Current Pediatric Research

Abstract

Purpose: Some controversies have recently arisen regarding the frequency of post-operative haemorrhagic complications in relation to the surgical procedures adopted for tonsillectomy. The authors set out to verify the relationship between different surgical techniques and postoperative haemorrhage based on the analysis of data derived from multi-centric studies appeared in the last fifteen years. Materials and methods: Multi-centric English and Italian studies pertaining to the frequency of post-tonsillectomy haemorrhage secondary to different surgical techniques published between 2000 and 2015 were selected. The data relevant to post-surgical haemorrhagic complications were elaborated by ANOVA test. Results: Eight multi-centric studies were analysed. The mean frequency of post-tonsillectomy haemorrhage was: 1.13% for primary haemorrhage, 5.37% for secondary haemorrhage and 6.5% as overall for cold dissection and cold haemostasis; 0.99% for primary haemorrhage, 2.91% for secondary haemorrhage and 3.9% as overall for cold dissection with hot haemostasis; 1.31% for primary haemorrhage, 7.38% for secondary haemorrhage and 8.69% as overall for hot dissection with hot haemostasis. Statistical comparison did not show significant differences between the frequencies of post-tonsillectomy primary, secondary and total haemorrhage in relation to the surgical techniques employed. Conclusion: A great variability in the frequency of haemorrhagic complications reported in the selected articles was found, regardless of the surgical technique employed. These findings, together with lack of a statistically significant difference in post-tonsillectomy haemorrhage between the techniques employed, must be carefully considered by professionals involved in health organization in clinical wards and the relative problems linked to medical liability.

Keywords

Tonsillectomy, Post-tonsillectomy haemorrhage, Post-tonsillectomy complications.

Introduction

Adeno-tonsillar pathology and the surgical treatments that this condition may require still raise concerns leading to the formulation of several guidelines, particularly in relation to potential post-operative complications [1-3]. Studies in literature present no uniform results regarding the general frequency of post-tonsillectomy haemorrhage and the possible relationship between the type of surgical technique employed and the rate of haemorrhagic complications [3-5].

Post-tonsillectomy haemorrhage, in addition to representing one of the most feared complications of this operation, also constitutes an important cause of medical-legal dispute in otolaryngologic field, in which data from international literature can be referred to for various purposes [6].

Recent national guide-lines published in Italy on the appropriateness of tonsillectomy, as well as studies specifically devoted to the safety of surgical techniques in tonsillectomy, have supplied particularly rigid addresses on this topic, that appear to be in contrast with some scientific data and that deserve a greater critical examination [7-16].

Aim of Study

The present study has set out to verify the frequency of post-tonsillectomy haemorrhagic complications reported in recent studies and the possible differences in posttonsillectomy haemorrhage rate according to the most employed surgical techniques.

Materials and Methods

A med-line bibliographic inquiry was carried out using Pub-med, Scopus and Inter-Wiley as database, inserting the key words “post-tonsillectomy haemorrhage” and “post-tonsillectomy bleeding” and restricting the research to studies published between 2000 and 2015.

231 studies were identified; from these the multi-centric English language, papers were extrapolated in which the three most commonly used dissection and haemostasis techniques were analysed (cold dissection with cold haemostasis, CD/CH; cold dissection with hot haemostasis, CD/HH; hot dissection with hot haemostasis, HD/HH) in relation to the percentage of post-surgical haemorrhage (primary, secondary and total) [17].

Thus, eight studies were selected reporting data on the frequency of post-tonsillectomy haemorrhage relative to the three techniques under examination (Tables 1-3), excluding a multi-centric study in English language, as only the total percentage of post-operative bleeding was reported and including a multi-centric Italian study, conducted in 15 centres between 2002 and 2008 and published in 2011 [23,25].

Table 1. Frequency of post-tonsillectomy haemorrhage relative to cold dissection with cold haemostasis CD/CH

Table 2. Frequency of post-tonsillectomy haemorrhage relative to cold dissection with hot haemostasis CD/HH

Table 3. Frequency of post-tonsillectomy haemorrhage relative to hot dissection with hot haemostasis HD/HH

In Lowe et al. [21] paper, the data, divided by the authors into two groups- before and after guidance. They were analysed with reference to the global series [26].

ANOVA test was used to compare the surgical techniques under study, considering p<0.05 as the minimum level of statistical significance. The data analysis was conducted using software R, of the R Development Core Team, free software, distributed under the GNU GPL license.

Results

The data, both absolute and in terms of percentage frequency, relative to post-operative hemorrhage are reported in Table 4.

Table 4. Average percentage of post-operative haemorrhage (primary, secondary and total) for each surgical technique.

No significant differences were found in the frequency of primary, secondary and total haemorrhage among the different surgical techniques employed (Table 5).

Table 5. Comparison between the frequency of primary, secondary and total post-operative haemorrhage among the different surgical technique employed.

Considerations

Tonsillectomy is amongst the most commonly performed surgical, although the scientific literature hardly ever provides the prevalence of tonsillectomy and adenotonsillectomy [27,28]. Some data are found for Denmark: approximately 7,000 annual tonsillectomies, Scotland: 14,530 (sum from 2002-2005) and 3,605 (sum from 2006-2007), Sweden [29,30]: about 10,000 procedures per year, England with Wales: 19,250 tonsillectomies per year, Italy [31,32]: 44,000 (2000) and 59,916 (2002) and 51,983 (2003), France [7,33]: about 50,000 pediatric tonsillectomies each year, Great Britain: 78,000 (during 1994 and 1995) and about 90,000 annual surgical procedures, and USA [34-36]: 1,400,000 (1959) and 500,000 (1979), 286,000 (1994) as well as 287,000 children (1996) and 530,000 and 250,000 annual pediatric tonsillectomy [37-44]. In Italy the rate of tonsillectomy reported is of 10.7 (2000), 10.5 (2002), 9.1 (2003) and 9.4 (2004) per 10,000 inhabitants [45].

Some authors point out how the continuing disagreement regarding the indication for tonsillectomy leads to different rates of this surgical procedure both between nations and within single countries [45-48].

The choice of which surgical technique to employ in tonsillectomy is of great practical importance considering that this can either favor or reduce the probability of postoperative hemorrhage [7].

Our investigation focused on the three most commonly used techniques in tonsillectomy that is CD/CH, CD/HH and HD/HH [49].

Previous studies suggest that the different surgical techniques for tonsillectomy have different impacts on post-operative mortality even though no technique has ever been described as the “gold standard” [50,51].

Hot techniques however remain the most performed techniques in many countries [52]: hot dissection is used in about 50% of tonsillectomies in Great Britain, whereas in Australia 64% of tonsillectomies are performed using various types of “hot” techniques [53,54]. In the same way an investigation carried out in the USA in 2011 indicates the mono-polar cauterization as the most widespread technique used for hemostasis for tonsillectomy [55]. In Sweden the majority of procedures are carried out by hot techniques, whereas the cold techniques are seldom used nowadays [52].

Mowatt et al. [55] report a significantly lower frequency of primary haemorrhage in subjects who underwent a hot technique or cold procedures with hot hemostasis, whereas the frequency of secondary haemorrhage was higher in subjects who underwent cold technique surgery, although not significantly (the data was significant only when coblation was used).

Lowe et al. [20], in the “Prospective National Audit” for the National Health Service, conducted a survey involving 277 hospitals and including data relative to 33,921 patients: the authors found hemorrhagic episodes more frequently in subjects operated by the “hot” techniques.

The reliability of the results however has been questioned by the authors themselves for the imprecise definition of primary or secondary hemorrhage (e.g. hemorrhage that has onset in the first 24 h sometimes extends beyond this temporal limit) or for the partial informations supplied by responders. The authors also note that the higher frequency of post-operative haemorrhage in subjects operated by cold technique but in which hot hemostasis was carried out, could depend on the energy “dosage” employed.

Hilton et al. [56] underlines the advantages that diathermy offers (reduced bleeding during surgery; shortening of surgical time), but also points out that the risks are practically negligible: in fact, its use brings about an actual increase in the number of bleeding episodes of only 1-2%.

However, hemorrhagic complications occur at very variable rates, and are reported in literature as between 0.3% and over 10% [45] independently of the surgical technique used; this could depend on a series of biases in the evaluation of the hemorrhagic event, amongst which we consider important to point out the following:

Definition of bleeding

Many authors only report those haemorrhages that have required second surgery, whilst others report all the episodes of post-tonsillectomy bleeding [5]; thus, in the publications in which only the haemorrhages that needed surgical treatment are considered, the rate of post-tonsillectomy hemorrhage is lower, but mortality percentages rise, compared to those studies in which all hemorrhages are reported [57].

In this regard, Tomkinson et al. [22], not only reports the incidence of primary and secondary post-surgical hemorrhage, but also distinguishes slight hemorrhagic complications (primary and secondary) from those that have required second surgery, thus giving a more precise evaluation of the true risk of post-operative bleeding associated with the surgical technique employed. In the same way Soderman [24] reports the percentages of postoperative bleeding, also specifying the percentage of patients that had required second surgery.

Chronology of hemorrhagic complication

The lack of information on the time interval between surgery and the onset of the hemorrhage renders the differentiation between primary and secondary bleeding unreliable [58].

Definition of surgical technique

Some studies indicate the cold technique as the “gold standard” for dissection, but the technique used to achieve hemostasis is not reported and therefore it is impossible to establish whether the cold technique was used alone or a hot hemostasis was performed [59,60-68].

In the present study only those scientific publications in which both the dissection and hemostasis techniques were specified, were selected, and in which the primary hemorrhage was distinguished from secondary one, with an accurate chronology of the hemorrhagic event.

Other variables and the role of the surgeon

The greater frequency of hemorrhage in those subjects in which hot hemostasis was performed could have been due to heat damage, caused by diathermy coagulation of the vessels responsible for intra-operative bleeding [40,51]. However, cold dissection, just as any potential sutures for hemostasis, must be carried out with an extreme caution in order to avoid vascular damage, which could lead to successive bleeding [61-63,67,69].

It is probable, therefore, that the skill and experience of the single surgeon represents an important factor in the origin of these events.

In the Italian multi-centic study of 2011, Motta et al. [23,68,70] did not find any statistically significant difference regarding the frequency of primary, secondary and total haemorrhage, in relation to the surgical techniques employed.

On the other hand, the authors note that the rate of haemorrhage reported by some of the medical institutions that took part in the study was significantly higher for the same techniques used; in light of these results, the authors conclude that this variability can be attributed to possible errors in the individual behavior of the surgeon himself, rather than the kind of technique adopted.

Age of patient

Michael et al. [64] in a study on 337 cases (145 operated by cold technique, 192 by hot technique) observed a higher frequency of haemorrhage in the adults compared to the children, confirmed by Mosges in a paper published in 2011, according to which the increased frequency of bleeding in adults could be due to variables independent of the surgical technique, such as the variability in compliance of patients with the post-operative instructions (post-surgical diet and physical rest), smoking, presence of comorbidity, conditions of the tonsils and coagulation defects [65].

In this regard, Tomkinson et al. [22] underline that in patients over 12 years of age, the risk of post-operative bleeding (primary or secondary), that required a surgical treatment, was 1,5 to 3 times greater than the population of patients under 12 years of age.

This data is confirmed by Walker [16] who, in the evaluation of the frequency of post-tonsillectomy haemorrhage, observes how this increased in a statistically significant way above all for secondary haemorrhage in the different groups of patients according to age, with a risk which ranges from 0.6% in the patients below 4 years of age to 10.1% in the patients over 18 years of age.

The findings emerged from the present study regarding the comparison between data from multi-centric studies do not demonstrate any difference in primary, secondary and total hemorrhage frequency between the three surgical techniques studied, differently from other authors [8- 12,27].

The differences between mean percentages of postoperative bleeding do not appear to be attributable to the technique employed, but to the “experimental” variability that includes a set of not easily definable factors, as they are intrinsic to the surgery [67].

The findings that we have reported suggest greater caution in recommending excessively rigid practical addresses regarding the surgical methods to prefer in performing tonsillectomy. It should be added that for each of the surgical techniques considered, a wide variability in the rate of haemorrhage is generally verified, especially with regard to the hot techniques. This leads to the necessity for a critical analysis not so much of general surgical orientations but of individual behavior, in order to identify possible deviations from the standard reference.

Conclusion

The results of our investigation did not show statistically significant differences regarding post-tonsillectomy haemorrhage between the considered surgical techniques.

A considerably low frequency of hemorrhagic complications following tonsillectomy surgery with a notable difference between the studies emerged from the publications examined.

The onset of these complications can be conditioned, regardless of the technique used, by other factors, amongst which the most important the experience of the surgeon and the modalities with which diathermy of bleeding vessels is carried out. These data integrate the results of similar and recent studies on this issue, raising doubts on the value of the strict clinical recommendations regarding the choice of techniques to use for tonsillectomy.

References

1. Baugh RF, Archer SM, Mitchell RB, et al. Clinical practice guideline; Tonsillectomy in children. Otolaryngol Head Neck Surg 2011; 144: 1-30. 
2. Scottish Intercollegiate Guidelines Network. Management of sore throat and indications for tonsillectomy. A National Clinical Guideline. Edinburgh: SIGN 1999: 34.
3. Motta G, Motta S, Cassano P, et al. Effects of guidelines on adenotonsillar surgery on the clinical behavior of otorhinolaryngologists in Italy. BMC Ear, Nose Throat Disord 2013; 13: 1.
4. Sarny S, Ossimitz G, Habermann W, Stammberger H. Austrian tonsil study part 3: Surgical technique and postoperative hemorrhage after tonsillectomy. Laryngorhinootologie 2013; 92: 92-96.
5. Mösges R, Hellmich M, Allekotte S, et al. Hemorrhage rate after coblationtonsillectomy: A meta-analysis of published trials. Eur Arch Otorhinolaryngol 2011; 268: 807-816.
6. Subramanyam R, Varughese A, Willging JP, et al. Future of pediatric tonsillectomy and perioperative outcomes. Int J Pediatr Otorhinolaryngol 2013; 77: 194-199.
7. National Guideline System (SNLG). Italian National Institute of Health (ISS). Appropriateness and safety of tonsillectomy and/or adenoidectomy 2008.
8. Mowatt G, Cook JA, Fraser C, et al. Systematic review of the safety of electrosurgery for tonsillectomy. Clin Otolaryngol 2006; 31: 95-102.
9. National Prospective Tonsillectomy Audit. Tonsillectomy technique as a risk factor for postoperative hemorrhage. Lancet 2004; 364: 697-702.
10. Lowe D, van der Meulen J, Cromwell D, et al. Key messages from the National Prospective Tonsillectomy Audit. Laryngoscope 2007; 117: 717-24. 123.
11. Haddow K, Montague ML, Hussain SS. Post-tonsillectomy hemorrhage: A prospective, randomized, controlled clinical trial of cold dissection versus bipolar diathermy dissection. J Laryngol Otol 2006; 120: 450-4.
12. Lee MS, Montague ML, Hussain SS. Post-tonsillectomy hemorrhage: Cold versus hot dissection. Otolaryngol Head Neck Surg 2004; 131: 833-836.
13. Mowatt G, Cook JA, Fraser C, et al. Systematic review of the safety of electrosurgery for tonsillectomy. Clin Otolaryngol 2006; 31: 95-102.
14. Lowe D, van der Meulen J, Cromwell D, et al. Key messages from the National Prospective Tonsillectomy Audit. Laryngoscope 2007; 117: 717-724.
15. Brown PM. How safe is padiatric tonsillectomy? Intr J Pediatric Otorhinolaryngol 2006; 70: 575-577.
16. Walker P, Gilles D. Post-tonsillectomy hemorrhage rates: are they technique-dependent? Otolaryngol Head Neck surg 2007; 136: S27-31.
17. Macfarlane PL, Nasser S, Coman WB, et al. Tonsillectomy in Australia: An audit of surgical technique and post-operative care. Otolaryngol Head Neck Surg 2008; 139: 109-114.
18. Raut V, Bhat N, Kinsella J, et al. Bipolar scissors versus cold dissection tonsillectomy; a prospective, randomized, multi-unit study. Laryngoscope 2001.
19. Raut VV, Bhat N, SinnathurayAR, Kinsella JB, et al. Bipolar scissors versus cold dissection for pediatric tonsillectomy - a prospective, randomized pilot study. Int J Pediatr Otorhinolaryngol 2002; 64: 9-15
20. National Prospective Tonsillectomy Audit. Tonsillectomy technique as a risk factor postoperative haemorrage. Lancet 2004; 364: 697-702.
21. Lowe D, van der Meulen J, Cromwell D, et al. Key messages from the National Prospective Tonsillectomy Audit. Laryngoscope 2007; 117: 717-724.
22. Tomkinson A, Harrison W, Owens D, et al. Risk factors for postoperative hemorrhage following tonsillectomy. Laryngoscope 2011: 121.
23. Motta G, Motta S, Cassano P, et al. A mulicentric study on guidelines and (adeno)-tonsillectomy. Acta Otorhinolaryngologica Italica (Argomenti) 2011; 5: 1-32.
24. Söderman AC, Odhagen E, Ericsson E, et al. Post-tonsillectomy haemorrhage rates are related to technique for dissection and for haemostasis. An analysis of 15734 patients in the National Tonsil Surgery Register in Sweden. Clin Otolaryngol 2015; 40: 248-254.
25. Sarny S, Ossimitz G, Habermann W, et al. Hemorrhage following tonsil surgery: A multicenter prospective study. Laryngoscope 2011; 121: 2553-2560.
26. http://www.nice.org.uk
27. Palmieri AM, Testa D, Salafia M, et al. Il vomito post-operatorio nell?intervento di adenotonsillecomia in pazienti pediatrici. L'Otorinolaringologia Pediatrica 1996; 7: 3-4.
28. Darrow DH, Siemens C. Indications for tonsillectomy and adenoidectomy. Laryngoscope 2002; 112: 6.
29. Windfuhr JP. Specified data for tonsil surgery in Germany. Head Neck Surg 2016; 15.
30. Ovesen T, Kamarauskas G, Dahl M, et al. Pain and bleeding are the main determinants of unscheduled contacts after outpatient tonsillectomy. Dan Med J 2012; 59: A4382.
31. Management of sore throat and indications for tonsillectomy. A National Clinical Guideline. Edinburgh: Scottish Intercollegiate Guidelines Network. 2010.
32. Hessén Söderman AC, Ericsson E, Hemlin C, et al. Reduced risk of primary postoperative hemorrhage after tonsil surgery in Sweden: results from the National Tonsil Surgery Register in Sweden covering more than 10 years and 54,696 operations. Laryngoscope 2011; 121: 2322-2326.
33. Stafford N, von Haacke N, Sene A, Croft C. The treatment of recurrent tonsillitis in adults. J Laryngol Otol 1986; 100: 175-177.
34. Materia E, Baglio G, Bellussi L, et al. The clinical and organisational appropriateness of tonsillectomy and adenoidectomy-an Italian perspective. Int J Pediatr Otorhinolaryngol 2005; 69: 497-500.
35. Lescanne E, Chiron B, Constant I, et al. French Society of ENT (SFORL); French Association for Ambulatory Surgery (AFCA); French Society for Anaesthesia, Intensive Care (SFAR). Pediatric tonsillectomy: clinical practice guidelines. Eur Ann Otorhinolaryngol Head Neck Dis 2012; 129: 264-271.
36. Marshall T. A review of tonsillectomy for recurrent throat infection. Br J Gen Pract 1998; 48: 1331-1335.
37. Lock C, Wilson J, Steen N, et al. North of England and Scotland study of tonsillectomy and adenotonsillectomy in children (NESSTAC): A pragmatic randomized controlled trial with a parallel non-randomised preference study. Health Technol Assess 2010; 14: 1-164.
38. Rosenfeld RM, Green RP. Tonsillectomy and adenoidectomy: Changing trends. Ann Otol Rhinol Laryngol 1990; 99: 187-191.
39. Paradise JL, Bluestone CD, Colborn DK, et al. Adenoidectomy and adenotonsillectomy for recurrent acute otitis media: Parallel randomized clinical trials in children not previously treated with tympanostomy tubes. JAMA 1999; 282: 945-953.
40. Hall MJ, Kozak LJ, Gillum BS. National survey of ambulatory surgery: 1994. Stat Bull Metrop Insur Co 1997; 78: 18-27.
41. Paradise JL, Bluestone CD, Colborn DK, et al. Tonsillectomy and adenotonsillectomy for recurrent throat infection in moderately affected children. Pediatrics 2002; 110: 7-15.
42. Oomen KP, Modi VK, Stewart MG. Evidence-based practice: pediatric tonsillectomy. Otolaryngol Clin North Am 2012; 45: 1071-1081.
43. Ramos SD, Mukerji S, Pine HS. Tonsillectomy and adenoidectomy. Pediatr Clin North Am 2013; 60: 793-807.
44. Baugh RF, Archer SM, Mitchell RB, et al. Clinical practice guideline: Tonsillectomy in children. Otolaryngol Head Neck Surg 2011; 144: S1-30.
45. Friedman M, Wilson M, Lin HC, et al. Updated systematic review of tonsillectomy and adenoidectomy for treatment of pediatric obstructive sleep apnea/hypopnea syndrome. Otolaryngol Head Neck Surg 2009; 140: 800-808.
46. Bellussi LM, Marchisio P, Materia E, et al. Clinical guideline on adenotonsillectomy: The Italian experience. Adv Otorhinolaryngol 2011; 72: 142-145.
47. Van Den Akker EH, Hoes AW, Burton MJ, et al. Large international differences in (adeno)tonsillectomy rates. Clin Otolaryngol Allied Sci 2004; 29: 161-164
48. Pearson RJC, Smedby B, Berfenstam R. Hospital caseloads in Liverpool, New England and Uppsala. An international comparison. Lancet 1968; 2: 559-566.
49. Stockwell H, Vayda E. Variations in surgery in Ontario. Med Care 1979; 17: 390-396.
50. Materia E, Di Domenicantonio R, Baglio G, et al. Epidemiology of tonsillectomy and/or adenoidectomy in Italy. Pediatr Med Chir 2004; 26: 179-186.
51. Mink. Making sense out of tonsillectomy literature. INT J Pediatr Otorhinolaryngol 2009.
52. Windfuhr J. PWienke A, Chen YS. Electrosurgery as a risk factor for secondary post-tonsillectomy hemorrhage. Eur Arch Otorhinolaryngol 2009; 266:111-116.
53. Lowe D, van der Meulen J. Tonsillectomy technique as a risk factor for postoperative haemorrhage. Lancet 2004; 364: 697-702
54. Söderman AC, Odhagen E, Ericsson E, et al. Post-tonsillectomy hemorrhage rates are related to technique for dissection and for hemostasis. An analysis of 15734 patients in the National Tonsil Surgery Register in Sweden. Clin Otolaryngol 2015; 40: 248-254.
55. Macfarlane PL, Nasser S, Coman WB, et al. Tonsillectomy in Australia: an audit of surgical technique and postoperative care. Otolaryngol Head Neck Surg 2008; 139: 109-114.
56. Setabutr D, Adil EA, Adil TK, et al. Emerging trends in tonsillectomy. Otolaryngol Head Neck Surg 2011; 145: 223-229.
57. Mowatt G, Cook JA, Fraser C, et al. Systematic review of the safety of electrosurgery for tonsillectomy. Clin Otolaryngol 2006; 31: 95-102.
58. Hilton M. Tonsillectomy technique-tradition versus technology. Lancet 2004, 364: 642-643.
59. Liu JH, Anderson KE, Willging JP, et al. Posttonsillectomy hemorrhage: what is it and what should be recorder? Arch Otolaryngol Head Neck Surg 2001; 127: 1271-1275.
60. Brian W. Blakley. Post-tonsillectomy bleeding: How much is too much? Otolaryngol Head Neck Surg 2009; 140: 288-290.
61. Blanchford H, Lowe D. Cold versus hot tonsillectomy: State of the art and recommendations. ORL J Otorhinolaryngol Relat Spec 2013; 75: 136-141.
62. Burton MJ, Doree C. Coblation versus other surgical techniques for tonsillectomy. Cochrane Database Syst Rev 2007.
63. Nathan MD, Sessions DG. Massive post-tonsillectomy hemorrhage. South Med J 1981; 74: 1153-1156.
64. Gardner JF. Sutures and disasters in tonsillectomy. Arch Otolaryngol 1968; 88:551?555.
65. Hertzanu Y, Hirsch M, Tovi F. Pseudoaneurysm of internal carotid artery secondary to tonsillectomy: combined radiologic and surgical treatment. Cardiovasc Intervent Radiol 1987; 10: 147-149.
66. Lee MS, Montague ML, Hussain SSM. Post-tonsillectomy hemorrhage: Cold versus hot dissection. Otolaryngol Head Neck Surg 2004; 131: 833-836.
67. Macarone Palmieri A, Meglio M, Testa D, et al. Anesthesiologic and surgical problems in adenotonsillectomy in pediatric patients: Our current trend. Minerva Anestesiologica 1998; 64: 545-552.
68. Motta G, Esposito E, Motta S, et al. Surgical treatment of acute recurrent throat infections in children. Auris Nasus Larynx 2011; 38: 356-361.
69. Mosges R, Hellmich M, Allekotte S. Hemorrhage rate after coblation tonsillectomy. A meta-analysis of published trials. Eur Arch Otorhinolaryngol 2011; 68: 807-816.
70. Motta G, Esposito E, Motta S, et al. Acute recurrent pharyngonsillitis and otitis media. Acta Otorhinolaryngol (Ital) 2006; 84: 30-55.