In the last 20 years, rates of adult tonsillectomy have fallen in the order of 50%. The flipside to this, is that the number of admissions of patients with acute tonsilitis is more than double the reduction in tonsillectomy rates. A significant reason for this is the labelling of tonsillectomy as an ‘intervention of limited clinical value’. Yet, despite this, tonsillectomy is still one of the most common adult operations performed by the NHS, in the order of 16,000 procedures per year. The NATTINA trial undertaken in Newcastle in 2023 has shown that it is more cost effective for the NHS to offer this surgery to eligible patients than other treatments, such as analgesia and antibiotics. Accordingly, patients who meet appropriate criteria for tonsillectomy will gain a clear benefit from undergoing the procedure. However, as with any operation, the risks need to be balanced against the benefits – bleeding being one of the commonest concerns, quoted as one in five in the above-mentioned NATTINA study. Not all patients with bleeds will attend hospital but, of those who do, a small percentage will require a return to theatre for management of the postop bleed. The Editors’ Choice this month is an interesting systematic review of the use of nebulised tranexamic acid in post-tonsillectomy bleeds. The use of this antifibrinolytic agent delivered in a nebulised form rather than systemically, shows excellent efficacy in management of post-tonsillectomy bleeds and a reduction in the need for revision surgery. The cost of this relatively inexpensive medication in comparison to the cost of an emergency return to theatre shows some promise in the acute care setting. Thank you, as always, to our wonderful reviewers for their contributions.
Hannah and Nazia
Post-tonsillectomy bleeding is a challenging issue and associated with significant postoperative morbidity. Typically, patients return to the emergency department (ED) within hours to days after surgery. Tranexamic acid (TXA) is an antifibrinolytic agent which can reduce bleeding. Nebulised TXA compared to systemic TXA is emerging as a safe and effective treatment option for the management of post-tonsillectomy bleeding. The authors screened six databases and assessed the quality of the relevant studies with validated tools. Their results show that the nebulised TXA had excellent efficacy in the ED and reduced the rates of revision surgery for management of post-tonsillectomy bleeding. They conclude that nebulised TXA is a safe and promising treatment in acute care settings.
