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Proceedings S.Z.M.C. Vol: 34(4): pp. 64-69, 2020.      PSZMC-773-34-4-2020 
 
Secondary Heamorrhage After Cold Steel Tonsillectomy:  
An Audit Performed in Shalamar Hospital 
1Arshadullah Afridi, 2Sana Tariq, 3Muhammad Dawood, 4Sarwat Iqbal, 5Usna Athar,  
1Aisha Hanif 
1Department of ENT, Shalamar Hospital, Lahore 
2Department of Bioethics, Shalamar Medical & Dental College, Lahore 
3Department of Forensic Medicine, Shalamar Hospital, Lahore 
4Department of Medicine, Shalamar Hospital, Lahore 
5Department of Community Medicine, Shalamar Hospital, Lahore 

 
ABSTRACT 

Introduction: Tonsillectomy is a common surgical procedure in which post tonsillectomy heamorrhage 
remains the most serious complication. The cold steel dissection method is the oldest and safest method used 
to perform tonsillectomies. Aims & Objectives: This study was done to see the frequency of post-
tonsillectomy heamorrhage with cold steel dissection method. It was a clinical audit performed retrospectively 
to compare our results with International standards. Place and duration of study: Our clinical audit was 
conducted at Otolaryngology department in Shalamar Hospital, Lahore, Pakistan. This study was conducted 
in a period of 6 months. Material & Methods: The charts of patients (n=344) that underwent tonsillectomy at 
Shalamar Hospital from January 2016 till December 2019 were retrospectively viewed, in a cross-sectional, 
pilot study, using convenience sampling technique. All the tonsillectomy procedures were performed using 
the cold steel dissection method. Frequencies were recorded and chi-square test was applied. Results: The 
complication of secondary heamorrhage occurred in 7 patients and the frequency was calculated as 2%. A 
significant difference (P=0.01) of age was found in patients suffering from secondary heamorrhage. The 
incidence was lower in patients below 18 years of age (0.7%) as compared to patients above 18 years of age 
(7.14%). The rate of heamorrhage was found to be slightly higher in males than in females (2.6% and 1.31% 
respectively). Conclusion: We conclude that the rate of secondary heamorrhage in our institution is up to the 
rate reported in literature. Different hot techniques for tonsillectomy should also be performed in clinical 
settings and compared with the standard cold steel dissection tonsillectomy. 
 
Key words: Tonsillectomy, Adeno-tonsillectomy, Secondary Heamorrhage, Cold Steel Method 
 
 

INTRODUCTION 

Tonsillectomy is one of the most common and 
frequently performed surgical procedures in 
otolaryngology practices in which both palatine 
tonsils are removed from the throat. In some cases, 
the adenoid may also be removed which is then  
termed as "adeno-tonsillectomy".1 It is often 
categorized as low risk operation with quite a few 
chances of complications whilst the post 
tonsillectomy heamorrhages remains the most 
serious complication.2 Post-tonsillectomy 
heamorrhages are fairly divided into two main 
categories: Primary heamorrhage in which 
postoperative bleeding occurs within 24 hours after 
the surgery while the patient is in hospital, and the 

Secondary heamorrhage which occurs up to 2 weeks 
post operatively.3 
To reduce both the intra and post-operative 
compilations, and to minimize the surgery duration 
and morbidity, the tonsillectomy techniques are 
evolving constantly.4 Tonsillectomy can be 
performed by various methods which are divided 
into two major categories including ‘cold’ and ‘hot’ 
methods.  Dissection and snare, Guillotine Method, 
Intra-capsular, Harmonic Scalpel, Plasma mediated 
ablation technique and Cryosurgical techniques are 
the cold methods to perform tonsillectomy.5 The hot 
methods include; Electrocautery, Laser 
Tonsillectomy using (CO2 or KTP), Colbation 
tonsillectomy and Radio frequency.6 However, it 
cannot be clearly stated that which of these 
techniques shows ascendancy over the other.4 

 



65

Secondary Heamorrhage After Cold Steel Tonsillectomy: An Audit Performed in Shalamar Hospital 

Primarily, the main indications for tonsillectomy are 
based on obstructive and infectious causes. A 
surgery is required when there are periodic episodes 
of throat infections whose record is maintained 
through proper documentation. The physician might 
recommend tonsillectomy if the frequency of throat 
infection is of seven episodes per year, five episodes 
per 2 years or at least three episodes per 3 year, 
including the history ofPFAPA syndrome ( Periodic 
fever, Aphthous stomatitis, Pharyngitis and Cervical 
adenitis) , peri-tonsillar abscesses multiple antibiotic 
allergy and drug intolerance.1 Other indicators such 
as Obstructive Sleep Apnoea syndrome, Dysphonia, 
Dysphagia, Suspected Malignancy, Chronic 
Tonsillitis, Halitosis, Tonsilloliths are also the 
reasons for considering tonsillectomy.1,7 
The cold steel dissection method was introduced 
about 100 years ago, in which the blunt dissection is 
done involving a metal instrument and the 
subsequent bleeding is controlled with the help of 
gauze.8 The cold steel method is often considered as 
the gold standard because every other innovative 
techniques for tonsillectomy are compared with it.9 
It is also suggested that the young ENT trainees 
must be taught to perform tonsillectomy with cold 
method first.10 
The primary rationale behind this institutional 
review and analysis is to determine the frequency of 
secondary heamorrhages over the period of four 
years in Shalamar Medical and Dental College and 
Shalamar Hospital. This will help in ascertaining the 
risk factors associated with cold steel dissection 
tonsillectomy. This clinical audit may prove 
beneficial as a scaffold for comparing the results 
with different studies in order to monitor and 
modify our practices. This would help in improving 
patients’ clinical outcomes. Clinical audits and 
reviews are essential in health care services. As 
clinical practices and guidelines are changing with 
time and the advent of technology, surgeons must 
put their work under a microscope and modify their 
techniques accordingly for a state-of-the-art health 
care provision. 
 

MATERIAL AND METHODS 

A retrospective, cross sectional study was conducted 
in Ear, Nose and Throat Department (ENT) of 
Shalamar Hospital. This study can be classified as a 
pilot audit conducted by the authors. Ethical 
approval was taken from the Institutional Review 
Board (IRB) at Shalamar Institute of Health 
Sciences (SIHS). After the IRB approval, the study 
was completed within 6 months. Since this is a 
clinical audit, so it needs no specific sample size 

calculation. Convenience sampling was used; the 
study was conducted in duration of 6 months. 
The medical charts of the patients that underwent 
the tonsillectomy and/or Adeno- tonsillectomy were 
prepared dating from January 2016 till December 
2019. The data of total of 344 cases was obtained 
from the Otolaryngology (ENT) department of 
SMDC which included both adults and children. 
The inclusion criteria was determined as patients 
with a history of recurrent attack of recurrent attacks 
of tonsillitis accompanied by clinical examination 
findings of high grade fever, palpable jugulo-
digastric lymph nodes, exudates on tonsil and 
absence of cough. All patients aged 3 years and 
above, who underwent the ‘cold steel dissection’ 
method for tonsillectomy were included. Patients 
having suspicion of malignancy or undergoing 
tonsillectomy as a part of uvulopalatoplasty were 
excluded. According to the set pattern of surgery, 
operations were performed on each patient and the 
surgical technique followed for tonsillectomy was 
‘cold steel dissection’ specifically. The tonsils were 
removed using tonsillar dissector and haemostasis 
was secured by ligation and bipolar electro-cautery. 
Heamorrhage was monitored qualitatively in the 
post-operative phase during their stay in the 
hospital. The oropharyngeal cavity including the 
surgical site was examined every six hours using a 
tongue depressor and a light source to check for any 
possible bleeding. The patients were asked to report 
back to the hospital in case of any signs of bleeding, 
after discharge. 
 
Statistical analysis: 
The data of tonsillectomy cases was analyzed by 
using SPSS version 20. Frequency tables were 
formed. Chi-square test was applied for analytical 
comparison and P-value was set as 0.05 with 95% 
Confidence Interval. 
 

RESULTS 

A total of 344 patients underwent tonsillectomy and 
adeno-tonsillectomy by the cold steel method only 
during January 2016 till December 2019. 
Demographic features and frequency of secondary 
heamorrhage were studied. Chi-square test was 
applied with the level of significance set at 0.05. 
Figure 1 shows the frequency of operations done 
according to the age of the patients. 
 



66

Secondary Heamorrhage After Cold Steel Tonsillectomy: An Audit Performed in Shalamar Hospital 

 
Fig-1: Frequency of tonsillectomy cases against the age 

of the patients. 
 
Table-1 illustrates other demographic features as 
well as the results. Out of the total number of 
tonsillectomy cases, 337 cases did not experience 
secondary heamorrhage. Only 7 cases reported post-
operative heamorrhage so the rate of secondary 
heamorrhage recorded was 2%. There were zero 
cases reported in our hospital for mortality as a 
result of tonsillectomy.  
 

Age (in Years) 
Mean 13.66 
Median 10 
Mode 7 
Std. Deviation 10.11 
Range 52 
Minimum 3 
Maximum 55 
Sex 
Male 192 (55.8%)  
Female 152 (44.2%) 
Type of Surgery: 
Adenotonsillectomy 137 (39.8%) 
Tonsillectomy 207 (60.2%) 
Rate of secondary haemorrhage 
Haemorrhage  7(2%) 

Table-1: Characteristics of study participants undergoing 
tonsillectomy (n=344) 

 
Shalamar Institute of Health Sciences is a trust 
hospital where people from different financial 
backgrounds are treated. Fig-2 represents the 
statistics of 4 consecutive years starting from 2016, 
where the mode of payment for the number of 
different patients is categorized into 3 categories 
accordingly.  
 

 
Fig-2: Comparison of ‘General, Private & Company’ 

patients of tonsillectomy over past 4 Years. 
 
The data of the patients were divided into two 
groups on the basis of their age. Our study shows 
that only 0.72% of patients under the years of 18 
experienced secondary heamorrhage whereas for the 
patients older than 18 years of age the percentage 
was 7.14%.  The rate of secondary heamorrhage was 
higher for the patient with age more than 18 years 
and this result was statistically significant (P 
value=0.01) 
In our study, the rate of secondary heamorrhage in 
males is 2.6% and for females it is 1.31%. There is 
no significant difference between male and female 
regarding the rate of secondary heamorrhage (P 
value=0.401) 
In our study, no statistically significant difference 
was recorded between adeno-tonsillectomy and 
tonsillectomy regarding the rate of secondary 
heamorrhage (P value=0.869). 
 

DISCUSSION 

The rate of secondary heamorrhage in our study is 
2% which is higher than the rates reported by 
O'Leary and Vorrath (1.85%) but lower than 
described by Brick et al. 4.23%.4,11 Harju and 
Numminen reported higher secondary heamorrhage 
rate (12%) as 208 patients out of total 1734 patients 
who underwent tonsillectomy experienced 
secondary haemorrhage.12 
When looking at the two groups divided on the basis 
of age, 0ur study showed similar results to the one 
done by Walker P, in which post-tonsillectomy 
heamorrhage for 18 years old patients was 10.1% 
and age was defined as a highly statistically 
significant (P value=0.001) risk factor for post-
tonsillectomy haemorrhage.13 The cold steel 
dissection method has been preferred in older 
children, adolescents and adults.9 

0

5

10

15

20

25

30

35

40

3 6 9 12 15 18 21 24 27 30 33 37 40 45 53

Fr
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ue
nc

y

Age

16 18
13 13

45

25
28

16

26

8 10 9

0
5

10
15
20
25
30
35
40
45
50

2019 2018 2017 2016

General
Private
Company



67

Secondary Heamorrhage After Cold Steel Tonsillectomy: An Audit Performed in Shalamar Hospital 

In contrast to our findings, Ali et al. shows a high 
rate of post tonsillectomy bleeding (6.68%) in and it 
was indicted that the bleeding rate was higher in 
males as compared to the females (7.66 and 5.9% 
respectively).14 
In another comparative study, the group of patients 
(n=40) subjected to the cold steel dissection 
tonsillectomy showed 2.5% of secondary 
heamorrhage rate. It was also indicated that the 
patients who underwent tonsillectomy with the cold 
steel method showed quick healing with lesser 
amount of pain as compared to the other group 
patients subjected to bipolar diathermy.15 
Preforming tonsillectomy through the cold steel 
method is quite a common practice even in the 
United States of America as it is characterized as 
cheaper and safer.16 As the tissue healing is better in 
cold steel method, it is reported as less painful 
technique in the literature.17 Cold steel dissection 
method may have certain advantages but surgeons 
should be trained in several other techniques of 
tonsillectomy and should be permitted to use 
different methods for individual patients as well. 
Extreme precautions are required for cold dissection 
in order to avoid the vascular damage.  
 Regardless of the operative technique, the 
frequency of post-operative bleeding also depends 
upon the skills and experiences individual 
surgeon.18It has been seen in a study that the 
complication of post-tonsillectomy heamorrhageis 
reportedly higher when young resident perform the 
coblation technique. Hence, when younger surgeons 
are to perform this specific technique, supervision 
and surveillance are extremely vital.19 To further 
emphasize this, a research described that the rate of 
post-tonsillectomy heamorrhage was not dependent 
on the method used specially when the consultants 
performed the surgery.20 Post-operative 
administration of dexamethasone was also seen to 
raise the frequency of heamorrhage after 
tonsillectomy.21 Male gender and age were also 
studied as some of the risk factors for increased 
post-tonsillectomy heamorrhage rates and returns to 
the operating table.22 
The complication of post-tonsillectomy 
heamorrhage has high mortality and thus must be 
evaluated with priority. Some patients with this 
particular complication may be managed 
conservatively, but most of them need an 
intervention ranging from cautery to external carotid 
artery ligation.23 Rising rates of secondary 
heamorrhage after tonsillectomy can be reduced by 
employing quality improvement projects like the 
one used in Sweden which included hands-on 
workshops and supervision.24 Various quality 

assurance programs targeting the local hospitals and 
clinics can improve the clinical outcomes, which is 
an indicator of health care provision in a country.25 
An important component of such quality 
improvement programs is clinical audit, much 
similar to the one performed by us. A regular audit 
and maintenance of a registry can provide clinicians 
and surgeons with evidence to modify practice 
guidelines. 
 

CONCLUSION 

There are many studies published showing the 
frequency of secondary heamorrhage after 
tonsillectomies but no study has been published 
containing data from Shalamar Institute of Health 
Sciences. It was seen in our pilot study that the 
frequency of secondary heamorrhagic complication 
was similar to what was reported in other peer-
reviewed publication. This in turn exhibits that 
standard techniques are being applied by our 
surgeons performing tonsillectomies. The 
introduction of Electronic Surgical Performa along 
with the manual notes has resulted in improving the 
quality of data maintenance for routinely performed 
tonsillectomies. As evident, there is a low amount of 
data available right now, over the years the re-
auditing for different factors will become systematic 
and easy. 
 
Limitations: 
There is a lot of literature available on this topic 
with the with sample size ranging in thousands. 
Since before 4 years the electronic data system did 
not exist, our study only comprises of records of the 
past 4 years hence the sample size is low. In other 
studies, the comparison of different tonsillectomy 
technique is analyzed. However, in Shalamar 
medical and dental college tonsillectomy is only 
performed with cold steel dissection method. The 
proper documentation of the initial indicators for 
performing tonsillectomy is also lacking. 
 

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Secondary Heamorrhage After Cold Steel Tonsillectomy: An Audit Performed in Shalamar Hospital 

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69

Secondary Heamorrhage After Cold Steel Tonsillectomy: An Audit Performed in Shalamar Hospital 

The Authors: 
Dr. Arshadullah Afridi 
Assistant Professor, 
Department of ENT, 
Shalamar Hospital, Lahore. 
 
Dr. Sana Tariq 
Research Associate, 
Department of Bioethics, 
Shalamar Medical & Dental College, Lahore. 
 
Dr. Muhammad Dawood 
Demonstrator, 
Department of Forensic Medicine, 
Shalamar Hospital, Lahore. 
 
Dr. Sarwat Iqbal 
Assistant Professor, 
Department of Medicine, 
Shalamar Hospital, Lahore. 
 

Dr. Usna Athar 
Demonstrator, 
Department of Community Medicine, 
Shalamar Hospital, Lahore. 
 
Dr. Aisha Hanif 
Medical Officer, 
Department of ENT, 
Shalamar Hospital, Lahore. 
 
Corresponding Author: 
Dr. Arshad Ullah Afridi 
Assistant Professor, 
Department of ENT, 
Shalamar Hospital, Lahore. 
E-mail: arshadullah@hotmail.com