BACKGROUND:In patients with cleft palate (CP), the impact of primary palatoplasty technique on otologic outcomes remains a major point of contention. While some studies report improved outcomes after certain techniques of palatal repair, there is a lack of consensus on the most effective procedure. OBJECTIVE:We sought to characterize the effects of primary palatoplasty technique on otologic outcomes in children with CP. METHODS:A single institution retrospective review of patients with CP who underwent primary palatoplasty (straight-line repair or Furlow Z-plasty) was performed. Primary outcomes of interest included time to placement of T-tubes, number of tympanostomy tube placements, tympanic membrane (TM) perforation, and 3-year and 6-year postoperative hearing thresholds. RESULTS:A total of 140 patients were included in this study. The mean number of tympanostomy tube placements in the straight-line repair group (1.93 ± 1.28) was significantly higher than in the Furlow Z-plasty group (1.42 ± 1.03, p = 0.03). Median time from primary palate repair to T-tube placement was 38.93 (IQR 33.03) months. Higher birth weight (p < 0.01) and multiple tympanostomy tube placements (p < 0.05) were associated with longer time to T-tube placement. T-tube replacement was associated with a 16.9 times higher likelihood of TM perforation (p < 0.05). The median PTA significantly improved from 16.25 (IQR 7) dB at 3 years to 11.00 (IQR 5.25) dB at 6 years (p < 0.01). CONCLUSIONS:Furlow palatoplasty technique was associated with fewer number of tympanostomy tube placements; however, palatoplasty technique did not significantly impact time to T-tube placement, TM perforation, or hearing outcomes. There were no significant differences in long-term hearing outcomes between patients who underwent Furlow Z-plasty and those who had straight-line repair. Most patients achieved normal hearing thresholds by 6 years after primary palatoplasty and tympanostomy tube placement. These are important considerations to discuss when counseling patients' families on surgical management of CP and otologic outcomes.

Background: The Occupational Safety and Health Administration (OSHA) considers acoustic exposure of 90 decibels (dB) an occupational risk for noise-induced hearing loss. Pediatric healthcare clinicians are exposed to considerable noise especially during invasive procedures, predisposing them to noise-induced hearing loss, increased work-related stress, and increased complications associated with intense noise exposure. While there has been extensive research in noise exposure in dentistry, to date there has been no research on noise exposure in the pediatric otolaryngology clinic setting. The objective of this study is to quantify the degree of noise exposure that pediatric otolaryngologists encounter in the clinical setting.Methods: A sound survey was performed of 420 pediatric otolaryngology clinic visits within a single-institution tertiary care facility from January 2022 to March 2022, with a total of 409 visits included. At each visit, noise was measured using a calibrated National Institute for Occupational Safety and Health (NIOSH) Sound Meter application, an iPad, and a microphone. The Equivalent Continuous Sound Pressure Level (LAeq), peak sound pressure level (SPL), C-weighted peak noise level (LCpeak), and the 8-hour time-weighted average (TWA) sound level were recorded.Results: The average LAeq was 61.1 dB, the median LAeq was 60.3 dB, and the average peak SPL was 80.5 dB. Only 0.5 % of visits reached an LAeq above 80 dB, however, 51 % were above 60 dB and 99 % were above 45 dB. No clinicians were exposed to noise exceeding established limits of safety. Patients younger than ten years old (p < 0.001) and those who underwent procedures such as cerumen removal (p < 0.001) elicited higher ranges of elevated noise. Multivariate analysis confirmed that increased age decreased acoustic exposure while procedures increased acoustic exposure.Conclusions: The results of this study suggest that pediatric otolaryngology clinicians do not exceed hazardous noise limit exposure. However, they are exposed to levels above those which have been linked to stress, poor productivity, and stress-related disorders. This analysis also reports that patients who are younger and those that undergo procedures, specifically cerumen removal, tend to expose their providers to the highest levels of noise. This is the first study examining noise exposure in pediatric otolaryngology, and further research should evaluate the risks of noise exposure in this environment.

Background: Reliable use of surgical navigation depends upon the registration process. The gold standard is paired-point registration with bone-anchored fiducials, but contour-map registration is more practical. Surgeons may employ variable contour maps and less experienced team members often perform this critical step. The impact of these practices on target registration error (TRE) is not well-studied. Methods: A dry lab set-up consisting of a navigation system (Fusion ENT, Medtronic, Jacksonville, FL) and a sinus phantom with 2 mm radiopaque spheres in the sphenoid and ethmoid regions was developed. A CT (0.625 mm slice thickness) was obtained. Registration was performed with a contour-based protocol. Accuracy was determined using the software’s distance measurement tool. Registration was performed with narrow-field (NF; forehead points medial to the mid-pupillary line) and wide field (WF; entire forehead) contour maps. An experienced rhinologist and a resident surgeon performed each registration in triplicate and TRE at the sphenoid and ethmoid markers was measured in triplicate. Results: WF mapping had a lower TRE than NF (1.09 mm [95% Confidence Interval (CI) 0.96-1.22] vs 1.68 mm [95% CI 1.50-1.86]). The experienced surgeon had a lower TRE compared to the resident (1.21 mm [95% CI 1.08-1.34] vs 1.54 mm [95% CI 1.35-1.74]). Conclusions: In this navigation model, wide field mapping offers better accuracy than narrow-field mapping, and an experienced surgeon seemed to achieve better accuracy than a resident surgeon. These observations have potential implications for the use of this technology in the operating room.

Chronic cough is defined as cough lasting more than 4 weeks in children aged 14 years or older. Normal children, without pathophysiology, can cough up to more than 30 times a day. When cough occurs pathologically, it is often more often and can be divided into specific and nonspecific cough types. Inputs from otolaryngology, pulmonary medicine, and gastroenterology, along with other specialties in an aerodigestive team setting, allow a team approach to consider a wide variety of causes of cough and coordinate diagnostic procedures with treatment.

Objectives: Adenotonsillectomy (T&A) is one of the most common surgical procedures performed in the United States. Several studies have defined the safety of laryngeal mask airway (LMA) during this surgery, and conflicting evidence exists describing the role it plays in reducing intraoperative times. Our objective is to describe the role LMA and operating on a stretcher have on reducing intraoperative time during pediatric T&A. Methods: This is a retrospective review between October 2017 and January 2020. We included patients between the ages of 4-18 years old undergoing T&A. We excluded medically complex patients with chromosomal, craniofacial, and metabolic abnormalities, patients with cerebral palsy, and those who were tracheostomy dependent. Patient demographics included surgical indication, age, sex, obesity, use of preoperative midazolam, type of airway used, use of traditional operating room (OR) bed versus transport stretcher, surgeon type, and intraoperative times. Data was analyzed with univariate t-test and multivariate linear regression. Results: One hundred seventy-nine patients were included with an average age of 7.2 years. LMA and stretcher were used on 46.4% and 40.2% of patients, respectively. On multivariate linear regression LMA reduced emergence time by 4.4 min (p < 0.001, 95% CI -6.7 to -2.1) and transport stretcher reduced induction time by 2.5 min (p = 0.04, 95% CI -4.9 to -0.1). Use of LMA and stretcher did not have a statistically significant difference on actual procedure time. Conclusion: Our study further supports the role LMA has in reducing intraoperative times in addition to describing a novel method of reducing intraoperative time by operating on a transport stretcher for healthy children undergoing T&A. Level of evidence: 3.

Purpose: To evaluate the effectiveness and ease of N95 respirator decontamination methods in a clinic setting and to identify the extent of microbial colonization on respirators associated with reuse. Methods: In a prospective fashion, N95 respirators (n = 15) were randomized to a decontamination process (time, dry heat, or ultraviolet C light [UVC]) in outpatient clinics. Each respirator was re-used up to 5 separate clinic sessions. Swabs on each respirator for SARS-CoV-2, bacteria, and fungi were obtained before clinic, after clinic and post-treatment. Mask integrity was checked after each treatment (n = 68). Statistical analyses were performed to determine factors for positive samples. Results: All three decontamination processes reduced bacteria counts similarly. On multivariate mixed model analysis, there were an additional 8.1 colonies of bacteria (95% CI 5.7 to 10.5; p < 0.01) on the inside compared to the outside surface of the respirators. Treatment resulted in a decrease of bacterial load by 8.6 colonies (95% CI-11.6 to-5.5; p < 0.01). Although no decontamination treatment affected the respirator filtration efficiency, heat treatments were associated with the breakdown of thermoplastic elastomer straps. Contamination with fungal and SARS-CoV-2 viral particles were minimal to non-existent. Conclusions: Time, heat and UVC all reduced bacterial load on reused N95 respirators. Fungal contamination was minimal. Heat could permanently damage some elastic straps making the respirators nonfunctional. Given its effectiveness against microbes, lack of damage to re-treated respirators and logistical ease, UVC represents an optimal decontamination method for individual N95 respirators when reuse is necessary.

Objectives To compare outcomes of early and late tracheostomy change in neonatal patients. Early tracheostomy change (ETC) occurred 3 to 4 days after surgery, and late tracheostomy change (LTC) occurred 5 to 7 days after surgery. Study Design Retrospective cohort. Setting Tertiary neonatal/pediatric intensive care unit. Methods A retrospective review of patients who underwent tracheostomy from 2015 to 2019 was performed for infants <1 year old. Data were recorded regarding age at tracheostomy, days until tracheostomy tube change, postoperative complications, and total number of days on sedative or paralytic drugs. Results Forty-six patients were included: 18 (39%) were male, with a mean age of 140 days (SD, 78). Of these, 28 (61%) received ETC. There were no accidental decannulation events in either group. Wound breakdown developed in 4 (14%) patients with ETC versus 5 (28%) with LTC (P = .3). Use of FlexTend tracheostomy tubes was associated with decreased odds of breakdown (odds ratio, 0.03; P = .01). Postoperatively, 46 (100%) patients received sedation, and 12 (26%) received paralysis. Mean duration of paralysis was 0.5 days in ETC as opposed to 2.2 days in LTC (P = .02) on univariate analysis, but the significance was not maintained on multivariate regression (P = .07). Conclusions ETC appears to be feasible in children less than a year of age. There does not appear to be an increased risk of accidental decannulation events or false passage tracts. Further investigations are warranted to investigate safety and possible impact on wound breakdown.

OBJECTIVES:Clinical trials have reported increases in the survival of pediatric rhabdomyosarcoma (RMS) from 25% in 1970 to 73% in 2001. The purpose of this study was to examine whether survival of pediatric patients with RMS of the head and neck improved at the US population level. METHODS:A population-based cohort of patients with rhabdomyosarcoma of the head and neck aged 0-19 years in the Surveillance, Epidemiology, and End Results (SEER) registry from 1973 to 2013 was queried. The cumulative incidence competing risks (CICR) method was used to estimate risk and survival trends. RESULTS:718 cases were identified for analysis. Survival rates at 1-, 5-, and 10-years after diagnosis were 91.2%, 73.2%, and 69.4% respectively. Survival rates at 1 year after diagnosis increased from 82.6% to 93.1% during the study period. In the subdistributional hazard analysis, there was a significantly improved disease-specific risk of death in the first year after diagnosis. Overall risk of death did not improve significantly. Favorable prognostic factors included age <10 years at diagnosis, smaller tumor size, absence of distant metastasis, localized tumors, earlier stage at presentation, grossly complete surgical resection, and embryonal or botryoid histology. CONCLUSIONS:Disease-specific survival in the first year following diagnosis improved, but the change in overall survival at the population level was not statistically significant. These findings should be interpreted in light of the inclusion of patients with distant metastasis at diagnosis, who have poor prognoses, together with the limited statistical power afforded in studies of rare diseases.

BACKGROUND:Nonallergic rhinitis (NAR) is currently a diagnosis of exclusion with an unclear pathophysiologic mechanism and limited treatment options. In patients diagnosed with NAR based on symptoms, negative skin testing and positive optical rhinometry (ORM), the study's objective was to evaluate the therapeutic action of intranasal capsaicin in the management of rhinitic symptoms and the effect on ORM readings. METHODS:Patients with a history of NAR underwent screening by a diagnostic intranasal capsaicin challenge with ORM and skin-prick testing. Twenty-two NAR patients were enrolled and randomized to either treatment with 0.1mM capsaicin (n = 11) or placebo (n = 11). Treatment consisted of 5 consecutive intranasal applications separated by 1 hour with follow-up at 4 and 12 weeks. At each visit, subjects underwent intranasal capsaicin challenge with ORM reading and a visual analog scale scoring of rhinitis symptoms. RESULTS:Treatment with intranasal capsaicin resulted in a median change with improvement in total symptom score (TSS) of -5 from baseline vs an increase of 2 with placebo at 4 weeks, which remained significantly different between the groups at 12 weeks (p = 0.03). At 12 weeks posttreatment, 60% of the intervention group vs 80% of placebo-treated patients still met objective criteria for NAR by ORM. CONCLUSION:Using ORM in the objective diagnosis of NAR, this trial showed that intranasal 0.1mM capsaicin not only improved rhinitic symptoms but also objectively reduced nasal reactivity and nasal congestion with a 40% responder rate at 12 weeks as noted by ORM.

PURPOSE:Identify variables that are predictive of morbidity and mortality in children under the age of two undergoing tracheostomy and to provide longitudinal data on this patient population. METHODS:Patients were retrospectively identified using Current Procedural Terminology codes 31600, 31601, 31610 from 2009 to 2016. RESULTS:Median age at time of tracheostomy was 0.43 years (interquartile range, 0.27-0.61). Patients were followed for a median of 1.39 years (range 0.03-4.25). Overall mortality rate in this cohort was 23.5% with the majority (81.3%) of deaths occurring >30 days following tracheostomy. The most frequently encountered major complication was cardiopulmonary arrest (10.29%) in the short-term follow up period (<30 days) and accidental decannulation (32.81%) during long-term follow up (>30 days). Peristomal skin breakdown was less likely to develop in patients who did not receive paralytics following tracheostomy. Most patients (54.4%) were discharged to home following initial admission and experienced a mean of 2.10 readmissions for any reason during the follow-up period. 64.4% of patients underwent surveillance direct laryngoscopy and bronchoscopy during the follow-up period and suprastomal granuloma formation was detected in 31.2% of these patients. 9 patients underwent decannulation at a median of 2 years from original tracheostomy placement. CONCLUSION:Pediatric patients under the age of 2 undergoing tracheostomy exhibit high morbidity during both the initial hospital admission and the subsequent months following discharge. However, major complications were low and mortality was not directly related to tracheostomy status in any case.

Objective Chronic rhinosinusitis (CRS) has been associated with comorbid depression, yet the prevalence of depression among all patients with CRS is not well described. The Patient Health Questionnaire-9 (PHQ-9), a validated instrument for diagnosing depression, has been used to assess depression in a variety of clinical settings. PHQ-9 scores >= 10 are the threshold for a depression diagnosis. The purpose of this study was to assess the prevalence of depression in a rhinology practice and compare the PHQ-9 with the 22-item Sinonasal Outcome Test (SNOT-22). Study Design Retrospective chart review. Setting Tertiary rhinology practice. Subjects and Methods During the 2-month period ending April 30, 2018, all rhinology patients were asked to complete the PHQ-9 and SNOT-22. Results Among 216 patients, 46 (21.3%) had a self-reported history of depression, and 39 (18.1%) had a PHQ-9 score >= 10. Of the 39 patients screening positive for depression, 18 (41.9%) had no history of depression. Comparison of PHQ-9 with overall SNOT-22 score had a Pearson's coefficient of 0.632 (P < .005). Logistic regression showed that the highest 2 quintiles of SNOT-22 scores had an odds ratio of 60.6 (95% CI, 9.7-378.3) for a positive depression screen (PHQ-9 score >= 10). Conclusion Depression rates (estimated by PHQ-9 responses) among rhinology patients are similar to chronic disease populations; depression may be underdiagnosed in rhinology patients. Higher SNOT-22 scores were associated with higher PHQ-9 scores. Further studies are warranted to understand the impact of comorbid conditions of depression and CRS in patient quality of life.

Purpose: To review rates of post-tonsillectomy hemorrhage (PTH) at a quaternary medical center, including the impact of narcotic versus nonsteroidal anti-inflammatory drug (NSAID) postoperative pain management. Materials and methods: A retrospective review was performed of tonsillectomies conducted at a single institution between 1/1/2013 and 1/1/2017. The rates of PTH and subsequent intervention were calculated. These were categorized into patients having surgery pre- and post-July 1, 2015, the former group receiving narcotics and the latter ibuprofen with acetaminophen. Results: Of 1351 total tonsillectomies, 3.04% had PTH requiring return to the hospital. 0.74% required no further surgical intervention, whereas 2.30% required secondary surgical control. The bleed rate prior to July 2015 was 3.15%, with 1.05% non-surgical bleeds and 2.10% requiring surgery. Post-July 2015, the bleed rate was 2.92%, with 0.44% non-surgical bleeds and 2.49% requiring surgery. There were no statistically significant differences between the two groups with respect to overall, non-surgical, and surgical hemorrhage rates (p > 0.05). Of the total bleeds, the need for secondary surgery in the narcotic group was 66.7% and 85% in the NSAID group (p = 0.18). During the study period, 36 patients with PTH had their initial tonsillectomy performed at outside institutions; 53% required surgical intervention. Conclusions: Secondary hemorrhage remains a significant cause of morbidity in post-tonsillectomy patients, often requiring surgical intervention. This review found no increased bleeding risk associated with use of ibuprofen and acetaminophen as opposed to narcotic pain relief. Level of evidence: III

CXCR5 mediates homing of both B and follicular helper T (T FH ) cells into follicles of secondary lymphoid organs. We found that CXCR5 + CD8 + T cells are present in human tonsils and follicular lymphoma, inhibit T FH -mediated B cell differentiation, and exhibit strong cytotoxic activity. Consistent with these findings, adoptive transfer of CXCR5 + CD8 + T cells into an animal model of lymphoma resulted in significantly greater antitumor activity than CXCR5 − CD8 + T cells. Furthermore, RNA-Seq-based transcriptional profiling revealed 77 differentially expressed genes unique to CXCR5 + CD8 + T cells. Among these, a signature comprised of 33 upregulated genes correlated with improved survival in follicular lymphoma patients. We also showed that CXCR5 + CD8 + T cells could be induced and expanded ex vivo using IL-23 plus TGF-β, suggesting a possible strategy to generate these cells for clinical application. In summary, our study identified CXCR5 + CD8 + T cells as a distinct T cell subset with ability to suppress T FH -mediated B cell differentiation, exert strong antitumor activity, and confer favorable prognosis in follicular lymphoma patients.

Objective: Children with single ventricle cardiac physiology (SVC) often require airway procedures as an adjunct to their care. Descriptive analysis with a focus on outcomes of airway procedures in SVC patients have not been fully described in the literature. Methods: Retrospective, single-center cohort review of 270 patients born between Aug-2007 and Jan-2017. Patients were identified by cardiac database for single ventricle pathophysiology. A subset of these patients were identified to have been evaluated by otolaryngology with airway evaluations and/or interventions. Results: 88/270 patients (32.6%) required investigation or intervention for airway pathology. The most frequent procedure was flexible fiberoptic laryngoscopy (58/88 patients); it was the only procedure performed in 40 patients. Seventeen patients required tracheostomies with an associated increased length of stay (p < 0.001). Patients with cardiac procedures involving dissection around the aortic arch were considered higher airway risk due to the threat of recurrent laryngeal nerve injury, and were more likely to have vocal cord paralysis (58%) compared to patients with lower risk procedures (21%; p < 0.001). However, on multivariate logistic regression, vocal cord paralysis did not statistically impact the odds for tracheostomy placement, although the presence of subglottic stenosis increased the odds ratio of tracheostomy by 14.7 (p = 0.02). Conclusions: Children with SVC often require airway evaluation and intervention. Patients with high risk cardiac procedures had a higher risk of recurrent laryngeal nerve injury but the presence of subglottic stenosis was the best predictor for a tracheostomy. This study represents one of the largest series of SVC children evaluated for airway pathology.

Oropharyngeal hemorrhage after tonsillectomy is one of the most common postprocedural ENT emergencies that require immediate attention. Management choices depend on the severity of bleeding, underlying platelet or coagulation disorders, and the patient’s maturity and age. Treatment range from simple observation to an emergent need to both secure the airway and stop the hemorrhage. The workup of the hemorrhagic patient will be discussed from the preoperative to postoperative time period. Surgical techniques in response to various acuity will be discussed to fully elucidate options to control the hemorrhage. Oropharyngeal hemorrhage after tonsillectomy is one of the most common postprocedural ENT emergencies that require immediate attention. Management choices depend on the severity of bleeding, underlying platelet or coagulation disorders, and the patient’s maturity and age. Treatment range from simple observation to an emergent need to both secure the airway and stop the hemorrhage. The workup of the hemorrhagic patient will be discussed from the preoperative to postoperative time period. Surgical techniques in response to various acuity will be discussed to fully elucidate options to control the hemorrhage. Tonsillectomy with or without adenoidectomy is one of the most common surgeries performed in the United States, especially for children, with rates exceeding half a million per year.1Bhattacharyya N. Lin H.W. Changes and consistencies in the epidemiology of pediatric adenotonsillar surgery, 1996-2006.Otolaryngol Head Neck Surg. 2010; 143 ([PubMed PMID: 20974339]): 680-684https://doi.org/10.1016/j.otohns.2010.06.918Crossref PubMed Scopus (103) Google Scholar Posttonsillectomy hemorrhage or bleeding (PTB) remains a common source of phone calls and emergency center visits following tonsillectomy. A longitudinal study from the Pediatric Health Information System database involving 111,813 children from 2009-2013 suggest 2.8% rate of unplanned revisits for bleeding after tonsillectomy. Only 1.6% was readmitted from the emergency department and approximately 0.8% necessitated a procedure.2Mahant S. Hall M. Ishman S.L. et al.Association of National Guidelines With Tonsillectomy Perioperative Care and Outcomes.Pediatrics. 2015; 136 ([PubMed PMID: 26101361): 53-60https://doi.org/10.1542/peds.2015-0127Crossref PubMed Scopus (26) Google Scholar Significant variations do exist for revisits to the emergency department (range: 1.0%-8.8%).3Mahant S. Keren R. Localio R. et al.Pediatric Research in Inpatient Settings (PRIS) NetworkVariation in quality of tonsillectomy perioperative care and revisit rates in children’s hospitals.Pediatrics. 2014; 133 ([PubMed PMID: 24446446]): 280-288https://doi.org/10.1542/peds.2013-1884Crossref PubMed Scopus (74) Google Scholar Contrary to anecdotal belief, PTB do not occur more frequently during the weekends than weekdays.4Patel A. Foden N. Rachmanidou A. Is weekend surgery a risk factor for post-tonsillectomy haemorrhage?.J Laryngol Otol. 2016; 130 ([PubMed PMID: 27292442]): 763-767https://doi.org/10.1017/S0022215116008161Crossref PubMed Scopus (4) Google Scholar However, the frequency of bleeding is higher at night (71.2% vs 28.8%, P = 0.002). In fact, more than 50% of the bleeding occurs from a 6-total hour window between 10 pm-1 am and 6-9 am.5D’Agostino R. Tarantino V. Calevo M.G. Post-tonsillectomy late haemorrhage: Is it a preferably night-time event?.Int J Pediatr Otorhinolaryngol. 2009; 73 ([PubMed PMID: 19230985]): 713-716https://doi.org/10.1016/j.ijporl.2009.01.011Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar The reason for this is unclear but circadian rhythms may play a role in neuroendocrine and hemodynamic measures throughout the day. The vibratory effect of snoring and drier oral mucosa from chronic mouth breathing during sleep may also play a role. Furthermore, slight regional variation also exists in the United States with the lowest bleeding rate in the South at 2.5%, although the data did not incorporate all states in the country.6Harounian J.A. Schaefer E. Schubart J. et al.Pediatric adenotonsillectomy and postoperative hemorrhage: Demographic and geographic variation in the US.Int J Pediatr Otorhinolaryngol. 2016; 87 ([PubMed PMID: 27368442]): 50-54https://doi.org/10.1016/j.ijporl.2016.05.018Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar The risk of bleeding in children with known coagulopathies may be as high as 53% although other estimates are lower with suggestions that the odds are twice as the normal population.7Warad D. Hussain F.T. Rao A.N. et al.Haemorrhagic complications with adenotonsillectomy in children and young adults with bleeding disorders.Haemophilia. 2015; 21 ([PubMed PMID:25581525]): e151-e155https://doi.org/10.1111/hae.12577Crossref PubMed Scopus (7) Google Scholar, 8Allareddy V. Martinez-Schlurmann N. Rampa S. et al.Predictors of complications of tonsillectomy with or without adenoidectomy in hospitalized children and adolescents in the United States, 2001-2010: A population-based study.Clin Pediatr (Phila). 2016; 55 ([PubMed PMID: 26603580]): 593-602https://doi.org/10.1177/0009922815616885Crossref PubMed Scopus (24) Google Scholar Hemophilia A and B as well as Factor VII deficiency are coagulopathies that are often the most dramatic in presentation but are rare. Meanwhile, von Willebrand disease is relatively common in the general population with a prevalence of up to 2%.9Mannucci P.M. Treatment of von Willebrand’s disease.N Engl J Med. 2004 12; 351 ([Review. PubMed PMID: 15306670]): 683-694Crossref PubMed Scopus (397) Google Scholar Patients may not always have an easy bruising or bleeding history. Tests for coagulopathies before tonsillectomies on children with no clinical suspicion for bleeding problems have low sensitivity, low bleeding predictive value, and are not routinely advised.10Asaf T. Reuveni H. Yermiahu T. et al.The need for routine pre-operative coagulation screening tests (prothrombin time PT/partial thromboplastin time PTT) for healthy children undergoing elective tonsillectomy and/or adenoidectomy.Int J Pediatr Otorhinolaryngol. 2001; 61 ([PubMed PMID: 11700191.f]): 217-222Abstract Full Text Full Text PDF PubMed Scopus (93) Google Scholar, 11Manning S.C. Beste D. McBride T. et al.An assessment of preoperative coagulation screening for tonsillectomy and adenoidectomy.Int J Pediatr Otorhinolaryngol. 1987; 13 ([PubMed PMID: 3679679]): 237-244Abstract Full Text PDF PubMed Scopus (82) Google Scholar Therefore, sporadic cases are difficult to identify preoperatively if the patient has no previous history of easy bruising or bleeding. Posttonsillectomy hemorrhage can rarely occur in the first 24 hours after tonsillectomy (primary PTB). Commonly, it occurs more than 24 hours (usually 5-10 days) after tonsillectomy (secondary PTB).12Edmonson M.B. Eickhoff J.C. Zhang C. A population-based study of acute care revisits following tonsillectomy.J Pediatr. 2015; 166 (607-12.e5) ([PubMed PMID: 25524315])https://doi.org/10.1016/j.jpeds.2014.11.009Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar Previous studies have identified older age as a possible risk factor for secondary PTB.13Wei J.L. Beatty C.W. Gustafson R.O. Evaluation of posttonsillectomy hemorrhage and risk factors.Otolaryngol Head Neck Surg. 2000; 123 ([PubMed PMID: 10964296]): 229-235Crossref PubMed Scopus (98) Google Scholar, 14Perkins J.N. Liang C. Gao D. et al.Risk of post-tonsillectomy hemorrhage by clinical diagnosis.Laryngoscope. 2012; 122 ([PubMed PMID: 22778043]): 2311-2315https://doi.org/10.1002/lary.23421Crossref PubMed Scopus (52) Google Scholar, 15Spektor Z. Saint-Victor S. Kay D.J. et al.Risk factors for pediatric post-tonsillectomy hemorrhage.Int J Pediatr Otorhinolaryngol. 2016; 84 ([PubMed PMID: 27063772]): 151-155https://doi.org/10.1016/j.ijporl.2016.03.005Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar In a large database study of 35,085 tonsillectomies performed at hospital-owned ambulatory and inpatient facilities, male sex and increasing age were found to be independent risk factors for revisits related to bleeding.12Edmonson M.B. Eickhoff J.C. Zhang C. A population-based study of acute care revisits following tonsillectomy.J Pediatr. 2015; 166 (607-12.e5) ([PubMed PMID: 25524315])https://doi.org/10.1016/j.jpeds.2014.11.009Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar The inherent risk of PTB with stratification by surgical indication is controversial. Some authors have suggested tonsillectomies performed on children with sleep apnea may have a higher risk of bleeding than those performed on children with chronic tonsillitis.16Achar P. Sharma R.K. De S. et al.Does primary indication for tonsillectomy influence post-tonsillectomy haemorrhage rates in children?.Int J Pediatr Otorhinolaryngol. 2015; 79 ([PubMed PMID: 25575427]): 246-250https://doi.org/10.1016/j.ijporl.2014.12.022Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar The obstructive nature of sleep apnea has been theorized to increase the chance of bleeding by causing a stronger negative pressure gradient in the pharynx during the recovery period. A database study of over 138,998 procedures in California suggested older age and obesity as risk factors for PTB, but not sleep apnea.17Kshirsagar R. Mahboubi H. Moriyama D. et al.Increased immediate postoperative hemorrhage in older and obese children after outpatient tonsillectomy.Int J Pediatr Otorhinolaryngol. 2016; 84 ([PubMed PMID: 27063766]): 119-123https://doi.org/10.1016/j.ijporl.2016.02.019Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar Still others have found increased bleeding risk in those patients who have chronic tonsillitis.14Perkins J.N. Liang C. Gao D. et al.Risk of post-tonsillectomy hemorrhage by clinical diagnosis.Laryngoscope. 2012; 122 ([PubMed PMID: 22778043]): 2311-2315https://doi.org/10.1002/lary.23421Crossref PubMed Scopus (52) Google Scholar, 15Spektor Z. Saint-Victor S. Kay D.J. et al.Risk factors for pediatric post-tonsillectomy hemorrhage.Int J Pediatr Otorhinolaryngol. 2016; 84 ([PubMed PMID: 27063772]): 151-155https://doi.org/10.1016/j.ijporl.2016.03.005Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar, 18De Luca Canto G. Pachêco-Pereira C. Aydinoz S. et al.Adenotonsillectomy complications: A meta-analysis.Pediatrics. 2015; 136 ([Review. PubMed PMID: 26391937]): 702-718https://doi.org/10.1542/peds.2015-1283Crossref PubMed Scopus (119) Google Scholar Quinsy tonsillectomies has not been found to be associated with an increased hemorrhage rate.19Haddow K. Montague M.L. Hussain S.S. Post-tonsillectomy haemorrhage: A prospective, randomized, controlled clinical trial of cold dissection versus bipolar diathermy dissection.J Laryngol Otol. 2006; 120 ([PubMed PMID: 16441968]): 450-454Crossref PubMed Scopus (22) Google Scholar Intraoperative adjuncts such as peritonsillar injection of local anesthesia (with or without epinephrine) and painting of bismuth onto the tonsillar fossa has not found to be associated with a decrease chance of bleeding.13Wei J.L. Beatty C.W. Gustafson R.O. Evaluation of posttonsillectomy hemorrhage and risk factors.Otolaryngol Head Neck Surg. 2000; 123 ([PubMed PMID: 10964296]): 229-235Crossref PubMed Scopus (98) Google Scholar Neither were the use of perioperative antibiotics and ketorolac. Use of sucralfate postoperatively also was not associated with an increased chance of bleeding.20Siupsinskiene N. Žekonienė J. Padervinskis E. et al.Efficacy of sucralfate for the treatment of post-tonsillectomy symptoms.Eur Arch Otorhinolaryngol. 2015; 272 ([PubMed PMID: 24691853]): 271-278https://doi.org/10.1007/s00405-014-3023-5Crossref PubMed Scopus (14) Google Scholar A recent Cochrane review suggested a nonsignificant increased odd of bleeding requiring surgical intervention with nonsteroidal anti-inflammatory drug use (odds ratio = 1.69, 95% CI: 0.71-4.01).21Lewis S.R. Nicholson A. Cardwell M.E. et al.Nonsteroidal anti-inflammatory drugs and perioperative bleeding in paediatric tonsillectomy.Cochrane Database Syst Rev. 2013; ([Review. PubMed PMID: 23881651]): CD003591https://doi.org/10.1002/14651858.CD003591.pub3Crossref PubMed Scopus (105) Google Scholar Similarly, the odds of bleeding requiring nonsurgical intervention was found to be odds ratio of 0.99 (95% CI: 0.41-2.40) suggesting little if any effect of nonsteroidal anti-inflammatory drug use of bleeding risk after tonsillectomy. Operative technique has been one of controversy surrounding PTB rates. More recent developments of intracapsular tonsillectomy have favored the technique as causing less bleeding risk and pain. The trade-off comes from the risk of tonsillar regrowth and return of chronic tonsillitis or worsening of sleep apnea in the future.22Gallagher T.Q. Wilcox L. McGuire E. et al.Analyzing factors associated with major complications after adenotonsillectomy in 4776 patients: Comparing three tonsillectomy techniques.Otolaryngol Head Neck Surg. 2010; 142 ([PubMed PMID: 20493363]): 886-892https://doi.org/10.1016/j.otohns.2010.02.019Crossref PubMed Scopus (87) Google Scholar Other studies have shown no difference in bleeding risk between electrocautery tonsillectomy and intracapsular tonsillectomy with a microdebrider.23Derkay C.S. Darrow D.H. Welch C. et al.Post-tonsillectomy morbidity and quality of life in pediatric patients with obstructive tonsils and adenoid: Microdebrider vs electrocautery.Otolaryngol Head Neck Surg. 2006; 134 ([PubMed PMID: 16399190]): 114-120Crossref PubMed Scopus (93) Google Scholar Similarly, a study looking at blunt dissection vs bipolar electrocautery shows no difference in PTB rates.24D’Agostino R. Tarantino V. Calevo M.G. Blunt dissection versus electronic molecular resonance bipolar dissection for tonsillectomy: Operative time and intraoperative and postoperative bleeding and pain.Int J Pediatr Otorhinolaryngol. 2008; 72 ([PubMed PMID: 18479755]): 1077-1084https://doi.org/10.1016/j.ijporl.2008.03.018Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar Coblation vs electrocautery tonsillectomy has also been studied and the recent result of a meta-analysis suggests no difference in PTB rates.25Mösges R. Hellmich M. Allekotte S. et al.Hemorrhage rate after coblation tonsillectomy: A meta-analysis of published trials.Eur Arch Otorhinolaryngol. 2011; 268 ([Review. PubMed PMID: 21373898; PubMed Central PMCID: PMC3087106]): 807-816https://doi.org/10.1007/s00405-011-1535-9Crossref PubMed Scopus (38) Google Scholar The tonsils are mainly supplied by branches of the external carotid artery: lingual, facial, ascending pharyngeal, and internal maxillary arteries (in ascending order).26Sholehvar J. Hunsicker R.C. Stool S.E. Arteriography in posttonsillectomy hemorrhage.Arch Otolaryngol. 1972; 95 ([PubMed PMID: 4666430]): 581-583Crossref PubMed Scopus (18) Google Scholar The ascending pharyngeal artery is a terminal branch artery (no other branching before supplying the tonsils). Meanwhile, the lingual artery supplies the tonsils via the tonsillar branch, the facial via the ascending palatal and tonsillar branch, and the internal maxillary via the descending palatal branch (Figure 1). The lingual artery itself has occasionally a contribution from the hyoid branch of the superior thyroid artery.27Pratt L.W. Root J.A. Catastrophic post-tonsillectomy secondary hemorrhage.J Maine Med Assoc. 1960; 51: 7-12PubMed Google Scholar The superior thyroid, lingual, and facial arteries can also arise together from the external carotid as the thyrolingual or facial trunk.28Won S.Y. Anatomical considerations of the superior thyroid artery: Its origins, variations, and position relative to the hyoid bone and thyroid cartilage.Anat Cell Biol. 2016; 49 ([PubMed PMID: 27382516; PubMed Central PMCID: PMC4927429]): 138-142https://doi.org/10.5115/acb.2016.49.2.138Crossref PubMed Scopus (14) Google Scholar Occasional collateral anastomosis with the internal carotid system is possible. The ophthalmic artery (arising from the internal carotid) can anastomose with the internal maxillary artery via the middle meningeal artery and the facial artery via the infraorbital artery. Further connection with the vertebral artery system is possible via the occipital and cervical branches of the external carotid artery. Contralateral supply from the superior thyroid, lingual, facial, occipital, and temporal branches of the opposite carotid can also exist.29Dorrance G.M. Ligation of the great vessels of the neck.Ann Surg. 1934; 99 ([PubMed PMID: 17867182; PubMed Central PMCID: PMC1390084]): 721-742Crossref PubMed Google Scholar As the tonsils receive its blood supply from such a vast network of vessels, indiscriminate ligation of a major vessel may not be adequate to definitively stop bleeding. Aside from proper operative technique and avoidance of thermal and mechanical injury to the peritonsillar fossa, very little has been found to be effective in preventing PTB.30Blanchford H. Lowe D. Cold versus hot tonsillectomy: State of the art and recommendations.ORL J Otorhinolaryngol Relat Spec. 2013; 75 ([Review. PubMed PMID: 23978797]): 136-141https://doi.org/10.1159/000342315Crossref PubMed Scopus (18) Google Scholar, 31Magdalena M.L. Solé A. Blanco V. et al.Histological analysis of tonsillectomies: Relationship with surgical technique, post-operative pain and haemorrhage.J Laryngol Otol. 2016; 130 ([PubMed PMID: 27830635]): 1142-1146Crossref PubMed Scopus (7) Google Scholar Routine oversewing and closure of the tonsillar fossa does not prevent PTB.32Matt B.H. Krol B.J. Ding Y. et al.Effect of tonsillar fossa closure on postoperative pain and bleeding risk after tonsillectomy.Int J Pediatr Otorhinolaryngol. 2012; 76 ([PubMed PMID: 23021465]): 1799-1805https://doi.org/10.1016/j.ijporl.2012.09.004Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar, 33Nguyen T.B. Chin R.Y. Paramaesvaran S. et al.Routine tonsillar bed oversew after diathermy tonsillectomy: Does it reduce secondary tonsillar haemorrhage?.Eur Arch Otorhinolaryngol. 2014; 271 ([PubMed PMID: 24792067]): 3005-3010https://doi.org/10.1007/s00405-014-3075-6Crossref PubMed Scopus (5) Google Scholar, 34Sproat R. Radford P. Hunt A. Hemostatic glues in tonsillectomy: A systematic review.Laryngoscope. 2016; 126 ([review. PubMed PMID: 25946391]): 236-242https://doi.org/10.1002/lary.25256Crossref PubMed Scopus (8) Google Scholar A systematic review of 7 studies also failed to find a significant benefit from the use of fibrin glue hemostatic sealant in preventing PTB.34Sproat R. Radford P. Hunt A. Hemostatic glues in tonsillectomy: A systematic review.Laryngoscope. 2016; 126 ([review. PubMed PMID: 25946391]): 236-242https://doi.org/10.1002/lary.25256Crossref PubMed Scopus (8) Google Scholar The use of Floseal has also been found to be ineffective in decreasing the risk of PTB but it has been shown to aid in mucosal recovery and to shorten the duration of pain-medication use.35Mozet C. Prettin C. Dietze M. et al.Use of floseal and effects on wound healing and pain in adults undergoing tonsillectomy: Randomized comparison versus electrocautery.Eur Arch Otorhinolaryngol. 2012; 269 ([PubMed PMID: 22207530]): 2247-2254https://doi.org/10.1007/s00405-011-1904-4Crossref PubMed Scopus (24) Google Scholar Similarly, systemic, antihemorrhagic agents have been proposed. Agents such as vitamin K and tranexamic acid’s role in preventing PTB have not been fully studied but there appears to be little effect in PTB rates.24D’Agostino R. Tarantino V. Calevo M.G. Blunt dissection versus electronic molecular resonance bipolar dissection for tonsillectomy: Operative time and intraoperative and postoperative bleeding and pain.Int J Pediatr Otorhinolaryngol. 2008; 72 ([PubMed PMID: 18479755]): 1077-1084https://doi.org/10.1016/j.ijporl.2008.03.018Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar Tranexamic acid appears to decrease the volume of blood loss during PTB episodes but does not significantly reduce the risk of bleeding itself.36Chan C.C. Chan Y.Y. Tanweer F. Systematic review and meta-analysis of the use of tranexamic acid in tonsillectomy.Eur Arch Otorhinolaryngol. 2013; 270 ([Review. PubMed PMID: 22996082]): 735-748https://doi.org/10.1007/s00405-012-2184-3Crossref PubMed Scopus (44) Google Scholar Evaluation of the PTB patient must be focused to answer important questions in the acute setting:(1)Is the patient’s airway secure?(2)Is the patient hemodynamically compromised and need resuscitation?(3)Does the patient need operative intervention to control bleeding or to prevent future bleeds? Complete blood count as well as prothrombin time or international normalized ratio or partial thromboplastin time can help determine how much bleeding has occurred as well as the relevant platelet counts and the presence of any coagulation disorders. Prothrombin time or international normalized ratio or partial thromboplastin time may be normal in patients with von Willebrand factor (vWF) disease and platelet function assay (PFA-100) is the most sensitive screening test. Other tests including vWF antigen levels, ristocetin cofactor activity, factor VIII activity, and vWF multimer analysis can be used.9Mannucci P.M. Treatment of von Willebrand’s disease.N Engl J Med. 2004 12; 351 ([Review. PubMed PMID: 15306670]): 683-694Crossref PubMed Scopus (397) Google Scholar Limited evidence exists for directing management in patients with coagulation disorders. Aminocaproic acid have been used in acute mucocutaneous bleeds in patients with von Willebrand disease. Its antifibrinolysis ability has been postulated to help in promoting coagulation in PTB. However, the medication appears to be more useful during acute episodes of hemorrhage rather than as a prevention. In a recent retrospective study on vWF patients matched to normal controls, use of aminocaproic acid did not decrease the likelihood of PTB.37Rodriguez K.D. Sun G.H. Pike F. et al.Post-tonsillectomy bleeding in children with von Willebrand disease: A single-institution experience.Otolaryngol Head Neck Surg. 2010; 142 ([PubMed PMID: 20416462; PubMed Central PMCID: PMC3275349]): 715-721https://doi.org/10.1016/j.otohns.2010.01.029Crossref PubMed Scopus (22) Google Scholar However, desmopressin and oral aminocaproic acid may be enough alone to stop bleeding in some patients with vWD without surgery.38Witmer C.M. Elden L. Butler R.B. et al.Incidence of bleeding complications in pediatric patients with type 1 von Willebrand disease undergoing adenotonsillar procedures.J Pediatr. 2009; 155 ([PubMed PMID: 19394040]): 68-72https://doi.org/10.1016/j.jpeds.2009.01.051Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar After presentation of postoperative bleeding, up to 50% of patient have no bleeding recurrence and can be managed conservatively.13Wei J.L. Beatty C.W. Gustafson R.O. Evaluation of posttonsillectomy hemorrhage and risk factors.Otolaryngol Head Neck Surg. 2000; 123 ([PubMed PMID: 10964296]): 229-235Crossref PubMed Scopus (98) Google Scholar, 39Gratacap M. Couloigner V. Boulouis G. et al.Embolization in the management of recurrent secondary post-tonsillectomy haemorrhage in children.Eur Radiol. 2015; 25 ([PubMed PMID: 25163899]): 239-245https://doi.org/10.1007/s00330-014-3387-3Crossref PubMed Scopus (10) Google Scholar Of those taken back to surgery for hemostasis, approximately 90% are successful in controlling hemorrhage (first attempt at surgical hemostasis). If bleeding recurs in subsequent episodes, the chances of success decreases to 50%-67% in a retrospective study for posttonsillectomy bleeds requiring surgical intervention in 209 patients.39Gratacap M. Couloigner V. Boulouis G. et al.Embolization in the management of recurrent secondary post-tonsillectomy haemorrhage in children.Eur Radiol. 2015; 25 ([PubMed PMID: 25163899]): 239-245https://doi.org/10.1007/s00330-014-3387-3Crossref PubMed Scopus (10) Google Scholar In a study of 181 patients with PTB, upon presentation, most patients have a positive oropharyngeal examination (65.3%). A positive examination includes presence of a clot (49.4%), ooze (21.5%), ooze and clot at the same time (6.3%), or active bleeding (18%).40Arora R. Saraiya S. Niu X. et al.Post tonsillectomy hemorrhage: who needs intervention?.Int J Pediatr Otorhinolaryngol. 2015; 79 ([PubMed PMID: 25547960]): 165-169https://doi.org/10.1016/j.ijporl.2014.11.034Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar The variability in practice patterns across physicians in their approach to each of the scenarios is unclear. It is conceivable that almost all physicians would take an actively bleeding patient back to the operating room for controlling hemorrhage. An oozing tonsillar fossa, especially in the presence of a clot is somewhat controversial and more conservative management such as transoral compression may be attempted although others may still take the child to the operating room. The presence of a clot alone prompts many physicians to ask the patient to gargle water to determine if bleeding would resume once the clot falls off. No studies were found specifically investigating this aspect of the decision tree for PTB. Transoral compression of the bleeding area with clamped swab or index finger can control bleeding. One author suggests that this can be more effective that awaiting intubation and revision surgery as it stops the bleeding and protects the airway.41Windfuhr J.P. Schloendorff G. Sesterhenn A.M. et al.A devastating outcome after adenoidectomy and tonsillectomy: Ideas for improved prevention and management.Otolaryngol Head Neck Surg. 2009; 140 ([PubMed PMID: 19201287]): 191-196https://doi.org/10.1016/j.otohns.2008.11.012Crossref PubMed Scopus (47) Google Scholar The patient does have to cooperate with this uncomfortable maneuver and feasibility is likely limited to older children and mature adults. Silver nitrate can be applied to the area of hemorrhage before application of pressure. The use of kaolin-impregnated gauze has recently been studied as a hemostatic agent during tonsillectomy and has shown some promise during tonsillectomy but its role in posttonsillectomy hemorrhage is not clear.42Chávez-Delgado M.E. Kishi-Sutto C.V. Albores de la-Riva X.N. et al.Topic usage of kaolin-impregnated gauze as a hemostatic in tonsillectomy.J Surg Res. 2014; 192 ([PubMed PMID: 24952410]): 678-685https://doi.org/10.1016/j.jss.2014.05.040Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar However, its use has been studied in trauma situations with external open wounds and is often sold and marketed as QuikClot Combat Gauze.43Gegel B.T. Austin P.N. Johnson A.D. An evidence-based review of the use of a combat gauze (QuikClot) for hemorrhage control.AANA J. 2013; 81 ([Review. PubMed PMID: 24597007]): 453-458PubMed Google Scholar As controlling hemorrhage can often be a high pressured, time sensitive procedure, proper preparation for the operating room is key. Increased hemorrhage at any point should be anticipated. Two suctions should be assembled and tested in preparation to evacuate blood. The McIvor and Crowe-Davis mouth retractors with the full spectrum of tongue blades should be in the room to ensure efficient placement of mouth retractions for exposure. The electrocautery machine should be tested with a suction cautery already assembled. Permanent suture, such as 4-0 silk, should also be available in the operating room should suture ligation be necessary. During bleeding emergencies of the oropharynx, nothing by mouth times are largely irrelevant . Securing the airway takes precedence over the risk of aspiration. Furthermore, blood in the stomach is similar to having at least a full liquid diet. Induction for general anesthesia is accomplished largely by rapid sequence induction, most commonly with succinylcholine.44Fields R.G. Gencorelli F.J. Litman R.S. Anesthetic management of the pediatric bleeding tonsil.Paediatr Anaesth. 2010; 20 ([PubMed PMID: 20964765]): 982-986https://doi.org/10.1111/j.1460-9592.2010.03426.xCrossref PubMed Scopus (25) Google Scholar This allows rapid intubation of the child with minimal risk of vomiting and aspiration. Cricoid pressure is usually applied to decrease the risk of aspiration. In a retrospective cohort of 475 patients undergoing surgery for PTB, 2.7% (13 patients) were noted to have difficult intubation and none of these were difficult to intubation during the initial tonsillectomy. Most often the cause was blood in the upper airway and of the thirteen patients, 2 required more than one attempt at intubation. The use of a tracheostomy to secure the airway is exceedingly rare and not reported in large cases series in the literature.44Fields R.G. Gencorelli F.J. Litman R.S. Anesthetic management of the pediatric bleeding tonsil.Paediatr Anaesth. 2010; 20 ([PubMed PMID: 20964765]): 982-986https://doi.org/10.1111/j.1460-9592.2010.03426.xCrossref PubMed Scopus (25) Google Scholar, 45Windfuhr J.P. Chen Y.S. Remmert S. Hemorrhage following tonsillectomy and adenoidectomy in 15,218 patients.Otolaryngol Head Neck Surg. 2005; 132 ([PubMed PMID: 15692542]): 281-286Crossref PubMed Scopus (231) Google Scholar Most patients can be resuscitated by infusion of crystalloid and rarely do patients need intraoperative red blood cell transfusions if bleeding is controlled.44Fields R.G. Gencorelli F.J. Litman R.S. Anesthetic management of the pediatric bleeding tonsil.Paediatr Anaesth. 2010; 20 ([PubMed PMID: 20964765]): 982-986https://doi.org/10.1111/j.1460-9592.2010.03426.xCrossref PubMed Scopus (25) Google Scholar Surgical hemostasis can then proceed with full evaluation of the tonsillar fossa and recauterization or suture ligation of the offending site or vessel. Surgical hemostasis may require indiscriminate use of cautery because of several factors. The decrease in blood pressure due to bleeding or general anesthesia may temporarily stop bleeding, making identification of the bleeding source difficult. The offending vessel may also be retracted within the inflamed granulation tissue in the tonsillar fossa.39Gratacap M. Couloigner V. Boulouis G. et al.Embolization in the management of recurrent secondary post-tonsillectomy haemorrhage in children.Eur Radiol. 2015; 25 ([PubMed PMID: 25163899]): 239-245https://doi.org/10.1007/s00330-014-3387-3Crossref PubMed Scopus (10) Google Scholar In rare cases, vascular anomalies or pseudoaneurysms from the tonsillar, lingual, or internal carotid arteries can also be responsible for hemorrhage, although this is usually suspected during the initial tonsillectomy.46Mitchell R.B. Pereira K.D. Lazar R.H. et al.Pseudoaneurysm of the right lingual artery: An unusual cause of severe hemorrhage during tonsillectomy.Ear Nose Throat J. 1997; 76 ([PubMed PMID: 9282466]): 575-576PubMed Google Scholar, 47Hertzanu Y. Hirsch M. Tovi F. Pseudoaneurysm of internal carotid artery secondary to tonsillectomy: Combined radiologic and surgical treatment.Cardiovasc Intervent Radiol. 1987; 10 ([PubMed PMID: 3111695]): 147-149Crossref PubMed Scopus (13) Google Scholar, 48Cohen J.E. Gomori J.M. Itshayek E. Endovascular treatment of tonsillar artery pseudoaneurysm causing recurrent hemorrhages after tonsillectomy.Isr Med Assoc J. 2015; 17 ([PubMed PMID: 26357725]): 453-454PubMed Google Scholar Transoral suture ligation can be attempted if the source of bleeding is easily found and access permissible to placement of permanent sutures over the injured vessels in a figure of eight. If the vessel is small, it can also be ligated with a permanent suture at both cut ends. The use of absorbable suture during repair has been implicated to cause delayed bleeding, as in the process of absorption, the suture can cause a fistulous connection from the vessel to the pharynx.49Gardner J.F. Sutures and disasters in tonsillectomy.Arch Otolaryngol. 1968; 88 ([PubMed PMID: 4879283]): 551-555Crossref PubMed Scopus (45) Google Scholar If bleeding persists, pressure should be applied and endovascular techniques can be attempted to embolize feeding vessels to the tonsillar fossa. As a last resort, in the face of hemodynamic instability and shock, ligation of the external carotid through an open neck incision can be performed. Endovascular approaches usually involve cannulation of the right femoral artery using a 4 Fr catheter via percutaneous Seldinger technique (Figure 2). Bilateral angiography is performed first to search for anomalous vessel branching patterns and to identify abnormal connections between the external carotid and internal carotid systems, aneurysms, and arteriovenous malformations. A guide wire is then introduced into each of the vessels supplying the affected bleeding area: ascending palatine and tonsillar artery from the facial artery, then dorsal lingual artery from the lingual artery and descending palatine artery from the internal maxillary artery. Finally, the superior tonsillar artery from the ascending pharyngeal artery is targeted and embolized with polyvinyl alcohol particles. Success of the embolization is tested by demonstrating signification reduction or termination of blood flow to the tonsillar fossa.39Gratacap M. Couloigner V. Boulouis G. et al.Embolization in the management of recurrent secondary post-tonsillectomy haemorrhage in children.Eur Radiol. 2015; 25 ([PubMed PMID: 25163899]): 239-245https://doi.org/10.1007/s00330-014-3387-3Crossref PubMed Scopus (10) Google Scholar Use of endovascular technique compared to open surgery has a high success rate and is associated with a shorter hospital length of stay and lower need for red blood cell transfusions.39Gratacap M. Couloigner V. Boulouis G. et al.Embolization in the management of recurrent secondary post-tonsillectomy haemorrhage in children.Eur Radiol. 2015; 25 ([PubMed PMID: 25163899]): 239-245https://doi.org/10.1007/s00330-014-3387-3Crossref PubMed Scopus (10) Google Scholar Use of endovascular technique have variable success in identifying the exact source of bleeding (0%-33%).39Gratacap M. Couloigner V. Boulouis G. et al.Embolization in the management of recurrent secondary post-tonsillectomy haemorrhage in children.Eur Radiol. 2015; 25 ([PubMed PMID: 25163899]): 239-245https://doi.org/10.1007/s00330-014-3387-3Crossref PubMed Scopus (10) Google Scholar, 50Schrock A. Jakob M. Strach K. et al.Transarterial endovascular treatment in the management of life-threatening intra- and postoperative haemorrhages after otorhinolaryngological surgery.Eur Arch Otorhinolaryngol. 2012; 269 ([PubMed PMID: 22081095]): 1677-1683https://doi.org/10.1007/s00405-011-1823-4Crossref PubMed Scopus (11) Google Scholar Risks of the endovascular approach include unintended migration of embolization particles into the internal carotid or ophthalmic artery system. Use of coils are also possible but must be used at a more proximal location. Coil extrusion into the pharynx or surrounding head and neck region is also possible and carries a risk of infection. Perforation of the branch-vessel with extravasation of embolic material or contrast is also possible.51Opatowsky M.J. Browne J.D. McGuirt Jr Jr, W.F. et al.Endovascular treatment of hemorrhage after tonsillectomy in children.AJNR Am J Neuroradiol. 2001; 22 ([PubMed PMID: 11290484]): 713-716PubMed Google Scholar There is also a theoretical risk of occlusion at the femoral artery access site as systemic anticoagulation is usually not given owing to the nature of the acute hemorrhage. Nevertheless, the duration of the procedure is typically short (35 minutes) and risk minimal.39Gratacap M. Couloigner V. Boulouis G. et al.Embolization in the management of recurrent secondary post-tonsillectomy haemorrhage in children.Eur Radiol. 2015; 25 ([PubMed PMID: 25163899]): 239-245https://doi.org/10.1007/s00330-014-3387-3Crossref PubMed Scopus (10) Google Scholar In dire situations, where bleeding cannot be controlled by surgical hemostasis (ie, electrocautery) or endovascular techniques and the patient is hemodynamically unstable, large vessel surgical ligation of the vascular supply to the tonsils may be necessary. Some authors even advocate for external carotid ligation if the patient has undergone 3 unsuccessful attempts at surgical hemostasis with concurrent low hemoglobin concentration.39Gratacap M. Couloigner V. Boulouis G. et al.Embolization in the management of recurrent secondary post-tonsillectomy haemorrhage in children.Eur Radiol. 2015; 25 ([PubMed PMID: 25163899]): 239-245https://doi.org/10.1007/s00330-014-3387-3Crossref PubMed Scopus (10) Google Scholar An incision is made along the supper 2/3 of the sternocleidomastoid muscle to expose the internal jugular and facial veins. The facial vein is then ligated to allow lateral and posterior retraction of the internal jugular vein. The carotid sheath should be identified and opened slightly below the level of the larynx. At this point, the vagus nerve should also be identified and protected (Figure 3). The external carotid artery can be differentiated from the internal carotid artery at this level by the presence of branches. The hypoglossal nerve should also be identified and protected near this location. Branches of the external carotid supplying the tonsillar fossa are individually ligated with a 0-silk suture.52Windfuhr J.P. Excessive post-tonsillectomy hemorrhage requiring ligature of the external carotid artery.Auris Nasus Larynx. 2002; 29: 159-164Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar If bleeding does not stop at this point, collaterals from the internal carotid system need to be identified. It is not advisable to ligate the common carotid artery due to risk of causing a stroke as well as the possibility of retrograde flow from the circle of Willis supplied by the vertebral artery.53Tindall G.T. Odom G.L. Dillon M.L. et al.Direction of blood flow in the internal and external carotid arteries following occlusion of the ipsilateral common carotid artery.J Neurosurg. 1963; 20: 985-994Crossref PubMed Scopus (23) Google Scholar Posttonsillectomy hemorrhage remains a low, but potentially life-threatening risk after tonsillectomy. Approximately half of patients presenting to the emergency department with bleeding can be managed conservatively. Aside from proper technique, very little proscriptive interventions have been found to be effective in preventing PTB. The remaining proportion of patients is managed with surgical cautery of the tonsillar fossa as mainstay therapy. Endovascular techniques with interventional radiology remain an option for patients where vascular malformations are suspected or for recalcitrant cases. Finally, ligation of the branches of the external carotid artery can be performed in life-threatening hemorrhage in hemodynamically unstable patients.

Background The etiology of spontaneous cerebrospinal fluid (CSF) rhinorrhea remains unknown, though emerging evidence suggests that this likely represents a variant of idiopathic intracranial hypertension. Long-term success rates for repair and postoperative management strategies remain variable. Methods Retrospective review of patients undergoing surgical management of spontaneous CSF rhinorrhea was conducted over a 5-year period. Analysis was performed to correlate recurrence with demographics and perioperative variables. Lumbar puncture usage and neuro-ophthalmological examinations in clinical management were also assessed. Results Forty-eight patients were included in the study. The mean age was 51.4 years with 94% females. Leaks were most commonly located in the sphenoid (43.8%) and cribriform region (33.3%). The most common findings on magnetic resonance imaging were empty sella (48%) and Meckel's cave diverticula (24%). Nine patients (18.8%) had recurrent CSF leaks. Six occurred >1month postoperatively. Three had repeat endoscopic repairs, two received ventriculoperitoneal shunts, and one was managed with a lumbar drain, with overall success rate of 93.8%. Acetazolamide was utilized in 19 cases (39.6%) postoperatively. Overall, 59% of patients had elevated opening pressures on postoperative lumbar puncture ( n =32). Neuro-ophthalmology evaluated 28 patients; 25% had visual field deficits, and 7.1% had papilledema. Conclusions Management of spontaneous CSF leaks remains a significant challenge. Endoscopic repair is successful in most patients with little morbidity; however, postoperative management remains inconsistent, and further studies are warranted to establish consensus on post-surgical care. The association with elevated intracranial pressure and visual field deficits/papilledema suggests opening pressures, and neuro-ophthalmologic evaluation should be considered in the treatment algorithm.

Background: Endoscopically guided cultures are frequently employed to guide antimicrobial therapy in refractory chronic rhinosinusitis (CRS) patients. The objective of this study was to determine the impact of culture-directed antibiotics on patient symptoms.Methods: Retrospective review was conducted of 105 adult CRS patients undergoing evaluation in the ambulatory clinic of tertiary care academic medical center.Results: The most common microbes were Staphylococcus aureus (29.5%), Pseudomonas aeruginosa (23.8%) and methicillin-resistant S. aureus (11.4%). Normal respiratory flora or no growth was found in 19% of patients. Culture results changed antibiotic choices in 77% of patients. Statistically significant change in total SNOT-20 scores and all 4 subdomains was noted, with improvement being clinically meaningful in the rhinologic subdomain (-1.10, p < 0.0001). Repeat purulence was only noted in 5 cases (4.8%). Multivariate regression analysis demonstrated that concurrent use of oral steroids was independently associated with improvement in the rhinologic subdomain (p = 0.0041). The mean length of follow-up was 37 days. Length of follow-up (14-30, 31-60, 61-90 days) did not statistically impact SNOT-20 scores.Conclusion: Endoscopic-derived sinus cultures are associated with clinically meaningful change in the rhinologic subdomain of SNOT-20 scores, and repeat purulence was infrequently noted at follow-up. Further prospective studies are needed to better delineate the role of cultures in CRS management. (C) 2015 Elsevier Inc. All rights reserved.