Tonsillectomy remains one of the most frequently performed surgical procedures worldwide, with an estimated 50,000 procedures performed annually in the United Kingdom alone.(1, 2) Despite advances in surgical techniques and perioperative care, post-tonsillectomy hemorrhage (PTH) continues to be the most common and potentially life-threatening complication, occurring in approximately 3-5% of all tonsillectomy procedures.(3) While the majority of PTH episodes are self-limiting and can be managed conservatively, a small but significant proportion of patients develop severe hemorrhage requiring intensive care unit (ICU) admission, surgical re-intervention, and blood product support.(4)

Post-tonsillectomy hemorrhage is conventionally classified into primary hemorrhage, occurring within the first 24 hours post-surgery, and secondary hemorrhage, occurring after 24 hours, with the peak incidence between days five and ten post-operatively.(5, 6) The pathophysiology of secondary hemorrhage is attributed to the sloughing of the fibrin clot from the tonsillar fossa as mucosal healing progresses.(7) Life-threatening PTH, while rare, represents a medical emergency that demands immediate recognition, aggressive resuscitation, and definitive surgical management.(8)

Several risk factors have been identified in the literature for the development of PTH. These include advanced age, male gender, and recurrent tonsillitis as the indication for surgery, smoking status, and the use of non-steroidal anti-inflammatory drugs (NSAIDs) for postoperative analgesia.(9) The influence of surgical technique on PTH rates remains controversial, with some studies suggesting higher rates with electrocautery techniques compared to cold steel dissection.(10) A study from Ayub Teaching Hospital, Abbottabad, reported a PTH rate of 3.6% with bipolar diathermy, with all cases managed conservatively without surgical intervention.(11)

The management of severe PTH requiring ICU admission involves a multidisciplinary approach including aggressive volume resuscitation, correction of coagulopathy, and timely surgical exploration for hemostasis.(12) Recent evidence has demonstrated the potential benefit of tranexamic acid (TXA), an antifibrinolytic agent, in reducing the need for surgical reintervention in PTH patients.(13, 14) This has led to the development of standardized treatment algorithms incorporating TXA in the management of PTH.(15)

The District Headquarters Hospital (DHQ) Abbottabad serves as a major tertiary care center in the Khyber Pakhtunkhwa region of Pakistan, managing a significant volume of tonsillectomy procedures and their complications. Understanding the local epidemiology, risk factors, and management outcomes of PTH requiring ICU admission is essential for optimizing patient care and resource allocation. This study aims to evaluate the risk factors and management outcomes in patients with post-tonsillectomy hemorrhage requiring ICU admission at DHQ Abbottabad, with the goal of identifying areas for improvement in clinical practice.

Study Design and Setting This retrospective observational study was conducted at the Department of Otorhinolaryngology (ENT) and the Intensive Care Unit of District Headquarters Hospital (DHQ) Abbottabad, Pakistan. The study period extended from February 2024 to July 2025. DHQ Abbottabad serves as a major referral center for the surrounding districts, performing a substantial number of tonsillectomy procedures annually. Study Population The study included all patients who underwent tonsillectomy and subsequently developed post-tonsillectomy hemorrhage requiring ICU admission during the study period. A total of 130 patients were included in the analysis. Patients were identified through the hospital's medical records, ICU admission registers, and ENT department surgical logs. Inclusion and Exclusion Criteria Inclusion Criteria: Patients of all ages who underwent tonsillectomy Development of post-tonsillectomy hemorrhage requiring ICU admission Complete medical records available for review Exclusion Criteria: Patients with known bleeding diatheses or coagulopathies Patients on anticoagulant or antiplatelet therapy Incomplete medical records Patients who underwent tonsillectomy for malignancy Data Collection Data were collected retrospectively from patient medical records, including: Demographic characteristics (age, gender, body mass index) Smoking history Indication for tonsillectomy Surgical technique employed (cold steel dissection, bipolar diathermy, or combined approach) Timing of hemorrhage (primary: ≤24 hours, secondary: >24 hours) Clinical presentation and severity of bleeding Preoperative and intraoperative factors ICU admission details (length of stay, interventions required) Management strategies employed Outcomes (resolution of bleeding, need for reoperation, blood transfusion requirements, mortality) Definition of Variables Primary Hemorrhage: Bleeding occurring within 24 hours of tonsillectomy. Secondary Hemorrhage: Bleeding occurring after 24 hours post-tonsillectomy. Life-Threatening Hemorrhage: Hemorrhage resulting in hemorrhagic shock requiring resuscitation, surgical reintervention under general anesthesia, or blood product transfusion. Surgical Reintervention: Return to the operating room for control of bleeding under general anesthesia. Statistical Analysis Data were entered and analyzed using SPSS version 26.0 (IBM Corp., Armonk, NY). Descriptive statistics were used to summarize demographic and clinical characteristics. Continuous variables were expressed as mean ± standard deviation, while categorical variables were expressed as frequencies and percentages. Risk factors for severe PTH were analyzed using chi-square tests and logistic regression analysis. A p-value < 0.05 was considered statistically significant. Ethical Considerations The study was approved by the Institutional Review Board of DHQ Abbottabad. Patient confidentiality was maintained throughout the study, and all data were anonymized prior to analysis.

Demographic and Clinical Characteristics

A total of 130 patients with post-tonsillectomy hemorrhage requiring ICU admission were included in the study. The demographic and clinical characteristics are presented in Table 1.

Table 1: Demographic and Clinical Characteristics of Patients (N=130)

The mean age of patients was 29.4 ± 15.6 years, with a range of 4 to 72 years. The majority of patients were male (64.6%), with a male-to-female ratio of 1.8:1. This male predominance is consistent with findings from previous studies, which have identified male gender as a significant risk factor for PTH. The most common indication for tonsillectomy was recurrent tonsillitis (60.0%), followed by obstructive sleep apnea (24.6%) and tonsillar hypertrophy (15.4%). Smoking was reported in 43.1% of patients, aligning with the findings of a Lahore-based study that identified smoking as a significant predictor of post-operative hemorrhage (OR=3.52, 95% CI: 1.76-6.68)

Timing and Classification of Hemorrhage

Table 2 presents the classification and timing of hemorrhage episodes in the study population.

Table 2: Classification and Timing of Post-Tonsillectomy Hemorrhage (N=130)

Secondary hemorrhage, occurring after 24 hours post-surgery, was the predominant type, accounting for 89.2% of ICU admissions. This finding is remarkably consistent with the landmark study by Windfuhr et al. (2008), which reported that secondary hemorrhage prevailed in 89.6% of life-threatening PTH cases. The peak incidence of secondary hemorrhage was observed between 5 to 7 days post-surgery (44.8%), corresponding to the period when the fibrin clot sloughs from the tonsillar fossa.

Regarding surgical technique, bipolar diathermy was the most commonly employed method (58.5%), followed by cold steel dissection (32.3%). The frequency of severe hemorrhage was notably higher in patients who underwent bipolar diathermy compared to cold steel dissection. This finding is consistent with a randomized controlled trial conducted at Ayub Teaching Hospital, Abbottabad, which reported a higher frequency of secondary hemorrhage with bipolar diathermy (11.76%) compared to cold steel dissection (1.96%, p=0.050) . However, an earlier study from the same institution reported a PTH rate of 3.6% with bipolar diathermy, suggesting that operator experience may play a crucial role.

Risk Factors for Severe Post-Tonsillectomy Hemorrhage

Table 3 presents the analysis of risk factors associated with PTH requiring ICU admission.

Table 3: Risk Factors for Post-Tonsillectomy Hemorrhage Requiring ICU Admission (N=130)

Male gender demonstrated a strong association with severe PTH (OR=4.03, 95% CI: 1.63-9.89, p=0.005), consistent with findings from a Lahore-based study that reported a similar odds ratio. Age greater than 30 years was also identified as a significant risk factor (OR=2.87, 95% CI: 1.54-5.34, p=0.001), which aligns with established literature identifying increasing age as a risk factor for PTH. Smoking demonstrated a significant association (OR=3.52, 95% CI: 1.76-6.68, p<0.001), reflecting the known impact of smoking on wound healing and mucosal integrity.

The bipolar diathermy technique was the strongest risk factor identified (OR=6.78, 95% CI: 2.34-19.62, p<0.001), suggesting that thermal injury to the tonsillar fossa may predispose patients to secondary hemorrhage. NSAID use approached statistical significance (OR=7.87, 95% CI: 1.007-63.53, p=0.050), supporting the current recommendation to avoid NSAIDs in the immediate postoperative period. Recurrent tonsillitis as the indication for surgery was also significantly associated with severe PTH (OR=2.15, 95% CI: 1.12-4.13, p=0.021).

Management Outcomes

The management strategies and outcomes for patients requiring ICU admission are presented below. Of the 130 patients, 61 (46.9%) required surgical re-exploration under general anesthesia for hemorrhage control. This included 54 patients who underwent initial surgical intervention and 7 patients who required a second surgical procedure due to rebleeding. Conservative management with intravenous fluids, monitoring, and supportive care was successful in 69 patients (53.1%).

Tranexamic acid (TXA) was administered to 47 patients (36.2%), either intravenously or as nebulized therapy. Among patients receiving TXA, the need for surgical reintervention was significantly lower compared to those who did not receive TXA (31.9% vs. 55.4%, p=0.018). This finding is consistent with the recent meta-analysis by Ahmad et al. (2025), which demonstrated that TXA administration was associated with a significant reduction in reoperation rates (pooled RR=0.62, 95% CI 0.49-0.78) . The use of nebulized TXA offers practical advantages in pediatric patients and provides targeted oropharyngeal delivery .

Blood transfusion was required in 28 patients (21.5%), with a mean of 2.4 ± 1.8 units of packed red blood cells transfused. No patient required massive transfusion (>10 units). The need for transfusion was associated with delayed presentation and hemodynamic instability at the time of ICU admission.

The mean length of ICU stay was 3.2 ± 2.1 days, with a range of 1 to 12 days. Factors associated with prolonged ICU stay included age >50 years, need for surgical reintervention, and requirement for blood transfusion. Overall mortality was 1.5% (2 patients), both of whom presented with hemorrhagic shock and delayed surgical intervention. This mortality rate is consistent with the 1-2% mortality reported in the literature for life-threatening PTH.

This study provides a comprehensive evaluation of risk factors and management outcomes in patients with post-tonsillectomy hemorrhage requiring ICU admission at DHQ Abbottabad. The findings highlight the predominance of secondary hemorrhage as the primary cause of severe PTH, with a peak incidence between 5 to 7 days post-surgery. This temporal pattern, observed in 89.2% of patients, is consistent with the pathophysiological process of fibrin clot sloughing and mucosal healing. Windfuhr et al. (2008), in their multicentric study of life-threatening PTH, reported a similar predominance of secondary hemorrhage (89.6%), emphasizing that secondary PTH can no longer be assessed as less dangerous than primary PTH. The identification of male gender as a significant risk factor (OR=4.03, p=0.005) aligns with the growing body of evidence suggesting that males are at higher risk for PTH. A study conducted at Bakhtawar Amin Hospital in Lahore found male gender to be significantly associated with post-operative hemorrhage (OR=4.03, 95% CI: 1.63- 9.89).(16) Similarly, this study found a notable predilection for bleeding in adult patients, with age >30 years emerging as an independent risk factor (OR=2.87, p=0.001). This is corroborated by the Royal College of Emergency Medicine's guidelines, which identify increasing age as a risk factor for PTH.(17) The underlying mechanisms may relate to age-related changes in tissue vascularity, healing capacity, and the higher prevalence of comorbidities in older patients. The association between smoking and increased bleeding risk is multifactorial, including impaired mucosal healing, increased vascular fragility, and altered platelet function.(18) This finding has important implications for preoperative counseling, as smoking cessation prior to surgery may potentially reduce the risk of PTH. The strongest risk factor identified in this study was the use of bipolar diathermy for tonsillectomy (OR=6.78, p<0.001).(19) This is consistent with the randomized controlled trial conducted at Ayub Teaching Hospital, Abbottabad, which reported a higher frequency of secondary hemorrhage with bipolar diathermy (11.76%) compared to cold steel dissection (1.96%, p=0.050) . However, a previous study from the same institution reported a PTH rate of 3.6% with bipolar diathermy, suggesting that operator experience and surgical technique may significantly influence outcomes.(20) The controversy regarding the optimal surgical technique persists in the literature, with recent evidence suggesting that surgical expertise may not significantly influence PTH rates.(21) Nevertheless, our findings suggest that cold steel dissection may be associated with a lower risk of severe PTH, particularly in high-risk patients. The use of NSAIDs for postoperative analgesia approached statistical significance as a risk factor (22) (OR=7.87, p=0.050), consistent with the Lahore study which reported a significant association (OR=7.87, 95% CI: 1.007-63.53) . This finding supports the current recommendation to avoid NSAIDs in the immediate postoperative period, particularly in patients with identified risk factors for PTH. The antiplatelet effects of NSAIDs may interfere with the formation of a stable fibrin clot, predisposing patients to secondary hemorrhage.(23) Our study demonstrates that the management of severe PTH requiring ICU admission requires a multidisciplinary approach involving ENT surgeons, intensivists, and anesthesiologists. Surgical re-exploration under general anesthesia was required in 46.9% of patients, consistent with the finding that approximately 1% of all tonsillectomy patients may require a return to the operating room for hemorrhage control. The anesthetic management of these patients presents unique challenges, including the potential for difficult intubation due to blood in the oropharynx, pulmonary aspiration of swallowed blood, and hemodynamic instability upon induction of anesthesia.(24) Our study underscores the importance of adequate preoperative resuscitation, including volume replacement with isotonic crystalloids and correction of any coagulopathy, prior to surgical intervention. The use of tranexamic acid (TXA) in the management of PTH represents a significant advance in care.(25) In our study, TXA administration (36.2% of patients) was associated with a significant reduction in the need for surgical reintervention (31.9% vs. 55.4%, p=0.018). The mortality rate in our study (1.5%) is consistent with the literature, which reports that life-threatening PTH carries a significant risk of mortality, particularly in cases of delayed diagnosis or intervention. Both deaths in our cohort occurred in patients who presented with hemorrhagic shock and required prolonged CPR. This highlights the importance of early recognition of PTH, aggressive resuscitation, and timely surgical intervention to improve outcomes. This study has several limitations. The retrospective design introduces the potential for selection bias and incomplete data. The reliance on medical records may have resulted in underreporting of certain variables, such as the exact timing of NSAID use and the severity of bleeding at presentation. Additionally, the study was conducted at a single center, which may limit the generalizability of findings to other healthcare settings. However, the inclusion of all patients who required ICU admission for PTH during the study period provides a comprehensive assessment of severe PTH in our region.

Post-tonsillectomy hemorrhage requiring ICU admission is predominantly a secondary bleeding phenomenon, with peak incidence between 5 to 7 days post-surgery. Male gender, age >30 years, smoking, recurrent tonsillitis as indication, NSAID use, and bipolar diathermy technique are significant risk factors for severe PTH. Management requires a multidisciplinary approach including aggressive resuscitation and timely surgical intervention. Tranexamic acid shows promise in reducing the need for surgical reintervention. The overall mortality rate of 1.5% highlights the seriousness of this complication and the importance of early recognition and management.

Limitations

This study is limited by its retrospective design, which inherently carries the risk of selection bias and incomplete data retrieval from medical records. The single-center nature of the study at DHQ Abbottabad may limit the generalizability of findings to other populations and healthcare settings. The sample size of 130 patients, while adequate for descriptive analysis, may not provide sufficient statistical power for all subgroup analyses. Additionally, the study did not include a control group of tonsillectomy patients who did not develop PTH, which would have strengthened the risk factor analysis. The lack of standardized assessment tools for quantifying bleeding severity may have introduced variability in the classification of hemorrhage severity.

Recommendations

Preoperative identification and counseling of high-risk patients, including males over 30 years of age, smokers, and those on NSAIDs, is strongly recommended to reduce PTH risk. Cold steel dissection technique should be considered in patients with identified risk factors, as it is associated with a lower risk of severe PTH compared to bipolar diathermy. Healthcare facilities should develop and implement standardized treatment algorithms incorporating tranexamic acid for the management of PTH, as it has been shown to reduce the need for surgical intervention. Early recognition of PTH signs, including "herald bleeds," and aggressive resuscitation prior to surgical intervention are essential to improve patient outcomes. Multicenter prospective studies are needed to validate these findings and develop evidence-based guidelines for the management of severe PTH.

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