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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 9  |  Issue : 1  |  Page : 47-50

Dissection and snare method of tonsillectomy, hemostasis by ligature technique in a tertiary care center: A decade study


1 Department of ENT, Government Chengalpattu Medical College, Chengalpattu, Tamil Nadu, India
2 Department of ENT, Government Villupuram Medical College, Viluppuram, Tamil Nadu, India

Date of Submission01-Dec-2020
Date of Decision07-Dec-2020
Date of Acceptance15-Dec-2020
Date of Web Publication29-Jun-2021

Correspondence Address:
D Senthamarai Kannan
Department of ENT, Chengalpattu Medical College and Hospital, Chengalpattu, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jhnps.jhnps_62_20

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  Abstract 


Background: Despite advances in surgical technique, postoperative hemorrhage remains a common cause of morbidity and mortality for patients following tonsillectomy. Attempts to reduce the morbidity of tonsillectomy have included changes to the surgical techniques and perioperative medications to reduce the risk of bleeding. Here, we did a decade study about ligature technique in tonsillectomy for the achievement of hemostasis and its effectiveness in controlling morbidity. Aim: The aim of this study was to analyze the posttonsillectomy hemorrhage rate when we use ligature technique in tonsillectomy procedure. Materials and Methods: We retrospectively reviewed data of all patients who underwent tonsillectomy by dissection and snare method in the ENT Department, Chengalpattu Medical College and Hospital, Tamil Nadu, between March 1, 2010, and February 29, 2020. The rate of postoperative hemorrhage after using ligature technique was measured and compared with other methods used in other studies. Results: Totally 12,536 patients who underwent tonsillectomy were analyzed in this study. Posttonsillectomy hemorrhage occurred only in 62 patients (0.494%). Only 14 (0.001)) patients required re-intubation and correction procedure. The hemorrhage rate was very minimal when compared with other techniques in other studies. Conclusion: We conclude that the ligature technique used in tonsillectomy for hemostasis remains one of the best methods even though it is an ancient method.

Keywords: Complication, hemorrhage, ligature technique, tonsillectomy


How to cite this article:
Kannan D S, Rajan G S, Narendrakumar V, Baby AN. Dissection and snare method of tonsillectomy, hemostasis by ligature technique in a tertiary care center: A decade study. J Head Neck Physicians Surg 2021;9:47-50

How to cite this URL:
Kannan D S, Rajan G S, Narendrakumar V, Baby AN. Dissection and snare method of tonsillectomy, hemostasis by ligature technique in a tertiary care center: A decade study. J Head Neck Physicians Surg [serial online] 2021 [cited 2021 Sep 25];9:47-50. Available from: https://www.jhnps.org/text.asp?2021/9/1/47/319747




  Introduction Top


Tonsillectomy remains one of the most common surgical procedures worldwide.[1] Tonsillectomy is a surgical procedure which includes complete removal of the tonsil with its capsule. It may involve adenoidectomy also.[2] Obstructive sleep disorders and recurrent throat infections are the two most common and accepted indications for tonsillectomy.[3] It also performs for recurrent throat infections. Peritonsillar cellulitis or abscess, pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections, cryptic tonsillitis, and chronic carrier state of Group A beta-hemolytic streptococci are several controversial indications for tonsillectomy.[4] Several different techniques have been used for performing tonsillectomies. In that hemostasis, achievement is the most important consideration. The ideal method should be safe, efficient, and affordable for the patient and physicians. Here, we did a decade study of hemostasis management using ligature technique in tonsillectomies by dissection and snare method and its effectiveness.


  Materials and Methods Top


This is a retrospective study of 10 years (March 1, 2010–February 29, 2020, inclusive). All tonsillectomies done in the above period was included in our study. We retrospectively reviewed the records of all patients who had undergone a tonsillectomy with or without adenoidectomy in the ENT Department of Chengalpattu Medical College and Hospital, Tamil Nadu, India.

Totally 12,536 tonsillectomy cases were included, which were sometimes accompanied by adenoidectomy. The sample included both children and adults of both sexes. All patients underwent dissection and snare method of tonsillectomy. Information was obtained regarding indication of surgery, demographic characteristics (gender and age), episodes of reactionary hemorrhage, return to operation theaters for reactionary hemorrhage, secondary hemorrhage, and postoperative pain. Information regarding complications was obtained from our morbidity and mortality database. We also reviewed operation theater and re-admission records. All the patients were discharged on the 3rd day of surgery and followed up on the 7th and 14th postoperative days.


  Results Top


Our study group was made up of 12,536 patients. Of these patients, 7102 (56.6%) were male and 5432 (43.4%) were female. The number of patients <18 years of age was 10,672 (85.1%). 1864 (14.9%) patients were adults who underwent surgery for various indications.

The most common age group who underwent surgery was from 6 to 10 years of age (42.8%). The second most common age group was 11–15 years of age, which is about 35.8%. Only 0.36% of people did surgery after 40 years of age in our hospital during the study period. Children <5 years who did surgery were also very less (1.5%) [Figure 1]. The most common indication was chronic adenotonsillitis in our hospital. 11,722 (93.55%) patients underwent surgery for chronic adenotonsillitis. Other indications were adenotonsillar hypertrophy with obstructive sleep apnea (4.1%), peritonsillar abscess followed by interval tonsillectomy (2%), and suspected malignancy (0.36%). The least common indication was suspected malignancy [Table 1].
Table 1: Indications for surgery

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Figure 1: Age distribution

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After tonsillectomy, the most common and important complication we came across was postoperative hemorrhage. There were also other complications such as postoperative infections, temporomandibular joint dysfunction, and postoperative pain. As our study is mainly concentrated on postoperative hemorrhage, we followed the details of those patients. Of 12,536 patients, 62 (0.494%) patients experienced postoperative hemorrhage. Of these patients, 37 (59.6%) were male and 25 (40.3%) were female. No patients developed secondary hemorrhage during our study period. Eight (0.06%) patients developed postoperative infections and managed with intravenous antibiotics and supportive treatment. Two (0.02%) patients developed temporomandibular joint dysfunction [Figure 2].
Figure 2: Postoperative complications

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There was a significantly higher postoperative hemorrhage rate in the older age group. Fifty-five (88.7%) patients were above 18 years of age. Post operative hemorrhage was more common in 21-30 years of age in our study. In patients <18 years of age, only 7 (11.28%) patients developed hemorrhage [Figure 3]. The most common cause of postoperative hemorrhage was peritonsillar abscess followed by interval tonsillectomy. Out of 62 patients, 30 (0.23%) patients did interval tonsillectomy. Recurrent adenotonsillitis was the second most common cause of hemorrhage, 15 (0.11%). Out of 62 patients who developed hemorrhage, 9 (0.07%) patients' indication for tonsillectomy was suspected malignancy [Table 2]. Most of the patients developed postoperative hemorrhage within 0–2 h of surgery, which is about 80.6%. Twelve (0.09%) patients developed hemorrhage between 2 and 6 h of surgery. In these patients, 14 (0.11%) patients required re-intubation and second surgery. Three patients were diagnosed to have bleeding disorder after managing postoperative hemorrhage [Figure 4].
Table 2: Indications of surgery for the patients who developed hemorrhage

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Figure 3: Age distribution of postoperative hemorrhage

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Figure 4: Time duration of reactionary hemorrhage after surgery

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  Discussion Top


The tonsils, which form a protective ring around the posterior aspect of the nasal cavity and oral cavity, are the parts of the immune system. A tonsillectomy is a surgical procedure to remove the tonsils to treat an underlying disease. It is one of the most common surgeries that perform worldwide. Celsus in 30 B.C. performed the first tonsil removal.[1] According to the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS), more than 530,000 tonsillectomies are performing every year for various indications in children and adolescents.[2] Among the indications for tonsillectomy are recurrent throat infections, recurrent tonsillitis, peritonsillar abscess formation, and obstructive sleep apnea.[3] To improve the quality of life and to reduce the antibiotic usage, the AAO-HNS recommends tonsillectomy in cases of recurrent throat infections with cervical lymphadenopathy, tonsillar exudates, or positive throat culture for Group A beta-hemolytic streptococci. Dissection of tonsil along with its capsule is called as tonsillectomy.[4] There are many techniques for tonsillectomy today including cold techniques and hot techniques. Cold techniques are traditional techniques which use sharp instruments to incise and blunt instruments to dissect the tonsil. Direct pressure, silk ligation, and chemical cautery are the methods to achieve hemostasis. Hot methods involve electrosurgical methods and thermal instruments. Bipolar scissor dissection, coblation technique, microdebrider endoscopic tonsillectomy, harmonic scalpel using ultrasonic energy, radiofrequency excision with probes, and laser tonsillectomy are the newer methods for tonsillectomy.[5] These new ways are considered to reduce the size of the tonsil, to decrease the tie period, to minimize and prompt control of bleeding during surgery, and to decline postoperative pain enabling the patient to resume his or her normal day-to-day activities.

Postoperative hemorrhages, pain, and postoperative infection with secondary hemorrhage are the major morbidities associated with tonsillectomy.[6] There are several hemostatic methods to reduce the blood loss which include traditional silk ligation, electrocautery, oxymetazoline hydrochloride packs, tannic acid, topical thrombin, and bismuth subgallate.[7] Coblation is a relatively new technique. Production of plasma filed of high ionized particles is the mechanism. Electrocautery method cuts tissues at 400°C.[8] The ideal method should be safe, painless, and fast with rapid recovery. Debate continues within the literature regarding the ideal technique for achievement of hemostasis.

We compared our results of conventional method of tonsillectomy with silk ligation method with various studies done in the world using various methods. Several investigators have explored the frequency of posttonsillectomy hemorrhage. In a study done by Noordzij et al. in 2006, the postoperative hemorrhage rate for coblation tonsillectomy was 2.1% and for electrocautery was 6.2%.[8] Reusser et al. did a study, which showed that 1.04% of patients developed hemorrhage after coblation procedure of 3177 patients. 1.71% developed hemorrhage out of 1633 patients when they used coblation with partial suture closure procedures. When they used diathermy method in 1850 patients, 29 (1.57%) developed postoperative bleeding.[9]

Mosges et al. studied the hemorrhage rate after coblation tonsillectomy. Data of 796 patients who had undergone coblation tonsillectomy were analyzed, and the rate of postoperative hemorrhage was 4.1%.[10] Kim et al. studied posttonsillectomy hemorrhage in children using coblation surgery and diathermy. Totally 1397 children underwent surgery by a single surgeon in a single center from 2005 to 2011. 2.9% of patients in the diathermy group and 2.8% in the coblation group developed postoperative hemorrhage.[11]

In our study, the postoperative hemorrhage rate is only 0.49%, which means that 62 patients out of 12,536 developed hemorrhage after surgery by ligature method in dissection and snare tonsillectomy. Hence, we can conclude that even if ligature technique is an old method, it is a very effective method to prevent hemorrhage after surgery than any other methods.


  Conclusion Top


Postoperative hemorrhage following tonsillectomy is one of the common and dangerous complications. Management of hemorrhage by suturing technique is an oldest method. However, our study proved that it is still one of the best methods for hemostasis control.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Disclosure

This material has never been published and is not currently under evaluation in any other peer-reviewed publication.

Ethical approval

The permission was taken from the Institutional Ethics Committee prior to starting the project. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.



 
  References Top

1.
Belloso A, Chidambaram A, Morar P, Timms MS. “Coblation tonsillectomy versus dissection tonsillectomy: Postoperative hemorrhage.” Laryngoscope 2003;113:2010-3.  Back to cited text no. 1
    
2.
Cooper CM, Checketts JX, Brame L, Gray H, Downs JB, Vassar M. “An analysis of the literature addressing tonsillectomy knowledge gaps.” Int J Pediatr Otorhinolaryngol 2018;115:89-93.  Back to cited text no. 2
    
3.
Randel A. “AAO-HNS guidelines for tonsillectomy in children and adolescents.” Am Fam Physician 2011;84:566-73.  Back to cited text no. 3
    
4.
Wall JJ, Tay KY. Postoperative Tonsillectomy Hemorrhage.Emerg Med Clin North Am. 2018;36:415-26.  Back to cited text no. 4
    
5.
Brkic F, Mujic M, Umihanic S, Hrncic N, Goga A, Goretic E. Haemorrhage Rates After Two Commonly Used Tonsillectomy Methods: a Multicenter Study. Med Arch. 2017;71:119-21.  Back to cited text no. 5
    
6.
Johnson LB, Elluru RG, Myer III CM, “Complications of adenotonsillectomy.” Laryngoscope 2002;112:35-7.  Back to cited text no. 6
    
7.
Leach J, Manning S, Schaefer S. “Comparison of two methods of tonsillectomy.” Laryngoscope 1993;103:619-22.  Back to cited text no. 7
    
8.
Noordzij JP, Affleck BD. “Coblation versus inipolar electrocautery tonsillectomy: A prospective, randomized, single blind study in adult patients.” laryngoscope 2006;116:1303-9.  Back to cited text no. 8
    
9.
Reusser NM, Bender RW, Agrawal NA, Albright JT, Duncan NO, Edmonds JL. Post-tonsillectomy hemorrhage rates in children compared by surgical technique. Ear Nose Throat J 2017;96:E7-11.  Back to cited text no. 9
    
10.
Mösges R, Hellmich M, Allekotte S, Albrecht K, Böhm M. Hemorrhage rate after coblation tonsillectomy: a meta-analysis of published trials. Eur Arch Otorhinolaryngol. 2011;268:807-16.  Back to cited text no. 10
    
11.
Kim JW, Mun SJ, Lee WH, Mo JH. Post-tonsillectomy hemorrhage in children: a single surgeon's experience with coblation compared to diathermy. Eur Arch Otorhinolaryngol. 2013;270:339-44.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2]



 

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