Eur Arch Otorhinolaryngol (2009) 266:1983–1987DOI 10.1007/s00405-009-0958-z

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MISCELLANEOUS

The role of histology and other risk factors for post-tonsillectomy haemorrhage

A. Schrock · T. Send · L. Heukamp · A. O. Gerstner · F. Bootz · M. Jakob

Received: 18 November 2008 / Accepted: 13 March 2009 / Published online: 25 March 2009© Springer-Verlag 2009

Abstract Tonsillectomy is a frequently performed surgi-cal procedure in children and adults. Postoperative bleedingis the most severe complication; however, the factors lead-ing to postoperative haemorrhage are still discussed contro-versially. 1,522 tonsillectomies were retrospectivelyreviewed. Histopathological tonsil composition was corre-lated with the incidence of postoperative haemorrhage.Patient charts were analysed with regard to demographicdata, characteristics of postoperative haemorrhage and indi-cation for surgery. Patients with post-tonsillectomy haem-orrhage were compared with uneventful cases.Histopathological signs of cryptic tonsillitis and actinomy-ces infection displayed a statistically signiWcant correlationwith the risk of postoperative haemorrhage (P = 0.018 andP = 0.02), but the odds ratio was low (1.9 and 2.0). 7.7% ofall patients had postoperative bleeding and 3.5% had toreturn to theatre for haemostasis. The incidence of haemor-rhages within hospitalization (5 postoperative days) was45% and after discharge 55%, respectively. In 11% of casesbleeding occurred on the fourth or Wfth day after surgery.While gender, season of surgery, abscess tonsillectomy“en chaud” in comparison with elective tonsillectomy werenot associated with an increased rate of postoperativehaemorrhage (P > 0.05), signiWcant more postoperative

haemorrhages were detected in the group of adults(P = 0.02). Despite signiWcant correlation of cryptic tonsil-litis and actinomyces infection with postoperative haemor-rhage, the risk for postoperative bleeding is only slightlyelevated and, therefore, the predictive value is low. Becausea multifactorial aetiology of post-tonsillectomy haemor-rhage has to be assumed, large multicenter studies are nec-essary to evaluate the signiWcance of diVerent risk factors.

Keywords Tonsillectomy · Haemorrhage · Histology · Risk factor

Introduction

Tonsillectomy is one of the most common surgical proce-dures performed on children and adults. The earliestdescription of tonsillectomy appears in the medical ency-clopaedia of Cornelius Celsus in AD 30. He enucleated thetonsil with his Wngernails and suggested the fossa should bewashed out with vinegar and painted with a medication toreduce bleeding [1]. Postoperative bleeding is still a seriousand potentially life-threatening complication. Dependingon the deWnition of post-tonsillectomy haemorrhage thereported rates varied from 1 to 40% [2]. Postoperativehaemorrhage is classiWed in primary (<24 h after tonsillec-tomy) or secondary (>24 h after tonsillectomy) bleeding.Up to now numerous potential risk factors for postoperativehaemorrhage have been investigated. However, the histopa-thological Wndings of the tonsil specimen have not beencorrelated with the risk of postoperative bleeding. There-fore, the aim of this study was to evaluate this correlation.In addition, the incidence of other potential risk factors forpostoperative bleeding (season of operation, age, gender)and characteristics of postoperative haemorrhage such as,

A. Schrock · T. Send · A. O. Gerstner · F. Bootz · M. JakobDepartment of Otolaryngology, Head and Neck Surgery, University of Bonn, Bonn, Germany

L. HeukampDepartment of Pathology, University of Bonn, Bonn, Germany

A. Schrock (&)Universität Bonn Klinik und Poliklinik für Hals-Nasen-Ohrenheilkunde/Chirurgie, Sigmund-Freud Straße 25, 53127 Bonn, Germanye-mail: andreasschroeck@web.de

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postoperative onset, the side of bleeding tonsillar fossa, andtype of bleeding whether diVuse or deWned vessel, wereassessed.

Materials and methods

All patients undergoing tonsillectomy at the ENT Depart-ment of the University Hospital Bonn/Germany between 1January 2002 and 1 March 2007 were, retrospectively, ana-lysed. The operation was always performed under generalanaesthesia by means of dissection technique. Operationsperformed under local anaesthesia were excluded. Intraop-erative haemostasis was achieved with diathermy. Ligaturewas only performed if bleeding occurred from larger ves-sels. In uneventful cases, patients were discharged 5 daysafter surgery. Postoperative haemorrhage was deWned asany bleeding that led to an additional consultation indepen-dent on the resulting therapy. Patients with postoperativehaemorrhage were divided into two subgroups: Group Aconsisted of all patients with postoperative bleedings.Group B comprises only patients with postoperative haem-orrhage who required another surgical treatment in theoperating theatre to stop bleeding. Data of patients withpostoperative bleeding (group A/B) were compared withthose of the tonsillectomy patients without postoperativehaemorrhage. Histopathological Wndings of the tonsil spec-imens were correlated with the incidence of postoperativehaemorrhage. Other factors taken into consideration werethe patient age (patients older than 15 years were assignedto the group of adults) and gender, season of operation,onset of postoperative bleeding, side of aVected tonsillarfossa and type of bleeding vessel. Furthermore, we com-pared the risk for bleeding in patients with elective versusabscess tonsillectomy “en chaud”.

The data were analysed using Pearson’s !2 test. P < 0.05was considered as statistically signiWcant.

Results

During the respective 5 years, 1,522 tonsillectomies wereperformed in general anaesthesia at the University Hospital

Bonn/Germany, comprising 1,414 (92.9%) elective and 108(7.1%) abscess-tonsillectomies. 1,123 (73.8%) patientswere adults and 399 (26.2%) were children. 821 (53.9%)patients were male and 701 female (46.1%). 117/1,522(7.7%) patients were identiWed as having postoperativehaemorrhage (group A) of which 53/1,522 (3.5%) had toreturn to the operation theatre to stop post-tonsillectomyhaemorrhage (group B). In none of these patients ligatureof the external carotid artery, embolisation or blood transfu-sion was required. One of the patients in group B displayeda previously undiagnosed coagulation disorder (HIV anddrug induced malfunction of the thrombocytes), while theother patients with postoperative haemorrhage did not showa bleeding disorder.

Histopathologic tissue composition versus postoperative haemorrhage

No postoperative bleeding occurred in all 91 cases withmalignant tonsillar tumours. Of the benign histopatholo-gical results (Table 1) only cryptic tonsillitis and actinomy-ces infection showed a statistically signiWcant correlationwith postoperative haemorrhages (P = 0.018 and 0.02,respectively). The odds ratio was 1.9 and 2.0, respectively.

Age and gender versus postoperative haemorrhage

In group A, 62 of 117 (53%) patients and in group B, 29 of53 (54.7%) patients were male (Table 2). The mean age ingroups A and B was 25 (range 1–83) and 26 (range 1–76)years, respectively. The incidence of bleeding was highestwithin patients aged from 15 to 30 years in group A and 30to 45 years in group B (Table 3). In group A, postoperativehaemorrhage was statistically signiWcant increased in adults(97/1,123, 8.6%) compared with children (20/399, 5.0%,P = 0.02). In group B, no statistically signiWcant diVerencewas found between adults (44/1,123, 3.9%) and children(9/399, 2.3%) with postoperative bleeding.

Season of operation versus postoperative haemorrhage

The incidence of postoperative bleeding in the four mainseasons for both group A and B are shown in Table 4.

Table 1 Correlation of postoperative haemorrhage and histopathological diagnosis

Histology Patients with post-OP haemorrhage (group A)

All patients with the respective histopathological diagnosis

Statistics (odds ratio) (P)

Cryptic tonsillitis 101 1,180 0.018 (1.9)

Follicular hyperplasia 87 1,051 0.196

Fibrosis (peri- and tonsillar) 33 439 0.874

Peritonsillitis 24 282 0.565

Actinomyces infection 15 113 0.020 (2.0)

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There was no statistically signiWcant diVerence in the inci-dence of postoperative haemorrhage in both patient groupsbetween the four main seasons.

Postoperative bleeding with respect to time after operation, side of tonsillar fossa and type of bleeding vessel

Within group B, the mean number of days after tonsillec-tomy at which postoperative haemorrhage occured was5.8 § 3.4 (range 0–12 days). 24 of 53 patients (45.2%) whorequired operative haemostasis had haemorrhage within theWrst Wve postoperative days (before discharge); 29 of these53 (54.8%) requiring operative haemostasis had alreadybeen discharged. 10 of 53 patients (18.9%) suVered fromprimary and 43 of 53 (81.1%) from secondary haemor-rhage. The latter occurred most frequently within the Wrst2 days after discharge (day 6 and 7) (Fig. 1).

Based on the judgement of the treating ENT surgeon,34.6% of postoperative haemorrhage which had to be man-aged in the operating theatre was due to arterial and 65.4%due to venous bleeding. While arterial bleedings occurredwithin 6.3 § 2.2 days (range 3–11 days) after tonsillectomy,venous bleedings occurred within 4.8 § 3.8 days (range 0–11 days) after surgery. The side of bleeding was in 35.5%the right and in 64.5% the left tonsillar fossa.

Abscess tonsillectomy versus elective tonsillectomy

Nine of 108 patients (8.3%) undergoing abscess tonsillec-tomy suVered from postoperative haemorrhage and in 4

(3.7%) cases operative haemostasis was required. In con-trast, 108 of 1,414 (7.6%) patients who underwent electivetonsillectomy had postoperative haemorrhage and 49patients (3.5%) required operative haemostasis (Table 5).

Discussion

To our knowledge, this is the Wrst study assessing whetherroutine histologic examination of the tonsil specimen helpsto identify an increased risk for postoperative haemorrhage.In our study, we found a statistically signiWcant correlationbetween postoperative haemorrhage and the histopathological

Table 2 Gender of patients with and without postoperative haemorrhage after tonsillectomy

Gender Patients with post-OP haemorrhage group A/B

Total number of tonsillectomy patients

Risk for bleeding in % group A/B

Male 62/29 821 7.6/3.5

Female 55/24 701 7.8/3.4

Table 3 Age of patients with and without postoperative haemorrhage after tonsillectomy

Age (years) Patients with post-OP haemorrhage group A/B

Total number of tonsillectomy patients

Risk of bleeding in % group A/B

0–15 25/11 502 4.98/2.19

15–30 57/21 467 12.20/4.49

30–45 24/16 287 8.36/5.57

>45 11/5 266 4.13/1.87

Table 4 Tonsillectomy proce-dures and rates of postoperative haemorrhages for each season

Season Patients with post-OP haemorrhage group A/B

Total number of tonsillectomies

Risk for bleeding in % group A/B

Spring March–May 28/10 388 7.2/25.5

Summer June–August 27/12 363 7.4/23.9

Fall September–November 36/15 368 9.8/24.2

Winter December–February 26/16 403 6.5/26.5

Fig. 1 Post-tonsillectomy haemorrhage: postoperative number ofdays

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diagnosis of cryptic tonsillitis (P = 0.018) and actinomycesinfection (P = 0.02). However, the odds ratio was low (1.9and 2.0, respectively) and for both histologies the risk forpostoperative haemorrhage was only slightly elevated.Therefore, the predictive value seems to be low. In ourstudy, the overall incidence of postoperative bleeding aftertonsillectomy was 7.7% (group A). 3.5% of all haemor-rhages required operative haemostasis (group B). Themajority of bleedings occured in the left tonsillar fossa,which might be due to the fact that left-sided tonsillecto-mies are more demanding for right-handed surgeons. 10 ofthe 53 patients of group B (18.9%) presented with primaryand 43 (81.1%) with secondary haemorrhage, respectively.The main incidence of secondary haemorrhage in group Bwas between day 6 and 9, a time when ingestion increasesas odynophagia decreases. This Wnding correlates with theretrospective study of Windfuhr et al. (15,218 tonsillecto-mies), who detected that secondary haemorrhage peaks atday 6 [3]. In our study, 45% of the bleedings occurredwithin the Wrst Wve postoperative days. Although 34% ofthe haemorrhages took place until day 3, merely 11%occurred within the fourth or Wfth day. This Wnding is inter-esting due to the fact that in Germany tonsillectomypatients generally remain in hospital for 5 days. Therefore,the question arises whether shorter hospitalization periodsmight oVer a similar safety proWle with a better cost eVec-tiveness. Some authors even support the opinion that apostoperative monitoring for 6–8 h may be suYcient towarrant safety for non-risk patients [4, 5]. In contrast, riskfactors such as age <3 years, sleep apnoea, underlying dis-eases (e.g. heart disease, airway disorders), long distance tothe hospital, coagulations disorders, and mental retardation[3] should rule out ambulant tonsillectomies. The reductionof hospitalization time is supported by a large retrospectivestudy, which found that excessive post-tonsillectomy haem-orrhages (8/15,218, 0.05%) took place either at the day ofsurgery or as secondary haemorrhage after dischargebetween day 5 and 10 [3].

In agreement with Breson and Diepeveen [6] our datadid not show a statistically signiWcant seasonal variation ofpostoperative haemorrhages. In contrast, an associationbetween postoperative haemorrhage and season has beenobserved with a peak of haemorrhages in summer months

[7], late summer and early autumn months [8], wintermonths [9] or in the winter and summer months [10]. Simi-larly, conXicting results can be found for the correlationbetween gender and the risk of post-tonsillectomy bleed-ings: In our study, gender had no inXuence on the risk forpostoperative haemorrhage following tonsillectomy inagreement with data by Myssiorek and Alvi [11] or Tamiet al. [11, 12]. However, other studies have shown thatmales have a higher incidence of haemorrhage [7, 9, 11,13–16] and one study reported that females present with ahigher incidence of postoperative haemorrhage [9]. Over-all, these conXicting results point at a multifactorial aetiol-ogy rather than a direct correlation between season orgender and risk of postoperative bleeding.

Our data shows that patient age correlates with the riskfor post-tonsillectomy bleeding in agreement with the pre-vious literature Wndings [3, 7, 9, 11, 13, 17]. StatisticallysigniWcant more postoperative haemorrhages weredetected in the group of adults with a peak within patientsaged 15–30 years. This age-dependence has been attributedto the fact that older patients have suVered from recurringinfections of the tonsils. Myssiorek and Alvi [11] claimedthat chronic infection of the tonsils leads to Wbrosis, scar-ring and neovascularization of the tonsils, which leads to anincreased risk of post-tonsillectomy haemorrhage. How-ever, in our study, the postoperative haemorrhage ratedecreased in patients older than 40 years. Other authorsconWrmed the Wnding that mainly middle-aged patientsexperience a higher incidence of post-tonsillectomy haem-orrhage [7, 13]. This certain age dependance might be dueto the fact that patient incompliance with regard to postop-erative management including dietary intake and physicalrest increases in the age group between 11–40 years.

In our study, no statistical signiWcant diVerence wasfound between the incidence of postoperative haemorrhageafter abscess tonsillectomy “en chaud” (8.3%) and electivetonsillectomy (7.7%). This supports the claim that there isno elevated risk for postoperative haemorrhage after tonsil-lectomy “en chaud” for peritonsillar abscess [3, 15, 18–20].Therefore, abscess tonsillectomy seems to be economicallymore favourable than the alternative treatment with stabincision and elective tonsillectomy within a second hospi-talization. Furthermore, the abscess tonsillectomy obviates

Table 5 Characteristics of patients with postoperative haemorrhage receiving abscess tonsillectomy or elective tonsillectomy

Abscess tonsillectomy (n = 108)

Elective tonsillectomy (n = 1,414)

Number of patients with postoperative haemorrhage

9 (8.3%) 108 (7.6%)

Number of patients receiving operative haemostasis

4 (3.7%) 49 (3.5%)

Gender (male/female) 65/43 (60.2)/(39.8%) 756/658 (53.5)/(46.5%)

Mean age § SD 32.5 (§14.8) 26 (§19.8)

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complications due to an incomplete drainage or haemor-rhage due to injury of aberrant intratonsilar vessels duringstab incision. In addition, abscess tonsillectomy detectsmalignancies presenting as tonsillar abscess at an earlierstage [20].

Conclusion

Our data demonstrate a signiWcant correlation between theincidence of postoperative haemorrhage and histopatholo-gical signs of cryptic tonsillitis and actinomyces infection.However, the risk for postoperative bleeding was onlyslightly elevated, therefore the predictive value seems to below.

Most postoperative haemorrhages occur as primarybleeding on the day of surgery or as late second bleedingafter discharge (5th postoperative day). Only few haemor-rhages occurred on the fourth or Wfth day after surgery.Although gender and season of surgery were not associatedwith an increased rate of post-tonsillectomy haemorrhage,adult patients had signiWcantly increased risk for postopera-tive haemorrhage. In comparison with elective tonsillec-tomy abscess tonsillectomy was not associated with anincreased rate of postoperative haemorrhage and thereforeshould be the treatment of choice. Since a multifactorialaetiology of post-tonsillectomy haemorrhage has to beassumed, large multicenter studies are necessary to evaluatethe signiWcance of diVerent risk factors.

ConXict of interest statement The authors declare that they have noconXict of interest

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