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ORIGINAL ARTICLE
Year : 2021  |  Volume : 23  |  Issue : 1  |  Page : 36-40

Hydrogen peroxide as a hemostatic agent in tonsillectomy: Is it beneficial?


1 Department of Otorhinolaryngology, RVM Institute of Medical Sciences, Siddipet, Telangana, India
2 Department of Otorhinolaryngology, Kinder Multispecialty Hospital, Cochin, Kerala, India
3 Department of Otorhinolaryngology, Meenakshi Medical College and Hospital, Kanchipuram, Tamil Nadu, India

Date of Submission05-Sep-2020
Date of Decision21-Oct-2020
Date of Acceptance07-Nov-2020
Date of Web Publication06-May-2021

Correspondence Address:
Dr. Saai Ram Thejas
Department of Otorhinolaryngology, RVM Institute of Medical Sciences, Laxmakkapally Village, Mulugu Mandal, Siddipet - 502 279, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjoh.sjoh_40_20

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  Abstract 


Background: Tonsillectomy as a surgical procedure has been practiced by ENT surgeons for a very long time. A common indication for Tonsillectomy is Chronic Tonsillitis, among others. The surgery is largely safe irrespective of the method used. Haemorrhage can be a life-threatening complication post Tonsillectomy if it is not identified and treated immediately. Various techniques are used to achieve haemostasis and prevent haemorrhage including surgical tie, cautery, local application of adrenaline or hydrogen peroxide among others. Aims and Objectives: To understand the vasoconstrictive and haemostatic properties of Hydrogen Peroxide in Tonsillectomy. Materials and Methods: One hundred and thirty-three (133) patients undergoing Tonsillectomy for Chronic Tonsillitis were part of the study. Dissection and Snare technique was performed. 23 patients needed the use of cautery/knot for haemostasis and were then excluded from the study. To avoid bias, dissection of the right tonsil was taken as Group 1 and left tonsil as Group 2. Normal Saline soaked cotton ball was used to give local pressure in the tonsillar fossa in Group 1 and 3% Hydrogen Peroxide soaked cotton ball was used in Group 2. Blood loss and time taken to dissect were taken as parameters of study. Observations and Results: In Group 1, it took 14.29 minutes on an average from first incision to completion. In Group 2, it took 12.15 minutes on an average from first incision to completion. The time in Group 2 was 14.97% lesser than Group 1. The average blood loss in Group 1 was 56.47 ml and in Group 2 the same value stood at 47.41 ml. The blood loss in Group 2 was 16.04% lesser than in Group 1. There were no complications encountered. Conclusion: 3% Hydrogen Peroxide is a potent agent for antimicrobial activity and haemostasis when introduced in the tonsillar fossa post tonsillectomy. When used in moderation, it is very effective in preventing blood loss. Also, there are no serious complications associated with the use of Hydrogen Peroxide as a haemostatic agent.

Keywords: Hemostasis, hydrogen peroxide, primary hemorrhage, tonsillectomy


How to cite this article:
Thejas SR, Vinayak R, Sindu M. Hydrogen peroxide as a hemostatic agent in tonsillectomy: Is it beneficial?. Saudi J Otorhinolaryngol Head Neck Surg 2021;23:36-40

How to cite this URL:
Thejas SR, Vinayak R, Sindu M. Hydrogen peroxide as a hemostatic agent in tonsillectomy: Is it beneficial?. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2021 [cited 2021 Jun 25];23:36-40. Available from: https://www.sjohns.org/text.asp?2021/23/1/36/315575




  Introduction Top


Palatine tonsils are components of the immune system. Their infections are one of the most frequently involved diseases in ear, nose, and throat practice. Tonsils are immunologically more active in the 1st year of life.[1] With aging, this tissue regresses; subepithelial tissue changes into fibrotic tissue, and crypts alter into cavities to be filled with keratin. If infected, bacteria that inhabit the crypts spread into the tonsil to release their toxins, eventually leading to polymorphonuclear leukocyte infiltration, necrosis, swelling, and surface ulceration in tonsils. After multiple episodes of acute infection, bacteria inoculate into the core of the tonsil-producing symptoms.[2]

These infections are highly frequent, especially in childhood. Although antibiotic therapy is usually sufficient for acute tonsillitis, tonsillectomy is still the treatment of choice in the management of recurrent and chronic tonsillitis.[3] Despite being the most common and simplest surgery, the surgeon is always keen about the high risk of complications in tonsillectomy, i.e., intra- and postoperative hemorrhage, which may even lead to shock and death.[4]

Hydrogen peroxide (H2O2) is produced in many different human cell types such as fibroblast, vascular endothelial, smooth muscle, and inflammatory cells.[5] It is known to act as a cellular signaling molecule within blood vessels. It also plays key roles in regulating vascular smooth muscle cell growth, differentiation, and vascular inflammation.[6],[7] Delivering H2O2 into wounds kills fibroblasts and occludes local microvasculature.[8] It has been used for decades as an effervescent hemostatic agent in arthroplasty in orthopedics.[9]

When H2O2 dissociates, it forms water (H2O) and nascent oxygen (O). This nascent oxygen has oxidative properties and thus helps in achieving surface antimicrobial clearance.

Various mechanisms contribute to the vasoconstriction activity of H2O2. They include increase in Ca2+ influx from intracellular stores in smooth muscle cells, formation of cyclooxygenase-derived prostanoids, activation of enzymes, activation of potassium (K+) channels, and generation of hydroxyl radicals.[10]

Various newer methods are available for tonsillectomy today such as coblation and harmonic scalpel. The oldest method is the dissection and snare method, which has been used for hundreds of years now. The surgical procedure is usually based on the financial condition of the patient, availability, and surgical expertise. Irrespective of the method used, hemostasis is absolutely essential since hemorrhage the most common complication.

The types of bleed encountered in tonsillectomy are primarily venous bleed and mucosal bleed. Hemostasis is achieved primarily by the application of local pressure in the fossa postdissection, cauterization, surgical ties, and in worst cases, an adrenaline cotton pack with or without pillar suturing. The local pressure is usually given with a cotton ball soaked in normal saline (NS).

In this study, we have used cotton balls soaked in 3% H2O2 to apply pressure in the fossa after dissection to achieve hemostasis. The concentration of H2O2 to be used has been widely studied and documented in previous studies.[11] The amount of blood loss and time taken from first incision to hemostasis are the parameters used for the study.


  Materials and Methods Top


  • Source: All patients presenting to the department of otorhinolaryngology with symptoms of throat pain, dysphagia, odynophagia, change in voice, and multiple episodes of respiratory tract infections were considered
  • Sample size: 133.


Statistical analysis

It was performed using the SPSS Statistics 19 for Windows (IBM Corp., Armonk, NY, USA). Samples were compared by a paired t-test. A P < 0.05 was considered statistically significant. The confidence interval was set at 95%.

Inclusion criteria

  • Age between 6 and 30 years
  • Hemoglobin of more than 10 g%
  • Clinically diagnosed chronic tonsillitis by the paradise criteria.[12]


Exclusion criteria

  • Bleeding and clotting disorders
  • Enlarged tonsils which are not chronic tonsillitis, e.g., neoplasm and abscess
  • Pregnancy and lactation
  • Chronic systemic illnesses
  • Unilateral tonsillar growth.


Preoperative assessment

All the 133 patients underwent detailed evaluation and history taking with an examination of ear, nose, throat, head, and neck. If the patient was found to have chronic tonsillitis, he/she was asked for consent to be part of the study and general anesthesia. All patients with consent were then included in the study.

Intraoperative assessment

All the patients underwent tonsillectomy under general anesthesia. To avoid surgeon bias, all the surgeries were performed by the same surgeon with the same set of instruments. For the purpose of convenience, all the tonsils on the right were included in Group 1, and the ones on the left were included in Group 2. The order of preference of operating a particular side was left to the surgeon.

The first parameter used was the time taken from the first incision to achieve complete hemostasis. As soon as the first incision was placed, the timer was started. The incision was given with a Waugh toothed forceps at the junction of the tonsil and the anterior pillar after pulling the tonsil medially with the Dennis brown tonsil holding forceps. The loose areolar tissue was identified, and the plane of dissection was seen. Using a curved scissor, the superior pole attachments were released. Dissection was then performed using a Mollison's dissector, and the inferior pole was reached. The base was identified and crushed with an Eve's tonsillar snare. Suction was not used throughout to calculate accurately the amount of blood lost. Gauze packs were used to mop blood, if any, till the tonsil was dissected out. Cotton balls of diameter of 2 cm were made. In Group 1 (right side), the cotton ball was soaked in NS and placed in the fossa, after which gentle pressure was applied using the left index finger. In Group 2 (left side), the cotton ball was soaked in H2O2 and placed in the fossa, after which gentle pressure was applied using the right index finger. The cotton ball was left for 30 s, after which it was removed, and fossa was inspected for any bleed. On the confirmation of a clear field by the surgeon and the assistant surgeon, the timer was stopped. A microscope was used to look into the fossa for any bleed, venous or mucosal. Care was taken not to use more than 10 ml of solution in both groups. Count of the number of cotton balls were also kept at par for each side.

The second parameter was the amount of blood loss on each side. 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 volume of blood for each side separately. The volume of NS/H2O2 was subtracted. 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.[13]

Standard 10 cm × 10 cm gauze pieces were used for mopping the area according to previously documented studies.[14] Blood loss in the cotton packs was also accounted for.

Among the 133 patients, 23 of them had bleeding, which could not be controlled by packing and local pressure. They needed cauterization of the paratonsillar vein, numerous silk ties on one side or both sides. It was decided that these patients would not be included in the study. Thus, the sample size came down to 110.

Postoperative assessment

All the patients received the same set of antibiotics and analgesics. Fossa was visualized every 6th hourly for the next 2 days to look for evidence of secondary hemorrhage. No complications of any sort were reported.


  Observations and Results Top


In our study, 45 were male and 65 were female [Figure 1]. The maximum number of patients operated belonged to the age group of 15–20 years [Figure 2].
Figure 1: Distribution based on gender

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Figure 2: Distribution based on age

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In Group 1, where NS was used to achieve hemostasis, it took 14.29 min on an average from the first incision to completion. In Group 2, where H2O2 was used to achieve hemostasis, it took 12.15 min on an average from the first incision to completion [Table 1]. The time in Group 2 was 14.97% lesser than Group 1. The average blood loss in Group 1 was 56.47 ml, and in Group 2, the same value stood at 47.41 ml [Table 2]. The blood loss in Group 2 was 16.04% lesser than in Group 1. The significance was found to be 0.001 in both the groups [Table 3] and [Table 4].
Table 1: Paired sample statistics for time taken

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Table 2: Paired sample statistics for blood loss

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Table 3: Paid sample correlations for time taken

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Table 4: Paid sample correlations for blood loss

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  Discussion Top


The first known tonsillectomy was performed by Cornelius Celsus about 200 years ago, after enucleating the tonsil with his fingernail. He suggested that the fossae should be washed with vinegar and painted with a topical medication to reduce bleeding.[15]

The surgical dissection of the tonsil from its bed is fairly a straightforward technique with respect to the concept related to the surgery. Complications arising during and postsurgery include hemorrhage and secondary infection. Thus, hemostasis is the most important factor to be noted before extubating the patient.

The tonsil is a highly vascular organ with supply from the tonsillar branches of five arteries: the dorsal lingual artery (from lingual artery), ascending palatine artery (from facial artery), tonsillar branch (from facial artery), ascending pharyngeal artery (from external carotid artery), and the lesser palatine artery (from descending palatine artery, itself a branch of the maxillary artery). The tonsils venous drainage is by the peritonsillar plexus, which drain into the lingual and pharyngeal veins and in turn drain into the internal jugular vein. The complexity of the arterial and venous supply makes it very difficult to identify the exact source of bleed in case of a primary hemorrhage during surgery.

As a broad categorization, the bleed can be divided into two causes: vascular and mucosal. Venous bleed is mostly from the peritonsillar vein. Mucosal bleed is accelerated by the movement of the muscles of the anterior and posterior pillars, i.e., palatoglossus and palatopharyngeus. Posttonsillectomy hemorrhage can be divided into two broad categories: primary which occurs <24 h after surgery and secondary, which occurs after 24 h, commonly 5–10 days after the operation.

A study has shown that the rate of posttonsillectomy hemorrhage has increased from 1991 to 2012 in hospitals.[16] Another study from 2012 among 2216 patients undergoing tonsillectomy found a primary hemorrhage incidence rate of 10% and a re-operative rate due to hemorrhage of 6%.[17] Thus, it has been extensively proved that hemorrhage needs to be assessed on table to prevent serious threats.

Use of intraoperative vasoconstrictors has proved to be useful to reduce blood loss.[18] Irrespective of the technique used, some studies have reported that the hemorrhage rate appeared to remain similar to each other in comparison between groups.[19] Lignocaine-adrenaline injection in the peritonsillar area intraoperatively had a marked reduction in blood loss as compared to injection with NS.[20] Various authors in their studies have used electrocauterization and bismuth subgallate for hemostasis.[13],[21],[22]

The beneficial effects of H2O2 are plenty ranging from its cost-effectiveness to the fact that there are very few side effects when used in moderation. We have studied the same in our study, and the results pointed out that the blood loss and time taken to perform the surgery were markedly reduced in the side where H2O2 was used instead of NS. The time in Group 2 was 14.97% lesser than Group 1. The blood loss in Group 2 was 16.04% lesser than in Group 1. The P < 0.05, which proved to be statistically significant.

The bleeding from the fossa in all the cases included in our study stopped with local pressure and the application of topical agents. None of the cases had a secondary hemorrhage and did not need other ways to control bleeding such as ligation of the external carotid artery, pillar suturing, or oropharyngeal packing around the endotracheal tube.[23],[24]

Based on the data obtained by us along the course of the study, there is enough evidence to prove that H2O2 can be used instead of various combinations of adrenaline/lignocaine/bupivacaine to control a primary hemorrhage posttonsillectomy.


  Conclusion Top


3% H2O2 is a potent agent for antimicrobial activity and hemostasis when introduced in the tonsillar fossa posttonsillectomy. When used in moderation, it is very effective in preventing blood loss. Furthermore, there are no serious complications associated with the use of H2O2 as a hemostatic agent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Uppal K, Bais AS. Tonsillar microflora Superficial surface vs deep. J Laryngol Otol 1989;103:175-7.  Back to cited text no. 1
    
2.
Discolo CH, Darrow PJ, Koltai KH. Infectious Indications for tonsillectomy. Pediatr Clin North Am 2003;50:445-58.  Back to cited text no. 2
    
3.
Gul M, Okur E, Ciragil P, Yildirim I, Aral M, Akif Kilic M. The comparison of tonsillar surface and core cultures in recurrent tonsillitis. Am J Otolaryngol 2007;28:173-6.  Back to cited text no. 3
    
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Muthubabu K, Rekha A, Thejas SR, Vinayak R, Srinivasan MK, Alagammai S, et al. Tonsillectomy by cold dissection and coblation techniques: A prospective comparative study. Indian J Otolaryngol Head Neck Surg 2019;71:665-70.  Back to cited text no. 4
    
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Halliwell B, Clement MV, Long LH. Hydrogen peroxide in the human body. FEBS Lett 2000;486:10-3.  Back to cited text no. 5
    
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Faraci FM. Hydrogen peroxide: Watery fuel for change in vascular biology. Arterioscler Thromb Vasc Biol 2006;26:1931-3.  Back to cited text no. 6
    
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Branemark PI, Ekholm R. Tissue injury caused by wound disinfection. J Bone Joint Surg 1967;49:48-62.  Back to cited text no. 8
    
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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 Neurosci 2007;14:488-90.  Back to cited text no. 9
    
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Moreno JM, Rodriguez Gomez I, Wangensteen R, Perez-Abud R, Duarte J, Osuna A, et al. Mechanisms of hydrogen peroxide-induced vasoconstriction in the isolated perfused rat kidney. J Physiol Pharmacol 2010;61:325-32.  Back to cited text no. 10
    
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Al-Abbasi AM, Saeed ZK. Hydrogen peroxide 3%: Is it beneficial in tonsillectomy? Sultan Qaboos Univ Med J 2008;8:201-4.  Back to cited text no. 11
    
12.
Paradise JL, Bluestone CD, Colborn DK, Bernard BS, Rockette HE, Kurs-Lasky M. Tonsillectomy and adenotonsillectomy for recurrent throat infection in moderately affected children. Pediatrics 2002;110:7-15.  Back to cited text no. 12
    
13.
Agrawal SR, Jain AK, Marathe D, Agrawal R. The effect of bismuth subgallate as haemostatic agent in tonsillectomy. Indian J Otolaryngol Head Neck Surg 2005;57:287-9.  Back to cited text no. 13
    
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Ali Algadiem E, Aleisa AA, Alsubaie HI, Buhlaiqah NR, Algadeeb JB, Alsneini HA. Blood loss estimation using gauze visual analogue. Trauma Mon 2016;21:e34131.  Back to cited text no. 14
    
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Curtiss MC, Auliffe J. The history of tonsil and adenoid surgery. Laryngol Otol 1995;98:363-5.   Back to cited text no. 15
    
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Juul ML, Rasmussen ER, Howitz MF. Incidence of post-tonsillectomy haemorrhaging in Denmark. Dan Med J 2020;67:A11190640.  Back to cited text no. 16
    
17.
Mueller J, Boeger D, Buentzel J, Esser D, Hoffmann K, Jecker P, et al. Population-based analysis of tonsil surgery and postoperative haemorrhage. Eur Archi Otorhinolaryngol 2014;272:3769-77.  Back to cited text no. 17
    
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Collison PJ, Mettler B. Factors associated with post-tonsillectomy hemorrhage. Ear Nose Throat J 2000;79:640-2.  Back to cited text no. 18
    
19.
Francis DO, Fonnesbeck C, Sathe N, McPheeters M, Krishnaswami S, Chinnadurai S. Postoperative bleeding and associated utilization following tonsillectomy in children. Otolaryngol Head Neck Surg 2017;156:442-55.  Back to cited text no. 19
    
20.
Junaid M, Shah G. Comparison of peritonsillar injection of lignocaine-adrenaline and normal saline (placebo) before tonsillectomy in terms of mean per-operative blood loss. JIMDC 2018;7:29-35.  Back to cited text no. 20
    
21.
Callanan V, Currass AJ. The influence of BSG and adrenaline paste upon operating time and operative blood loss in tonsillectomy. J Laryngol Otol 1995;98:363-5.  Back to cited text no. 21
    
22.
Papangelou L. Hemostasis in tonsillectomy. A comparison of electrocoagulation and ligation. Arch Otolaryngol 1972;96:358-60.  Back to cited text no. 22
    
23.
Windfuhr JP. Excessive post-tonsillectomy haemorrhage requiring ligature of the external carotid artery. Auris Nasus Larynx 2002;29:159-64.  Back to cited text no. 23
    
24.
Goda M, Anwar MW, Elnashar I, Gumaa E, et al. Oropharyngeal packing for resistant post-tonsillectomy bleeding. Egypt J Otolaryngol 2014;30:347-50.  Back to cited text no. 24
  [Full text]  


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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