Is there any role of post operative antibiotics in reducing secondary haemorrhage after tonsillectomy

Objective: To compare with and without the antibiotic therapy in reducing post-tonsillectomy secondary haemorrhage. Method: A prospective study was conducted at Shaheed Shamsuddin Ahmed Hospital, Sylhet from April 2010 to April 2012. 170 patients who underwent tonsillectomy divided into two groups randomly each consisting of 85 patients. In group A (intervention group) antibiotic was given post-operatively, while in group B (control group) no antibiotic was given. Postoperative follow-up was done till the tonsillar fossa healed. Results: Among 170 patients 61.18% were female and 38.82% were male, mean age was 21.58 years. One patient from antibiotic group had secondary haemorrhage (1.18%), while no haemorrhage was observed in nonantibiotic group. Secondary haemorrhage rate was 0.59% in total study population. Conclusion: The study showed that antibiotic did not have any significant role in reducing the post-tonsillectomy secondary haemorrhage.


Introduction:
Tonsillectomy is one of the most frequently performed surgical procedures in the field of otolaryngology, representing approximately 20-40% of the total procedures 1,2 .Approximately 2,50,000 tonsillectomies with or without adenoidectomy are performed in the United States each year 3 .The traditional methods for removing the tonsils are the 'cold steel' techniques using conventional metallic instruments.Cold steel dissection may be combined with diathermy to aid haemostasis; many surgeons prefer ties or swabs.In the NPTA (National Prospective Tonsillectomy Audit, UK) the use of 'cold steel' dissection without diathermy was associated with the lowest haemorrhage rate 4 .
The main complications of tonsillectomy are pain, infection and haemorrhage 1 .Haemorrhage is defined as reactionary, occurring within 24 hours of operation, secondary, occurring after 24 hours and during the phase of healing of the tonsillar bed, commonly 5-10 days after operation 1,5 .Secondary haemorrhage after tonsillectomy has been reported 1 to 7.1% in different literatures leading to re-admission in hospital 6,7 .
After tonsillectomy the tonsillar fossa heals by secondary intention.It is contaminated by bacterial commensals naturally present in the oropharyngeal mucosa 8 .Several authors stated that, this predisposes an inflammatory reaction and infection, increasing postoperative morbidity.Therefore, they recommended prophylactic post operative antibiotics to reduce the morbidity 9 .
It has traditionally been assumed that post tonsillectomy secondary haemorrhage is caused by infection, despite a lack of evidence to support this 10 .Ahsan et al found no evidence of infection in patients with post tonsilletomy secondary haemorrhage.In fact, a number of studies have demonstrated that the use of prophylactic antibiotics has no significant effect on the subsequent complication rates 1,7,10,11 .
Therefore, there are considerable variations in practice worldwide: a recent study from the UK showed that only 12% 0f otolaryngologists routinely prescribe post operative antibiotics 12 while another study showed a figure of 79% among American otolaryngologists 13 .
To investigate the role of antibiotics in reducing secondary haemorrhage after tonsillectomy we selected 170 patients who underwent tonsillectomy.Tonsillectomy was done by Cold steel dissection technique and bipolar diathermy.Post operatively the patients were randomly selected into two groups each comprising 85 patients.Group A (case group) was given antibiotics (amoxicillin and cloxacillin) with analgesic (diclofenac sodium and paracetamol), and hydrogen peroxide mouthwash.Group B (control group) -treated with only analgesic (diclofenac sodium and paracetamol), and hydrogen peroxide mouthwash without antibiotics.Postoperative follow-up was done till healing of the tonsillar fossa.

Methods:
Aim and Objective: To see the role of antibiotics in reducing secondary haemorrhage after tonsillectomy operation.Methods of sampling: Cases were selected randomly from the patients who underwent tonsillectomy with chronic/ recurrent acute tonsillitis.

Technique of tonsillectomy: Cold steel dissection technique and bipolar diathermy haemostasis under general anaesthesia.
Data collection: Relevant data were collected in a pre-formed data collection sheet for each of the patient who underwent tonsillectomy.
Post operative management: In post operative period we randomly selected the patients into two equal groups each comprising of 85 patients.Group A (case group) was given antibiotics (amoxicillin and cloxacillin) with analgesic (diclofenac sodium and paracetamol), and hydrogen peroxide mouthwash.Group B (control group) -treated with only analgesic (diclofenac sodium and paracetamol), and hydrogen peroxide mouthwash without antibiotics.Postoperative follow-up was done till the tonsillar fossa healed.Ethical approval was obtained from the hospital authority, while informed written consent was taken from the patients before the study.
Postoperative follow-up: Post-operative follows up was done till healing of the tonsillar fossa.

Results:
Table

Discussion:
As tonsillectomy is one of the most commonly performed operation by an Otolaryngologist, post-operative haemorrhage is a major concern.Episode of post tonsillectomy haemorrhage is unpredictable and often potentially life threatening.Based on severity of haemorrhage, it can be classified as mild (no active surgical management), moderate (requiring surgical intervention), or severe (requiring surgical intervention and blood transfusion).
In our study, among 170 patients 61.18%were female and 38.82% were male, the age of the patients in the study ranged from 6 years to 55 years with a mean age was 21.58 years.
One patient from antibiotic group had secondary haemorrhage (1.18%), while no haemorrhage was observed in non-antibiotic group.Secondary haemorrhage rate was 0.59% in total study population.Patients had mild bleeding from mouth on 5 th post operative day and no active treatment was needed except gargle with ice and hydrogen peroxide.
In comparison to clinical results demonstrated from this study we see Qureshi et al 14 found incidence of secondary haemorrhage in 3.4% cases.He didn't mention the use of antibiotic in post operative period.Baloch MA et al 15 showed, incidence of secondary haemorrhage was 5% and antibiotics did not have any significant impact in reducing the post-tonsillectomy morbidities.Ranajit et al 7 found incidence of secondary haemorrhage 7.1%, and again use of post-operative antibiotics did not affect the incidence of haemorrhage.
It has traditionally been assumed that post tonsillectomy secondary haemorrhage is a result of secondery infection, antibiotics are routinely prescribed; despite a lack of evidence to support this 10 .Ahsan et al 1 found no evidence of infection in patients with post tonsilletomy secondary haemorrhage.Kumar found that of 24 patients with secondary posttonsillectomy haemorrhage who were not on antibiotics, only four had a positive culture on throat swab 11 .Therefore bacterial infection as an aetiology is questionable.
A more plausible explanation is that sloughing of the primary eschar, which usually occurs between day 5 and day 10 in the postoperative period, manifests as a secondary haemorrhage 16 .Further support of this theory comes from the large prospective audit of tonsillectomies conducted in UK, in which diathermy dissection was found to increase the risk of secondary haemorrhage.The authors concluded that compared to traditional cold steel, diathermy dissection causes more tissue damage and hence a larger eschar formation, thus conferring a higher risk of secondary haemorrhage 17 .
Due to high potential for contamination by commensals, culture results of the tonsillar bed are difficult to interpret.Hence the definition and incidence of post-tonsillectomy infection are unclear.Clinically worsening pain, continuing inability to resume to normal diet and raised temperature are considered features of infection and these patients are typically administered antibiotics 18 .Any putative benefit of antibiotics also need to be carefully weighed against the risk of adverse events and other negative consequences that are more difficult to evaluate and quantify, such as the possible emergence of resistant bacteria and fungal colonization and infection.

Conclusion:
In this study, secondary haemorrhage rate was 0.59%.Use of antibiotics after tonsillectomy operation did not have any role in reducing the incidence of secondary haemorrhage.Therefore antibiotics should be prescribed in a few selected cases where indicated.
Type of Study: Prospective study Study Place: Inpatient department of Shaheed Shamsuddin Ahmed (Sadar) Hospital, Sylhet.Study Period: April 2010 to April 2012.Sample population: 170 patients of tonsillectomy.