Adenoidectomy and/or tonsillotomy are the most common procedures performed at departments of paediatric otolaryngology. Due to the fact that these procedures are often the first surgical procedures performed in children, not only is proper evaluation of indications important, but also appropriate preoperative management connected to co-existing conditions. Excessive bleeding in patients with coagulation disorders or bronchial spasm in children with bronchial hyper-reactivity leading to acute respiratory insufficiency are life-threatening conditions.

The incidence of peri-operative haemorrhage after tonsillotomy or adenoidectomy ranges from 0.5% to 10%, depending on authors (1). Massive and prolonged bleeding may occur just after surgery, even before anaesthesia is finished. Such situations may develop due to coagulation defects evidenced or not prior to surgery, to a irregular course of the descending pharyngeal artery and its injury during adenoidectomy, to an increased blood pressure or to remnants of adenoid tissues in the nasopharynx. Uncommon, genetically determined defects of the coagulation system are being evidenced during such procedures. Thus, it is recommended to asses platelets count, bleeding time, PT-prothrombin time, INR-Quick ratio, PTT – partial thromboplastin time in all children prepared for tonsillotomy or/and adenoidectomy. These tests estimate the function of the intrinsic and extrinsic coagulation pathways.

The most common serum-related coagulation defect is von Willebrand´s disease – VWD (prevalence 0.8%), inherited by autosomal dominant way. The clinical course of VWD is different depending on the degree of quantitative decrease and qualitative abnormalities of von Willebrand factor (VWF) multimers. The severity of the disease may vary from time to time in the same patient (2). Because of various clinical courses of VWD, usually only severe conditions are being diagnosed. VWF causes platelets to adhere to injured epithelium and consequently to proper clot formation. Intra-operative bleeding in patients with VWD, even not excessive, may decrease VWF levels and intensify perturbations of the platelets functions, thus leading to clinical presentations in the form of bleeding onset a few days after surgery. This condition does not disqualify the patient from surgery, but special haematological management is recommended. In some types of VWD (type I), synthetic vasopressin, desmopressin (DDAVP), is being used, releasing VWF from tissues (3).

Among a total of 286 children operated at the Department of Paediatric Otolaryngology in 2004, there were 172 boys (60%) and 114 girls (40%) aged from 2.5 to 15 years. The mean age was 6 years and 2 months. In 164 children, adenoidectomy was performed, while in 122 cases adenoidectomy was accompanied by tonsillotomy. At the same time, myryngotomy was performed in 74 children and in 10 cases ventilation tubes were potted. Co-existing disorders were found in 146 children (Table 1).

In the analysed group, 37 children (13%) presented bronchial asthma. Five children were diagnosed with concurrent bronchial asthma and coagulation defects. In 35 children (12%), coagulation tests were incorrect, and – among them – in 32 cases, these results were related to a deficiency of a particular coagulation factor, while in 3 cases, in spite of prolonged PTT test results, levels of particular factors were normal. (Table 2).

Bleeding associated with adenoidectomy or/and tonsillotomy occurred in 23 children (0.8%); 17 cases (6.8%) in the group of 250 children without diagnosed coagulation defect and 5 cases (17.2%) in the group of children with abnormal coagulation tests. In 13 cases bleeding occurred within a few hours after surgery, in 9 cases it was intra-operative bleeding, and in 1 case bleeding occurred intra- and postoperatively. In 5 cases, posterior packing was installed (children without coagulation defect), two children needed blood transfusion (one child with VWD and one child with prolonged PTT test results). In all cases, coagulation defects were diagnoses before surgery.

Bronchial spasm during anaesthesia and surgery occurred in 1 child with previously diagnosed bronchial asthma. The child´s parents did provide information regarding that risk factor before surgery.

Coagulation tests in the form of PT time, PTT time and platelets count are being performed in all children prepared for adenoidectomy or/and tonsillotomy. Diagnosing coagulation defects in pre-operative period enables the administration of sufficient coagulation factors following the haematologist´s recommendations (Table 3).

In many centres, the PT, PTT, INR, bleeding time tests are performed as routine screening tests. According to other authors coagulation tests should be performed only in children with bleeding history or examination suggesting coagulation problems. Due to the fact that adenoidectomy or/and tonsillotomy are often the first surgical procedures, bleeding history in children may not be present. Preoperative evaluation of the coagulation system should be performed in all children.

As in certain coagulation defects performed coagulation tests may prove normal, taking medical history of any bleeding tendency is very important and should include questions concerning bleeding after tongue, lip or cheek cutting, bruises appearing after small injuries, bleeding after tooth removal, bleeding in the peri-operative period, repeated nose bleedings questions concerning coagulation issues in relatives (4). Acetylsalicylic acid and ibuprofen should not be administered within two weeks prior to surgery because of anti-aggregation properties. Valproic acid, an antiepileptic drug (Depakine, Convulex), also causes platelet aggregation to be disturbed. The risk of bleeding during surgery is higher when the child experiences an infection of the respiratory tract or an aggravation of allergy. In such conditions vessels are dilated and haemostasis is difficult to achieve.

Another very dangerous complication which may develop even during general anaesthesia induction is bronchial spasm. Bronchial spasm may cause acute respiratory failure. It occurs more often in children with bronchial asthma or with hyperactivity of the bronchi. As some drugs used for anaesthesia may cause constriction of the bronchi, it is very important to assess any medical history of earlier episodes of bronchial spasm. Preoperative preparation in patients with bronchial asthma increases procedure safety. The scheme for preoperative preparation of patients with bronchial asthma was introduced at our Department to decrease the risk of respiratory complications. The classification of asthma degrees is based on medical course before treatment, current treatment and efficiency of treatment according to GINA 2002 recommendations (Global Strategy for asthma management and prevention National Heart, Lung and Blood Institute) (5, 6).

It is recommended to administer current treatment and additionally short-acting beta2-agonists 1 hour before surgery for patients with well-controlled asthma (degree 1-3), without symptoms of bronchial constriction. In case of severe asthma (degree 4), it is necessary to additionally administer prednisone 5 days before surgery at a dose of 1 mg/kg body weight per day.

In patients with asthma under limited control, it is recommended to administer treatment as for patients in superior severity group (i.e. treatment as for 2⁰ for children with 1⁰ asthma) for at least 7 days before surgery. If a patient with asthma symptoms is not treated or is inadequately treated, it is recommended to administer drugs according to GINA, for several weeks before surgery, with short-acting beta2-agonists additionally administered on the day of surgery. If the respiratory tract infection occurred within 2 weeks prior to surgery date, surgery should be postponed.

1. Evidence of coagulation defects before adenoidectomy and/or tonsillotomy requires an analysis of indications for surgery. In case of absolute indications, the procedure is permitted after proper substitution treatment.

2. In case of bronchial asthma the adenoidectomy and/or tonsillotomy should be performed in a period without exacerbation and after appropriate preoperative management according to the degree of asthma.