A CASE CONTROL STUDY TO COMPARE THE EFFICACY OF PRE-OPERATIVE INTRAVENOUS TRANEXAMIC ACID IN THE CONTROL OF INTRAOPERATIVE TONSILLECTOMY BLEEDING.

Dr. Sathiyamoorthy  Karunakaran; Dr. Aishwarya  Panneerselvam; Dr. Tamilarasi  Panneerselvam

doi:10.51168/sjhrafrica.v6i12.2202

Authors

Dr. Sathiyamoorthy Karunakaran Assistant Professor, MS Ent, PSP Medical College and Hospital.
Dr. Aishwarya Panneerselvam Assistant Professor, MD Anaesthesia, ACS Medical College and Hospital.
Dr. Tamilarasi Panneerselvam Senior Resident, MD, Immunohematology and Transfusion Medicine, SRM Medical College and Hospital.

DOI:

https://doi.org/10.51168/sjhrafrica.v6i12.2202

Keywords:

Tonsillectomy, Tranexamic acid, post-tonsillectomy hemorrhage, Tonsillar hemorrhage, blood loss, antifibrinolytic drugs

Abstract

INTRODUCTION

Tonsillectomy is one of the most performed surgeries all over the world. Modern methodologies, use of bipolar scissor dissection, bipolar radio frequency ablation, harmonic scalpel, micro-debrider endoscopic tonsillectomy, laser tonsillectomy, and the like, have revolutionized the tonsillectomy procedure. To compare the efficacy of preoperative intravenous Tranexamic acid in the control of intraoperative tonsillectomy bleeding.

MATERIALS AND METHODS:

This prospective clinical study was conducted in the Department of Otorhinolaryngology and Head and Neck Surgery, Adichunchanagiri Institute of Medical Sciences, B. G. Nagara, Mandya District. The study period was from November 2016 to May 2018. A sample size of a minimum of 107 patients who satisfied the inclusion criteria was included in the study. Dissection tonsillectomy was done in all cases. In the study group, pre-operative intravenous Tranexamic acid will be given in the dosage of 10mg/kg/body weight.

RESULTS:

The most common age group in the study and control group was 11-20 years. In the study group, 30 females (56.6%) and 23 males (43.4%), and in the control group, 33 females (61.1%) and 21 males (38.9%). The grading was done according to Brodsky's grading scale; in the study group, maximum cases (39.6%) had grade 3 tonsillar hypertrophy, and in the control group, maximum cases (31.5%) had grade 2 and grade 3, respectively. Mean intraoperative blood loss was 135.96 ml in the study group and 159.81 ml in the control group. P value was calculated to be <0.001, thus statistically proving significance.

CONCLUSION:

In this study, we have proved the efficacy of pre-operative intravenous use of Tranexamic acid in the control of intra-operative tonsillectomy bleeding with no recorded side effects. No side effects of tranexamic acid were noted during the study. So, it is a safe drug to be used.

References

Kayvani K. Frequency and predictors of tonsil surgery. University of Ontario Institute of Technology (Canada); 2018. (doi: not available)

Feldmann H. 2000-year history of tonsillectomy. Images from the history of otorhinolaryngology, highlighted by instruments from the collection of the German Medical History Museum in Ingolstadt. Laryngo-rhino-otologie. 1997 Dec 1;76(12):751-60. https://doi.org/10.1055/s-2007-997520

Waitrak BJ, Willging JP. Harmonic scalpel for tonsillectomy. The laryngoscope. 2002 Aug;112(S100):14-6. https://doi.org/10.1002/lary.5541121406

Júnior JF, Hermann DR, Américo RR, Stamm RG, Hirata CW. A brief history of tonsillectomy. Int Arch Otorhinolaryngol. 2006;10(4):314-7. (doi: not available)

Weir N. Otorhinolaryngology. Postgraduate medical journal. 2000 Feb;76(892):65-9.

https://doi.org/10.1136/pmj.76.892.65

Watts G. Utako Okamoto. The Lancet. 2016 Jun 4;387(10035):2286. https://doi.org/10.1016/S0140-6736(16)30697-3

Standring S, Ellis H, Healy J, Johnson D, Williams A, Collins P, Wigley C. Gray's anatomy: the anatomical basis of clinical practice. American journal of neuroradiology. 2005 Nov;26(10):2703. PMCID: PMC7976199

Wadie M, Adam SI, Sasaki CT. Development, anatomy, and physiology of the larynx. In Principles of deglutition: a multidisciplinary text for swallowing and its disorders, 2012 Jul 25 (pp. 175-197). New York, NY: Springer New York. (doi: not available)

https://doi.org/10.1007/978-1-4614-3794-9_13

Richardson MA. Sore throat, tonsillitis, and adenoiditis. Medical Clinics of North America. 1999 Jan 1;83(1):75-83. https://doi.org/10.1016/S0025-7125(05)70088-2

Shido F, Kobayashi K, Yamanaka N. Cell-size distribution of human tonsillar lymphocytes. Archives of Oto-Rhino-Laryngology. 1984 Apr;239(3):211-8. https://doi.org/10.1007/BF00464246

Yamanaka N, Matsuyama H, Harabuchi Y, Kataura A. Distribution of lymphoid cells in tonsillar compartments in relation to infection and age: a quantitative study using image analysis. Acta oto-laryngologica. 1992 Jan 1;112(1):128-37. https://doi.org/10.3109/00016489209100794

Kuki K, Hotomi M, Yamanaka N. A study of apoptosis in the human palatine tonsil. Acta oto-laryngologica. Supplementum. 1996;523:68-70. PMID: 9082813

Bergler W, Adam S, GROSS HJ, Hörmann K, Schwartz‐Albiez R. Age‐dependent altered proportions in subpopulations of tonsillar lymphocytes. Clinical & Experimental Immunology. 1999 Apr;116(1):09-18. https://doi.org/10.1046/j.1365-2249.1999.00850.x

Brandtzaeg P, Surjan L, Berdal P. Immunoglobulin systems of human tonsils. I. Control subjects of various ages: qualification of Ig-producing cells, tonsillar morphometry, and serum Ig concentrations. Clinical and Experimental Immunology. 1978 Mar;31(3):367. PMID: 350457

Karchev T. Specialization of tonsils as analyzers of the human immune system. Acta Oto-Laryngologica. 1988 Jan 1;105(sup454):23-7. https://doi.org/10.3109/00016488809124999

Brandtzaeg P, Halstensen TS. Immunology and Immunopathology of Tonsils¹. InTonsils: A Clinical Oriented Update: 2nd International Symposium on Tonsils, Pavia, September 1991 1992 Sep 23 (Vol. 47, p. 62). Karger Medical and Scientific Publishers. https://doi.org/10.1159/000421721

Yamanaka N, Yokoyama M, Kawaguchi T, Tamaki K, Ishii H. Role of gamma delta-T cells in the palatine tonsil. Acta Otolaryngol 1996;523:90-3. PMID: 9082821

Brandtzaeg P. Regionalized immune function of tonsils and adenoids. Immunology today. 1999 Aug 1;20(8):383-4. https://doi.org/10.1016/S0167-5699(99)01498-X

Andersson J, Abrams J, Björk L, Funa K, Litton M, Agren K, Andersson U. Concomitant in vivo production of 19 different cytokines in human tonsils. Immunology. 1994 Sep;83(1):16. PMID: 7821961

Harabuchi Y, Wakashima J, Murakata H, Yoshioka I, Yokoyama Y, Kataura A. Cytokine expression and production by tonsillar lymphocytes. Acta oto-laryngologica. Supplementum. 1996 Jan 1;523:75-7. PMID: 9082815

Perry M, Whyte A. Immunology of the tonsils. Immunology today. 1998 Sep 1;19(9):414-21. https://doi.org/10.1016/S0167-5699(98)01307-3

Banchereau J, Brière F, Liu YJ, Rousset F. Molecular control of B lymphocyte growth and differentiation. Stem cells. 1994;12(3):278-88. https://doi.org/10.1002/stem.5530120304

Liu YJ, Barthélémy C, De Bouteiller O, Arpin C, Isabelle D, Banchereau J. Memory B cells from human tonsils colonize mucosal epithelium and directly present antigen to T cells by rapid up-regulation of B7-1 and B7-2. Immunity. 1995 Mar 1;2(3):239-48. https://doi.org/10.1016/1074-7613(95)90048-9

Korsrud FR, Brandtzaeg P. Immune systems of human nasopharyngeal and palatine tonsils: histomorphometry of lymphoid components and quantification of immunoglobulin-producing cells in health and disease. Clinical and Experimental Immunology. 1980 Feb;39(2):361. PMID: 6993071

Brandtzaeg P. Immune functions and immunopathology of palatine and nasopharyngeal tonsils. Immunology of the Ear. 1987:63-106. (doi: not available)

Quiding-Järbrink M, Granström G, Nordström I, Holmgren J, Czerkinsky C. Induction of compartmentalized B-cell responses in human tonsils. Infection and immunity. 1995 Mar;63(3):853-7. https://doi.org/10.1128/iai.63.3.853-857.1995

Clark EA, Ledbetter JA. How B and T cells talk to each other. Nature. 1994 Feb 3;367(6462):425-8. https://doi.org/10.1038/367425a0

Schriever F, Korinth D, Salahi A, Lefterova P, Schmidt‐Wolf IG, Behr SI. Human T lymphocytes bind to germinal centers of human tonsils via integrin α4/VCAM‐1 and LFA‐1/ICAM− 1 and− 2. European journal of immunology. 1997 Jan;27(1):35-9. https://doi.org/10.1002/eji.1830270106

Westermann J, Pabst R. Lymphocyte subsets in the blood: a diagnostic window on the lymphoid system?. Immunology today. 1990 Jan 1;11:406-10. https://doi.org/10.1016/0167-5699(90)90160-B

Koornstra PJ, Duijvestijn AM, Vlek LF, Marres EH, van Breda Vriesman PJ. Tonsillar (Waldyer's ring equivalent) lymphoid tissue in the rat: lymphocyte subset binding to high endothelial venules (HEV) and in situ distribution. Regional immunology. 1992 Nov 1;4(6):401-8. PMID: 1297410

Baekkevold ES, Jahnsen FL, Johansen FE, Bakke O, Gaudernack G, Brandtzaeg P, Haraldsen G. Culture characterization of differentiated high endothelial venule cells from human tonsils. Laboratory investigation: a journal of technical methods and pathology. 1999 Mar;79(3):327-36. PMID: 10092069

Baekkevold ES, Yamanaka T, Palframan RT, Carlsen HS, Reinholt FP, Von Andrian UH, Brandtzaeg P, Haraldsen G. The CCR7 ligand elc (CCL19) is transcytosed in high endothelial venules and mediates T cell recruitment. The Journal of Experimental Medicine. 2001 May 7;193(9):1105-12. https://doi.org/10.1084/jem.193.9.1105

Nowara E, Pabst R. Die Gaumentonsillen als Teil des lymphatischen Systems. Ein- und Ausstrom neugebildeter Lymphozyten. HNO. Hals-, Nasen-, Ohrenärzte. 1986;34(4):164-9.

Girard JP, Springer TA. High endothelial venules (HEVs): specialized endothelium for lymphocyte migration. Immunology today. 1995 Sep 1;16(9):449-57. https://doi.org/10.1016/0167-5699(95)80023-9

Westermann J, Walter S, Nagahori Y, Heerwagen C, Miyasaka M, Pabst R. Blood leucocyte subsets of the rat: expression of adhesion molecules and localization within high endothelial venules. Scandinavian journal of immunology. 1996 Mar;43(3):297-303. https://doi.org/10.1046/j.1365-3083.1996.d01-38.x

Zidan, Jecker, Pabst. Differences in lymphocyte subsets in the wall of high endothelial venules and the lymphatics of human palatine tonsils. Scandinavian Journal of Immunology. 2000 Apr;51(4):372-6. https://doi.org/10.1046/j.1365-3083.2000.00681.x

Schaerli P, Willimann K, Lang AB, Lipp M, Loetscher P, Moser B. CXC chemokine receptor 5 expression defines follicular homing T cells with B cell helper function. The Journal of Experimental Medicine. 2000 Dec 4;192(11):1553-62. https://doi.org/10.1084/jem.192.11.1553

Casamayor-Palleja M, Mondiere P, Amara A, Bella C, Dieu-Nosjean MC, Caux C, Defrance T. Expression of macrophage inflammatory protein-3α, stromal cell-derived factor-1, and B-cell-attracting chemokine-1 identifies the tonsil crypt as an attractive site for B cells. Blood, The Journal of the American Society of Hematology. 2001 Jun 15;97(12):3992-4. https://doi.org/10.1182/blood.V97.12.3992

Surjan Jr L. Tonsils and lympho-epithelial structures in the pharynx as immuno-barriers. Acta Oto-laryngologica. 1987 May 1;103(5-6):369-72. PMID: 3303820

Scadding GK. Immunology of the tonsil: a review. Journal of the Royal Society of Medicine. 1990 Feb;83(2):104-7. https://doi.org/10.1177/014107689008300216

Ying, MD. Immunological basis of indications for tonsillectomy and adenoidectomy. Acta Oto-Laryngologica. 1988 Jan 1;105(sup454):279-85. https://doi.org/10.3109/00016488809125041

Witt RL. The tonsil and adenoid controversy. Delaware Medical Journal. 1989 Jun 1;61(6):289-94. PMID: 2666179

Böck A, Popp W, Herkner KR. Tonsillectomy and the immune system: a long-term follow-up comparison between tonsillectomized and non-tonsillectomized children. European archives of Oto-rhino-laryngology. 1994 Nov;251(7):423-7. https://doi.org/10.1007/BF00181969

Harper SJ, Allen AC, Bene MC, Pringle JH, Faure G, Lauder I, Feehally J. Increased dimeric IgA-producing B cells in tonsils in IgA nephropathy determined by in situ hybridization for J chain mRNA. Clinical & Experimental Immunology. 1995 Sep;101(3):442-8. https://doi.org/10.1111/j.1365-2249.1995.tb03132.x

Hotta O, Taguma Y, Yoshizawa N, Oda T, Nishiyama J, Yusa N, Chiba S, Horigome I, Sudo K, Tomioka S. Long-term effects of intensive therapy combined with tonsillectomy in patients with IgA nephropathy. Acta oto-laryngologica. Supplementum. 1996 Jan 1;523:165-8. PMID: 9082770

Mattila, Tarkkanen. Differentiation of T lymphocytes in the human adenoid as measured by the expression of CD45 isoforms. Scandinavian journal of immunology. 1998 Jul;48(1):59-64. https://doi.org/10.1046/j.1365-3083.1998.00371.x

Pantaleo G, Graziosi C, Butini L, Pizzo PA, Schnittman SM, Kotler DP, Fauci AS. Lymphoid organs function as major reservoirs for human immunodeficiency virus. Proceedings of the National Academy of Sciences. 1991 Nov 1;88(21):9838-42. https://doi.org/10.1073/pnas.88.21.9838

Frankel SS, Tenner-Racz K, Racz P, Wenig BM, Hansen CH, Heffner D, Nelson AM, Pope M, Steinman RM. Active replication of HIV-1 at the lymphoepithelial surface of the tonsil. The American journal of pathology. 1997 Jul;151(1):89. PMID: 9212735

Kornblut AD. Non-neoplastic diseases of the tonsils and adenoids. Otolaryngology. 1991;3:2129-47.

Scott-Brown WG. Scott-Brown's Otorhinolaryngology, Head and Neck Surgery. Hodder Education; 2008.

Ebell MH, Smith MA, Barry HC, Ives K, Carey M. Does this patient have strep throat?. Jama. 2000 Dec 13;284(22):2912-8. https://doi.org/10.1001/jama.284.22.2912

Jain A, Sahni JK. Polysomnographic studies in children undergoing adenoidectomy and/or tonsillectomy. The Journal of Laryngology & Otology. 2002 Sep;116(9):711-5. https://doi.org/10.1258/002221502760238019

Nieminen P, Tolonen U, Löppönen H. Snoring and obstructive sleep apnea in children: a 6-month follow-up study. Archives of Otolaryngology-Head & Neck Surgery. 2000 Apr 1;126(4):481-6. https://doi.org/10.1001/archotol.126.4.481

Wang RC, Elkins TP, Keech D, Wauquier A, Hubbard D. Accuracy of clinical evaluation in pediatric obstructive sleep apnea. Otolaryngology--Head and Neck Surgery. 1998 Jan;118(1):69-73. https://doi.org/10.1016/S0194-5998(98)70377-8

Suen JS, Arnold JE, Brooks LJ. Adenotonsillectomy for treatment of obstructive sleep apnea in children. Archives of Otolaryngology-Head & Neck Surgery. 1995 May 1;121(5):525-30. https://doi.org/10.1001/archotol.1995.01890050023005