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In this detailed narrative review article, the authors have addressed several factors which could be related to postoperative bleeding after tonsillectomy. As regards to microbiology, the significance of micro-organisms present both on surface and within the tonsils is emphasised and the role of bio-films is highlighted. Of the three phases of healing – early, intermediate and late – it is proliferation of blood vessels and granulation tissue in the intermediate phase which induces bleeding. The epidemiology suggests a threefold increase in bleeding rates and patients returning to the theatre in the 2013-2017 cohort, compared to the 1998-2002 cohort. Surgical techniques do influence the rate of bleeding, this being higher in all techniques other than the ‘cold steel’ method. Older patients bleed more than those under the age of 15. Meteorological factors, such as winter months and cyclonic weather, are associated with higher bleeding rates. Established coagulopathy is related to greater bleeding rates but such undiagnosed conditions do not influence, thus rendering it unnecessary to do a routine check for coagulopathies. Bacterial infection has been considered in details as a risk factor. It may have some role but is a less confounding factor compared to other variables. Whether tonsillar abscesses influence the rate of bleeding remains controversial, but one study found higher rate of bleeding in the unaffected tonsil. Patients with positive cultures have a significantly higher rate of bleeding and this supports the common practice of not operating in acute infection. The use of perioperative antibiotics does not reduce the rate of bleeding. Studies show that non-anti-microbial interventions, such as use of tranexamic acid, reduce bleeding rates and intraoperative blood loss. This was not the case with use of fibrin sealants or hydrogen peroxide, the latter possibly inducing risk of embolism. Useful practical points for one of the commonest otolaryngologic procedures can be gathered from this study.

Does infection play a role in post-tonsillectomy haemorrhage? A narrative review.
Williamson A, Coleman H and Douglas C.
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Madhup K Chaurasia

Mid and South Essex NHS Foundation Trust, UK.

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