The Risks of Hemostaic Material in Tonsillectomy

A 4 year old girl was admitted to the E.R at Hillel Yaffe Medical Center with the complaints of fever, odynophagia, malaise, difficulty opening the mouth and muffled voice. The complaints started 4 days earlier, after tonsillectomy and adenoidectomy in another hospital. Upon physical examination the findings were signs of dehydration, muffled voice, and a refusal to open the mouth. When the child finally opened her mouth, we noted two round solid packing, one at each tonsil bed. The packing was removed and inspected thoroughly (Figure 1). The packing was a round condensed Surgicel, which was pre-formed by the surgeon to fit the size and shape of the tonsil beds. The surgeon put the material on both tonsil beds at the end of the surgery to create a prolonged haemostatic effect. The surgeon sutured the anterior and posterior pillars to apply local pressure and cease the ongoing oozing of blood on both sides. Unfortunately the partial dehiscence of the suture line exposed the foreign material, which was only partly anchored and bulged into the lumen on both sides. Thus put the child in a risk of aspiration and suffocation and contributed to the deterioration in her general condition. Rapid recovery was made once the Surgicel spherical foreign bodies were removed.


Introduction
Surgicel (Ethicon, USA) is a haemostatic agent made of an oxidized cellulose polymer, manufactured by Johnson and Johnson's Ethicon subsidiary. It was first introduced into practice in 1947. Its main usage was to control intra-operative bleeding. For example, surgicel is widely used in oral and maxillofacial surgery in order to control intra-osseous hemorrhage [1].

Case Report
A 4 year old girl was admitted to the E.R at Hillel Yaffe Medical Center with the complaints of fever, odynophagia, malaise, difficulty opening the mouth and muffled voice. The complaints started 4 days earlier, after tonsillectomy and adenoidectomy in another hospital. Upon physical examination the findings were signs of dehydration, muffled voice, and a refusal to open the mouth. When the child finally opened her mouth, we noted two round solid packing, one at each tonsil bed. The packing was removed and inspected thoroughly ( Figure 1). The packing was a round condensed Surgicel, which was pre-formed by the surgeon to fit the size and shape of the tonsil beds. The surgeon put the material on both tonsil beds at the end of the surgery to create a prolonged haemostatic effect. The surgeon sutured the anterior and posterior pillars to apply local pressure and cease the ongoing oozing of blood on both sides. Unfortunately the partial dehiscence of the suture line exposed the foreign material, which was only partly anchored and bulged into the lumen on both sides. Thus put the child in a risk of aspiration and suffocation and contributed to the deterioration in her general condition. Rapid recovery was made once the Surgicel spherical foreign bodies were removed.
The institutional ethical committee approved the publication of this case report.

Discussion
There are few references reporting the use of haemostatic material in tonsillectomy. The main benefit of surgicel is in controlling the non-  There are reports of post-operative bleeding that occurred several days after tonsillectomy that was halted with Surgicel.
One should remember that complete absorption takes 28 to 72 days, hence leaving the Surgicel in the tonsil bed put the patient in a risk of foreign body with the potential to dislodge into the airway [1].
For this reason, the minimum should be left in the fossa, attached to the surrounding tissues [1,4].
In this case, the surgeon rolled the Surgicel into a tufted ball, and left it in the fossa. The pillars were sutured with absorbable sutures. On the post-operative course these sutures partially dissolved due to the increased pressure caused by the hydrated Surgicel on the suture line. The result was a medial dislodgement of the round Surgicel impactions to the oropharynx lumen, blocking incompletely the passage of air and food. This obstruction was the reason for the complaints that the patient had. The foreign material posed a risk of either aspiration or swallowing of the Surgicel impactions, which could result in suffocation and death.

Conclusion
Our recommendation is to minimize the use of haemostatic material as a bulky substance left in the tonsil bed in tonsillectomy. When no alternative exist due to profound blood oozing, the fossa should be carefully packed with Surgicel pieces that are substantially anchored to the tonsil bed with sutures. The Surgicel should be used unfolded in its mono-layer form. Avoid condensed spherical shapes that would accumulate secretions and enlarge significantly postoperatively. In these cases further inspection should be scheduled to the third or fourth day post-operative to verify that the Surgicel is still in the fossa with the option of removing emerging Surgicel pieces.