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Incidence and risk factors of pediatric post-tonsillectomy hemorrhage: a systematic review and meta-analysis
Xi Zhang1, Qicheng Deng2, Ling Yang3
1Department of Otolaryngology Head and Neck Surgery of Beijing Anzhen Hospital of Capital Medical University & Nanchong Central Hospital, Nanchong, Sichuan, 637000, China.
Insights
Post-tonsillectomy hemorrhage (PTH) occurs in 3% of pediatric patients. Risk factors include older age, male sex, chronic tonsillitis, and specific surgical techniques, guiding preventive strategies.
Area of Science:
- Pediatric Surgery
- Otolaryngology
- Evidence-Based Medicine
Background:
- Tonsillectomy is a common pediatric procedure.
- Post-tonsillectomy hemorrhage (PTH) is a severe complication with undefined incidence and risk factors.
- This study aims to define PTH incidence and identify associated risk factors.
Purpose of the Study:
- To systematically review and meta-analyze the incidence of pediatric post-tonsillectomy hemorrhage (PTH).
- To identify and quantify perioperative risk factors associated with PTH in children.
- To inform risk stratification and preventive strategies for pediatric tonsillectomy.
Main Methods:
- Systematic literature search of six electronic databases up to June 1, 2025.
- Inclusion of observational studies on pediatric patients (0-18 years) undergoing tonsillectomy.
- Meta-analysis using Stata 16.0 and Review Manager 5.4.1.
Main Results:
- Pooled PTH incidence was 3% across 18 studies (844,123 children).
- Significant risk factors identified: increasing age, male sex, abnormal coagulation, chronic tonsillitis history, severe tonsillar embedment, junior surgeon, cold steel dissection, postoperative analgesics, and poor diet.
- Odds ratios ranged from 1.12 for increasing age to 4.82 for postoperative analgesics.
Conclusions:
- A 3% incidence of PTH in pediatric tonsillectomy patients was quantified.
- Multiple perioperative factors significantly increase PTH risk.
- Findings support tailored preventive strategies and perioperative optimization to enhance surgical safety.
Background:
Tonsillectomy ranks among the most frequently performed surgical procedures in the pediatric population. Post-tonsillectomy hemorrhage (PTH) represents one of its most severe complications, potentially resulting in anemia, hemodynamic instability, reoperation, and even mortality. Nevertheless, the incidence of and risk factors for PTH are not well defined. Consequently, we performed a systematic review and meta-analysis to examine and identify risk factors for this postoperative complication.
Methods:
An extensive literature search was executed across six electronic databases (PubMed, Embase, Web of Science, Scopus, Cochrane Library, and Ovid MEDLINE) from their inception until June 1, 2025. We included observational studies (case-control, cohort, cross-sectional) that enrolled pediatric patients (aged 0-18 years) undergoing tonsillectomy. Data analysis was performed using Stata 16.0 and Review Manager 5.4.1.
Results:
A total of 18 studies, encompassing 844,123 children, were included in the analysis. The pooled incidence of PTH was 3% (95% CI 3%-4%; I2 = 98.61%). The following factors were identified as significant risk factors: increasing age (OR = 1.12, 95% CI 1.10-1.13), age ≥ 9 years (OR = 2.47, 95% CI 2.05-2.99), age ≥ 12 years (OR = 2.40, 95% CI 1.83-3.03), male sex (OR = 1.19, 95% CI 1.08-1.31), abnormal coagulation parameters (OR = 3.14, 95% CI 1.15-8.56), a history of chronic tonsillitis (OR = 1.55, 95% CI 1.10-2.19), severe tonsillar embedment (OR = 2.74, 95% CI 1.66-4.50), surgery performed by a junior surgeon (OR = 1.74, 95% CI 1.36-2.22), use of cold steel dissection techniques (OR = 1.87, 95% CI 1.41-2.48), use of postoperative analgesics (OR = 4.82, 95% CI 1.25-18.58), and poor postoperative diet (OR = 4.60, 95% CI 2.22-9.52).
Conclusions:
This meta-analysis quantified a pooled PTH incidence of 3% in the pediatric population and identified multiple perioperative factors associated with increased odds of PTH. The findings may guide the risk stratification of patients and inform tailored preventive strategies and perioperative optimization, ultimately enhancing surgical safety and improving postoperative outcomes.
Trial Registration:
PROSPERO CRD420251066627.
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