INTRODUCTION

Palatine tonsillectomy, associated or not with adenoidectomy, is still one of the most frequent surgeries in childhood. Since the year 50 DC, when Celsus Cornelius described the technique for surgical extirpation of palatine tonsils, postoperative hemorrhage has been recognized as a fearful complication. Despite the technical evolution that followed the procedure to current days, postoperative bleeding is still prevalent in 0.1 to 20% of the cases in world reports 1, 2, 3.

Most of the studies described in the literature refer to statistical operative cases of different surgeons, generally otorhinolaryngologists, but also pediatric surgeons, many of them resident physicians in training programs, which could have influenced the times 3, 4, 5.

In an attempt to reduce expenses, the value of preoperative laboratory tests in patients with no clinical history suggestive of specific diseases, especially blood disorders, has been questioned. Moreover, the conduction of surgeries in day hospital settings for selected patients has been advocated, being a routine in the United States and Canada 1, 6, 7, 8.

In order to reduce the prevalence of hemorrhage after palatine tonsillectomy, many techniques to reach effective hemostasis have been described and one of them is the use of gauze packing soaked in bismuth subgallate solution, a heavy metal salt that stimulates cascade activation of coagulation 3, 6.

The authors conducted a retrospective study of data in the medical charts of 204 patients submitted to palatine tonsillectomy in the period between January 2001 and October 2003. Hemostasis was conducted through packing of tonsil site with gauze soaked in bismuth subgallate solution at 100%, a cheap and accessible method in most hospitals, even in those that belong to the public healthcare service. We correlated efficacy of the method with palatine tonsil volume through statistical descriptive procedures in order to investigate whether the method would be effective to all grades of hypertrophy/ organ hyperplasia. To analyze the association between the categorized variables, we conducted the chi-square associated test.

MATERIAL AND METHOD

We conducted a retrospective statistical study with the data contained in the medical charts of 204 patients submitted to palatine tonsillectomy in the period between January 2001 and October 2003, in private hospitals of the municipal region of Sorocaba, SP, whose surgical indications were: upper airways obstruction with or without sleep apnea; dysphagia by oropharyxn obstruction owing to increase in palatine tonsils, causing reduction of expected weight gain; bacterial repetitive tonsillitis characterized by more than 3 episodes in the year for the past 3 years, more than 4 episodes per year in the past 2 years, or more than 5 episodes per year in the last year; caseous tonsillitis leading to halitosis and social embarrassment or their association.

Palatine tonsil volume was carefully assessed through oropharyngoscopy and classified into four groups according to degree of obstruction provided at the oropharynx, according to Table 1, for later analysis of the association between categorized variables through the chi-square associated test.

For all patients, we ordered preoperative complete blood test and coagulation times and when the clinical assessment required it, specific tests were performed, such as chest x-rays, electrocardiograms or plasma electrolyte dosage. Once the clinical and laboratory examinations were normal, we performed palatine tonsillectomy using the dissection technique. Special attention was given in order not to leave any lymphoid tissue behind or even the capsule of the surgical bed to prevent early postoperative bleeding or late infection recurrence.

General anesthesia was used in all patients, and hemostasis was obtained by using bleeding packing with gauze soaked in 100% bismuth subgallate solution, in saline solution, for a period of 3 minutes. After removal of the packing, if there were still bleeding points, we conducted a suture with categut simple thread 2-0 with a 2 cm needle. While we waited for the hemostasis of the site, we conducted contralateral tonsillectomy and adenoidectomy was made at the beginning of the surgery with Beckman curette. The paranasal region was packed with gauze soaked in the same hemostatic solution during the time used to conduct the palatine tonsillectomy.

We operated under day-hospital conditions, and patients were discharged at 7pm and we prescribed PO drugs: dipirone was the drug indicated for patients up to 12 years of age, and older patients received dispersible tablets of nimesulide.

Postoperative instructions were written on the back of the prescription emphasizing early signs of bleeding.

On the 7th postoperative day, patients were reassessed. If the site presented normal aspect, they were discharged from the outpatient follow-up.

In case of signs of bleeding, the patient was reassessed immediately and then submitted to the necessary intervention at the discretion of the otorhinolaryngologist that had performed the surgery.

The cases that required ligation/suture of vessels or reintervention for the control of bleeding were considered as failure of hemostatic method, being statistically analyzed and correlated with palatine tonsil volume to check whether these variables were correlated or not.

RESULTS

Out of 204 patients submitted to palatine tonsillectomy, 12 were classified as Grade I, 67 as Grade II, 108 as Grade III and 17 as Grade IV, as shown in Graph 1.

All in all, there were 99 male patients and 105 female patients, ages ranging from 2.25 to 48.44 years, mean of 10.03 years (SD = 8,82). Surgical indications of palatine tonsillectomy were: 135 cases of upper airway-digestive tract disorders, 66 cases of repetitive bacterial tonsillitis, and 3 cases of caseous tonsillitis with halitosis, leading to social limitations, being 2 female and 1 male subjects, respectively aged 30 years and 6 months (grade I tonsils), 18y11m (grade II tonsils) and 24y5m (grade II tonsils).

Out of 204 operated cases, only 4 had bleeding, being 3 intraoperatively (2 with grade III tonsils and 1 with grade I tonsils) that bled after strict suture and 1 (grade II tonsil) on the 3rd postoperative day after intake of solid foods and physical exercise, going against the post-surgical instructions. The patient required reintervention under general anesthesia to have the clot aspirated and sutured. Therefore, out of 204 operated cases, only 4 had failure in the hemostatic method, as provided by Graph 2.

All the 4 cases presented complete blood count and coagulation times that presented values within the normal range and there was no personal or family history that would indicate blood dyscrasia, even after the occurrence when we proceeded with detailed investigation. After the analysis of the association between the categorized variables through the chi-square associated test we did not find any correlation between size of palatine tonsils and prevalence of postoperative bleeding (X2 = 2.96; p=0.398).

DISCUSSION

Many investigators have dedicated to improving their surgical techniques to help to reduce post-surgical complications of palatine tonsillectomy, considering its repercussion over the safety of the procedure, especially in young children who have smaller respiratory pathways and less amount of blood in them to cause complete obstruction and even death if not properly managed 9-13.

The introduction of more sophisticated methods to conduct surgery, whose peak was the use of laser, has not shown lower indexes of postoperative morbidity, in addition increasing costs 14.

The examination of tissues with optical devices that can enlarge the image during the surgical procedures has helped ENT surgeons. An accessible instrument in most hospitals in which ENT surgeries are conducted is surgical microscope. It has been employed in palatine tonsillectomy associated with bipolar electrocautery, providing less bleeding and greater preservation of tissues owing to increased visibility to the ENT, who should be skilled to manipulate the device. Therefore, at zero cost, we can improve the surgical technique 20-22.

Bismuth subgallate, a heavy metal that is relatively soluble and little absorbed by the surgical wound, of low cost and easy to use, has presented good efficacy as local hemostatic agent. Its mechanism of action is attributed to activation of coagulation factor XII, in addition to providing local astringent effect 3-6.

The authors have obtained excellent hemostatic results in the wound area left after the palatine tonsillectomy with the use of gauze packing soaked in bismuth subgallate solution at 100%, dispensing the need for suture or ligation of tonsil site vessels. Only 3 patients required suture with simple categut thread 2-0 transoperatively owing to bleeding. The patient that required reintervention experienced bleeding on the 3rd postoperative day after having eaten solid foods and exercised. Our prevalence of hemorrhagic complication was 2% and the international literature reports rates that vary from 0.1 to 20% 1, 2, 3.

A trend in many ENT centers is not to perform preoperative lab tests in patients to be submitted to tonsillectomy when they do not have clinical history that may suggest blood dyscrasia 15-17. All our patients presented normal results of coagulation and complete blood count tests, even those that had greater intraoperative bleeding and the one that required reintervention. Some drugs have been related with post-tonsillectomy bleeding 18, 19 but none of our patients had used them.

CONCLUSION

Hemostasis obtained in palatine tonsillectomy using a packing in the bleeding area with gauze soaked in bismuth subgallate solution at 100% for a 3-minute period proved to be effective, of low cost and easy to use. There were few cases that required complementation of the method using suture of bleeding points with categut 2-0 thread.

Palatine tonsils volume and failure of hemostatic method did not produce statistically significant correlation in the present study.

Even in cases of marked hyperplasia and hypertrophy, in which we assume there was increased local vascularization, there were no intra or postoperative hemostatic differences.





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1 Otorhinolaryngologist, Master studies in Health Sciences, Hospital Heliópolis - HOSPHEL.
2 Coordinator of the Post-graduation Course in Health Sciences, Hospital Heliópolis - HOSPHEL.
Address correspondence to: Prof. Dr. Abrão Rapoport - Rua Iramaia, nº 136 Jd. Europa 01450-020 Sao Paulo SP