Study of Patients’ Return to Surgery Post-Tonsillectomy and/or Adenoidectomy: A Relation Between Patient Age and Timing of Uncontrolled Bleeding


  • Matthew A. Taylor, PhD Patient Safety Authority



return to surgery, hemorrhage, primary bleed, secondary bleed, tonsil, adenoid, patient safety, patient harm, adverse event, risk, otolaryngology, ENT, perioperative, postoperative complication


Visual abstract for Study of Patients’ Return to Surgery Post-Tonsillectomy and/or Adenoidectomy: A Relation Between Patient Age and Timing of Uncontrolled Bleeding

Background: Tonsillectomy and/or adenoidectomy (T/A) are common surgical procedures. Postoperative uncontrolled bleeding is a well-established complication; however, the relation between certain variables and uncontrolled bleeding are unclear.

Methods: We explored the Pennsylvania Patient Safety Reporting System database for event reports that described a patient who had a T/A procedure and later returned to surgery to control bleeding. We analyzed the post-T/A bleeding events according to numerous variables, such as patient sex and age, timing of the bleed, procedure performed (i.e., tonsillectomy and/or adenoidectomy), and bleeding site.

Results: We identified 219 event reports from 56 healthcare facilities over a four-year period. The study revealed that 78% of the patients were discharged and then returned to surgery to control bleeding. Patients ranged in age from 1–45 years and 53% were female. Among the 219 events, 41% were a primary bleed (0–1 postoperative days) and 59% were a secondary bleed (2–30 postoperative day). Additionally, 0–1 days and 6–7 days after operation were the periods when patients most frequently returned to surgery (range of 0–30 days). We expanded upon much of the previous research by exploring the relation between patient age and days postoperative return to surgery. We found that a majority of patients in age categories 1–10, 11–20, and 21–30 years had a secondary bleed; in contrast, a majority of patients age 31–45 had a primary bleed.

Conclusion: Our findings indicate that the post-T/A timing of uncontrolled bleeding may vary systematically as a function of patient age; however, future research is needed to better understand this topic. We encourage readers to use our findings, along with findings from previous research, to inform their practice and strategies to mitigate risk of patient harm.

Author Biography

Matthew A. Taylor, PhD, Patient Safety Authority

Matthew A. Taylor ( is a patient safety analyst for the Patient Safety Authority (PSA), where he conducts research; uses data to identify patient safety concerns and trends; and develops tools and materials to help facilities and clinicians improve patient safety. Prior to joining the PSA, Taylor was a scientific writer and research specialist at the University of Pittsburgh School of Pharmacy, and he has served fellowships at the Centers for Disease Control and Prevention (CDC) and the VA Pittsburgh Healthcare System. His expertise in data analysis and research covers a range of topics, including patient safety, public health, employee training, process efficiency, human factors, workplace culture/climate, behavior change interventions, and organizational management.


Hall MJ, Schwartzman A, Zhang J, Liu X. Ambulatory Surgery Data from Hospitals and Ambulatory Surgery Centers: United States, 2010. National Health Statistics Reports. 2017(102):1-15.

Bohr C, Shermetaro C. Tonsillectomy and Adenoidectomy. StatPearls [Internet]: StatPearls Publishing; 2019.

Mitchell RB, Archer SM, Ishman SL, Rosenfeld RM, Coles S, Finestone SA, et al. Clinical Practice Guideline: Tonsillectomy in Children (update). Otolaryngol Head Neck Surg. 2019;160(1_suppl):S1-S42.

Royal College of Surgeons of England. National Prospective Tonsillectomy Audit: Final Report of an Audit Carried Out in England and Northern Ireland between July 2003 and September 2004. London, UK: Clinical Effectiveness Unit; 2005.

Liu JH, Anderson KE, Willging JP, Myer Iii CM, Shott SR, Bratcher GO, et al. Posttonsillectomy Hemorrhage: What Is It and What Should Be Recorded? Arch Otolaryngol Head Neck Surg. 2001;127(10):1271-5. doi: 10.1001/archotol.127.10.1271.

Collison PJ, Mettler B. Factors Associated with Post-Tonsillectomy Hemorrhage. Ear Nose Throat J. 2000;79(8):640-2, 4, 6 passim. Epub 2000/09/02. PubMed PMID: 10969475.

Cadd B, Rogers M, Patel H, Crossland G. (Ton)silly Seasons? Do Atmospheric Conditions Actually Affect Post-Tonsillectomy Secondary Haemorrhage Rates? J Laryngol Otol. 2015;129(7):702-5. doi: 10.1017/S0022215115001292.

Burckardt E, Rebholz W, Allen S, Cash E, Goldman J. Predictors for Hemorrhage Following Pediatric Adenotonsillectomy. Int J Pediatr Otorhinolaryngol. 2019;117:143-7. doi: 10.1016/j.ijporl.2018.11.029.

Kim DW, Koo J-W, Ahn S-H, Lee CH, Kim J-W. Difference of Delayed Post-Tonsillectomy Bleeding Between Children and Adults. Auris Nasus Larynx. 2010;37(4):456-60.

Harounian JA, Schaefer E, Schubart J, Carr MM. Pediatric Adenotonsillectomy and Postoperative Hemorrhage: Demographic and Geographic Variation in the US. Int J Pediatr Otorhinolaryngol. 2016;87:50-4.

Hsueh W-Y, Hsu W-C, Ko J-Y, Yeh T-H, Lee C-H, Kang K-T. Population-Based Survey of Inpatient Pediatric Tonsillectomy and Postoperative Hemorrhage in Taiwan, 1997–2012. Int J Pediatr Otorhinolaryngol. 2018;108:55-62. doi: 10.1016/j.ijporl.2018.02.021.

Kshirsagar R, Mahboubi H, Moriyama D, Ajose-Popoola O, Pham NS, Ahuja GS. Increased Immediate Postoperative Hemorrhage in Older and Obese Children after Outpatient Tonsillectomy. Int J Pediatr Otorhinolaryngol. 2016;84:119-23. doi: 10.1016/j.ijporl.2016.02.019.

Lee WT, Witsell DL, Parham K, Shin JJ, Chapurin N, Pynnonen MA, et al. Tonsillectomy Bleed Rates Across the CHEER Practice Research Network: Pursuing Guideline Adherence and Quality Improvement. Otolaryngol Head Neck Surg. 2016;155(1):28-32.

Mahant S, Keren R, Localio R, Luan X, Song L, Shah SS, et al. Variation in Quality of Tonsillectomy Perioperative Care and Revisit Rates in Children’s Hospitals. Pediatrics. 2014;133(2):280-8.

Achar P, Sharma RK, De S, Donne AJ. Does Primary Indication for Tonsillectomy Influence Post-Tonsillectomy Haemorrhage Rates in Children? Int J Pediatr Otorhinolaryngol. 2014;79(2):246-50. doi: 10.1016/j.ijporl.2014.12.022.

Tomkinson A, De Martin S, Gilchrist CR, Temple M. Instrumentation and Patient Characteristics that Influence Postoperative Haemorrhage Rates Following Tonsil and Adenoid Surgery. Clin Otolaryngol. 2005;30(4):338-46. doi: 10.1111/j.1365-2273.2005.01045.x.

Verma A, Nabhani SA, Al-Khabori M. Adult Tonsillectomy and Day Care Surgery. Indian J Otolaryngol. 2007;59:341-5.

Windfuhr JP, Chen YS, Remmert S. Hemorrhage Following Tonsillectomy and Adenoidectomy in 15,218 Patients. Otolaryngol Head Neck Surg. 2005;132(2):281-6. doi: 10.1016/j.otohns.2004.09.007.

Aldrees T, Alzuwayed A, Majed A, Alzamil A, Almutairi M, Aloqaili Y. Evaluation of Secondary Post-Tonsillectomy Bleeding Among Children in Saudi Arabia: Risk Factor Analysis. Ear Nose Throat J. 2020:1-8. doi: 10.1177/0145561320944662.

Kim SJ, Walsh J, Tunkel DE, Boss EF, Ryan M, Lee AH. Frequency of Post‐Tonsillectomy Hemorrhage Relative to Time of Day. Laryngoscope. 2020;130(7):1823-7.

Miller AL, McCarty JC, Bergmark RW, Gadkaree SK, Cohen MS, Diercks GR, et al. Association of Perioperative Ibuprofen Exposure with Post-Tonsillectomy Bleeding Requiring Operative Management. Int J Pediatr Otorhinolaryngol. 2021;142:110627. doi: 10.1016/j.ijporl.2021.110627.

Gross JH, Lindburg M, Kallogjeri D, Molter M, Molter D, Lieu JE. Predictors of Occurrence and Timing of Post-Tonsillectomy Hemorrhage: A Case-Control Study. Ann Otol Rhinol Laryngol. 2021;130(7):825-32.

Clark CM, Schubart JR, Carr MM. Trends in the Management of Secondary Post-Tonsillectomy Hemorrhage in Children. Int J Pediatr Otorhinolaryngol. 2018;108:196-201. doi: 10.1016/j.ijporl.2018.03.004.

Carter A, Warner E, Roberton A, Liu X, Abdul-Hamid A, Natt R, et al. Tonsillectomy Discharge Information-An Improvement in Both Patient Safety and Satisfaction. BMJ Open Qual. 2014;2(2):u203433. w1546.

Peterson J, Losek JD. Post-Tonsillectomy Hemorrhage and Pediatric Emergency Care. Clin Pediatr. 2004;43(5):445-8. doi: 10.1177/000992280404300505.

Pennsylvania Department of Health. Medical Care Availability and Reduction of Error (MCARE) Act, Pub. L. No. 154 Stat. 13 (2002). DOH website. Published 2002. Accessed March 4, 2022.

Baugh RF, Archer SM, Mitchell RB, Rosenfeld RM, Amin R, Burns JJ, et al. Clinical Practice Guideline: Tonsillectomy In Children. Otolaryngol Head Neck Surg. 2011;144(1_suppl):S1-S30.

Loeb S, Dynarski S, McFarland D, Morris P, Reardon S, Reber S. Descriptive Analysis in Education: A Guide for Researchers. (NCEE 2017-4023). Washington, DC: U.S. Department of Education, Institute of Education Sciences, National Center for Education Evaluation and Regional Assistance; 2017.

Yonash R, Taylor M. Wrong-Site Surgery in Pennsylvania During 2015–2019: A Study of Variables Associated With 368 Events From 178 Facilities. Patient Saf. 2020;2(4):24-39.

Statmod: Statistical Modeling. Power of Fisher’s Exact Test for Comparing Proportions. R Package Documentation. Published 2021. Accessed February 2, 2022.

Coordes A, Soudry J, Hofmann VM, Lenarz M. Gender-Specific Risk Factors in Post-Tonsillectomy Hemorrhage. Eur Arch Oto-Rhino-L. 2016;273(12):4535-41. doi: 10.1007/s00405-016-4146-7.

Tomkinson A, Harrison W, Owens D, Harris S, McClure V, Temple M. Risk Factors for Postoperative Hemorrhage Following Tonsillectomy. Laryngoscope. 2011;121(2):279-88. doi: 10.1002/lary.21242.

McLean JE, Hill CJ, Riddick JB, Folsom CR. Investigation of Adult Post‐Tonsillectomy Hemorrhage Rates and the Impact of NSAID Use. Laryngoscope. 2021. doi: 10.1002/lary.29844.

Spektor ZMD, Saint-Victor SMD, Kay DJMDMPH, Mandell DLMD. Risk Factors for Pediatric Post-Tonsillectomy Hemorrhage. Int J Pediatr Otorhinolaryngol. 2016;84:151-5. doi: 10.1016/j.ijporl.2016.03.005.

Riechelmann H, Blassnigg E, Profanter C, Greier K, Kral F, Bender B. No Association Between Obesity and Post-Tonsillectomy Haemorrhage. J Laryngol Otol. 2014;128(5):463-7.

Walker P, Gillies D. Post-Tonsillectomy Hemorrhage Rates: Are They Technique-Dependent? Otolaryngol Head Neck Surg. 2007;136(4):S27-S31. doi: 10.1016/j.otohns.2006.10.022.

Windfuhr JP, Chen YS. Hemorrhage Following Pediatric Tonsillectomy Before Puberty. Int J Pediatr Otorhinolaryngol. 2001;58(3):197-204. doi: 10.1016/S0165-5876(01)00428-1.

Hussain S, O’Connell Ferster AP, Carr MM. Time Between First and Second Posttonsillectomy Bleeds. Int J Otolaryngol. 2017:1-5. doi: 10.1155/2017/3275683.

Grasl S, Mekhail P, Janik S, Grasl CM, Vyskocil E, Erovic BM, et al. Temporal Fluctuations of Post-Tonsillectomy Haemorrhage. Eur Arch Oto-Rhino-L. 2021:1-7. doi: 10.1007/s00405-021-07080-1.

Lee M, Montague M, Hussain S. The Influence of Weather on the Frequency of Secondary Post-Tonsillectomy Haemorrhage. J Laryngol Otol. 2005;119(11):894-8.

Odhagen E, Sunnergren O, Söderman A-CH, Thor J, Stalfors J, Hhj I, et al. Reducing Post-Tonsillectomy Haemorrhage Rates Through a Quality Improvement Project using a Swedish National Quality Register: A Case Study. Eur Arch Oto-Rhino-L. 2018;275(6):1631-9. doi: 10.1007/s00405-018-4942-3.

Verma R, Verma RR, Verma RR. Tonsillectomy-Comparative Study of Various Techniques and Changing Trend. Indian J Otolaryngol. 2017;69(4):549-58.

Abdelhamid AO, Sobhy TS, El-Mehairy HM, Hamid O. Role of Antibiotics in Post-Tonsillectomy Morbidities; A Systematic Review. Int J Pediatr Otorhinolaryngol. 2019;118:192-200.

Bannister M, Thompson C. Post-Tonsillectomy Dietary Advice and Haemorrhage Risk: Systematic Review. Int J Pediatr Otorhinolaryngol. 2017;103:29-31. doi: 10.1016/j.ijporl.2017.09.031.

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How to Cite

Taylor, M. A. (2022). Study of Patients’ Return to Surgery Post-Tonsillectomy and/or Adenoidectomy: A Relation Between Patient Age and Timing of Uncontrolled Bleeding. Patient Safety, 4(1), 6–17.



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