of hemorrhage are exceedingly rare. A variety of surgical techniques and hemostatic agents have been used to reduce the rate of hemorrhage, although none eliminate the risk. Numerous patient, surgical, and postoperative care factors have been studied for an association with PTH. The most consistent risk factors for PTH seem to be patient age and coagulopathies. Surgeon skill and surgical technique are most consistently associated with primary PTH.
Key learning points
At the end of this article, the reader will:
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Appreciate the incidence of bleeding complications associated with tonsillectomy.
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Be able to review the relevant surgical vascular anatomy.
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Gain familiarity with methods of obtaining hemostasis during tonsillectomy and managing posttonsillectomy hemorrhage.
What is the incidence of posttonsillectomy hemorrhage?
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Overall hemorrhage rate of 3% to 5% is generally accepted
- •
Primary posttonsillectomy hemorrhage: ∼2%
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Secondary posttonsillectomy hemorrhage: most commonly between 5 and 10 days after surgery: ∼3.7%
- •
Reported rates of posttonsillectomy mortality resulting from hemorrhage reported 1 per 7000 to 1 per 170,000
Tonsillectomy and/or adenoidectomy is performed over several hundred thousand times per year in adults and children in the United States. There are significant variations in the reported incidence of posttonsillectomy hemorrhage (PTH) among studies, which may be caused by various definitions of hemorrhage, technique of tonsillectomy, postoperative care, and the study populations. Hemorrhage after tonsillectomy is not a rare event, but mortality caused by hemorrhage is rare. Primary PTH occurs within 24 hours of surgery and is considered to usually result from blood vessels not effectively controlled during surgery. Secondary PTH occurs after 24 hours of surgery and is thought to occur from exposed blood vessels after sloughing of the eschar.
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Blood supply to the palatine tonsils arises from the
- ○
Tonsillar branch of the facial artery
- ○
Dorsal lingual artery
- ○
Ascending pharyngeal artery
- ○
Lesser palatine artery
- ○
Ascending palatine artery
- ○
The lateral surface of the palatine tonsils is covered by a condensation of pharyngobasilar fascia, which has septae extending into the tonsils that transmits arteries, veins, and nerves. On removal of the tonsils, transected blood vessels may spasm and reduce blood loss or stop bleeding altogether.
Primary PTH may result from a blood vessel that initially spasms and later resumes bleeding if a method is not used to promote coagulation. Some surgeons elect to treat only sites observed to bleed during the tonsillectomy to reduce surrounding tissue damage. Other surgeons elect to treat all potential bleeding sites with the goal of potentially reducing the risk of PTH, although this may slow tissue healing and increase postoperative pain and need for analgesics.
Vascular anomalies and anatomic variations may cause some concern for potential injury or increased risk of PTH. In particular, the course of the cervical internal carotid artery has a high reported rate of variable anatomy, particularly in association with velocardiofacial syndrome. However, there are no data to support an increased risk of PTH because of variable vascular anatomy.
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Surgical technique
- ○
Cold dissection (sharp, blunt, snares) and hemostasis with ties or diathermy
- ○
“Hot” dissection
- ▪
Diathermy or electrocautery
- •
Direct contact with tissue (monopolar, bipolar)
- •
Indirect (argon)
- •
- ▪
Laser
- ▪
- ○
Bipolar radiofrequency ablation (coblation)
- ○
Harmonic scalpel
- ○
Argon
- ○
Intracapsular tonsillectomy/tonsillotomy
- ○
- •
Patient factors
- ○
Age
- ○
Indication for tonsillectomy
- ○
Coagulopathy
- ○
Vascular anatomy, aberrant blood vessels
- ○
Numerous studies have sought to identify which tonsillectomy method is associated with the lowest risk of PTH, although no technique has definitively been shown to have a clinically significant benefit. A possible explanation is that secondary PTH is generally thought to occur from sloughing of fibrinous exudate approximately 7 days after tonsillectomy. By this point in time, the method of dissection may be less relevant. Suturing of the faucial pillars, which is also performed with many uvulopalatopharyngoplasty techniques, has been proposed to reduce bleeding that occurs from exposed blood vessels after fibrinous sloughing. One study showed that this technique was associated with a lower risk of needing operative management of PTH, and may reduce the overall risk of PTH, although this study was underpowered.
- •
Fischer knife, snare, microdebrider, other methods
- •
Hemostasis must be achieved as a second step
- •
May have higher intraoperative blood loss compared with “hot” techniques
- •
May have lower PTH rates because of reduced thermal injury to adjacent muscle compared with “hot” techniques
Cold dissection depends on operator skill for dissection and hemostasis. A variety of methods have been reported for achieving hemostasis following cold dissection, and allow the operator to target sources of bleeding and reduce tissue damage in nonbleeding regions. The risk of PTH with cold dissection may be lower because of reduced collateral tissue injury, therefore a reduced thickness of fibrinous slough; however, larger studies are required to substantiate this. Cold dissection technique for tonsillectomy is currently standard of practice against which outcomes and complications of newer techniques are compared.
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Monopolar cautery: high-frequency electrical current passing through tissue as either continuous (“cut” mode), interrupted (“coag” mode), or a mixture of current flow
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Tissue temperatures near the active electrode frequently exceed 200°C
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Continuous current flow creates higher tissue temperatures and results in explosive vaporization
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Bipolar cautery also uses high-frequency electrical current, but the current is limited to the tissue between the two electrodes
Electrocautery is frequently used in tonsillectomy, either for dissection and hemostasis, or for hemostasis following other dissection techniques. A variety of active electrode shapes are used with the monopolar cautery, including a needle tip; a funnel-shaped tip; or a broad, flat electrode. A suction cautery device with a round, hollow electrode through which the surgeon may also suction is frequently used for hemostasis alone ( Fig. 1 ).
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First approved by the US Food and Drug Administration for tonsillectomy in 2001 (Coblation device, Smith & Nephew, London, UK)
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Capable of tissue dissection and achieving hemostasis
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Potentially less surrounding thermal tissue injury than monopolar cautery
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Reduced thermal injury has been proposed to reduce postoperative pain and possibly the risk of hemorrhage
- •
Similar hemorrhage rates compared with electrocautery
Radiofrequency is a relatively new technique compared with electrocautery methods of tonsillectomy. This technique uses radiofrequency signals to produce an electrodissociation effect to generate a plasma of excited ions or an ionized field. Two electrodes immersed in electrolyte solution are used to create a plasma field of high energy charged particles that break molecular bonds between 40°C and 70°C. Monopolar cautery is frequently compared with coblation because of similar applications and technique, although the disposable Coblator handpieces are significantly more expensive than typical monopolar cautery handpieces. Monopolar cautery may still be used with radiofrequency for brisk bleeding control. One large study with 1918 children (<20 years old) showed overall 4.5% incidence of PTH. There was no association between surgeon experience and rate of PTH, and 1% required electrocautery for intraoperative hemostasis. The English National Tonsillectomy Audit showed that coblation was associated with a 1.6 to 2.7 times greater hemorrhage rate than cold dissection techniques. However, there were some confounding factors and a larger study is required to examine this further.
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Vibration of a blade at 55.5 kHz over a distance of 50 to 100 μm transmits ultrasonic energy to tissue and heats it to 55°C to 100°C, and causes denaturation and coagulation of proteins
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Capable of tissue dissection and achieving hemostasis
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Causes surrounding tissue thermal injury
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Most studies reported no primary hemorrhages; however, most also report a secondary method was frequently used to achieve hemostasis
Harmonic scalpel is capable of performing dissection and hemostasis; however, other methods are frequently needed to achieve hemostasis. This obscures the data regarding the true amount of intraoperative hemorrhage and incidence of PTH related to the harmonic scalpel. A systematic review failed to show overall difference in hemorrhage rate compared with any other method; however, this review was limited by poor reporting within studies and small sample sizes.
What is the incidence of posttonsillectomy hemorrhage?
- •
Overall hemorrhage rate of 3% to 5% is generally accepted
- •
Primary posttonsillectomy hemorrhage: ∼2%
- •
Secondary posttonsillectomy hemorrhage: most commonly between 5 and 10 days after surgery: ∼3.7%
- •
Reported rates of posttonsillectomy mortality resulting from hemorrhage reported 1 per 7000 to 1 per 170,000
Tonsillectomy and/or adenoidectomy is performed over several hundred thousand times per year in adults and children in the United States. There are significant variations in the reported incidence of posttonsillectomy hemorrhage (PTH) among studies, which may be caused by various definitions of hemorrhage, technique of tonsillectomy, postoperative care, and the study populations. Hemorrhage after tonsillectomy is not a rare event, but mortality caused by hemorrhage is rare. Primary PTH occurs within 24 hours of surgery and is considered to usually result from blood vessels not effectively controlled during surgery. Secondary PTH occurs after 24 hours of surgery and is thought to occur from exposed blood vessels after sloughing of the eschar.
- •
Blood supply to the palatine tonsils arises from the
- ○
Tonsillar branch of the facial artery
- ○
Dorsal lingual artery
- ○
Ascending pharyngeal artery
- ○
Lesser palatine artery
- ○
Ascending palatine artery
- ○
The lateral surface of the palatine tonsils is covered by a condensation of pharyngobasilar fascia, which has septae extending into the tonsils that transmits arteries, veins, and nerves. On removal of the tonsils, transected blood vessels may spasm and reduce blood loss or stop bleeding altogether.
Primary PTH may result from a blood vessel that initially spasms and later resumes bleeding if a method is not used to promote coagulation. Some surgeons elect to treat only sites observed to bleed during the tonsillectomy to reduce surrounding tissue damage. Other surgeons elect to treat all potential bleeding sites with the goal of potentially reducing the risk of PTH, although this may slow tissue healing and increase postoperative pain and need for analgesics.
Vascular anomalies and anatomic variations may cause some concern for potential injury or increased risk of PTH. In particular, the course of the cervical internal carotid artery has a high reported rate of variable anatomy, particularly in association with velocardiofacial syndrome. However, there are no data to support an increased risk of PTH because of variable vascular anatomy.
- •
Surgical technique
- ○
Cold dissection (sharp, blunt, snares) and hemostasis with ties or diathermy
- ○
“Hot” dissection
- ▪
Diathermy or electrocautery
- •
Direct contact with tissue (monopolar, bipolar)
- •
Indirect (argon)
- •
- ▪
Laser
- ▪
- ○
Bipolar radiofrequency ablation (coblation)
- ○
Harmonic scalpel
- ○
Argon
- ○
Intracapsular tonsillectomy/tonsillotomy
- ○
- •
Patient factors
- ○
Age
- ○
Indication for tonsillectomy
- ○
Coagulopathy
- ○
Vascular anatomy, aberrant blood vessels
- ○
Numerous studies have sought to identify which tonsillectomy method is associated with the lowest risk of PTH, although no technique has definitively been shown to have a clinically significant benefit. A possible explanation is that secondary PTH is generally thought to occur from sloughing of fibrinous exudate approximately 7 days after tonsillectomy. By this point in time, the method of dissection may be less relevant. Suturing of the faucial pillars, which is also performed with many uvulopalatopharyngoplasty techniques, has been proposed to reduce bleeding that occurs from exposed blood vessels after fibrinous sloughing. One study showed that this technique was associated with a lower risk of needing operative management of PTH, and may reduce the overall risk of PTH, although this study was underpowered.
- •
Fischer knife, snare, microdebrider, other methods
- •
Hemostasis must be achieved as a second step
- •
May have higher intraoperative blood loss compared with “hot” techniques
- •
May have lower PTH rates because of reduced thermal injury to adjacent muscle compared with “hot” techniques
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