Comparison between Post-tonsillectomy Bleeding of Three Different Techniques in Children

Introduction: Post-tonsillectomy bleeding remains the most serious complication of tonsillectomy. The rate of post tonsillectomy bleeding varies with different technique. The common used techniques are the bipolar, monopolar and cold. Methods: This was a retrospective case series study based on chart review of children under 14 years who underwent tonsillectomy during the period between January 2010 to December 2011 at King Abdulaziz Medical City (KAMC), Riyadh, Saudi Arabia – ENT department. The charts of all the patients were reviewed by the student and the data form filled for included patients for the age, gender, indications for tonsillectomy, previous surgery, medications, admission type, technique used which are the bipolar, monopolar and cold technique and complications. Results: Out of 60 patients reviewed, post tonsillectomy bleeding was reported in 16 (27%). Indications for tonsillectomy were six indications and most common one was recurrent adenotonsillitis in 27 (46%). Intraoprative bleeding was 8 cases (13%) which was the most common type of bleeding and there was no significant difference in post tonsillectomy bleeding between the three techniques (p=0.62). Conclusion: The result showed that there was no significant difference in post tonsillectomy bleeding between the three techniques.


Introduction
The tonsils are tissue mass at the back of the throat. If they keep becoming infected, or if they enlarged and cause problems such as shortness of breath (SOB), they may need to be removed in an operation called tonsillectomy [1,2]. The indications for operation included chronic or recurrent tonsillitis three times or more in each of the three preceding years despite adequate medical therapy and tonsillar hypertrophy associated with positive history of snoring and restless sleep [2,3].
Tonsillectomy is one of the most common surgical operations performed in the world, it is estimated to be more than 530,000 operations performed annually in children younger than 15 [2,4]. Post tonsillectomy bleeding remains the most serious complication of tonsillectomy [5]. The rate of post tonsillectomy bleeding varies with different technique [6]. Bleeding has been divided into two categories; primary, occurring less than 24 hour after surgery and secondary, occurring more than 24 hour, commonly 5-10 days after the operation. Secondary hemorrhage has a reported rate of 3-5% leading to re-admission to hospital [7,8].
Primary bleeding is generally considered to be related to surgical technique. Different techniques causing different rate of bleeding, systemic steroid can effect posttonsillectomy bleeding, environmental factors play a role in delaying healing process in secondary bleeding [7,9,10].
In monopolar microdissection tonsillectomy removal of the tonsils was through subcapsular dissection using Colorado needle tip (Stryker-Leibinger, Freiburg, Germany), in the bipolar uses a combination of power, waveform, frequency, electrode size and time of application to produce a tissue temperature that will result in predictable histological effect and In the cold dissection tonsillectomy removal of both tonsils was by using cold surgical instruments and hemostasis secured by the bipolar diathermy.
This study will compare the incidence of post tonsillectomy bleeding between the three techniques that performed at NGHA (bipolar, monopolar, cold technique) to find the least post tonsillectomy bleeding incidence [11].

Aim of the study
To find the least post tonsillectomy bleeding between the three techniques the bipolar, monopolar and cold technique in children younger than 14 years to reduce the risk of post-tonsillectomy bleeding rate.

Specific objectives
To compare the rate of post tonsillectomy bleeding between different techniques.

Methods
A retrospective case-series study in which a chart review performed on children under 14 years who underwent tonsillectomy during the period between January 2010 to December 2011.

Chart 1: Indications for Tonsillectomy.
The charts of all the patients were reviewed by the student and the data form filled for included patients for the age, gender, indications for tonsillectomy, previous surgery, medications, admission type, technique used which are the bipolar, monopolar and cold technique and complications (Charts 1-3).

Study area
The study conducted in King Abdulaziz Medical City (KAMC), Riyadh, Saudi Arabia -ENT department; There are 600 tonsillectomy operated per year.

Study subjects
Including criteria 1-Children 14 years old or younger.

Study design
Retrospective case-series.

Sample size
All patients who underwent tonsillectomy at KFNGH between January 2010 and December 2011 and after doing the sample size calculation of 90% confidence level and 5% margin of error to get least sample size that result in 97 patients but I had only 60 patients because of incomplete information in some files.

Sampling technique
This is a retrospective study of all patients who underwent tonsillectomy at KFNGH between January 2010 and December 2011 according to the inclusion and exclusion criteria. The chart of all patients reviewed by the student and the data form filled for included patients.

Data collection methods, Instrument used, Measurements
Through the Medical Record Department, the chart of all patients reviewed by the student according to the inclusion and exclusion criteria and the data form filled for included patients.

Data management and analysis plan
The study group divided into three groups: Group one: patients who underwent tonsillectomy with cold technique.
Group two: patients who underwent tonsillectomy with bipolar electrocautery technique.
Group three: patients who underwent tonsillectomy with monopolar electrocautery technique.
Then we took from each patient the indications for the surgery, the type of admission, medications and past medical history.
After that we record for each surgery if there is bleeding or not and the type of bleeding.
(In each group data regarding age, sex, post-operative bleeding had been taken) * Descriptive statistical presented as frequency and percentage.
Then we compared the incidence of bleeding between the three groups using Chi-squared test and SPSS statistical package.

Ethical considerations
The name and medical record number was not entered in the software, but had only accessible to the principal and CO-investigators.

Results
Sixty cases of tonsillectomy from different gender and age under 14 years were reviewed, the male gender was the majority of the sample 40 (67%), the ages were between one year to six years, Clinical indications for operation were six and the most common one is the recurrent adenotonsillitis with 27(46%) cases, the majority of the cases were done as case day surgery 50 (83%) ( Table 1), for the techniques used, the Bipolar in 20 cases, Monopolar in 17 cases and the cold technique in 23 cases ( Table 2).
The study results with analysis of all patients who underwent tonsillectomy at King Fahad National Guard between January 2010 and December 2011 that there were 16 (26.7%) cases of posttonsillectomy bleeding and the most type of bleeding was intraoperative bleeding with eight cases, primary bleeding was four cases and secondary bleeding was three cases.
For the techniques which one causing bleeding, the monopolar was six cases, the cold technique and the bipolar were five for each (Table  3).
At the end our study didn't find significant difference in posttonsillectomy bleeding between the three techniques (P=0.62).

Discussion
Post-tonsillectomy hemorrhage remains the most serious complication of tonsillectomy. In comparing with the more recent systematic literature review identified a difference in the rate of posttonsilliectomy bleeding after different techniques for tonsilliectomy.
Post-tonsillectomy bleeding among children undergoing traditional tonsillectomy with those undergoing electrodessiction tonsillectomy were compared. A total of 190 children (2-12 years old). Eighty-Nine males and 101 females, who were admitted to Al-Namas General Hospital during the period of 2008 to 2011 for tonsillectomy were randomized into either traditional tonsillectomy (97 patients) or electrodissection tonsillectomy (93 patients). Postoperative hemorrhage was experienced by 6 cases who underwent traditional tonsillectomy (6.2%) and 2 cases who underwent tonsillectomy by electrodissection (2.2%). Difference between both study groups regarding postoperative hemorrhage was not statistically significant.
In other study in 2007, Australian a prospective institutional study for if there is different rate of post-tonsillectomy bleeding between the commonly used techniques, with one thousand one hundred thirtythree consecutive cases were analyzed the primary post-tonsillectomy hemorrhage rate was 0.2% for blunt dissection plus diathermy hemostasis and 0.3% for monopolar diathermy dissection plus hemostasis. Monopolar diathermy had a lower rate of secondary postoperative hemorrhage. These differences, however, did not reach statistical significance, and neither did the relative risk between the two techniques. Two-way analysis of variance among secondary posttonsillectomy hemorrhage complications by technique and by age groups shows a highly statistically significant difference by age group.

Conclusion
Since the study didn't find any significant difference in posttonsillectomy bleeding between the three techniques, our recommendation is to increase the sample size.