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\begin{document}

\title{A quality improvement project evaluating haemostasis techniques during
tonsillectomy.}



\author[1]{Komal Parmanand}%
\author[2]{Mihiar Atfeh}%
\affil[1]{Russells Hall Hospital}%
\affil[2]{Plymouth Hospitals NHS Foundation Trust}%


\vspace{-1em}



  
  \date{May 21, 2024}


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\textbf{Title}

A quality improvement project evaluating haemostasis techniques during
tonsillectomy

\textbf{Key points}

\begin{itemize}
\tightlist
\item
  Tonsillectomies are one of the commonest ENT procedures performed in
  the UK.
\item
  Previous research suggests a possible correlation between surgical
  technique and the incidence of post-operative haemorrhage; however,
  these have not explored approaches to checking haemostasis.
\item
  Our study shows that a multi-step approach to checking haemostasis,
  which includes both the Valsalva manoeuvre and Trendelenburg position
  can significantly reduce the incidence of post-operative haemorrhage.
\item
  A second benefit to our multi-step approach is a reduction in the
  number of post-tonsillectomy bleeds that require a return to theatre
  for surgical exploration and intervention.
\item
  Further studies which extend to regional centres should be conducted
  for comparison following incorporation of our proposed change in
  practice for intra-operative haemostasis checks.
\end{itemize}

\textbf{Introduction}

Tonsillectomies are one of the commonest ENT procedures performed in the
UK. The last National Prospective Tonsillectomy Audit carried out in
2003/04 identified a total of 50,531 adult and paediatric patients who
underwent a tonsillectomy within the UK \textsuperscript{{[}1{]}}, and
interval commissioning reports conducted by The Royal College of
Surgeons of England have recorded continued high volumes of caseloads,
with over 31,000 performed in 2012/13 \textsuperscript{{[}2{]}} and more
than 27,000 performed in 2019/20 \textsuperscript{{[}3{]}}. Although
tonsillectomy is considered relatively low-risk, previous research has
suggested a possible correlation between surgical techniques and the
incidence of post-operative haemorrhage \textsuperscript{{[}1{]}};
however, most of these explore the surgical equipment and dissection
techniques used rather than the approach to checking haemostasis.

\textbf{Aims and objectives}

The aim of this quality improvement project was to evaluate our current
practice for achieving and checking haemostasis in tonsillectomies,
whilst considering if an alternative approach would result in improved
patient outcomes. In doing so, we thereby focussed on the following
objectives:

To identify a new practice, which is safe and sustainable, for achieving
and checking haemostasis during tonsillectomy.

To reduce the incidence of post-operative haemorrhage following
tonsillectomy.

\textbf{Methods}

We identified all patients who underwent a tonsillectomy (+/- other
concurrent ENT procedures) by the main author at our local hospital.
Informed consent was obtained from each participant prior to their
procedure. The SQUIRE framework was used as our reporting guideline.

A two-cycle design was used for data collection, which involved the
following: (1) a pre-intervention retrospective cycle covering two years
and (2) a post-intervention prospective cycle covering the subsequent
five-years. For each patient included in the study, the following
parameters were noted:

\begin{enumerate}
\tightlist
\item
  Type of procedure performed,
\item
  Indication for surgery,
\item
  Post-operative complications including,
\item
  Primary haemorrhage,
\item
  Secondary haemorrhage,
\item
  Post operative infection.
\end{enumerate}

We studied the management of all complications, particularly
highlighting those who required further surgical intervention. Following
this, we calculated the bleeding rate per annum for primary and
secondary bleeds, with the intention to compare this to our subsequent
data collection following implementation of our proposed change in
practice for achieving and checking haemostasis.

The inclusion criteria included all dissection tonsillectomy procedures
in children and adults by the main author. The exclusions included
patients who had a tonsillectomy for histology due to suspected
tonsillar cancer, and patients had a coblation intracapsular
tonsillotomy. Patients with suspected tonsillar cancer have a
potentially challenging vascular surgical field that might affect the
haemorrhagic tendency and therefore skew the results. Similarly,
intracapsular coblation tonsillotomy is a different procedure to
dissection tonsillectomy and cannot be included into the sample.

\textbf{Cycle one}

This was a pre-intervention, retrospective cycle covering a two-year
period (January 2013 -- December 2014) of paediatric tonsillectomies
performed by the main author at {[}\textbf{BLINDED} {]} (\emph{n} =
102). The surgical technique used for achieving and checking haemostasis
conformed to traditional ENT teachings, where each wound is packed with
a tonsillectomy swab, the Boyle--Davis mouth gag (BDG) relaxed, and the
neck positioned neutrally for one minute to check for any occult
bleeders.

\textbf{Intervention}

The main author adopted the common techniques that are utilised in other
otolaryngology and head and neck surgery procedures to develop the
following multi-step approach to the haemostatic check at the final
stage of a tonsillectomy:

\begin{enumerate}
\tightlist
\item
  Pack wound with swab, relax gag, and neutralise neck position for one
  minute.
\item
  Re-extend the Boyle--Davis mouth gag (BDG), remove swabs and wash the
  site with a saline-soaked swab.
\item
  Valsalva manoeuvre if allowed by airway device.
\item
  Trendelenburg position.
\end{enumerate}

To ensure patient safety was not compromised during the second cycle, we
carried out a researched, evidence-based approach to the implementation
of a change in practice for achieving and checking haemostasis in our
tonsillectomy cases. Recent studies have shown that the Trendelenburg
position can detect a significantly higher number of bleeding vessels in
head and neck surgery compared to the Valsalva manoeuvre alone, with one
study reporting additional bleeding points identified in 68\% of
patients with the use of the Trendelenburg tilt following
Valsalva\textsuperscript{{[}4{]}}. In this same study, it is also
important to note that in five cases, there was significant bleeding
that required suturing which were not identified using the Valsalva
manoeuvre alone.

\textbf{Cycle two}

This was a post-intervention, prospective cycle covering approximately a
five-year period (January 2015 -- September 2016; January 2018 -- July
2021) of tonsillectomies performed by the main author at
{[}\textbf{BLINDED} {]} (\emph{n} = 153). The process for checking
haemostasis outlined above was used in all cases, following which the
outcomes from both cycles were compared.

\textbf{Results}

In both cycles, the commonest procedures performed were tonsillectomy
and adenotonsillectomy, respectively (Table 1), with the most common
surgical indications being recurrent tonsillitis and obstructive sleep
apnoea (Table 2).\selectlanguage{english}
\begin{longtable}[]{@{}lll@{}}
\toprule
Procedure & Cycle 1 & Cycle 2\tabularnewline
\midrule
\endhead
Tonsillectomy & 74\% & 60\%\tabularnewline
Adenotonsillectomy & 11\% & 24\%\tabularnewline
Adenotonsillectomy + grommets & 7\% & 9\%\tabularnewline
Bilateral grommets + tonsillectomy & 7\% & 5\%\tabularnewline
Microlaryngoscopy and bronchoscopy (MLB) + tonsillectomy & 1\% &
1\%\tabularnewline
MLB + adenotonsillectomy & 0\% & 1\%\tabularnewline
\bottomrule
\end{longtable}

Table - Procedures performed\selectlanguage{english}
\begin{longtable}[]{@{}lll@{}}
\toprule
Indication & Cycle 1 & Cycle 2\tabularnewline
\midrule
\endhead
Recurrent tonsillitis & 59\% & 44\%\tabularnewline
Obstructive sleep apnoea (OSA) & 34\% & 47\%\tabularnewline
Tonsillar asymmetry & 5\% & 5\%\tabularnewline
Tonsillitis + OSA & 2\% & 0\%\tabularnewline
Croup + tonsillitis & 0\% & 1\%\tabularnewline
Croup + OSA & 1\% & 0\%\tabularnewline
Quinsy & 0\% & 1\%\tabularnewline
Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis
(PFAPA) & 0\% & 1\%\tabularnewline
\bottomrule
\end{longtable}

Table - Indications for procedure

As detailed in Table 3, 14\% of patients in the first cycle of this
project had endured post-operative bleeding compered to 7\% of patients
in the second cycle. However, the primary haemorrhage rate had dropped
from 3\% in the first cycle to complete absence (0\%) in the second
cycle. Secondary haemorrhage rates had also decreased between the two
cycles from 11\% to 7\%. Post-operative infection rates were similar in
both cycles. Antibiotics were given in 68\% and 100\% of post-operative
complications in cycle one and two respectively, with 37\% patients
returning to theatres for examination under anaesthetic and arrest of
haemorrhage in cycle one compared to only 5\% in cycle two (Table 4).
This need for further surgical exploration accounts for 50\% of
post-operative bleeds in cycle one, and 9\% cycle two following our
intervention.

Table 3 - Post-operative complications\selectlanguage{english}
\begin{longtable}[]{@{}lll@{}}
\toprule
\begin{minipage}[b]{0.30\columnwidth}\raggedright\strut
Management\strut
\end{minipage} & \begin{minipage}[b]{0.30\columnwidth}\raggedright\strut
Cycle 1\strut
\end{minipage} & \begin{minipage}[b]{0.30\columnwidth}\raggedright\strut
Cycle 2\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Antibiotics\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
68\%\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
100\%\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Return to theatre (EUA)\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
37\%\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
5\%\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Post-operative bleeds requiring further surgical exploration /
intervention\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
50\%\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
9\%\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}\selectlanguage{english}
\begin{longtable}[]{@{}lll@{}}
\toprule
Complication & Cycle 1 & Cycle 2\tabularnewline
\midrule
\endhead
Primary bleed & 3\% & 0\%\tabularnewline
Secondary bleed & 11\% & 7\%\tabularnewline
Infection & 5\% & 6\%\tabularnewline
\bottomrule
\end{longtable}

Table - Management of post-operative complications

\textbf{Discussion}

Our change in practice for checking for adequate intra-operative
haemostasis has successfully reduced the incidence of post-operative
haemorrhage in our tonsillectomy patients. The most important impact is
the significant absence of any primary post-tonsillectomy bleeding in
the second cycle. Moreover, the data suggests a second benefit of
reducing the number of post-operative bleeds requiring further surgical
exploration and intervention and therefore reducing patients' morbidity
and mortality. These successes not only have the potential to improve
the post-operative recovery of our paediatric patients, but also reduce
the incidence of re-admissions, length of hospital stay and resource
allocation.

One potential limitation that we have identified in this study is the
use of a single surgeon's patient workload, preventing us from comparing
operative surgical techniques for the tonsillectomy itself. However, as
the purpose of this study was to compare post-operative complications
following a change in our approach to checking haemostasis, we consider
that using the outcomes of one surgeon should rule out other factors
that could influence the outcomes due to operative technique
variability. To further add support to our results, we would propose
additional audits with a larger patient cohort, from multiple regions
and consultant workloads, so we may determine a consensus for adequate
haemostasis checks, regardless of methods of dissection.

\textbf{Conclusion}

Through the implementation of a four-step, evidence-based process of
achieving and checking adequate haemostasis, this project has
successfully reduced the overall incidence of post-operative haemorrhage
in our paediatric tonsillectomy cases. Furthermore, our change in
haemostasis practice has suggested a second benefit of reducing the
number of post-operative bleeds which require a return to theatre for
further surgical exploration and intervention. However, despite these
suggested improvements in patient outcomes, further audits should be
conducted to incorporate a larger patient cohort with extension to other
regional centres for comparison following incorporation of our proposed
change in practice for intra-operative haemostasis checks.

\textbf{References}

\begin{enumerate}
\tightlist
\item
  The British Association of Otorhinolaryngologists -- Head and Neck
  Surgeons Comparative Audit Group and The Royal College of Surgeons of
  England Clinical Effectiveness Unit. \emph{National Prospective
  Tonsillectomy Audit -- Final report of an audit carried out in England
  and Northern Ireland between July 2003 and September 2004.} The Royal
  College of Surgeons of England. 2005.
\item
  The Royal College of Surgeons of England. \emph{Tonsillectomy --
  Commissioning Guide.} The Royal College of Surgeons of England. 2013.
\item
  The Royal College of Surgeons of England. \emph{Tonsillectomy --
  Commissioning Guide.} The Royal College of Surgeons of England. 2021.
\item
  Moumoulidis I, Martinez Del Pero M, Brennan L, Jani P. Haemostasis in
  head and neck surgical procedures: Valsalva manoeuvre versus
  Trendelenburg tilt. \emph{The Annals of The Royal College of Surgeons
  of England.} 2010;92(4):292-294.
\end{enumerate}

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