Measurement of the True Incidence of Secondary Haemorrhage Post Tonsillectomy

Abstract

Aim: To determine the ‘true’ secondary haemorrhage rate post-tonsillectomy. Methods: A telephone survey was conducted of 127 consecutive patients who had a tonsillectomy at the Freeman Hospital over a two-month period. Results: 99 patients were contactable. There were 38 post-tonsillectomy bleeds, 23 of which were minor and 15 significant. 23 bleeds went unreported and four of these were significant. 11 percent of bleeds post-cold steel tonsillectomy were significant, compared to 28 percent of bleeds post-diathermy dissection. Conclusion: There is a high incidence of unreported bleeding (61 percent of those that bled) and a third of adults who suffered a significant bleed did not report it. Diathermy had a significantly higher proportion of significant bleeds compared to cold steel. It is recommended if secondary haemorrhage rates are reported in the literature then small studies should contact patients for ‘true’ secondary bleed rates while large studies should use return to theatre and need for transfusion rates. Surg Med Open Acc J Copyright © Vik Veer 2/3 How to cite this article: Luke H, Vik V. Measurement of the True Incidence of Secondary Haemorrhage Post Tonsillectomy. Surg Med Open Acc J. 2(1). SMOAJ.000529.2018. DOI: 10.31031/SMOAJ.2018.02.000529 Volume 2 Issue 1 F. If yes, how were you managed? A bleed of less than one minute was classified as minor, and a bleed greater than one minute as significant. This point was clearly qualified with the patient, as blood actively running for greater than a minute. Multiple presentations were only counted once. Details about each patient’s tonsillectomy operation were also collected from the medical notes. In a few cases the operative procedure wasn’t fully detailed and the individual surgeon’s usual practice was assumed. Results Data was obtained from 99 of the 127 patients who had tonsillectomies in the selected period, which represented 78 percent of the sample. Of these 99, 38 (38 percent) reported a posttonsillectomy bleed (Figure 1). Of the 38 post-tonsillectomy bleeds, 23 (61 percent) went unreported. In total there were 23 minor bleeds and 15 significant bleeds (Figure 2). Figure 1: Post-tonsillectomy bleed rates in 99 patients interviewed. Figure 2: Categorisation of 38 post-tonsillectomy bleeds. Figure 3: Comparison of bleed types in children and adults. Of the 38 people who experienced bleeding, only 15 reported the incident to a health professional, the vast majority of which visited A&E (14 of the 15 reported). Of the 23 people who didn’t report their bleeding, four individuals suffered a significant bleed, the remaining 19 described minor bleeding (Figure 2). Notably, of the four significant unreported bleeds, two heralded a larger episode of bleeding requiring hospital admission. Of the 15 reported bleeds, 11 were significant while four were minor (Figure 3). Of the 11 significant bleeds reported, seven of these were sent home by A&E without consulting ENT as the bleeding had resolved. There were a total of six readmissions equating to a 4.7 percent readmission rate and a 0.8 percent return to theatre rate (accounted for by one individual). There were seven children in whom a bleed occurred, five of these were significant and reported, while two minor bleeds went unreported. 31 adults bled and 18 of these were minor, of which 14 went unreported (Figure 3). Of the 13 significant bleeds in adults, four went unreported (31 percent). The majority of minor bleeds occurred in the first 24-72 hours while significant bleeds tended to occur between days three and eight (Figure 4). Figure 4: Timing of reported bleeds. Of the 99 procedures performed on interviewees, there were 74 cold steel operations and 25 used a diathermy technique see Table 1. Pearson’s Chi-squared analysis revealed no significant difference when comparing the overall bleed rates for these two techniques, 37 percent and 40 percent for cold steel and diathermy respectively (p=0.754). However, looking at the severity of the bleed experienced, diathermy demonstrated a significantly higher rate of significant bleeds, 28 percent versus 11 percent (p=0.038). Table 1: Comparison of “hot” versus cold steel technique bleed rates. Method No. Ops No. Bleeds % Bleeds No. Sig. Bleeds % Sig. Bleeds Cold Steel 74 27 37% 8 11% Diathermy 25 10 40% 7 28% Discussion This study has highlighted a high incidence of some degree of post-tonsillectomy bleeding (38 percent of the sample) and that much of this goes unreported (62 percent of those that experienced a bleed). Significant bleeds tended to occur between days 3-8 as opposed to minor bleeds that were often in the first 24-72 hours. Significant bleeds were always reported in children but four adults with a significant bleed went unreported. This has important ramifications, especially considering two of these individuals