AmJOtolaryngol4
1(2020)102341
Contents lists available at ScienceDirect
Am J Otolaryngol
journal homepage: www.elsevier.com/locate/amjoto
Risk factors for post-tonsillectomy hemorrhage in adult population:
Does smoking history have an impact?
Nurullah Seyhun⁎, Senem Kurt Dizdar, Alican Çoktur, Merve Ekici Bektaş, Onuralp
Albuz, Zeynep Nur Erol, Suat Turgut
Sisli HAMIDIYE ETFAL TRAINING AND RESEARCH HOSPITAL, ENT Clinic, Sisli, ISTANBUL, Turkey
1. Introduction
Tonsillectomy is one of the most common procedures in
otolar- yngology practice. In United States, around 300,000
adult tonsillec- tomies are performed annually [1]. Most common
complications fol- lowing tonsillectomy are pain, hemorrhage,
nausea and vomiting [2]. Posttonsillectomy hemorrhage(PTH)
rates vary in different studies which is reported to be between 5
and 13,9% in adult population and is reported to occur more
common in adults than children [3]. In the case of PTH, close
observation is mostly sufficient but if the hemorrhage is severe,
or life-threatening, surgical intervention may be required. Sev- eral
risk factors for PTH have been identified such as age, male
gender, history of peritonsillar abscess, hypertension [4,5]. Since
tonsillectomy is a very common procedure, it is important to
determine the risk fac- tors for PTH to decrease morbidity
following tonsillectomy.
Smoking adversely affects the oral, gingival, and pharyngeal
mu- cosal surfaces, causing structural changes and atrophy [6]. In
addition, smoking severely impairs the histological architecture of
tonsils which might cause an increased rate of complications
following tonsillectomy. Smoking has not been determined as a
risk factor for PTH yet, and in this study we aimed to reassess
the risk factors for PTH and reveal the relationship with
smoking history and PTH.
2. Materials and methods
The present study was carried out in Sisli Hamidiye Etfal
Training and Research Hospital, Istanbul/Turkey. 364 adult
patients(218 male, 146 female) aged between 18 and 72 who
underwent cold dissection tonsillectomy in our clinic between
January 2015–December 2018 were included in the study. Medical
charts of the patients were analyzed retrospectively. All patients
were operated under general anesthesia by 6 different experienced
senior residents, and in all of the patients in- dication for
tonsillectomy was recurrent tonsillitis with or without history of
peritonsillar abscess. Cold dissection tonsillectomy was car- ried out
in all patients, hemostasis was obtained by compression and
bipolar coagulation intraoperatively. A dietary restriction list was
given to all the patients in postoperative period and asked to
comply with the
⁎
Corresponding author.
E-MAIL ADDRESS: drnurullahseyhun@gmail.com (N. Seyhun).
https://doi.org/10.1016/j.amjoto.2019.102341
Received 24 October 2019
restrictions and abstain from smoking for at least two weeks.
Patients who were previously diagnosed with coagulopathy,
ma- lignancy, anemia, and patients who were operated using
techniques other than cold dissection were excluded from the
study to prevent technique dependent factors affecting the
outcome. Anticoagulant medication use and chronic medication
use which could cause coagu- lation disorders(such as non-
steroid antiinflammatory medications) were also other exclusion
criterias. Patient characteristics, PTH rates, smoking, hypertension
and peritonsillar abscess history of patients and frequency and
duration of recurrent tonsillitis were recorded. Smoking history of
patients was both recorded as smokers/nonsmokers and as
pack/year formula. In our clinic, before admission for surgery, all
pa- tients are routinely asked about the history of recurrent
tonsillitis. We simply ask the patients, for how many years they
have the history of recurrent tonsillitis, and how many episodes
of tonsillitis they experi- ence per year. To assess the severity of
recurrent tonsillitis history, we calculated the index of tonsillitis(IT)
which is calculated by multiplying the number of episodes per year
by the number of years of recurrent tonsillitis history. To give an
example, if a patient encountered 3 epi- sodes of tonsillitis a
year, and had the recurrent tonsillitis history for 5 years, IT was
recorded as 15 for that patient.
PTH was defined as bleeding either seen by the surgeon or
bleeding episode stated by the patient. All patients with PTH
were admitted to hospital for close observation and/or
medical/surgical intervention. Patients were classified as 2
groups as following: Group 1 consisted of patients with PTH and
Group 2 consisted of patients without PTH. Patients with PTH
were also divided into 3 subgroups according to the severity of
the hemorrhage. Subgroup 1 consisted of bleeding episodes which
ceased spontaneously without any intervention, Subgroup 2
consisted of bleeding episodes which needed non-surgical
intervention and Subgroup 3 consisted of bleeding episodes which
needed surgical intervention to provide hemostasis. Non-surgical
intervention was carried out by hydration, compression of
bleeding area with adrenalin soaked cotton balls, and
intravenous tranexamic acid when needed. Surgical intervention
was carried out under general anesthesia, bleeding areas were
compressed and coagulated with bipolar cautery. Hemoglobin levels
preoperatively and after the bleeding episode were
0196-0709/©2019ElsevierInc.Allrightsreserved.
N. Seyhun, et AL. AmJOtolAryngol4
1(2020)102341

recorded. The day that PTH occurred was also recorded in patients
Table 2
with PTH. Re-bleeding in patients with
SPSS 15.0 Windows software was used for statistical analysis. PTH.
Descriptive statistics were given as number and percentage for Re-bleeding

cate- gorical variables, and mean, standard deviation, minimum Not present
Present p
and max-
imum for numeric variables. Since numeric variables did not (n = 43) (n = 10)

meet
normal distribution condition in independent groups, comparison Wallis test. In
of two independent groups was done using Mann Whitney U test, Gender n (%) Male 35 (81.4) 9 (90.0) 1.000
com- parison of more than two groups was done using Kruskal Female 8 (18.6) 1 (10.0)
Age median (min-max) 24 (18–48) 23.5 (20–39) 0.553
subgroup analysis, Mann Whitney test was used and interpreted Smoking(pack/year) 7.1 ± 8.5 3.7 ± 3.7 0.405
mean. ± SD (min- (0–36) (0−10)
with Bonferroni correction. Analysis of dependent groups were max)
done using
Paired t-test when numeric variables met normal distribution PTA history n (%) 3 (7.0) 1 (10.0) 1.000
condition, HT n (%) 0 (0.0) 1 (10.0) 0.189
and using Wilcoxon test when numeric variables did not meet
normal
distribution condition. Chi square test was used to compare Index of tonsillitis 28.0 ± 16.0 33.6 ± 16.4 0.294
ratios in groups. The effect of predictive factors were analyzed mean ± SD (min- (7–90) (15–60)
max)
using logistic regression analysis. Age, gender, smoking status, PTA
and HT history and IT were included in this model as these variables PTA: Peritonsillar
were investigated as potential risk factors were PTH. Statistical Abscess. HT:
significance was con- sidered as p < 0,05. Hypertension.
SD: Standard Deviation.
n:number of patients.
mean ± SD (min- (4–80) (7–90)
3. Results max)

PTA: Peritonsillar Abscess. HT:

218 male, 146 female patients who underwent cold dissection Hypertension.
tonsillectomy were included in the study. Median age of patients SD: Standard Deviation.
was 27(18–72). PTH occurred in 53 patients (%14.6). PTH rates n:number of patients.
were sig- nificantly higher in male patients (p < .001). The Group 1: Patients without post-tonsillectomy hemorrhage. Group
number of smokers in our study population was 176(48.3%), 2: Patients with post-tonsillectomy hemorrhage.
and nonsmokers was 188(51.7%). The percentage of smokers
was 59.7% in male population and 31.7% in female population.
Smoking rate was significantly higher in male patients(p < .000).
In patients with PTH, mean age was sig- nificantly low
compared to patients without PTH(p = .010). Mean pack/year
smoking status and IT of patients in PTH group was sig-
nificantly higher than patients without PTH group(p = .004, p = .
031). There was no statistically significant difference between
two groups regarding peritonsillar abscess history and
hypertension history (p = .273 p = 1.000) (Table 1). In
patients without PTH, 140(45%) were smokers and 171(55%)
were nonsmokers. In patients with PTH, 36(67.9%) were smokers
and 17(32.1%) were nonsmokers. When pa- tients were compared
as smokers and nonsmokers, PTH rate was sig- nificantly higher
in smokers(p = .002). IT was not significantly dif- ferent
between smokers and nonsmokers(p = .926). Mean
postoperative day of PTH was 6.4 (1−12).
In patients with PTH, 10 patients (%18.9) experienced a second
or third episode of bleeding. Second episode occurred in 8
patients and

Table 1
Patient characteristics.
Group 1 Group 2 p
(n = 311) (n = 53)

Gender n (%) Male 174 (55.9) 44 (83.0) < 0.001

Female 137 (44.1) 9 (17.0)
Age median (min-max) 28 (18–72) 24 (18–48) 0.010
Smoking(pack/year) 4.4 ± 7.3 6.5 ± 7.9 0.004
mean. ± SD (min- (0–40) (0–36)
max)
PTA history n (%) 40 (12.9) 4 (7.5) 0.273
HT n (%) 10 (3.2) 1 (1.9) 1.000
Index of tonsillitis 23.8 ± 12.3 29.0 ± 16.1 0.031

2
N. Seyhun, et AL. AmJOtolAryngol4
PTH: Post tonsillectomy hemorrhage. 1(2020)102341

third episode occurred in 2 patients. When patients with

recurrent PTH were compared to patients without recurrent PTH,
there was no sta- tistically significant difference regarding gender,
age, smoking status, hypertension and peritonsillar abscess
history and IT (Table 2). In 8 of 10 patients with re-bleeding,
hemostasis was obtained via surgical in- tervention.
In PTH group, 65 bleeding episodes occurred in 53 different
pa- tients. Subgroup 1 consisted of 33 bleeding episodes which
ceased spontaneously (%50.8), In subgroup 2 consisted of 11
episodes which required non-surgical intervention (%16.9), and
subgroup 3 consisted of 21 episodes which required surgical
intervention for hemostasis (%32.3). When subgroups were
compared, preoperative hemoglobin levels were not significantly
different (p = .071), but postoperative hemoglobin levels were
significantly different, with lowest hemoglobin levels in subgroup 3
(p = .003). There was no statistically significant difference
between subgroups regarding gender, age, smoking status,
peritonsillar abscess history and hypertension history and IT
score (Table 3).
In the logistic regression analysis to determine the risk
factors for PTH; age, male gender, smoking history, and IT were
strongly asso- ciated with PTH(p < .001 p < .001 p = .004 p =
.001). PTA history and HT history was found to be not
associated with the risk of PTH (p = .245, p = .248
respectively)(Table 4). These findings confirm that age, male
gender, smoking history and IT are significant risk factors for PTH.
In the logistic regression analysis to determine the risk factors for
recurrent PTH; there were no statistically significant risk factors
for recurrent PTH(Table 5).

4. Discussion

The aim of this study was to investigate the risk factors for
PTH and to assess the impact of smoking history on PTH rates.
In the present study, overall PTH rate was %14.6 which is
higher than previous findings [2,7]. Reoperation rates was found
to be %5. In the literature, there are significant variations in
reported PTH rates. In a study by Blakley et al. [8], literature
review revealed that PTH rate was around
%5, and maximum ‘expected’ sustained bleeding rate was found to
be around %13.9. In another study by Tolska et al. [9], PTH
rate was re- ported as %14.5 which is consistent with our
finding. We believe that our PTH rates were found to be higher
than the current literature due to several reasons: In our
practice, we strictly instruct patients to refer to hospital in any
bleeding from mouth, even in the case of blood tinged saliva.
Therefore, we defined PTH as any bleeding witnessed by the
surgeon or stated by the patient. Although Walner et al. [10]
suggested

3
Table 3
Patient characteristics in subgroups.

Subgroup 1 (N = 33) Subgroup 2 (N = 11) Subgroup 3 (N = 21) p

Gender n (%) Male 27 (81,8) 10 (90,9) 17 (81,0) 0.822

Female 6 (18,2) 1 (9,1) 4 (19,0)
Age median (min-max) 23 (18–39) 27 (18–37) 24 (18–48) 0.263
Smoking(pack/year) mean. ± SD (min-max) 6.2 ± 8.6 (0–36) 6.5 ± 7.0 (0−20) 5.3 ± 5.5 (0–18) 0.876
Bleeding day 7.2 ± 3.1 (1–14) 7.5 ± 2.0 (5–11) 7.0 ± 3.5 (1–15) 0.801
mean. ± SD (min-max)
PTA history n (%) 2 (6.1) 1 (9.1) 3 (14.3) 0.631
HT n (%) 1 (3.0) 0 (0.0) 2 (9.5) 0.576
Hemoglobin levels Preop 14.8 ± 1.1 (11.7–17) 14.6 ± 1.3 (12.5–16.3) 14.0 ± 1.3 (11.6–15.8) 0.071
mean. ± SD Postop 14.5 ± 1.5 (11.7–19.7) 13.6 ± 2.0 (9.9–16.9) 12.9 ± 1.7 (10.5–16.9) 0.003
(min-max)
p 0.013 0.049 0.004
Index of tonsillitis mean ± SD (min-max) 31.0 ± 16.9 (7–90) 28.8 ± 17.8 (10–60) 25.4 ± 13.2 (9–60) 0.479

PTA: Peritonsillar Abscess.

HT: Hypertension.
SD: Standard Deviation.
n:number of patients.
preop: preoperative.
postop: postoperative.
Subgroup 1: patients with bleeding episodes that ceased spontaneously without any
intervention. Subgroup 2: patients with bleeding episodes that needed non-surgical
intervention.
Subgroup 3: patients with bleeding episodes that needed surgical intervention.

Table 4
Multivariate regression analysis model of risk factors for PTH. lower than PTH rates in patients who were operated by resident
sur- geons. In our study all patients were operated by senior
p OR %95 CI (min-max)
residents which may be a potential factor affecting our PTH
Age < 0.001 0.894 0.843 0.949 rates.
Gender (male) < 0.001 5.854 2.510 13.657 In our study, 48.3% of the patients were smokers which is
Smoking (pack/year) 0.004 1.084 1.026 1.145 slightly
PTA 0.245 0.491 0.148 1.630 higher than reported smoking incidence in Turkey. In a recent report
HT 0.248 4.043 0.377 43.334
by ‘International Union Against Tuberculosis and Lung Disease’,
Index of tonsillitis 0.001 1.040 1.015 1.066
40% percent of population aged between 25 and 44 are smokers
OR: Odds Ratio. [13]. Our study population has a slightly higher smoking rate which
CI: Confidence Interval. can be tied to increased incidence of recurrent tonsillitis in
PTA: Peritonsillar Abscess. smokers. Cinamon et al.
HT: Hypertension. [6] reported a higher rate of recurrent tonsillitis episodes in
PTH: Post tonsillectomy hemorrhage. smokers than relevant adult general population and they also
reported a higher rate of smoking in their study population similar
Table 5 to our findings, which might explain the higher rate of smoking
Multivariate regression analysis of risk factors for recurrent PTH. compared to relevant adult population.
Enter model p OR %95 CI (min-max) Smoking has significant adverse effects on healing.
Impairment in epithelialization, decrease in tissue oxygenation,
Age 0,665 1,027 0,912 1,156 microvascular injury are some of the known effects of smoking
Gender (male) 0,999 .
[14]. Torre et al. [15] showed a dose-dependent correlation with
Smoking (pack/year) 0,112 0,864 0,722 1,035
PTA 0,235 6,867 0,285 165,175
smoking and clinical findings of re- current infections and
HT 0,999 . histological and ultrastructural damages to the palatine tonsils.
Dense collagen matrix, fibrosis, edema, hemorrhage, and crypt
OR: Odds Ratio. epithelium with focal basement membrane disruption, cel- lular
CI: Confidence Interval. degeneration and superficial erosions were observed in their
PTA: Peritonsillar Abscess. study. We found that mean pack/year smoking history of
HT: Hypertension. patients in PTH group was significantly higher than patients
PTH: Post tonsillectomy hemorrhage. without PTH group (p = .004). There are only a few studies
published in the literature regarding the impact of smoking on
a classification system for PTH, there is no standardized and PTH. In a study by Demars et al. [16],a significant correlation was
widely used classification of PTH and variations in reported rates found with smoking history of patient and PTH in patients who
are due to this fact. In a study by Windfuhr et al. [11], only underwent uvulopalatopharyngoplasty for obstructive sleep
the patients who needed surgical intervention for PTH in both apnea. But they did not find a significant relationship with
adult and pediatric po- pulation were included and PTH rate was smoking and PTH in patients who underwent tonsillectomy for
found to be %5.2 which is almost the same as our surgical chronic tonsillitis. This finding might be due to longer operative
intervention rates. On the other hand, in pediatric population, PTH time of uvulopalatopharyngoplasty operations, and besides they did
rates are significantly low compared to adults [12]. Thus, it is not specify the patient's exposure to tobacco. In our study, we
important to eliminate bias regarding the age factor. Surgeon's analyzed the smoking history using pack/year formula, and we
experience is also a potential factor influencing the outcome. Kim found a significant correlation with PTH and mean pack/year
et al. [12] stated that in adult population, PTH rates in patients smoking history of patient which increases the strength of our
who were operated by attending surgeons were significantly study. In another study in- vestigating the correlation of
smoking and PTH by Cinamon et al. [6], they found a
significant increase in PTH rates in smokers which is
consistent with our findings. However, they only classified
patients as smokers and non-smokers which also does not
specify the duration of tobacco exposures of patients. When we
compared smokers and
 nonsmokers, PTH was observed significantly higher in smokers, age(Tables 2, 5). Mean re-bleeding post- operative day was
con- sistent with their findings. Giger et al. [17] also reported a 10.5(5–15) and 8 of the patients (%80) needed surgical
significant increase in PTH rates in smokers, which is consistent intervention to control bleeding. Both patients who experi- enced
with our findings. Peritonsillar abscess is defined as pus third episode of bleeding were also taken back to operating
accumulation between ton- sillar capsule and constrictor theatre to provide hemostasis. Failure to find the risk factors for
pharyngeus muscle and is thought to be a complication of re- bleeding can be explained by the low number of patients. Re-
acute/recurrent tonsillitis [18]. In a recent study by Betancourt et bleeding is
al. [19] reported that prior peritonsillar abscess is an important
factor linked to PTH. In our study, 40 patients in Group 1 had a
prior history of peritonsillar abscess, and 4 patients had prior
history of peritonsillar abscess in Group 2 and there was no
statistically sig- nificant association between peritonsillar abscess
history and PTH rates which was not consistent with previous
studies [19–21]. Prior peri- tonsillar abscess history was relatively
low in our study and we believe
that this might be the factor affecting our outcome.
Hypertension is one of the most common diseases worldwide
with a prevalence of %34 in US population [22]. There are
limited data in the literature about the impact of hypertension
history on PTH. Gamiz et al.
[5] found a statistical significant relationship with systolic
blood pressure ≥ 140 mmHg, and the risk of PTH in adult
population. In our study, 10 patients in Group 1 had a history of
hypertension, whereas only 1 patient in Group 2 had a history of
hypertension. The only pa- tient with hypertension in Group 2
experienced 3 episodes of bleeding, first episode ceased
spontaneously, in other two episodes, hemostasis was obtained via
surgical intervention(Tables 1, 3). We did not find any significant
relationship with hypertension and the risk of PTH. The
prevalence of hypertension is reported as 11.6% among those
20 to 39 years of age, 37.3% among those 40 to 59 years of
age, and 67.2% among those ≥60 years of age [22]. Mean age in
our study group was 25,9 ± 9,8, and prevalence of hypertension
is relatively low compared to older population. Larger studies are
needed to reveal the relation- ship, if any, with hypertension
and the risk of PTH.
In a study by Fujihara et al. [23], IT was defined as
episodes of tonsillitis per year multiplied by morbidity period
(year). We also used the same calculation method they suggested.
In another study by Ka- senõmm et al. [24], they found a strong
correlation between higher number of frequency of tonsillitis
episodes a year with the presence of obstructed tonsillar crypts.
They also stated that the longer disease history correlated well
with the presence of tonsillar sclerosis. The optimal cut-off score
of IT was calculated as 36, and they concluded that an IT score ≥
36 predicted the sclerotic process in recurrently in- flamed
tonsils. In our study, mean IT of patients without PTH was
23.8 ± 12.3 (4–80), and mean IT of patients with PTH was
29.0 ± 16.1 (7–90), which was significantly higher in PTH group
(p = .031)(Table 1) and was found to be a significant risk factor
for PTH in logistic regression analysis(p = .001)(Table 4). The
underlying mechanism of this finding might be the sclerotic
process caused by chronic and recurrent inflammation in tonsils
and tonsillar fossa. Al- though we have found a significant
correlation with PTH and IT, this finding might be affected by the
retrospective nature of our study. We simply ask patients about
the frequency of tonsillitis per year and the duration of recurrent
tonsillitis history. We have reviewed the patient charts and
gathered these data and calculated IT. Most of the episodes of
tonsillitis were not diagnosed and documented by a physician,
but stated by the patient which is the limitation of this finding.
Prospective, controlled, randomized studies are needed to
confirm our results.
There is not enough data in the literature about re-bleeding
in pa- tients with PTH. In our study, 10 patients (%18.9) in PTH
group ex- perienced a second episode of bleeding and 2 of them
experienced a third episode of bleeding. We did not find a causal
relationship with re- bleeding and smoking history, prior
peritonsillar abscess history, hy- pertension, gender and
also another concern which needs to be investigated deeply in adults: analysis of indications and complications. Auris Nasus Larynx 2018.
https://doi. org/10.1016/j.anl.2017.08.012.
larger studies. [3] Wei JL, Beatty CW, Gustafson RO. Evaluation of posttonsillectomy hemorrhage
In previous studies comparing different surgical techniques, and risk factors. Otolaryngol - Head Neck Surg 2000.
dif- ferent rates of PTH were reported. Monopolar cautery https://doi.org/10.1067/mhn.
tonsillectomy is the most common technique used in United
States [25]. In a study by Brkic et al. [26] monopolar/bipolar
cautery for dissection and hemos- tasis technique was compared
to combined technique(cold dissection and hemostasis with
monopolar/bipolar cautery) which we used in our study. They
reported a lower rate of hemorrhage with hot dissection
technique(0.6% vs 4.88%). However, in that study, the number of
adult patients was low. Ozkiris [27] et al. compared three
different techni- ques in adult tonsillectomy; thermal welding,
cold dissection and bi- polar cautery dissection. They did not
find any significant difference between these three techniques
regarding PTH rates. Lee et al. [28] and Betancourt [19] et al.
reported that in cold dissection technique, the rate of PTH is
significantly lower compared to hot dissection technique. In our
study, we aimed to evaluate the effect of smoking on PTH, thus
we excluded patients who were operated using techniques other
than cold dissection tonsillectomy to prevent technique
dependent bias. Since there is debate in the literature regarding
PTH risk in different techniques, prospective, randomized
studies are needed in adult po- pulation comparing different
techniques.
In a survey of 552 otolaryngologists determined an
extrapolated
mortality rate of 1 in 27,000, or 0.004% following tonsillectomy
and only %16 of the deaths were attributed to bleeding [29].
Even though the mortality rates are low, severity of the
hemorrhage should be taken into account to prevent further
complications. In our study, PTH group was divided to 3
subgroups according to the severity of the hemor- rhage. We
did not find any significant causal relationship with severity of
the hemorrhage and age, gender, smoking history, peritonsillar ab-
scess history and hypertension. Hemoglobin levels were
significantly lower in subgroup 3, who needed surgical
intervention to provide he- mostasis. Hemoglobin levels should
be checked routinely in patients with PTH and should be
corrected if needed, especially in patients with severe
hemorrhage.

5. Conclusion

PTH is one of the most common complications of tonsillectomy.

Our study showed that smoking history of patients and index of
tonsillitis are strongly associated with increased risk of PTH.
Other risk factors were age, male gender. Any risk factor for re-
bleeding and risk factors affecting the severity of hemorrhage
in patients with PTH was not identified. The duration of
abstinence from smoking before tonsil- lectomy to lower the
risk of PTH is an important topic which needs to be studied
further.

Financial disclosure

There are no funding or financial relationships to disclose.

This study was carried out at the Sisli Hamidiye Etfal
Training and Research Hospital in Istanbul, Turkey.

Declaration of competing interest

The authors declare that they have no conflicts of interest.

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