Clinical Study

Ear, Nose & Throat Journal

1–7
Management of Recurrent and Delayed ª The Author(s) 2021
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Post-Tonsillectomy and Adenoidectomy DOI: 10.1177/0145561321999594
journals.sagepub.com/home/ear
Hemorrhage in Children

Phylannie K. F. Cheung, MBBS, BVSc, MS1 , Joanna Walton, MBBS, BSc, MS, FRACS1,
Megan L. Hobson, BMed, BMedSci, FRACS1, Piera Taylor, MBBS, BDS, FRACS1,
Michael Chin, Bs(Med), FRACS1, Simone Boardman, MBBS, FRACS1,
Alan T. L. Cheng, BHB, MBBS, FRACS1,2,
and Catherine S. Birman, MBBS, PhD, FRACS1,2,3

Abstract
Objective: To review our experience on post-tonsillectomy and/or adenoidectomy hemorrhage (PTAH) at a tertiary pediatric
referral hospital and to evaluate the management and risk factors for recurrent postoperative hemorrhage and for delayed
bleeding after day 14. Methods: A retrospective chart review was performed for all pediatric patients admitted to The Children’s
Hospital at Westmead for PTAH between July 01, 2014, and June 30, 2019. Patients with recurrent hemorrhage and those with
bleeding after day 14 were selected for subanalysis. Results: Of the 291 patients admitted for PTAH, 31 (11%) patients had
recurrent postoperative hemorrhage, and 11 (4%) patients had delayed bleeding after day 14. Surgical intervention for cessation of
hemorrhage was required in 88 (30%) patients, including 2 patients who required return to the theater more than once. Nine (3%)
patients received blood transfusions. The average number of days between bleeding episodes was 4 days. Recurrent post-
operative hemorrhage occurred in 8.5% of patients who were managed operatively at their first presentation compared to 11.4%
of patients who were managed nonoperatively (odds ratio: 1.1; 95% confidence interval 0.43-2.8). No association was found
between abnormal coagulation profile, surgical indication, and risk of delayed postoperative hemorrhage. Conclusions:
Recurrent or delayed postoperative hemorrhage represents a small proportion of children with postoperative bleeding and
cannot be reliably predicted. Management of first presentations with either a conservative or a surgical approach is reasonable
since the risk of recurrent of PTAH may be unrelated to the choice of management at initial presentation. Careful preoperative
counseling of patients and their families is important to help set expectations in the event of PTAH.

Keywords
tonsillectomy, adenoidectomy, recurrent, postoperative complication, delayed hemorrhage

Introduction 1
Department of Paediatric Otolaryngology, The Children’s Hospital at
Post-tonsillectomy and/or adenoidectomy hemorrhage (PTAH) Westmead, New South Wales, Australia
2
is one of the most common complications requiring admission Discipline of Paediatric and Adolescent Health, Sydney Medical School,
University of Sydney, New South Wales, Australia
for management in otolaryngology. Several factors such as 3
Faculty of Medicine and Health Sciences, Macquarie University, Macquarie,
patient’s age, gender, surgical indication, surgical technique, New South Wales, Australia
and choice of postoperative analgesia agent have been associ-
Received: December 29, 2020; revised: December 29, 2020; accepted: January
ated with increased rates of PTAH.1-6 Up to 7.5% of pediatric 07, 2021
patients undergoing tonsillectomy and/or adenoidectomy will
experience postoperative bleeding.7-9 However, few studies Corresponding Author:
Phylannie K. F. Cheung, MBBS, MS, Department of Paediatric Otolaryngology,
have reviewed the management and outcomes of children who The Children’s Hospital at Westmead. Locked Bag 4001, Westmead,
have recurrent PTAH or those who have bleeding beyond the New South Wales 2145, Australia.
expected 2-week recovery period. Email: pche6046@uni.sydney.edu.au

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provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).
2 Ear, Nose & Throat Journal

The aim of our study was to review our experience on PTAH Table 1. Patient Characteristics.
at a tertiary pediatric referral hospital and to identify factors
Mean age at surgery, years (range) 6.9 years (range: 1-17.2 y)
that may increase the risk of recurrent PTAH or for delayed Age category, n (%)
bleeding beyond 2 weeks postoperatively. <6 years 147 (51)
6-12 years 108 (37)
>12 years 36 (12)
Patients and Methods Gender, n (%)
A retrospective review was conducted on all patients admitted Male 173 (60)
Female 118 (40)
to The Children’s Hospital at Westmead, Sydney, Australia, for Indication, n (%)
PTAH between July 01, 2014, and June 30, 2019. Patients with OSA or SDB 126 (44)
PTAH were included, and those with hemorrhage from other Recurrent tonsillitis 33 (11)
sources (eg, inferior turbinate or septum) were excluded. OSA/SDB þ Recurrent tonsillitis 38 (13)
Recurrent PTAH was defined as 2 or more episodes of PTAH. Unknown 94 (32)
Delayed presentation was defined as any bleeding after post- Location of initial surgery, n (%)
operative day 14. CHW 61 (21)
Other 230 (79)
It is a standard practice at our institution to admit all patients Oropharyngeal examination on admission
who present to the emergency department with PTAH for a Ooze or fresh blood 146 (47)
period of observation. Patients were taken to theater if they Clot in tonsillar fossa 43 (14)
had active bleeding as evidenced by fresh blood on orophar- Post-nasal pack 2 (1)
yngeal examination or if there were concerns for significant Normal oropharynx 119 (38)
blood loss based on history, hemoglobin concentration, hemo- Abbreviations: OSA, obstructive sleep apnea; SDB, sleep disordered breathing.
dynamic changes, and age of the patient. Patients were trans-
fused if their hemoglobin was 70g/L or if there was
significant ongoing blood loss or hemodynamic instability. Delayed presentations after day 14 occurred in 11 (4%)
Coagulation studies (prothrombin time [PT], activated partial children, with one child presenting twice after day 14. Five
thromboplastin time [APTT], international normalized ratio (45%) of these children required surgical management, while
[INR], and fibrinogen) were routinely performed on children 3 (27%) required a blood transfusion (hemoglobin ranged from
who were admitted with PTAH. 55 g/L to 81 g/L). Three (27%) had presented on more than one
Deidentified data were collected on patient demographics occasion, and all 3 of these patients required operative inter-
including gender and age, indication for initial operation, vention after day 14.
hemoglobin concentration, coagulation profile, appearance of Routine coagulation studies were normal in 10 of 11 chil-
oropharynx (normal oropharynx, clots, and fresh blood) at time dren with delayed PTAH. One child’s results were not found.
of presentation, and postoperative day of bleeding. Require- On further hematological investigations, one child had a low
ment for blood transfusion or return to theater and length of vitamin C level which may have partially contributed to the
stay were also recorded. bleeding risk; another child had a mildly raised protein S of
Ethics approval was obtained from the Sydney Children’s unclear significance (Table 2).
Hospital Network Human Research Ethics Committee (2020/
ETH00143). Statistical analysis was performed using SPSS
(Version 23; IMB Corp).
Recurrent PTAH
Twenty children were admitted to our hospital more than
Results once for PTAH, while another 11 children were discharged
During the 5-year period, 291 children (118 females and 173 from another hospital for PTAH before re-presenting to our
males) were admitted with PTAH. Age at presentation ranged hospital. In total, 31 (11%) of children had recurrent
from 12 months to 17.2 years (mean: 6.9 years). Only 61 (21%) PTAH.
of the children had their surgery at our facility, while the rest The day of presentation for the first episode of bleeding
(79%) had their initial operation at other public and private hos- ranged from 4 to 21 days (mean: day 8), while the second
pitals. Data on the operative technique used were therefore not presentation ranged from days 6 to 28 (mean: day 12). The
available for most patients. Indication for tonsillectomy and/or mean number of days between the first and the second admis-
adenoidectomy was available for 197 (68%) children (Table 1). sion was 3.8 days (range: 0-9 days).
Of the 31 children who had recurrent PTAH, 17 (55%)
children required operative management, while 4 (13%)
Day of Postoperative Bleeding and Delayed Presentations required a blood transfusion. For these patients with multiple
Day of presentation for bleeding ranged from postoperative day presentations, the odds of requiring a return to theater was
0 (primary hemorrhage) to postoperative day 28 (median: post- 3.6 (95% confidence interval [CI]: 1.7-7.8), while the odds of
operative day 7; Figure 1). requiring a transfusion was 7.5 (95%CI: 1.9-29.9).
Cheung et al 3

70

60

50
Number of admissions

40

30

20

10

0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28
Postoperave Day

Figure 1. Distribution of postoperative hemorrhage based on postoperative day of bleeding.

Table 2. Patient Characteristics of Those With Delayed PTAH (>14 days Postoperatively).

Pt Age, POD of Oropharyngeal Return Blood Hb on Coagulation

No. gender Indication bleed examination to theater transfusion admission, g/L screen Other details

1 10, M SDB 7 R clot Yes No 131 Normal Low vitamin C level;

16 L fresh blood Yes No 119 required surgical
management both
admissions, different side
each time
2 11, M SDB 15 L clot No No 117 Normal
3 5, F Not reported 15 Normal OPx No No 113 Normal
4 3, M SDB 10 Normal OPx No No 98 Normal Bleeding from adenoid bed
15 Normal OPx Yes Yes 55
5 6, M Nasal obstruction 22 Normal OPx No No 124 Normal
6 11, F SDB 16 R fresh blood Yes No 119 Normal
7 14, F Not reported 21 L clot Yes No 122 Normal Slightly high Protein S
28 Normal OPx No No 109
8 7, F SDB 17 Normal OPx No No 118 Normal
9 2, F Not reported 19 R fresh blood Yes Yes 70 Normal Bleeding from both tonsil
fossa and adenoid bed
10 15, M SDB 15 R clot No No 109 Not done
11 3, F SDB 26 Normal OPx No Yes 81 Normal
Abbreviations: Hb, hemoglobin; L, left; OPx, oropharynx; POD, postoperative day; R, right; SDB, sleep disordered breathing.

For patients with recurrent PTAH, 45% patients had a repeat
bleed from the same side, while 15% bled from the contralat-
eral side. Three patients had bleeding from the adenoidectomy
site of which one bled from the adenoid bed on both admis-
sions. The remaining patients had a normal oropharyngeal
examination on at least one occasion.
Mean hemoglobin on initial presentation was 118 g/L
(range: 92-153 g/L), while the hemoglobin at their repeat pre-
sentation was 102 g/L (range: 55-136 g/L); there was an aver-
age hemoglobin drop of 16.6g/L (range: 0-43 g/L) between
presentations. Coagulation studies were available for 28
(90%) patients: 36% of patients had a prolonged PT, while
3.6% had a prolonged APTT. One patient was diagnosed with
factor XIII deficiency; their PT and APTT were both normal.
No other patient was diagnosed with a coagulation disorder
postoperatively (Table 3).
There was no association between hemoglobin levels,
platelet count, PT, APTT, age, gender, appearance of oro-
pharynx, and the risk of recurrent PTAH on regression
analysis.
4 Ear, Nose & Throat Journal

Management of PTAH were patients who had clots on examination of their oropharynx
(OR 8.2; 95%CI: 3.9-17.2). There were no deaths related to
Eighty-eight (30%) children required operative management
PTAH in this cohort.
for cessation of hemorrhage, including 2 children who required
Of the 71 children who were taken to theatre at their initial
return to the theater twice. Nine (3%) children received blood
presentation, 6 (8.5%) subsequently went on to have another
transfusions, with a mean hemoglobin of 81 g/L (range: 55-104 episode of bleeding, while 25 (11.4%) of the 220 children
g/L). Seven of the 9 (77%) children undergoing transfusions managed nonoperatively had recurrent PTAH (Figure 2). The
required a return to theater at the same time. rate of recurrent PTAH was not statistically different between
Patients who had a hemoglobin < 100g/L were more likely those managed operatively compared to those managed
to return to theater (odds ratio [OR] 3.2; 95%CI: 1.8-5.7) as conservatively at their initial presentation (OR 1.1; 95%CI:
0.43-2.8). The need for operative management at subsequent
Table 3. Clinical Presentation and Management of Patients With presentations was also not statistically significant between
Recurrent PTAH. those managed operatively versus those managed conserva-
Timing of presentation, mean (range)
tively at their first presentation (OR 3.6; 95%CI: 0.48-27.1).
Day of first PTAH 8 (4-21)
Day of subsequent PTAH 12 (6-28) Length of Stay
Number of days between PTAH 3.8 (0-9)
Operative management, n (%) Length of stay ranged from 9 hours to 8.8 days (mean:
Yes 17 (55) 1.6 days). The child who stayed nearly 9 days had factor XIII
No 14 (45) deficiency diagnosed postoperatively. Patients who had recur-
Blood transfusion, n (%) rent PTAH had a trend toward a longer length of stay compared
Yes 4 (13) to those who presented only once (mean 43 hours vs 36 hours,
No 28 (87)
Hemoglobin concentration in g/L, mean (range)
P ¼ .05).
Hb at first presentation 118 (92-153)
Hb at subsequent presentation 102 (55-136) Discussion
Decrease in Hb 16.6 (0-43)
Platelet count  10^9/L, mean (range) Postoperative hemorrhage is a potentially serious complication
Platelet count at first presentation 362 (129-540) following tonsillectomy and/or adenoidectomy, occurring in up
Platelet count at subsequent presentation 353 (141-701) to 7.5% of patients undergoing surgery.7-9 Although children
Prothrombin time, n (%) with delayed or recurrent PTAH represent only a small propor-
Prolonged (>14 seconds) 10 (36)
tion of those who present with PTAH, bleeding beyond the
Normal 18 (64)
Activated prothrombin time, n (%) expected 2-week postoperative recovery period can be distres-
Prolonged (>38 seconds) 1 (4) sing for patients and their families, and repeated admissions for
Normal 27 (96) PTAH can create a significant burden on not only the families
Fibrinogen, n (%) but also on the health care system.
Abnormal 0 (0) Our study showed that 11% of children experienced recur-
Normal 0 (0) rent PTAH, and 4% of children presented with delayed PTAH
Abbreviations: Hb, hemoglobin; PTAH, post-tonsillectomy and adenoidectomy beyond day 14. This is consistent with previous studies in the
hemorrhage. literature which report a rebleeding rate of between 4% and
17.5% for children following their initial PTAH.10-12

Total number of paents

admied with PTAH
n=291

Conservave
Surgical management on
management on inial
inial presentaon
presentaon
n=71
n=220

No further bleeding Recurrent PTAH No futher bleeding Recurrent PTAH

n=195 n=25 n=65 n=6

Figure 2. Outcome following management of postoperative hemorrhage.

Cheung et al
In our cohort, children with recurrent PTAH were 4 times
more likely to require surgical management and 8 times more
likely to undergo a blood transfusion compared to those who
present only once. This may reflect the lower threshold for
operative intervention for children with recurrent PTAH, as
well as the lower hemoglobin concentrations following recur-
rent PTAH, with children in our cohort having a mean hemo-
globin drop of 16.6 g/L between presentations. Children who
had recurrent PTAH also had a trend toward a longer length of
stay compared to those who presented only once, which may be
a consequence of a longer period of observation in hospital
following recurrent PTAH.
Previous studies have suggested that older patients, those
with recurrent tonsillitis, and those with a higher body mass
index were more likely to have recurrent PTAH.13,14 How-
ever, this was not reflected in our study, with no association
found between age, gender, appearance of oropharynx, and
recurrent PTAH. In addition, we did not find any associa-
tion between abnormalities in hemoglobin concentrations
and coagulation profile and risk of multiple bleeding epi-
sodes. This is consistent with a study by van der Meer et al
which also failed to find an association between abnormal
coagulation and recurrent bleeding in children with recur-
rent post-tonsillectomy bleeding.12 Furthermore, choice of
surgical technique, severity of first bleed, and NSAIDs use
have not been found to increase the risk of recurrent
PTAH.12,14 The risk of recurrent PTAH is therefore difficult
to predict for any given child.
We found that the proportion of patients who went on to
have recurrent PTAH was similar between those who were
managed conservatively at the first presentation compared to
those who were managed surgically (11.4% vs 8.5%, respec-
tively). This suggests that there is a risk of rebleeding regard-
less of choice of management at first presentation. It would
therefore be reasonable to manage the child with either
approach, depending on their clinical presentation. However,
given the limited number of recurrent PTAH in our cohort, care
must be taken in interpreting the impact of surgical versus
conservative management based on our study alone.
It is interesting to note that the 2 patients with recurrent
PTAH and required operative management on both occasions
had relied upon diathermy alone for hemostatic control during
their first return to theater; however, statistical analysis did not
find any difference between risk of recurrent PTAH based on
whether or not the tonsil pillars were sutured at the time of
return to theatre for hemostasis.
Overall, our study showed that children with a first episode
of PTAH have a 10% risk of having a second episode of bleed-
ing. On average, the second bleeding episode occurred 4 days
after the initial bleed, with nearly all recurrent bleeding occur-
ring within 7 days. This information is useful for both parents
and clinicians when planning to discharge a child after the first
postoperative bleeding episode.
Delayed bleeding beyond the expected recovery period may
also cause significant distress for patients and their families.
While it is widely accepted that PTAH can occur up to 14 days
5
after the initial operation, previous studies have found that
postoperative hemorrhage most commonly occurred between
5 and 10 days after the initial operation.11,15-18
Our study found that 18% of our cohort had postopera-
tive bleeding after day 10, and 4% presented after day 14.
Few studies report on these delayed presentations, particu-
larly the delayed PTAH of 14 to 28 days. In our study, over
half the patients with delayed presentations had clear evi-
dence of bleeding with either fresh blood or clot on exam-
ination. Over 40% of the patients presenting after day 14
required surgical intervention, while just over a quarter
underwent a blood transfusion. Visualization of the adenoid
bed of these delayed presenters is recommended in view of
our findings that a small but significant proportion (18%)
had bleeding from their adenoidectomy site as confirmed
intraoperatively.
The coagulation profiles were normal in these children with
delayed presentations, which is unsurprising, since previous
studies have suggested that unidentified coagulation disorders
were found in <1% of patients with post-tonsillectomy hemor-
rhage.19,20 Furthermore, despite other studies suggesting that
patients with recurrent tonsillitis were at an increased risk of
postoperative bleeding,3,4,19 none of the children with delayed
presentations in our study had recurrent tonsillitis as the indi-
cation for their original operation. This difficulty in identifying
risk factors for delayed bleeding beyond day 14 emphasizes the
importance of preoperative counseling of patients and their
families, especially those who live remotely without ready
access to hospital facilities.
Our study identified 1 patient with vitamin C deficiency
who presented with both recurrent and delayed PTAH, with
the second episode occurring on day 16. It is well recognized
that vitamin C deficiency can result in decreased collagen
synthesis, increased capillary fragility, and impaired wound
healing.21 Diffuse postoperative hemorrhage secondary to vita-
min C deficiency have been reported in adult patients under-
going abdominal, cardiothoracic, and neurosurgical
operations.22 However, the incidence of vitamin C deficiency
in our cohort remains unknown, as vitamin C levels were not
routinely performed in patients who present with PTAH. Nutri-
tional deficiencies, although uncommon, should therefore be
considered in patients who present with recurrent or delayed
PTAH.
Previous studies have also reported higher rates of post-
operative bleeding in patients with hemophilia and von Will-
ebrand disease, with secondary PTAH rates of up to 10% to
20%.23-25 However, it is unclear whether these patients are
more likely to have recurrent or delayed hemorrhage. Our
cohort included one child with hemophilia diagnosed preopera-
tively who had a single episode of PTAH at day 11, and none of
the children in our study were diagnosed with von Willebrand
disease following admission for recurrent or delayed PTAH.
Nevertheless, investigation for an underlying coagulation dis-
order should still be undertaken for children who present with
delayed or recurrent PTAH.
6 Ear, Nose & Throat Journal
The limitations of our retrospective study include the pos-
sibility of missed patients due to the absence of specific search
codes for recurrent or delayed PTAH. Our study did not take
into account patients who may have presented to other hospi-
tals for subsequent episodes of bleeding; the true incidence of
recurrent PTAH may therefore be underestimated. Also, the
majority of our patients had their initial operation performed
at various hospitals across the state; thus, surgical technique
and indications for surgery were not available in all patients.
In addition, the number of patients with a bleeding disorder
may be underestimated in our cohort, as further hematological
investigations were generally only performed on patients with
abnormal coagulation profiles. Finally, the relatively small
number of cases made assessment of the data’s significance
more difficult. Future multicenter studies may help us to fur-
ther evaluate risk factors responsible for recurrent or delayed
PTAH, and further studies on the impact of agents such as
tranexamic may help us better manage this subgroup of
patients.
Conclusions
Children who have an initial episode of PTAH have a 10% risk
of having a subsequent episode of bleeding. Although patients
who have recurrent PTAH were more likely to require return to
theater and blood transfusions, management of first presenta-
tion with either a conservative or a surgical approach is rea-
sonable, since there is a risk of recurrent PTAH irrespective of
choice of management at initial presentation.
Children who have recurrent or delayed PTAH beyond day
14 represent only a small proportion of those with PTAH.
However, it is difficult to predict those who will fall into these
subgroups. In view of this, careful preoperative counseling is
important to help set expectations in the event of post tonsil-
lectomy and/or adenoidectomy hemorrhage.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
ORCID iD
Phylannie K. F. Cheung https://orcid.org/0000-0002-7939-1942
References
1. Francis DO, Fonnesbeck C, Sathe N, McPheeters M, Krishnas-
wami S, Chinnadurai S. Postoperative bleeding and associated
utilization following tonsillectomy in children: a systematic
review and meta-analysis. Otolaryngol Head Neck Surg. 2017;
156(3):442-455.
2. Hsueh W-Y, Hsu W-C, Ko J-Y, Yeh T-H, Lee C-H, Kang K-T.
Population-based survey of inpatient pediatric tonsillectomy and
postoperative hemorrhage in Taiwan, 1997–2012. Int J Pediatr
Otorhinolaryngol. 2018;108:55-62.
3. Kwok MM, Subramaniyan M, Rimmer J, Karahalios A. Post-
tonsillectomy haemorrhage in Australia—a multivariable analysis
of risk factors. Aust J Otolaryngol. 2018;1(1).
4. Lowe D, Van Der Meulen J, Cromwell D, et al. Key messages
from the national prospective tonsillectomy audit. Laryngoscope.
2007;117(4):717-724.
5. Sarny S, Ossimitz G, Habermann W, Stammberger H. Hemor-
rhage following tonsil surgery: a multicenter prospective study.
Laryngoscope. 2011;121(12):2553-2560.
6. Spektor Z, Saint-Victor S, Kay DJ, Mandell DL. Risk factors for
pediatric post-tonsillectomy hemorrhage. Int J Pediatr Otorhino-
laryngol. 2016;84:151-155.
7. Alvo A, Hall A, Johnston J, Mahadevan M. Paediatric posttonsil-
lectomy haemorrhage rates in Auckland: a retrospective case
series. Int J Otolaryngol. 2019;2019:4101034-4101034.
8. Attner P, Haraldsson P-O, Hemlin C, Hessen Soderman A-C. A 4-
year consecutive study of post-tonsillectomy haemorrhage. ORL J
Otorhinolaryngol Relat Spec. 2009;71(5):273-278.
9. Mahadevan M, Van Der Meer G, Gruber M, et al. The starship
children’s hospital tonsillectomy: a further 10 years of experi-
ence. Laryngoscope. 2016;126(12):E416-E420.
10. Bhattacharyya N, Kepnes LJ. Revisits and postoperative hemor-
rhage after adult tonsillectomy. Laryngoscope. 2014;124(7):
1554-1556.
11. Liu JH, Anderson KE, Willging JP, et al. Posttonsillectomy
hemorrhage: what is it and what should be recorded? Arch
Otolaryngol Head Neck Surg. 2001;127(10):1271-1275.
12. van Der Meer G, Gruber M, Mahadevan M. Recurrent post
tonsillectomy bleeds: presentation and characteristics in the
paediatric population. Int J Pediatr Otorhinolaryngol. 2017;
98:68-70.
13. Hussain S, Ferster APOC, Carr MM. Time between first and
second posttonsillectomy bleeds [published online August 7,
2017]. Int J Otolaryngol. 2017;2017.
14. McKeon M, Kirsh E, Kawai K, Roberson D, Watters K. Risk
factors for multiple hemorrhages following tonsil surgery in chil-
dren. Laryngoscope. 2018;129(12):2765-2770.
15. Johnson RF, Chang A, Mitchell RB. Nationwide readmissions
after tonsillectomy among pediatric patients—United States. Int
J Pediatr Otorhinolaryngol. 2018;107:10-13.
16. Kim SJ, Walsh J, Tunkel DE, Boss EF, Lee AH. Frequency of
post-tonsillectomy hemorrhage relative to time of day. Laryngo-
scope. 2020;130(7):1823-1827.
17. Peterson J, Losek JD. Post-tonsillectomy hemorrhage and pedia-
tric emergency care. Clin Pediatr (Phila). 2004;43(5):445-448.
18. Wei JL, Beatty CW, Gustafson RO. Evaluation of posttonsillect-
omy hemorrhage and risk factors. Otolaryngol Head Neck Surg.
2000;123(3):229-235.
19. Kontorinis G, Schwab B. Significance of advanced haemostasis
investigation in recurrent, severe post-tonsillectomy bleeding.
J Laryngol Otol. 2011;125(9):952-957.
20. Windfuhr JP, Chen YS, Remmert S. Unidentified coagulation
disorders in post-tonsillectomy hemorrhage. Ear Nose Throat J.
2004;83(1):28, 30, 32 passim.
Cheung et al
21. Guo S, Dipietro LA. Factors affecting wound healing. J Dent Res.
2010;89(3):219-229.
22. Blee TH, Cogbill TH, Lambert PJ. Hemorrhage associated with
vitamin C deficiency in surgical patients. Surgery. 2002;131(4):
408-412.
23. Allen GC, Armfield DR, Bontempo FA, Kingsley LA, Goldstein
NA, Post JC. Adenotonsillectomy in children with von Willebrand
disease. Arch Otolaryngol Head Neck Surg. 1999;125(5):547-551.
7
24. Sun GH, Auger KA, Aliu O, Patrick SW, DeMonner S, Davis
MM. Posttonsillectomy hemorrhage in children with von Will-
ebrand disease or hemophilia. JAMA Otolaryngol Head Neck
Surg. 2013;139(3):245-249.
25. Witmer CM, Elden L, Butler RB, Manno CS, Raffini LJ. Inci-
dence of bleeding complications in pediatric patients with type 1
von Willebrand disease undergoing adenotonsillar procedures.
J Pediatr. 2009;155(1):68-72.