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Post-Tonsillectomy Hemorrhage and the Diagnosis of Occult Pediatric Coagulopathies
Stephen R Chorney1,2, Rena Weinberger3, Ari Y Weintraub3,4
1Department of Otolaryngology - Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A.
Insights
Coagulation panels are rarely useful for children with a single post-tonsillectomy hemorrhage (PTH). However, a second PTH event may indicate an underlying bleeding disorder, warranting hematology referral.
Area of Science:
- Pediatric Otolaryngology
- Hemostasis and Thrombosis
Background:
- Post-tonsillectomy hemorrhage (PTH) is a common complication in pediatric patients.
- Identifying underlying coagulopathies is crucial for managing recurrent bleeding events.
Purpose of the Study:
- To determine the rates of abnormal coagulation panels and coagulopathy diagnoses in children experiencing PTH.
- To identify patient demographics and hemorrhage characteristics associated with coagulopathy.
Main Methods:
- A retrospective case series was conducted, reviewing charts of pediatric patients who required operative control for PTH.
- Data collected included tonsillectomy details, hemorrhage characteristics, coagulation screening labs, hematology referrals, and bleeding disorder diagnoses.
Main Results:
- Of 250 children, 9.2% experienced a second PTH and 1.2% a third. Screening coagulation panels were abnormal in 38.3% of single PTH cases.
- No child with a single PTH was diagnosed with a bleeding disorder.
- Children with multiple PTHs had an 87.0% hematology referral rate, with 13.0% diagnosed with a bleeding disorder (P < .001).
Conclusions:
- Routine coagulation panel screening is infrequently useful for pediatric patients with a single PTH.
- Referral to hematology is recommended for children with a second PTH due to a higher incidence of undiagnosed bleeding disorders.
Objectives/Hypothesis:
The primary objective of this investigation was to determine rates of abnormal coagulation panels and diagnoses of coagulopathies in children with post-tonsillectomy hemorrhage (PTH). Secondary objectives identified patient demographics and hemorrhage event characteristics that correlated with a coagulopathy diagnosis.
Study Design:
Case series with chart review.
Methods:
Patients requiring operative control of PTH at a tertiary children's hospital between 2015 and 2019 were included. Details of tonsillectomy procedures and hemorrhage events were reviewed along with screening labs for coagulopathy, referrals to hematology and bleeding disorder diagnoses.
Results:
There were 250 children included. Mean age was 8.8 years (95% CI: 8.2-9.4) and 53.6% were males. PTH events occurred at a median of postoperative day six (mean: 5.9, 95% CI: 5.4-6.3), and 14.8% occurred within 24 hours of surgery. In this series, 23 patients (9.2%) had a second PTH, and three (1.2%) had a third PTH. Single and multiple PTH patients were similar with respect to age, gender, postoperative day, and technique (P > .05). Screening coagulation panels were obtained on presentation in 67.8% of children with one PTH and abnormally elevated in 38.3%. All children with multiple PTHs had labs drawn with 34.8% having elevated levels. No child with a single PTH was diagnosed with a bleeding disorder. Conversely, 87.0% of children with multiple PTHs saw hematology and three (13.0%) were diagnosed with a bleeding disorder (P < .001).
Conclusions:
Obtaining coagulation panels in pediatric patients presenting with PTH is rarely useful and diagnosing a coagulopathy is uncommon. However, among children with a second PTH, referral to hematology is reasonable as this group has a significantly higher, albeit small, incidence of undiagnosed bleeding disorders.
Level Of Evidence:
4 Laryngoscope, 131:E2069-E2073, 2021.
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