Researchers led by a team at UT Southwestern Medical Center created a statistical model to quantify criteria for typical, high or low bleeding rates after tonsillectomy in children. Results published in JAMA Otolaryngology, Head and Neck SurgeryIt can help doctors and hospitals improve outcomes for the third most common pediatric surgery in the United States
This model is a useful tool for inclusion in quality and safety initiatives around tonsillectomy. Now, clinicians have an approved model for judging their bleeding rates.”
Romine Johnson, MD, first author, professor of otolaryngology and head and neck surgery at UTSW and director of the Division of Quality and Safety
In 2019, the American Academy of Otolaryngology-Head and Neck Surgery Foundation released updated guidelines for pediatric tonsillectomy, which recommended that surgeons monitor their patients’ bleeding rates themselves after these procedures. Ron Mitchell, MD, professor of otolaryngology and head and neck surgery and chief of pediatric otolaryngology, was the lead author of these guidelines and the current study.
Although complications after tonsillectomy are rare, Dr. Johnson said, excessive bleeding is one of the most common causes and is often a factor in the very few deaths associated with this surgery. He said the change in the guidelines was an important step toward helping to improve the safety of tonsillectomy, but that doctors faced a major hurdle in using it effectively. There are no standards for informing clinicians whether their personal or institutional bleeding rates are considered normal, high, or low.
To develop the likelihood criteria, Dr. Johnson and colleagues collected data from the Children’s Hospital Association’s Children’s Health Information System database, which contains de-identified patient information covering hospital stays, outpatient surgeries, emergency department visits, and observation unit patient data from more than of 49 nonprofit children’s hospitals in the United States
The researchers were primarily interested in data on patients who came to the emergency department or were readmitted for bleeding after tonsillectomy — a sign that their bleeding after the procedure was considered excessive. The researchers collected demographic data on these patients as well as medical histories.
After dividing the bleeding rates at these institutions into percentages, the team found that the average bleeding probability rate among all patients was 1.97%. The lowest rate was hovering above 1%, and the highest in the 99% was 6.4%. Variables associated with increased rates of post-tonsillectomy bleeding included adolescence (older than 12 years of age), Hispanic ethnicity, residence in a relatively affluent zip code, and obesity.
Dr. Johnson emphasized that the study did not take into account the surgical technique or the many tools available to perform a tonsillectomy. The different training of the surgeons can also affect the results, he said, which is a difficult variable to capture. But Dr. Johnson stressed that the technique may not be responsible for the higher bleeding rates because many factors outside the surgeon’s control contribute to the risk, including the patient’s age or other comorbidities.
“This model provides a useful starting point to help surgeons look critically at their bleeding rates and help them understand why these complications occur,” said Dr. Johnson.
Other UTSW researchers who contributed to this study include Dylan R. Beams, Stephen R. Chorny, Yan Vu-koo, Felicity Lennis-Voight, Sekken Olalp, and Christopher Liu.
Dr. Johnson holds the Beth and Marvin C. “Cub” Culbertson Professor of Pediatric Otolaryngology. He also serves as Director of the Children’s Voice/FEES Clinic at Children’s Medical Center Dallas. Dr. Mitchell holds the William Beckner, MD, Distinguished Chair in Otolaryngology.
This study was funded by the Beth and Marvin “Cub” Culbertson Endowment in the Department of Otolaryngology, Head and Neck Surgery at UTSW.
Johnson, RF, et al. (2023). Estimated probability distribution of bleeding after tonsillectomy in children: a national retrospective cohort study of US children. JAMA Otolaryngology – Head and Neck Surgery. doi.org/10.1001/jamaoto.2023.0268.