July 2008.indd ABSTRACT Objectives: The world over, tonsillectomy is one of the operations most frequently performed by otolaryngologists, who are in search of a technique of tonsillectomy where the operation time and operative blood loss is reduced. This study was carried out to evaluate the effect of hydrogen peroxide 3% on tonsillectomy times, blood loss during the surgery and on the number of ties used. Methods: A pilot study of 30 patients was carried out in the Department of Otolaryngology of Basrah General Hospital, Iraq, in the period from February to July 2006. Tonsillectomy was performed using hydrogen peroxide 3% as a haemostatic agent in Group A (n = 5), while in Group B (n = 5) no agent was used with the gauze pack. Results: The application of hydrogen peroxide 3% in the ton- sillar fossae reduced the operation time by 3%, the operative blood loss by 32.9% and also reduced the number of ties used by 50% in Group A. All these results are statistically significant. Conclusion: The local application of 3% hydrogen peroxide on the tonsillar bed after tonsillectomy is beneficial in regard to decreasing the procedure time, the volume of blood loss, and the number of ties used. Keywords: Tonsillectomy; Hydrogen peroxide; Haemostasis. Hydrogen Peroxide 3%: Is it Beneficial in Tonsillectomy? *Ahmed M Al-Abbasi,1 Zahra K Saeed2 1Department of Surgery, Basrah Medical College, Basrah, Iraq; 2Basrah Dentistry College, Basrah, Iraq *To whom correspondence should be addressed. Email: mmalabbasi@yahoo.com اللوزتني؟ استئصال لعملية مفيد هو هل :3% الهيدروجني بيروكسيد زهره سعيد ، احمد العباسي أنحاء جميع ــي ف واحلنجرة ــاء األنف واألذن أطب قبل ــي تؤدى من الت العمليات أنواع ــر أكث إحدى هي اللوزتني ــتئصال ــة اس ــص: الهــدف: عملي امللخ 3% الهيدروجني ــيد بيروكس تأثير لتقييم ــة تهدف الدراس . فقدان الدم وكذلك وقت العملية تقلل ــة لطريق دائم بحث األطباء في ــؤالء ه ــم. العال عملية لهم أجريت مريضا ((30 ل ارتيادية ــة دراس هذه الطريقة: اللوزتني. ــتئصال اس لعملية الغرز املفقود وعدد الدم حجم ــتغرق، املس الوقت في .2006 لعام متوز إلى شهر ــباط ش ــهر ش من الفترة في ، العراق في البصرة العام ــفى مستش واألذن واحلنجرة- األنف ــعبة ش في اللوزتني ــتئصال اس شيء ــتخدم أي يس لم (15 مريضا)، بينما ــة الدراس مجموعة في للنزف موقف كعامل ــاش الش %3 مع حزمة الهيدروجني ــيد بيروكس ــتخدم اس %31 وتقليل بقدر تقليل وقت العملية إلى %3 أدى الهيدروجني ــيد بيروكس ــتخدام النتائج: اس (15 مريضا). اموعة الضابطة في ــاش الش مع معتدة. اخلالصة: إحصائية ذات داللة النتائج هذه كل . الضابطة اموعة مع %50 باملقارنة %32.9 وكذلك تقليل عدد الغرز إلى بقدر الدم فقدان الغرز وعدد املفقودة الدم وكمية العملية وقت اختزال إلى أدى استئصالها بعد اللوزة سرير %3 في الهيدروجني ــيد كس لبيرو املوضعي ــتخدام االس املستخدمة. . النزف ايقاف ، الهيدروجني بيروكسيد ، اللوزتني الكلمات: استئصال مفتاح SULTAN QABOOS UNIVERSITY MEDICAL JOURNAL JULY 2008, VOLUME 8, ISSUE 2, P. 201-204 SULTAN QABOOS UNIVERSITY© SUBMITTED - 30TH OCTOBER 2007 ACCEPTED - 3RD MARCH 2008 C L I N I C A L A N D B A S I C R E S E A R C H AS FAR AS WE KNOW, CELSUS WAS THE FIRST person to recognize tonsillar disease and its relationship to infection performing the first tonsillectomy in 40 A.D.1 The popularity of tonsillec- tomy peaked in the 1930s, but after the use of antibiot- ics became widespread, enthusiasm for the procedure waned and its use had decreased dramatically by the 1960s. Concerned about the morbidity inherent in the surgical procedure, paediatricians began to question its value relative to medical management with anti- microbials. The tide turned again in the 1980s, when Paradise et al demonstrated that surgery significantly improved patient outcomes compared with medical therapy.2 Chronic tonsillitis is one of the most common and frequent illnesses within otolaryngology. Tonsillecto- my is also one of the most frequently performed sur- gical procedures. Patients’ quality of life and general health becomes demonstrably reduced by chronic pal- ate and pharyngeal infections.3 Hitherto tonsillectomy outcome studies were mostly done on children.4, 5 Hydrogen peroxide has been used as a disinfectant.6 Delivering hydrogen peroxide into wounds kills fi- broblasts and occludes local microvasculature.7, 8 It has been used for decades as an effervescent haemostatic agent in arthroplasty in orthopedics.9 S H YA M S G A N G U LY, M O H A M M E D A A L -S H A FA E E , A B D U L L A H A A L - M A N I R I 202 The aims of this prospective study were to evaluate the effects of hydrogen peroxide 3% on tonsillectomy time, operative blood loss and the number of ties used to achieve complete haemostasis. M E T H O D S Thirty randomly selected patients underwent ton- sillectomy in the Department of Otolaryngology of Basrah General Hospital, Iraq. As air embolism is oc- casionally known following H202 usage, the risk was mentioned to all patients. Some then refused to take part in the study, but all those who were included ac- cepted the possibility of risk and gave their permis- sion. In Group A (n = 15), a hydrogen peroxide 3% impregnated gauze pack was applied to one tonsillar fossa after the tonsil had been removed; in Group B (n = 15), no agent was used with the pack. The tonsil- lectomy was performed by the conventional dissection and snare method. The stubborn bleeders were ligated with silk suture. Tonsillectomy operation time was calculated as the time interval between the first incision to the time when all bleeding and oozing was secured completely. The operative blood loss was calculated by weighing the blood impregnated gauze packs against an equal number of unused packs as well by measuring the vol- ume of blood for each group separately, subtracting the volume of hydrogen peroxide used. The volume of blood in the packs was calculated by dividing the weight of blood on the pack by the specific gravity of blood, i.e. 1.055.10 The results of the study were statis- tically analysed by using paired t -test for significance R E S U L T S The age range of the studied patients was 2-32 years: 17 were males and 13 were females. The average time for tonsillectomy in the non-hydrogen peroxide group was 12.9 minutes. With the use of hydrogen per- oxide 3%, the average time was reduced to 8.9 min- utes, which meant reduction in tonsillectomy time of 31%. This is statistically significant (p < 0.0001). The average operative blood loss in the non-hydro- gen peroxide group was 45.5 ml while that in hy- drogen peroxide group was 30.5 ml, which means a 32.9 % reduction in operative blood loss. These results are statistically significant (p < 0.0001). The maximum numbers of ties use were four. In the non-hydrogen peroxide group, the average number of ties was 1.5, while that in hydrogen peroxide group was 0.75. This mean a 50% reduction in the number of ligatures used in tonsillectomy after the use of hy- drogen peroxide as a haemostatic agent, which is also statistically significant (p < 0.0001). All these results are shown in Table 1. D I S C U S S I O N The first known tonsillectomy was performed by Cor- nelius Celsus about 2000 years ago. After enucleating the tonsil with his fingernail, he suggested the fossae should be washed with vinegar and painted with a medication to reduce bleeding.1 Since that time tech- niques for faster tonsillectomy with less bleeding have been searched for and various haemostatic agents and technique been tried. Sharp and Rogers,11 used calci- um alginate swabs to achieve haemostasis after tonsil- lectomy, but reduction in both tonsillectomy time and blood loss was not significant. In the past, many studies were done utilizing elec- tro cauterization for haemostasis with Papangelou12 demonstrated a 30% reduction. Waston and Murty, in their study of 1,036 cases, 13 achieved good haemos- tasis and a tonsillectomy time of 9.2 ± 40min, but the use of electro-cauterization results in increased post- operative pain and excessive slough formation in the tonsillar bed which results in infection and secondary haemorrhage.13 Laser tonsillectomy under general an- aesthesia is shown to reduce surgical blood loss and postoperative pain as well as increase the recovery rate.14-16 The use of hydrogen peroxide as a haemostatic agent in tonsillectomy was not found when review- Table 1: Comparison between non-H2O2 and H2O2 groups regarding time, blood loss and number of ties in tonsillectomy. Groups Average % Decrease % Time of tonsillectomy in minutes Group B (n=15), Non-H2O2 12.9 Group A (n=15), H2O2 8.9 31 Blood loss (ml) Group B, Non-H2O2 45.5 Group A, H2O2 30.5 32.9 No. of ties used Group B, Non-H2O2 1.5 Group A, H2O2 0.75 50 S O M E R I S K FA C T O R S F O R C O R O N A R Y H E A R T D I S E A S E A M O N G O M A N I M A L E S 203 ing the available literature. Hydrogen peroxide has been used for decades as a haemostatic agent in orthopaedics.9 Chang et al, 17 carried out a study in 120 pediatric patients undergoing adenoidectomy with use of cold hydrogen peroxide. They found that the in- cidence of oozing and active bleeding decreased when cold hydrogen peroxide was applied. The present study confirms that the use of hydro- gen peroxide in tonsillectomy achieved a reduction in tonsillectomy time and operative blood loss by 31% and 32.9%, respectively. All these results are statisti- cally significant. No adverse effect was reported by the use of hy- drogen peroxide in tonsillectomy in the present study despite some reports stating that dangerous sequelae can result from the use of such a preparation, especial- ly when used in neurosurgical fields. Dubey et al18 pre- sented a case of suspected gas embolism following hy- drogen peroxide irrigation of the surgical field during posterior fossa surgery in the prone position. Severe cardiovascular collapse occurred when the wound was irrigated with a hydrogen peroxide solution. The interesting additional benefit of hydrogen per- oxide is its action to clarify the exact localizations of bleeders which need to be ligated, especially in cases of difficult dissection in fibrotic tonsils with excessive bleeding. This advantage has been utilized by Kalloo et al, who used hydrogen peroxide spray through an endoscope. This resulted in enhancement of clot dis- solution and endoscopic visualization of the bleeding source.19 The limitations of this present study are the absence of testing the long term effect of hydrogen peroxide and no long term follow-up of the patients. The number of patients studied was also relatively small, indicating the need to perform a broader study with a longer period of follow up. C O N C L U S I O N Local application of 3% hydrogen peroxide on the tonsillar bed after tonsillectomy is beneficial as it de- creases the procedure time and the volume of blood loss as well as number of ties used. R E F E R E N C E S 1. Curtin JM. The history of tonsil and adenoid surgery. Otolaryngol Clin North Am 1987; 20:415-419. 2. Paradise JL, Bluestone CD, Bachman RZ, Colborn DK, Bernard BS, Taylor FH, et al. Efficacy of tonsillectomy for recurrent throat infection in severely affected chil- dren - Results of parallel randomized and nonrand- omized clinical trials. N Engl J Med 1984; 310:674-683. 3. Stewart MG, Friedman EM, Sulek M, Hulka GF, Kup- persmith RB, Harrill WC, et al. Quality of life and health status in pediatric tonsil and adenoid disease. Arch Otolaryngol Head Neck Surg 2000; 126:45–48. 4. Goldstein NA, Fatima M, Campbell TF, Rosenfeld RM. Child behaviour and quality of life before and after ton- sillectomy and adenoidectomy. Arch Otolaryngol Head Neck Surg 2002; 128:770–775. 5. Stewart MG, Friedman EM, Sulek M, DeJong A, Hulka GF, Bautista MH, et al. Validation of an outcomes instru- ment for tonsil and adenoid disease. Arch Otolaryngol Head Neck Surg 2001; 127:29–35. 6. Patai S, Rapporport Z, eds. The syntheses of sulphones, sulphoxides and cyclic sulphides. Chichester, UK: John Wiley and Sons, 1994. p. 112-116. 7. Branemark PI, Ekholm R. Tissue injury caused by wound disinfection. J Bone Joint Surg 1967; 49:48-62. 8. Lineweaver W, Howard R, Soucy D, McMorris S, Free- man J, Crain C, et al. Topical antimicrobial toxicity. Arch Surg 1985; 120:267-270. 9. Guerin S, O’Reilly P, Kelly D. Hydrogen peroxide as an irrigation solution: a comparative study of the effect of hydrogen peroxide versus normal saline on the strength of bone-cement interface in arthroplasty. J Clin Neuro- sci 2007; 14:488-490. 10. Agrawal SR, Jain AK, Marathe D, Agrawal R. The effect of bismuth subgallate as haemostatic agent in tonsillec- tomy. Indian J Otolaryngol 2005; 57:287-289. 11. Sharp JF, Rogers MJ. Combined study to assess the role of calcium alginate swabs and ligations of Inferior ton- sillar pole in the control of intra-operative blood loss during tonsillectomy. J Laryngol Otol 1991; 105:191- 194. 12. Papangelou L. Haemostasis in tonsillectomy a compari- son of electrocoagulation and ligation. Arch Otolaryn- gol Head Neck Surg 1970; 96:358-360. 13. Murty GE, Watson MG. Diathermy haemostasis at ton- sillectomy. J Laryngol Otol 1990; 104:549-52. 14. Densert O, Desai H, Eliasson A, Frederiksen L, Anders- son D, Olaison J, et al. Tonsillotomy in children with tonsillar hypertrophy. Acta Otolaryngol 2001; 121:854– 858. 15. Hultcrantz E, Linder A, Markstrom A. Tonsillectomy or tonsillotomy? A randomised study comparing postop- erative pain and long-term effects. Int J Pediatr Otorhi- nolaryngol 1999; 51:171–176. 16. Linder A, Markstrom A, Hultcrantz E. Using the carbon dioxide laser for tonsillotomy in children. Int J Pediatr Otorhinolaryngol 1999; 50:31–36. 17. Chang HJ, Baek SH, Choi CY, Kang SN, Park JB, Lee WY, et al. Hemostatic efficacy of topical application of S H YA M S G A N G U LY, M O H A M M E D A A L -S H A FA E E , A B D U L L A H A A L - M A N I R I 204 cold hydrogen peroxide in adenoidectomy. Korean J Otolaryngol - Head Neck Surg 2003; 46:946-949. 18. Dubey, Prakash K, Singh, Anuj K. Venous oxygen em- bolism due to hydrogen peroxide irrigation during posterior fossa surgery. J Neurosurg Anesthesiol 2000; 12:54-56. 19. Kalloo AN, Canto MI, Wadwa KS, Smith CL, Gislason GT, Okolo PI, et al. Clinical usefulness of 3% hydrogen peroxide in acute upper GI bleeding: a pilot study. Gas- trointest Endosc 1999; 49:518-21.