Eur Arch Otorhinolaryngol DOI 10.1007/s00405-014-3075-6
Laryngology
Routine tonsillar bed oversew after diathermy tonsillectomy: does it reduce secondary tonsillar haemorrhage? Thomas B. V. Nguyen · Ronald Y. Chin · Suchitra Paramaesvaran · Guy D. Eslick
Received: 14 January 2014 / Accepted: 22 April 2014 © Springer-Verlag Berlin Heidelberg 2014
Abstract Tonsillectomy is a common otolaryngological procedure and is associated with a small risk of postoperative pharyngeal haemorrhage. This study compares secondary post tonsillectomy haemorrhage rates between two operative techniques: diathermy tonsillectomy and diathermy tonsillectomy with tonsillar bed oversew. A total of 424 patients underwent tonsillectomies with or without other procedures such as adenoidectomy and grommet insertion by two ears, nose and throat surgeons at three hospitals from May 2012 to July 2013. A diathermy tonsillectomy was performed in 266 patients, while a diathermy tonsillectomy with tonsillar bed oversew was performed in 158 patients. All patients were followed up within 2–4 weeks of surgery. Primary haemorrhage did not occur in either surgical technique groups. Secondary haemorrhage occurred in 20 patients (7.52 %) in the diathermy tonsillectomy group and in 9 patients (5.70 %) in the diathermy with tonsillar bed oversew group. This result was not significantly different (OR = 0.74, 95 % CI 0.33–1.67, p = 0.47). Sex, age, indication for surgery and whether or not a tonsillectomy was performed alone or with other procedures were not significant factors for
T. B. V. Nguyen (*) · R. Y. Chin · S. Paramaesvaran Department of Otolaryngology, Head and Neck Surgery, Nepean Hospital, Derby St, Kingswood, Sydney, NSW 2750, Australia e-mail: [email protected] R. Y. Chin · S. Paramaesvaran Nepean Medical School, The University of Sydney, Sydney, NSW, Australia G. D. Eslick The Whiteley–Martin Research Unit, Sydney, NSW, Australia
secondary haemorrhage. In summary, routine tonsillar bed oversew after diathermy tonsillectomy does not reduce the risk of secondary tonsillar haemorrhage. Keywords Secondary tonsillar haemorrhage · Diathermy tonsillectomy · Tonsillar fossa closure
Introduction Tonsillectomy was first described by Cornelius Caesus in the first century AD and is now one of the most frequently performed operations worldwide, accounting for around 20 % of all otolaryngological operations [1–4]. Tonsillectomy performed for recurrent infection and airway obstruction improves the quality of life in children [5] and in adults [6]. Postoperative tonsillectomy haemorrhage is one of the most serious complications of tonsillectomy and is divided into primary (occurring within 24 h of surgery) and secondary (more than 24 h) haemorrhage. The reported incidence of bleeding after tonsillectomy differs broadly depending on the study, ranging from 0.5 to 15.9 % [7, 8]. This may be due to indistinct definitions of haemorrhage between these studies. Deaths are reported to occur in 1 of 20,000 patients [9]. Secondary haemorrhages can occur anytime during the first two postoperative weeks [3]. Surgeons have long sought out new operative techniques as well as changes in the medical therapy associated with tonsillectomies to try and reduce the rate of secondary tonsillar haemorrhage. Modern techniques have strived to improve efficiency and reduce complications while maintaining or enhancing safety levels. Described tonsillectomy techniques include cold steel dissection, monopolar and bipolar diathermy dissection, bipolar scissors dissection, laser,
13
cryosurgery, ultrasonic removal, microdebrider, coblation and thermal welding [7]. All these techniques are sufficient to remove the palatine tonsils and have their own unique advantages and disadvantages. Current research in comparing these techniques has failed to come up with a universally accepted, single, best technique which consistently produces a reduced morbidity rate [7, 8, 10–12]. As part of any operation, haemostasis is an essential component and is particularly important in tonsillectomy as postoperative haemorrhage is one of the most serious complications. Haemostasis is primarily achieved by ligature ties or electrocautery, or from a combination of these techniques [7]. Tonsillectomy is a unique procedure in that the tonsillar bed is left open and is one of the few routine operations that rely on secondary healing. Closure of the tonsillar bed can be achieved by suturing the anterior and posterior pharyngeal pillars together and is usually reserved to stop difficult bleeding when simple ties or electrocautery has failed or for an arrest of a postoperative tonsillar haemorrhage. Currently, there is conflicting evidence to determine whether additional, routine closure of the tonsillar bed with pharyngeal pillar suturing after a tonsillectomy protects against secondary haemorrhage [13, 14]. As postoperative tonsillar haemorrhage is potentially life threatening, especially in children, research into its prevention is vital. Our aim, therefore, was to assess the rate of secondary tonsillar haemorrhage between diathermy tonsillectomy with tonsillar bed oversew compared with diathermy tonsillectomy alone.
Materials and methods Patients and data collection A retrospective review at Nepean, Nepean Private and Westmead Private Hospitals was performed between May 1st, 2012 to July 31st, 2013. Nepean Hospital is a tertiary referral teaching hospital of The University of Sydney. Data were collected from operating theatre and hospital medical records of each hospital and referenced with data collected by the operating Consultants and Registrar. Data collected included age and sex of the patient, indication for surgery, whether the tonsillectomy was performed with or without another otolaryngological procedure and technique used for tonsillectomy. Complications including primary and secondary tonsillar haemorrhage, readmission to hospital, return to operating theatres and need for blood transfusion were analysed. This study was approved by the Human Research Ethics Committee, Nepean Blue Mountains Local Health District.
13
Eur Arch Otorhinolaryngol
Surgical indication and technique The indication for tonsillectomy was recurrent tonsillitis, upper airway obstruction associated with obstructive sleep apnoea (OSA) and for histopathology for suspicion of malignancy. Diathermy tonsillectomy This technique was performed by Surgeon 1 at Nepean and Westmead Private Hospitals. After induction with general anaesthesia and endotracheal intubation with a Rae tube, each patient was positioned supine, draped, and a Boyle– Davis mouth gag was inserted into the mouth and supported by Draffin bipods. The palatine tonsil was grasped and medialised with a Luc’s forceps. A monopolar diathermy instrument with an insulated tip was used to perform the extracapsular, tonsillar dissection (Valley Lab Force E2 diathermy machine, Force Triad Covidien). Haemostasis was achieved with diathermy using a forcep tip instrument with a power setting of 18 W. Diathermy tonsillectomy with tonsillar bed oversew This technique was utilised by Surgeon 2 at Nepean and Nepean Private Hospitals. Patient preparation was identical to that of Surgeon 1 except for a power setting of 26 W on the diathermy apparatus. After haemostasis was sufficiently achieved, the bilateral tonsillar bed oversew was performed by a single, horizontal mattress suture of the palatoglossus and palatopharyngeus muscles, using a 2-0 silk or vicryl tie, with the knot buried posterior to the palatopharyngeus muscle (Fig. 1). All patients were kept overnight and discharged the following day with analgesia and no antibiotics. All patients were instructed not to use non-steroidal anti-inflammatory analgesics and to commence a soft diet. Operating surgeons were the two Consultant Visiting Medical Officers or Otolaryngology Registrars under direct supervision. Haemorrhage post tonsillectomy is a serious complication and one that our department treats with extreme care. Primary haemorrhage is defined as pharyngeal bleeding within the first postoperative 24 h, whereas secondary haemorrhage between 24 h and 2 weeks. We defined post tonsillectomy haemorrhage in our study to include all oral bleeds. Any fresh bleeding from the throat whether large or small, which occurred after 24 h of surgery, was counted as a secondary haemorrhage. Patients were counselled about the serious nature of secondary haemorrhage and advised to present to our tertiary referral emergency centre for review of any bleeds. Only small blood streaked or minor spots in the saliva were excluded, and anything more than this was recorded as a true secondary tonsillar haemorrhage.
Eur Arch Otorhinolaryngol
Fig. 1 Photographs of the tonsillar oversew. The photographs are orientated from the surgeon’s perspective during the operation, seated at the head of the patient. A Boyle–Davis gag is inserted for exposure. a This photograph depicts the point in the operation where the palatine tonsils have been removed by diathermy tonsillectomy, Table 1 Demographics of patients from each treatment group
Variable
Age (mean) Sex, no. (%) Male Female Indication, no. (%) Recurrent tonsillitis OSA Malignancy Operation, no. (%) Tonsillectomy alone * Statistically significant
Tonsillectomy and other
All patients received follow-up. Two patients presented to other hospitals with secondary haemorrhages, one was transferred to our referral centre for observation, whereas the other required a second operation to arrest the bleeding. Patients who presented to our tertiary referral hospital with secondary haemorrhages who had initial operations elsewhere by other surgeons were not included in this study. Statistical analysis Demographic and clinical variables were compared between the two groups using t test (continuous variables) and χ2 testing (categorical variables). Logistic regression analysis was performed to evaluate risk factors and was calculated as odds ratios (OR) with 95 % confidence intervals (95 % CI). Differences were considered significant when the p value was
Laryngology
Routine tonsillar bed oversew after diathermy tonsillectomy: does it reduce secondary tonsillar haemorrhage? Thomas B. V. Nguyen · Ronald Y. Chin · Suchitra Paramaesvaran · Guy D. Eslick
Received: 14 January 2014 / Accepted: 22 April 2014 © Springer-Verlag Berlin Heidelberg 2014
Abstract Tonsillectomy is a common otolaryngological procedure and is associated with a small risk of postoperative pharyngeal haemorrhage. This study compares secondary post tonsillectomy haemorrhage rates between two operative techniques: diathermy tonsillectomy and diathermy tonsillectomy with tonsillar bed oversew. A total of 424 patients underwent tonsillectomies with or without other procedures such as adenoidectomy and grommet insertion by two ears, nose and throat surgeons at three hospitals from May 2012 to July 2013. A diathermy tonsillectomy was performed in 266 patients, while a diathermy tonsillectomy with tonsillar bed oversew was performed in 158 patients. All patients were followed up within 2–4 weeks of surgery. Primary haemorrhage did not occur in either surgical technique groups. Secondary haemorrhage occurred in 20 patients (7.52 %) in the diathermy tonsillectomy group and in 9 patients (5.70 %) in the diathermy with tonsillar bed oversew group. This result was not significantly different (OR = 0.74, 95 % CI 0.33–1.67, p = 0.47). Sex, age, indication for surgery and whether or not a tonsillectomy was performed alone or with other procedures were not significant factors for
T. B. V. Nguyen (*) · R. Y. Chin · S. Paramaesvaran Department of Otolaryngology, Head and Neck Surgery, Nepean Hospital, Derby St, Kingswood, Sydney, NSW 2750, Australia e-mail: [email protected] R. Y. Chin · S. Paramaesvaran Nepean Medical School, The University of Sydney, Sydney, NSW, Australia G. D. Eslick The Whiteley–Martin Research Unit, Sydney, NSW, Australia
secondary haemorrhage. In summary, routine tonsillar bed oversew after diathermy tonsillectomy does not reduce the risk of secondary tonsillar haemorrhage. Keywords Secondary tonsillar haemorrhage · Diathermy tonsillectomy · Tonsillar fossa closure
Introduction Tonsillectomy was first described by Cornelius Caesus in the first century AD and is now one of the most frequently performed operations worldwide, accounting for around 20 % of all otolaryngological operations [1–4]. Tonsillectomy performed for recurrent infection and airway obstruction improves the quality of life in children [5] and in adults [6]. Postoperative tonsillectomy haemorrhage is one of the most serious complications of tonsillectomy and is divided into primary (occurring within 24 h of surgery) and secondary (more than 24 h) haemorrhage. The reported incidence of bleeding after tonsillectomy differs broadly depending on the study, ranging from 0.5 to 15.9 % [7, 8]. This may be due to indistinct definitions of haemorrhage between these studies. Deaths are reported to occur in 1 of 20,000 patients [9]. Secondary haemorrhages can occur anytime during the first two postoperative weeks [3]. Surgeons have long sought out new operative techniques as well as changes in the medical therapy associated with tonsillectomies to try and reduce the rate of secondary tonsillar haemorrhage. Modern techniques have strived to improve efficiency and reduce complications while maintaining or enhancing safety levels. Described tonsillectomy techniques include cold steel dissection, monopolar and bipolar diathermy dissection, bipolar scissors dissection, laser,
13
cryosurgery, ultrasonic removal, microdebrider, coblation and thermal welding [7]. All these techniques are sufficient to remove the palatine tonsils and have their own unique advantages and disadvantages. Current research in comparing these techniques has failed to come up with a universally accepted, single, best technique which consistently produces a reduced morbidity rate [7, 8, 10–12]. As part of any operation, haemostasis is an essential component and is particularly important in tonsillectomy as postoperative haemorrhage is one of the most serious complications. Haemostasis is primarily achieved by ligature ties or electrocautery, or from a combination of these techniques [7]. Tonsillectomy is a unique procedure in that the tonsillar bed is left open and is one of the few routine operations that rely on secondary healing. Closure of the tonsillar bed can be achieved by suturing the anterior and posterior pharyngeal pillars together and is usually reserved to stop difficult bleeding when simple ties or electrocautery has failed or for an arrest of a postoperative tonsillar haemorrhage. Currently, there is conflicting evidence to determine whether additional, routine closure of the tonsillar bed with pharyngeal pillar suturing after a tonsillectomy protects against secondary haemorrhage [13, 14]. As postoperative tonsillar haemorrhage is potentially life threatening, especially in children, research into its prevention is vital. Our aim, therefore, was to assess the rate of secondary tonsillar haemorrhage between diathermy tonsillectomy with tonsillar bed oversew compared with diathermy tonsillectomy alone.
Materials and methods Patients and data collection A retrospective review at Nepean, Nepean Private and Westmead Private Hospitals was performed between May 1st, 2012 to July 31st, 2013. Nepean Hospital is a tertiary referral teaching hospital of The University of Sydney. Data were collected from operating theatre and hospital medical records of each hospital and referenced with data collected by the operating Consultants and Registrar. Data collected included age and sex of the patient, indication for surgery, whether the tonsillectomy was performed with or without another otolaryngological procedure and technique used for tonsillectomy. Complications including primary and secondary tonsillar haemorrhage, readmission to hospital, return to operating theatres and need for blood transfusion were analysed. This study was approved by the Human Research Ethics Committee, Nepean Blue Mountains Local Health District.
13
Eur Arch Otorhinolaryngol
Surgical indication and technique The indication for tonsillectomy was recurrent tonsillitis, upper airway obstruction associated with obstructive sleep apnoea (OSA) and for histopathology for suspicion of malignancy. Diathermy tonsillectomy This technique was performed by Surgeon 1 at Nepean and Westmead Private Hospitals. After induction with general anaesthesia and endotracheal intubation with a Rae tube, each patient was positioned supine, draped, and a Boyle– Davis mouth gag was inserted into the mouth and supported by Draffin bipods. The palatine tonsil was grasped and medialised with a Luc’s forceps. A monopolar diathermy instrument with an insulated tip was used to perform the extracapsular, tonsillar dissection (Valley Lab Force E2 diathermy machine, Force Triad Covidien). Haemostasis was achieved with diathermy using a forcep tip instrument with a power setting of 18 W. Diathermy tonsillectomy with tonsillar bed oversew This technique was utilised by Surgeon 2 at Nepean and Nepean Private Hospitals. Patient preparation was identical to that of Surgeon 1 except for a power setting of 26 W on the diathermy apparatus. After haemostasis was sufficiently achieved, the bilateral tonsillar bed oversew was performed by a single, horizontal mattress suture of the palatoglossus and palatopharyngeus muscles, using a 2-0 silk or vicryl tie, with the knot buried posterior to the palatopharyngeus muscle (Fig. 1). All patients were kept overnight and discharged the following day with analgesia and no antibiotics. All patients were instructed not to use non-steroidal anti-inflammatory analgesics and to commence a soft diet. Operating surgeons were the two Consultant Visiting Medical Officers or Otolaryngology Registrars under direct supervision. Haemorrhage post tonsillectomy is a serious complication and one that our department treats with extreme care. Primary haemorrhage is defined as pharyngeal bleeding within the first postoperative 24 h, whereas secondary haemorrhage between 24 h and 2 weeks. We defined post tonsillectomy haemorrhage in our study to include all oral bleeds. Any fresh bleeding from the throat whether large or small, which occurred after 24 h of surgery, was counted as a secondary haemorrhage. Patients were counselled about the serious nature of secondary haemorrhage and advised to present to our tertiary referral emergency centre for review of any bleeds. Only small blood streaked or minor spots in the saliva were excluded, and anything more than this was recorded as a true secondary tonsillar haemorrhage.
Eur Arch Otorhinolaryngol
Fig. 1 Photographs of the tonsillar oversew. The photographs are orientated from the surgeon’s perspective during the operation, seated at the head of the patient. A Boyle–Davis gag is inserted for exposure. a This photograph depicts the point in the operation where the palatine tonsils have been removed by diathermy tonsillectomy, Table 1 Demographics of patients from each treatment group
Variable
Age (mean) Sex, no. (%) Male Female Indication, no. (%) Recurrent tonsillitis OSA Malignancy Operation, no. (%) Tonsillectomy alone * Statistically significant
Tonsillectomy and other
All patients received follow-up. Two patients presented to other hospitals with secondary haemorrhages, one was transferred to our referral centre for observation, whereas the other required a second operation to arrest the bleeding. Patients who presented to our tertiary referral hospital with secondary haemorrhages who had initial operations elsewhere by other surgeons were not included in this study. Statistical analysis Demographic and clinical variables were compared between the two groups using t test (continuous variables) and χ2 testing (categorical variables). Logistic regression analysis was performed to evaluate risk factors and was calculated as odds ratios (OR) with 95 % confidence intervals (95 % CI). Differences were considered significant when the p value was
