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Surgicel use in control of primary postadenoidectomy bleeding.

Abstract

Although postadenoidectomy bleeding is a rare complication, it is serious and potentially fatal. Postnasal packing and cautery of the adenoid bed are the most popular methods of controlling postadenoidectomy bleeding. Many hazards and complications may arise from traditional nasopharyngeal packing and nasopharyngeal cautery. In this case series, oxidized regenerated cellulose (Surgicel Nu-Knit; Ethicon; Somerville, N.J) was inserted and used as postnasal packing to control primary postadenoidectomy bleeding in 9 cases after conventional curettage adenoidectomy. All patients underwent nasophayngoscopic examination with a 0[degrees] rigid telescope to re-curette if any remnant was still present, and were repacked with appropriate size ribbon gauzes for at least 15 minutes before applying Surgicel. Surgicel succeeded in controlling primary postadenoidectomy bleeding in all cases, with no need for any further intervention. At the 1-month follow-up, no complications were reported. We conclude that Surgicel postnasal pack effectively controls primary postadenoidectomy bleeding. Its many advantages make it superior to other traditionally used material. It is readily available, tolerable, relatively inexpensive, hemostatic, adhesive, freely reshaped, bactericidal, causes no granulation reaction, has no need to be removed, and the patient does not need to be in the ICU or sedated.

Introduction

Adenoidectomy is one of the most frequent operations in children. Postadenoidectomy bleeding is a rare but life-threatening complication of this surgery (<1%). (1-4) This is not only due to blood loss, which is sometimes invisibly swallowed, leading to a consequent collapse of the circulation, but also because of the possible risks of aspiration and laryngospasm.

Postadenoidectomy bleeding is usually classified as primary (<24 hours postoperatively) or secondary ([greater than or equal to] 24 hours, usually 5-10 days, postoperatively). (5) Secondary postadenoidectomy hemorrhage is extremely rare. (6)

Postnasal packing remains the preferred method for management of postadenoidectomy bleeding. However, some surgeons use other techniques such as suction diathermy, endoscopically assisted management with diathermy, diathermy after curettage adenoidectomy, or even sutures in the postnasal space. (7)

Surgicel is a cloth-like, woven material made from filaments of alpha-cellulose, which adheres to raw surfaces (8) and expands when hydrated. (9) Its hemostatic effect is achieved by its functioning as an artificial clot or as a scaffold for physiologic clot formation. (8)

Surgicel has been used for decades to control bleeding in many areas within the human body. (10) In otolaryngology, it is used to treat many bleeding situations, such as posterior epistaxis (11) and post-tonsillectomy bleeding. (10)

In this case series, we investigated the efficacy of Surgicel in controlling postadenoidectomy bleeding.

Patients and methods

This cases in this series occurred in the Otorhinolaryngology Department, Zagazig University Hospitals, from May 2011 to June 2015. The study was approved by the Institutional Review Board at Zagazig University Hospitals.

The series included 9 children with persistent primary postadenoidectomy bleeding (3 after adenoidectomy only and 6 after adenotonsillectomy) despite repeated traditional gauze nasopharyngeal packing. All patients underwent routine preoperative laboratory assessments: complete blood count (CBC), partial thromboplastin time, bleeding time, clotting time, and preoperative (lateral view) nasopharynx x-ray of the soft tissue.

All patients were free of any upper respiratory tract infection at least 2 weeks preoperatively and did not use aspirin or other nonsteroidal anti-inflammatory drugs at least 10 days preoperatively.

Adenoidectomy was performed by conventional curettage using a Beckman curette. Digital palpation of the nasopharynx was performed just before curettageto assess adenoid site, size, and degree of choanal occlusion, and then just after removal to determine whether there were any remnants and assess the opening of the posterior choana.

After removal of the adenoid, the nasopharynx was packed with two appropriate size ribbon gauzes soaked with saline. The pack was left for at least 15 minutes; in the patients in whom the adenoidectomy was accompanied by other operations, such as tonsillectomy and/or ventilation tube insertion, the adenoidectomy was done first. The pack was then removed, and if there was any oozing or bleeding from the nasopharynx, we used the 0[degrees] transnasal telescope to determine whether there were any remnants ofthe adenoid in the nasopharynx. It was re-curetted once more if there were any remnants, and the nasopharynx was packed again with ribbon gauze for at least 15 minutes.

In all 9 cases, after removal of the second pack there was still bleeding from the nasopharynx. A Surgicel pack was applied in the nasopharynx through the mouth. A single layer of Surgicel sheet (1 x 2 cm) was adjusted, fitted, and stretched in the nasopharynx, followed by gentle compression with a saline-soaked sponge for about 30 seconds. We then waited for a few minutes to ensure that bleeding had stopped, also allowing Surgicel to become adherent. If oozing persisted, another layer sheet was applied by the same maneuver.

The endotracheal tube was extubated only after full recovery and return of reflexes, with careful monitoring of the patient in the recovery period. All the patients were observed at the hospital until discharge on the subsequent day and followed up in the outpatient clinic. They were followed for at least 1 month postoperatively.

Results

This study involved 9 patients: 5 boys and 4 girls, with a mean age of mean 6.1 [+ or -] 2.08 (range: 4 to 10 years). All patients had primary postadenoidectomy bleeding (in 6 patients it occurred after adenotonsillectomy, and in 3 after adenoidectomy only). A CBC was obtained for all patients after the bleeding, and none needed a blood transfusion.

None of the patients had a history of coagulopathy, and their preoperative investigations were within normal limits. None of them had risk factors for bleeding, such as hypertension, hyperthyroidism, or anticoagulation therapy. They all presented with primary postadenoidectomy bleeding just after removal of the postadenoidectomy packs and did not respond to repeated nasopharyngeal packing.

Surgicel succeeded in controlling primary postadenoidectomy bleeding in all cases, with no need for further intervention. Recovery from anesthesia was eventless in all cases. All patients were able to be discharged after 24 hours. At 1-month follow-up, there were no complications from Surgicel, and no patients came back with rebleeding.

Discussion

Many different techniques are used in the management of primary postadenoidectomy bleeding; each has its hazards and major disadvantages. The most popular one is postnasal packing. (7)

Many complications can arise from the traditional postnasal packing, such as dry mouth, nasal discomfort, headache, infection, difficulty in eating and drinking, trauma to the soft palate and nose, hypoxia, obstructive sleep apnea, hypoventilation, and respiratory obstruction that sometimes requires tracheostomy. (7,12-14)

Children often become distressed by the adverse effects of nasal packing and frequently require analgesia or sedation. According to Leighton et al, therefore most of their doctors put their patients in the intensive care unit (ICU) and kept them sedated as long as the postnasal pack was applied. (15)

Using diathermy to control postadenoidectomy bleeding leads to areas of carbonization and necrotic tissue, with hazards such as severe postoperative pain, an increased likelihood of secondary infection, adhesion, scarring in the eustachian tube orifice, and even nasopharyngeal stenosis. (16,17) Sutures have also been used in the postnasal space to control bleeding, but this method is technically difficult.

Although gauze is the preferred material for packing the postnasal space to control postadenoidectomy bleeding, other materials such as sponge, a Foley catheter, bismuth iodoform paraffin paste in gauze, and calcium sodium alginate dressing have been described. (7) They all depend on the same idea, have the same risks, and need to be removed after bleeding is controlled.

Surgicel is a chemically altered form of cellulose manufactured from wood pulp. (18) It works via multiple mechanisms of action, including blood absorption, physical meshwork by surface interactions with proteins and platelets, and activation ofboth the intrinsic and extrinsic coagulation pathways. (19) It also has been proven to have bactericidal properties. (20) The low pH of Surgicel contributes to hemostasis by causing small vessel vasoconstriction. (18)

Using Surgicel to control postadenoidectomy bleeding not only avoids the complications of traditional postnasal packing, but it also has many advantages: It is readily available, easily applicable, tolerable, relatively inexpensive, hemostatic, and adhesive. It can be freely reshaped, is not associated with a granulation reaction, is bactericidal, and does not need to be removed. Patients in whom Surgical is used for postadenoidectomy bleeding do not in need to be admitted to the ICU or sedated.

Surgicel expands in situ when it becomes hydrated. (9) It also adheres to raw surfaces. (8) These properties help to keep it in place after its application in the postnasal space.

Surgicel has been used in control post-tonsillectomy bleeding and has been described by Goodman as safe and effective for that use. (10) Goodman reported that although Surgicel was gone within a few days, the patient healed uneventfully and there was no rebleeding after its absorption and there were no complications from swallowing or digesting the pack. (10)

In our case series, bleeding was controlled after application of the Surgicel pack in the nasopharynx in all cases. The patients recovered smoothly without rebleeding or complications.

Conclusion

Surgicel postnasal pack is effective in controlling primary postadenoidectomy bleeding with no need for removal and without the complications associated with traditional postnasal packing. We found that its advantages make Surgicel superior to other materials for packing of primary postadenoidectomy bleeding.

References

(1.) Windfuhr JP, Hubner R, Sesterhenn K. Guidelines for inpatient adenoidectomy [in German], HNO 2003;51(8):622-8.

(2.) Scheenstra RJ, Hilgevoord AA, Van Rijn PM. Serious haemorrhage after conventional (adeno)tonsillectomy: Rare and most often on the day of the procedure [in Dutch], Nederlands Tijdschrift Geneeskd 2007;151(10):598-601.

(3.) Arnoldner C, Grasl MCh, Thurnher D, et al. Surgical revision of hemorrhage in 8388 patients after cold-steel adenotonsillectomies. Wien Klin Wochenschr 2008;120(ll-12):336-42.

(4.) Demirbilek N, Evren C, Altun U. Postadenoidectomy hemorrhage: How we do it. Int J Clin Exp Med 2015;8(2):2799-803.

(5.) Windfuhr JP, Chen YS. Post-tonsillectomy and -adenoidectomy hemorrhage in nonselected patients. Ann Otol Rhinol Laryngol 2003;112(1):63--70.

(6.) Tomkinson A, Harrison W, Owens D, et al. Postoperative hemorrhage following adenoidectomy. Laryngoscope 2012;122(6):1246-53.

(7.) Tzifa KT, Skinner DW. A survey on the management of reactionary haemorrhage following adenoidectomy in the UK and our practice. Clin Otolaryngol Allied Sci 2004;29(2):153-6.

(8.) Huggins S. Control of hemorrhage in otorhinolaryngologic surgery with oxidized regenerated cellulose. Eye Ear Nose Throat Mon 1969;48(7):420-3.

(9.) Physicians Desk Reference. Montvale, NJ: Medical Economics; 1994:1104-6.

(10.) Goodman RS. Surgicel in the control of post-tonsillectomy bleeding. Laryngoscope 1996; 106(8): 1044-6.

(11.) Bhatnagar RK, Berry S. Selective surgicel packing for the treatment of posterior epistaxis. Ear Nose Throat J 2004;83(9):633.

(12.) Fairbanks DN. Complications of nasal packing. Otolaryngol Head Neck Surg 1996;94(3):412-15.

(13.) Becker GD. Posterior nasal packing, spontaneous perforation of the esophagus and gram-negative septicemia: Report of a case. Laryngoscope 1973;83(11):1828-33.

(14.) Bent JP, Wood BP. Complications resulting from treatment of severe posterior epistaxis. J Laryngol Otol 1999;113(3):252-4.

(15.) Leighton SE, Rowe-Jones JM, Knight JR, Moore-Gillon VL. Day case adenoidectomy. Clin Otolaryngol Allied Sci 1993;18(3):215-19.

(16.) Tan SR, Tope WD. Effectiveness of microporous polysaccharide hemospheres for achieving hemostasis in mohs micrographic surgery. Dermatol Surg 2004;30(6):908-14.

(17.) McLaughlin KE, Jacobs IN, Todd NW, et al. Management of nasopharyngeal and oropharyngeal stenosis in children. Laryngoscope 1997;107(10): 1322-31.

(18.) Acar B, Babademez MA, Karabulut H. Topical hemostatic agents in otolaryngologic surgery. Kulak Burun Bogaz Ihtis Derg 2010; 20(2): 100-9.

(19.) Maxwell JA, Goldware SI. Use of tissue adhesive in the surgical treatment of cerebrospinal fluid leaks. Experience with isobutyl 2-cyanoacrylate in 12 cases. J Neurosurg 1973;39(3):332-6.

(20.) Spangler D, Rothenburger S, Nguyen K, et al. In vitro antimicrobial activity of oxidized regenerated cellulose against antibiotic-resistant microorganisms. Surg Infect (Larchmt) 2003;4(3):255-62.

Mohammad Waheed El-Anwar, MD; Ahmad Abdel Fattah Nofal, MD; Ashraf Elmalt, MD

From the Otorhinolaryngology-Head and Neck Surgery Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt.

Corresponding author; Ahmad Abdel Fattah Nofal, Otorhinolaryngology-Head and Neck Surgery Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt. Email: nofal_9999@hotmail.com
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Title Annotation:ORIGINAL ARTICLE
Author:Anwar, Mohammad Waheed El-; Nofal, Ahmad Abdel Fattah; Elmalt, Ashraf
Publication:Ear, Nose and Throat Journal
Date:Sep 1, 2017
Words:2017
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