© Borgis - New Medicine 3/2005, s. 40-42
Małgorzata Dębska, Anna Bielicka, Marcin Partyka, Anna Kaczmarczyk, Mieczysław Chmielik
Tonsils surgery in children with bronchial asthma and coagulopathy
Department of Paediatric Otorhinolaryngology, Medical University of Warsaw, Poland
Head: Prof. Mieczysław Chmielik MD, PhD
The study was an analysis performed on a group of children operated for tonsil hypertrophy in 2004 at the Department of Paediatric Otorhinolaryngology of the Medical University of Warsaw, with co-existing conditions that may have influenced the course of surgery and the healing process. Special attention was paid to the preparation procedure for tonsil operations in children with bronchial asthma and coagulopathy.
Adenoidectomy and/or tonsillotomy are the most common procedures performed at departments of paediatric otolaryngology. Due to the fact that these procedures are often the first surgical procedures performed in children, not only is proper evaluation of indications important, but also appropriate preoperative management connected to co-existing conditions. Excessive bleeding in patients with coagulation disorders or bronchial spasm in children with bronchial hyper-reactivity leading to acute respiratory insufficiency are life-threatening conditions.
The incidence of peri-operative haemorrhage after tonsillotomy or adenoidectomy ranges from 0.5% to 10%, depending on authors (1). Massive and prolonged bleeding may occur just after surgery, even before anaesthesia is finished. Such situations may develop due to coagulation defects evidenced or not prior to surgery, to a irregular course of the descending pharyngeal artery and its injury during adenoidectomy, to an increased blood pressure or to remnants of adenoid tissues in the nasopharynx. Uncommon, genetically determined defects of the coagulation system are being evidenced during such procedures. Thus, it is recommended to asses platelets count, bleeding time, PT-prothrombin time, INR-Quick ratio, PTT – partial thromboplastin time in all children prepared for tonsillotomy or/and adenoidectomy. These tests estimate the function of the intrinsic and extrinsic coagulation pathways.
The most common serum-related coagulation defect is von Willebrand´s disease – VWD (prevalence 0.8%), inherited by autosomal dominant way. The clinical course of VWD is different depending on the degree of quantitative decrease and qualitative abnormalities of von Willebrand factor (VWF) multimers. The severity of the disease may vary from time to time in the same patient (2). Because of various clinical courses of VWD, usually only severe conditions are being diagnosed. VWF causes platelets to adhere to injured epithelium and consequently to proper clot formation. Intra-operative bleeding in patients with VWD, even not excessive, may decrease VWF levels and intensify perturbations of the platelets functions, thus leading to clinical presentations in the form of bleeding onset a few days after surgery. This condition does not disqualify the patient from surgery, but special haematological management is recommended. In some types of VWD (type I), synthetic vasopressin, desmopressin (DDAVP), is being used, releasing VWF from tissues (3).
Material and method
Among a total of 286 children operated at the Department of Paediatric Otolaryngology in 2004, there were 172 boys (60%) and 114 girls (40%) aged from 2.5 to 15 years. The mean age was 6 years and 2 months. In 164 children, adenoidectomy was performed, while in 122 cases adenoidectomy was accompanied by tonsillotomy. At the same time, myryngotomy was performed in 74 children and in 10 cases ventilation tubes were potted. Co-existing disorders were found in 146 children (Table 1).
Table 1. Co-existing diseases/conditions in children operated for tonsils and adenoid hypertrophy.
|Co-existing diseases/conditions ||Number of children||%|
|Coagulation defects, abnormal coagulation tests||35||12.2|
|Recurrent inflammation of the urinary tract, vesicoureteral reflux, haematuria, IgA nephropathy, nycturia||16||5.6|
|Heart rate disorders||7||2.4|
|Cardiac valve defects (bicuspid or tricuspid insufficiency), PFO, history of cardiac surgery ||7||2.4|
|Attention Deficit and Hyperactivity Disorder - ADHD||5||1.4|
In the analysed group, 37 children (13%) presented bronchial asthma. Five children were diagnosed with concurrent bronchial asthma and coagulation defects. In 35 children (12%), coagulation tests were incorrect, and – among them – in 32 cases, these results were related to a deficiency of a particular coagulation factor, while in 3 cases, in spite of prolonged PTT test results, levels of particular factors were normal. (Table 2).
Table 2. Coagulation factors deficiency in the study group.
|Type of coagulation defect||Number of children||%|
|Deficiency of factor XII - Hegeman´s defect||21||7.3|
|Von Willebrand´s Disease||8||2.8|
|Deficiency of factor VII||2||0.70|
|Deficiency of factor XI - Haemophilia C||1||0.35|
|Prolonged PPT test, normal levels of coagulation factors ||3||1|
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