Teresa Ryczer, *Lidia Zawadzka-Głos, Paulina Czarnecka, Katarzyna Sobczyk
Bleeding as the main complication after adenoidectomy and adenotonsillotomy
Department of Pediatric Otolaryngology, Medical University of Warsaw, Poland
Head of Department: Lidia Zawadzka-Głos, MD, PhD
Summary
Introduction. Adenoidectomy and adenotonsillotomy are one of the most common surgeries performed in children due to adenoid and tonsils hypertrophy. Although the complications after the surgery are quite rare, one of the most common complication is bleeding.
Aim. The aim of the study was to analyze the rate of bleeding as the most common early complication (within 24 hours) after adenoidectomy and adenotonsillotomy. The assessed factors were: age, sex, type of surgery, frequency of bleeding and applied surgical treatment, as well as coexisting coagulation disorders.
Material and methods. The retrospective analysis of clinical data of 1312 patients hospitalized in the Department of Pediatric Otolaryngology of Medical University of Warsaw between January 2011 and December 2012 who underwent adenoidectomy or adenotonsillotomy was done. The objective of the study was to analyze the rate of bleeding as the most common early complication (within 24 hours) after adenoidectomy and adenotonsillotomy. The assessed factors were: age, sex, type of surgery, frequency of bleeding and applied surgical treatment, coexisting coagulation disorders.
Results. Intense bleeding (p < 0.01) and complications requiring surgical treatment (p < 0.05) occured more often after adenotonsillotomy than after adenotomy. In patients with coexisting coagulation disorders early complications were observed more often (p < 0.01). Patients from specific age groups did not demonstrate statisticaly relevant higher complication rate, nor did male versus female group (p > 0.05).
Conclusions. The study showed that intense bleeding and complications requiring surgical treatment occured more often after adenotonsillotomy than after adenotomy. Patients with coagulation disorders were more likely to have intense intra- or post-operatively bleeding. The age and the sex of the patient did not correlate with the higher bleeding rate.
INTRODUCTION
Adenoidectomy and adenotonsillotomy are one of the most common surgeries performed by otorhinolaryngologists. Adenoidectomy is the removal of hypertrophied adenoid, whereas tonsillotomy is the partial removal of hypertrophied tonsils with preservation of the tonsillar capsule. Adenoidectomy can be performed alone or with tonsillotomy. The most common indications for adenoidectomy are nasal obstruction, recurrent upper respiratory tract infections, obstructive sleep apnea syndrome, otitis media with effusion or recurrent otitis media. If tonsillar hypertrophy coexists, adenotonsillotomy should be performed. There are various techniques to perform adenoidectomy, among which are curettage, electrocautery or microdebrider dissection. Tonsillotomy techniques may be as following: blunt dissection; guillotine excision; electrocautery or cryosurgery dissection; ultrasonic removal; laser tonsillectomy, along with monopolar and bipolar diathermy dissection (1).
AIM
The aim of the study was to analyze the rate of bleeding as the most common early complication (within 24 hours) after adenoidectomy and adenotonsillotomy. The assessed factors were: age, sex, type of surgery, frequency of bleeding and applied surgical treatment, as well as coexisting coagulation disorders.
MATERIAL AND METHODS
The patients’ data were analyzed retrospectively on the basis of medical records of 1312 patients hospitalized in the Department of Pediatric Otolaryngology of Medical University of Warsaw between January 2011 and December 2012 who underwent adenoidectomy and adenotonsillotomy. This study concentrates on the assessment of the frequency and management of intra- and postoperative bleeding as the main ocurring complication during adecoidectomy and adenotonsillotomy.
The patients with intense bleeding (> 200 ml) as the main early complication were divided into two groups, the first group with severe hemorrhage that occurred during surgery or directly afterwards in the operating room (OR) and the second group with bleeding that ocurred few minutes or hours after surgery in the recovery room (RR) or in the ward (W).
In the Department of Pediatric Otolaryngology of Medical University of Warsaw adenoidectomy is performed using La Force adenotome. In case of tonsillectomy a tonsillotome is used. Both procedures are performed under general anesthesia with endotracheal intubation. After the removal of adenoid gauze packing is inserted in the nasopharynx for 5 to 10 minutes to achieve hemostasis. For the same reason after tonsillectomy tonsils are pressed with gauze strip or if needed electrocautery is used.
The statistical analysis was done using the PSPP program. Evaluation of each group was performed with non-parametric χ2 test. Statistical significance was p < 0.05 with limits 0.05 > p > 0.01. Yates’s correction was used in order to prevent overestimation of statistical significance for small data.
RESULTS
The medium age of a female patient was 6 years 2 months, whereas in the male group 5 years 8 months. The age range was from 8 months to 18 years. There was male predominance, N = 735 (56%) versus female patients, N = 577 (44%), p > 0.05 (tab. 1).
Table 1. Age and sex structure of the patients included in the study.
| Data | Girls | Boys | p |
| N | % | N | % |
| Total number of patients: | 577 | 43.9 | 735 | 56.1 | NS |
| 0-4 y.o. | 199 | 15.2 | 291 | 22.2 | NS |
| 5-9 y.o. | 305 | 23.2 | 357 | 27.2 | NS |
| 10-15 y.o. | 66 | 5.0 | 82 | 6.25 | NS |
| > 15 y.o. | 7 | 0.5 | 5 | 0.4 | NS |
| Adenoidectomy | 348 | 26.5 | 440 | 33.5 | NS |
| Adentonsillotomy | 229 | 17.5 | 295 | 22.5 | NS |
| Medium age | 6 years 2 months old | 5 years 8 months old |
| The age of the youngest patient | 1 year 6 months old | 8 months old |
| The age of the oldest patient | 17 years 2 months old | 18 years old |
In the analyzed group of patients boys accounted for 43.9% and girls for 56.1% in comparison with the whole Polish population where the ratio presents as following 48.7 vs. 51.3% (due to data from Central Statistical Office). There was no statistical difference in more frequent incidence of adenoid and tonsils hypertrophy in males (p > 0.05).
Adenoidectomy was performed in 60.1% of cases (N = 788) and adenotonsillotomy in 39.9% (N = 524). Myringotomy was performed in 34.5% (N = 453) of patients (tab. 2). Other procedures performed simultaneously to adenoidectomy and adenotonsillotomy took place in 19 cases (1.45%): maxillar sinus puncture (N = 5), tongue frenuloplasty (N = 11), antromastoidectomy (N = 2), ciliary biopsy (N = 2).
Table 2. Number of procedures: adenoidectomy, adenotonsillotomy, myringotomy.
| Data | Adenoidectomy | Adenotonsillotomy | p |
| N | % | N | % |
| Myringotomy: | 270 | 20.6 | 183 | 14 | NS |
| bilateral myringotomy | 241 | 18.4 | 162 | 12.4 | NS |
| left sided myringotomy | 14 | 1.07 | 7 | 0.50 | NS |
| wright sided myringotomy | 15 | 1.14 | 14 | 1.07 | NS |
| Total number of procedures | 788 | 60.1 | 524 | 39.9 | NS |
There were 68 patients (5.18%) with coagulation disorders: hemophilia type A – 0.23% (N = 3), hemophilia type B – 0.15% (N = 2), fibrinogen deficiency – 0.08% (N = 1), factor VII deficiency – 0.61% (N = 8), factor XI deficiency – 0.08% (N = 1), factor XII deficiency – 3.5% (N = 46), thrombocytopenia – 0.08% (N = 1), von Willebrand disease – 0.8% (N = 10), spherocytosis – 0.08% (N = 1), unidentified coagulation disorders during diagnostic process – 0.15% (N = 2).
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Piśmiennictwo
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