The Impact of Surgical Technique on Post-Tonsillectomy Hemorrhage-A Registry-Based Cohort Study

The objective was to estimate the impact of surgical technique on the risk of post-tonsillectomy hemorrhage (PTH).

This was a registry-based cohort study between 2017 and 2025, covering all tonsillectomies (excluding tonsillotomies) in Norway during the study period. The primary exposure variable was surgical technique, divided into three groups: cold (non-thermal technique for both dissection and hemostasis), cold + warm (thermal technique for hemostasis), and warm (thermal technique for both dissection and hemostasis). The effect of surgical technique on risk of PTH was analyzed using logistic regression, adjusting for confounding factors. Absolute risks and numbers needed to harm were also calculated.

A total of 25,953 patients were included (16,318 females [62.9%], median [IQR] age 20 [13] years). PTH was reported in 1946 patients (7.5%). Cold surgical technique was used in 3348 patients (12.9%), combined cold + warm technique was used in 16,284 patients (62.7%), and warm technique was used in 6321 patients (24.4%). Use of partly or fully warm technique was significantly associated with PTH compared to a purely cold technique (cold + warm: OR 2.4, 95% CI 1.9-3.1; warm: OR 3.4, 95% CI 2.5-4.6). The absolute increase in risk of PTH was 4.5% (cold + warm) and 7.5% (warm) compared to the cold technique, with corresponding numbers needed to harm of 22 and 13. The increased risk with warm technique was more pronounced for adolescents and adults compared to children.

This population-based cohort study confirms that surgical technique is associated with PTH, with a significantly higher risk of PTH when using partially or fully warm technique compared to cold technique. Based on the cumulative evidence, it may be appropriate to raise the question whether one should recommend that tonsillectomies be performed with cold surgical technique, especially in adolescents and adults.

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