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DOI 10.1007/s00405-009-0958-z

MI SC E LLANEOUS



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 bleeding
is the most severe complication; however, the factors lead-
ing to postoperative haemorrhage are still discussed contro-
versially. 1,522 tonsillectomies were retrospectively
reviewed. Histopathological tonsil composition was corre-
lated with the incidence of postoperative haemorrhage.
Patient charts were analysed with regard to demographic
data, 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 correlation
with the risk of postoperative haemorrhage (P = 0.018 and
P = 0.02), but the odds ratio was low (1.9 and 2.0). 7.7% of
all patients had postoperative bleeding and 3.5% had to
return to theatre for haemostasis. The incidence of haemor-
rhages within hospitalization (5 postoperative days) was
45% and after discharge 55%, respectively. In 11% of cases
bleeding occurred on the fourth or Wfth day after surgery.
While gender, season of surgery, abscess tonsillectomy
en chaud in comparison with elective tonsillectomy were
not associated with an increased rate of postoperative
haemorrhage (P > 0.05), signiWcant more postoperative


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

L. Heukamp
Department of Pathology, University of Bonn, Bonn, Germany

A. Schrock (&)
Universitt Bonn Klinik und Poliklinik fr
Hals-Nasen-Ohrenheilkunde/Chirurgie,
Sigmund-Freud Strae 25, 53127 Bonn, Germany
e-mail: andreasschroeck@web.de
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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 slightly
elevated and, therefore, the predictive value is low. Because
a 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 earliest
description of tonsillectomy appears in the medical ency-
clopaedia of Cornelius Celsus in AD 30. He enucleated the
tonsil with his Wngernails and suggested the fossa should be
washed out with vinegar and painted with a medication to
reduce bleeding [1]. Postoperative bleeding is still a serious
and potentially life-threatening complication. Depending
on the deWnition of post-tonsillectomy haemorrhage the
reported rates varied from 1 to 40% [2]. Postoperative
haemorrhage is classiWed in primary (<24 h after tonsillec-
tomy) or secondary (>24 h after tonsillectomy) bleeding.
Up to now numerous potential risk factors for postoperative
haemorrhage have been investigated. However, the histopa-
thological Wndings of the tonsil specimen have not been
correlated 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 for
postoperative bleeding (season of operation, age, gender)
and characteristics of postoperative haemorrhage such as,
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Table 1 Correlation of
Histology
postoperative haemorrhage and
Patients with post-OP All patients with the Statistics
histopathological diagnosis

haemorrhage (group A ) respective histopath
diagnosis
ological (odds ratio)

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)


postoperative onset, the side of bleeding tonsillar fossa, and
type of bleeding whether diVuse or deWned vessel, were
assessed.



Materials and methods

All patients undergoing tonsillectomy at the ENT Depart-
ment of the University Hospital Bonn/Germany between 1
January 2002 and 1 March 2007 were, retrospectively, ana-
lysed. The operation was always performed under general
anaesthesia by means of dissection technique. Operations
performed under local anaesthesia were excluded. Intraop-
erative haemostasis was achieved with diathermy. Ligature
was only performed if bleeding occurred from larger ves-
sels. In uneventful cases, patients were discharged 5 days
after surgery. Postoperative haemorrhage was deWned as
any bleeding that led to an additional consultation indepen-
dent on the resulting therapy. Patients with postoperative
haemorrhage were divided into two subgroups: Group A
consisted of all patients with postoperative bleedings.
Group B comprises only patients with postoperative haem-
orrhage who required another surgical treatment in the
operating theatre to stop bleeding. Data of patients with
postoperative bleeding (group A/B) were compared with
those of the tonsillectomy patients without postoperative
haemorrhage. Histopathological Wndings of the tonsil spec-
imens were correlated with the incidence of postoperative
haemorrhage. Other factors taken into consideration were
the patient age (patients older than 15 years were assigned
to the group of adults) and gender, season of operation,
onset of postoperative bleeding, side of aVected tonsillar
fossa and type of bleeding vessel. Furthermore, we com-
pared the risk for bleeding in patients with elective versus
abscess tonsillectomy en chaud.
The data were analysed using Pearsons
2
test. P < 0.05
was considered as statistically signiWcant.



Results

During the respective 5 years, 1,522 tonsillectomies were
performed 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%) patients
were 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 postoperative
haemorrhage (group A) of which 53/1,522 (3.5%) had to
return to the operation theatre to stop post-tonsillectomy
haemorrhage (group B). In none of these patients ligature
of the external carotid artery, embolisation or blood transfu-
sion was required. One of the patients in group B displayed
a previously undiagnosed coagulation disorder (HIV and
drug induced malfunction of the thrombocytes), while the
other patients with postoperative haemorrhage did not show
a bleeding disorder.

Histopathologic tissue composition versus postoperative
haemorrhage

No postoperative bleeding occurred in all 91 cases with
malignant tonsillar tumours. Of the benign histopatholo-
gical results (Table 1) only cryptic tonsillitis and actinomy-
ces infection showed a statistically signiWcant correlation
with 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 of
53 (54.7%) patients were male (Table 2). The mean age in
groups A and B was 25 (range 183) and 26 (range 176)
years, respectively. The incidence of bleeding was highest
within patients aged from 15 to 30 years in group A and 30
to 45 years in group B (Table 3). In group A, postoperative
haemorrhage 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 diVerence
was 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 main
seasons for both group A and B are shown in Table 4.



(P)
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Spring MarchMay 28/10 388 7.2/25.5
Summer JuneAugust 27/12 363 7.4/23.9
Fall SeptemberNovember 36/15 368 9.8/24.2
Winter DecemberFebruary 26/16 403 6.5/26.5


Table 2 Gender of patients
with and without postoperative

Gender Patients with post-OP
haemorrhage group A/B


Total number of
tonsillectomy patients

Risk for bleeding
in % group A/B
haemorrhage after tonsillectomy
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
015 25/11 502 4.98/2.19
1530 57/21 467 12.20/4.49
3045 24/16 287 8.36/5.57
>45 11/5 266 4.13/1.87
Table 4 Tonsillectomy proce-
dures and rates of postoperative

Season Patients with post-OP
haemorrhage group A/B


Total number of
tonsillectomies

Risk for bleeding
in % group A/B
haemorrhages for each season







There was no statistically signiWcant diVerence in the inci-
dence of postoperative haemorrhage in both patient groups
between 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 was
5.8 3.4 (range 012 days). 24 of 53 patients (45.2%) who
required operative haemostasis had haemorrhage within the
Wrst Wve postoperative days (before discharge); 29 of these
53 (54.8%) requiring operative haemostasis had already
been discharged. 10 of 53 patients (18.9%) suVered from
primary and 43 of 53 (81.1%) from secondary haemor-
rhage. The latter occurred most frequently within the Wrst
2 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 occurred
within 6.3 2.2 days (range 311 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
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Fig. 1 Post-tonsillectomy haemorrhage: postoperative number of
days

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



Discussion

To our knowledge, this is the Wrst study assessing whether
routine histologic examination of the tonsil specimen helps
to identify an increased risk for postoperative haemorrhage.
In our study, we found a statistically signiWcant correlation
between postoperative haemorrhage and the histopathological
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Table 5 Characteristics
of patients with postoperative

Abscess tonsillectomy
(n = 108)


Elective tonsillectomy
(n = 1,414)
haemorrhage receiving abscess
tonsillectomy or elective
tonsillectomy
Number of patients with
postoperative haemorrhage
Number of patients
receiving operative haemostasis
9 (8.3%) 108 (7.6%)

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)

diagnosis of cryptic tonsillitis (P = 0.018) and actinomyces
infection (P = 0.02). However, the odds ratio was low (1.9
and 2.0, respectively) and for both histologies the risk for
postoperative haemorrhage was only slightly elevated.
Therefore, the predictive value seems to be low. In our
study, the overall incidence of postoperative bleeding after
tonsillectomy was 7.7% (group A). 3.5% of all haemor-
rhages required operative haemostasis (group B). The
majority 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 of
the 53 patients of group B (18.9%) presented with primary
and 43 (81.1%) with secondary haemorrhage, respectively.
The main incidence of secondary haemorrhage in group B
was between day 6 and 9, a time when ingestion increases
as odynophagia decreases. This Wnding correlates with the
retrospective study of Windfuhr et al. (15,218 tonsillecto-
mies), who detected that secondary haemorrhage peaks at
day 6 [3]. In our study, 45% of the bleedings occurred
within the Wrst Wve postoperative days. Although 34% of
the 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 tonsillectomy
patients generally remain in hospital for 5 days. Therefore,
the question arises whether shorter hospitalization periods
might oVer a similar safety proWle with a better cost eVec-
tiveness. Some authors even support the opinion that a
postoperative monitoring for 68 h may be suYcient to
warrant safety for non-risk patients [4, 5]. In contrast, risk
factors such as age <3 years, sleep apnoea, underlying dis-
eases (e.g. heart disease, airway disorders), long distance to
the hospital, coagulations disorders, and mental retardation
[3] should rule out ambulant tonsillectomies. The reduction
of hospitalization time is supported by a large retrospective
study, which found that excessive post-tonsillectomy haem-
orrhages (8/15,218, 0.05%) took place either at the day of
surgery or as secondary haemorrhage after discharge
between day 5 and 10 [3].
In agreement with Breson and Diepeveen [6] our data
did not show a statistically signiWcant seasonal variation of
postoperative haemorrhages. In contrast, an association
between postoperative haemorrhage and season has been
observed with a peak of haemorrhages in summer months
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[7], late summer and early autumn months [8], winter
months [9] or in the winter and summer months [10]. Simi-
larly, conXicting results can be found for the correlation
between gender and the risk of post-tonsillectomy bleed-
ings: In our study, gender had no inXuence on the risk for
postoperative haemorrhage following tonsillectomy in
agreement with data by Myssiorek and Alvi [11] or Tami
et al. [11, 12]. However, other studies have shown that
males have a higher incidence of haemorrhage [7, 9, 11,
1316] and one study reported that females present with a
higher incidence of postoperative haemorrhage [9]. Over-
all, these conXicting results point at a multifactorial aetiol-
ogy rather than a direct correlation between season or
gender and risk of postoperative bleeding.
Our data shows that patient age correlates with the risk
for post-tonsillectomy bleeding in agreement with the pre-
vious literature Wndings [3, 7, 9, 11, 13, 17]. Statistically
signiWcant more postoperative haemorrhages were
detected in the group of adults with a peak within patients
aged 1530 years. This age-dependence has been attributed
to the fact that older patients have suVered from recurring
infections of the tonsils. Myssiorek and Alvi [11] claimed
that chronic infection of the tonsils leads to Wbrosis, scar-
ring and neovascularization of the tonsils, which leads to an
increased risk of post-tonsillectomy haemorrhage. How-
ever, in our study, the postoperative haemorrhage rate
decreased in patients older than 40 years. Other authors
conWrmed the Wnding that mainly middle-aged patients
experience a higher incidence of post-tonsillectomy haem-
orrhage [7, 13]. This certain age dependance might be due
to the fact that patient incompliance with regard to postop-
erative management including dietary intake and physical
rest increases in the age group between 1140 years.
In our study, no statistical signiWcant diVerence was
found between the incidence of postoperative haemorrhage
after abscess tonsillectomy en chaud (8.3%) and elective
tonsillectomy (7.7%). This supports the claim that there is
no elevated risk for postoperative haemorrhage after tonsil-
lectomy en chaud for peritonsillar abscess [3, 15, 1820].
Therefore, abscess tonsillectomy seems to be economically
more favourable than the alternative treatment with stab
incision and elective tonsillectomy within a second hospi-
talization. Furthermore, the abscess tonsillectomy obviates
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complications due to an incomplete drainage or haemor-
rhage due to injury of aberrant intratonsilar vessels during
stab incision. In addition, abscess tonsillectomy detects
malignancies presenting as tonsillar abscess at an earlier
stage [20].



Conclusion

Our data demonstrate a signiWcant correlation between the
incidence of postoperative haemorrhage and histopatholo-
gical signs of cryptic tonsillitis and actinomyces infection.
However, the risk for postoperative bleeding was only
slightly elevated, therefore the predictive value seems to be
low.
Most postoperative haemorrhages occur as primary
bleeding on the day of surgery or as late second bleeding
after 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 associated
with 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 an
increased rate of postoperative haemorrhage and therefore
should be the treatment of choice. Since a multifactorial
aetiology of post-tonsillectomy haemorrhage has to be
assumed, large multicenter studies are necessary to evaluate
the signiWcance of diVerent risk factors.

ConXict of interest statement The authors declare that they have no
conXict of interest


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