Serious post-tonsillectomy hemorrhage with and without lethal outcome in children and adolescents

Serious post-tonsillectomy hemorrhage (PTH) is an uncommon complication requiring immediate and adequate medical treatment. This study was undertaken to describe and evaluate the clinical data and courses of serious PTH, with and without lethal outcome in children and adolescents.

Bleeding episodes accompanied by hemorrhagic shock requiring resuscitation and/or major medical treatment were labeled as serious PTH, with or without lethal outcome. Personal experiences as surgeons and expert reports in connection with lawsuits and Professional Boards, as well as reports collected after a published request contributed to the data collection.

Thirty-one boys and 21 girls (gender not stated for three patients) younger than 18 years of age were enrolled in our study (mean: 8.47; median: 6; S.D.: 4.73 years). Thirty-three children were 8 years of age or younger (60%). Lethal outcome was reported for 19 patients of whom 11 had experienced repeated episodes of bleeding. The majority of the surviving children experienced serious PTH without remaining sequelae (32), however, four children suffered from remaining sequelae. Forty-three children experienced repeated episodes of PTH. The first episode of PTH occurred either at home (32) or in the hospital (22; location not stated for one child). Primary hemorrhage (<24h) was reported for three, secondary bleeding (>24h) for 52 children (94.5%). A total of 169 bleeding episodes was reported of whom 149 were specified as massive (56), major (31), minor (15), diffuse (12), with spontaneous cessation (19) or vomiting of considerable amounts of blood (16). Aspiration was confirmed at the autopsy of seven patients. Ligature of greater arteries in the neck was performed in 35 cases, suturing of the faucal pillars in four and packing of the oropharynx in six patients. Twenty-four children received blood transfusions. Resuscitation was performed in 17 cases but remained ineffective in seven patients.

Repeated episodes of bleeding should be considered as a warning sign of serious PTH. Inpatient observation does not eliminate the risk of lethal outcome. Children up to 8 years of age seem to be more susceptible to serious PTH, whereas gender remained irrelevant as a contributing risk factor. Life-threatening PTH is likely to occur as secondary PTH.