الفهرس 
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Abstract
Tonsillectomy with or without adenoidectomy is considered one of the most commonly performed surgeries in pediatrics, with many indications including recurrent attacks of adenotonsillitis, obstructive sleep apnea, and peritonsillar abscesses. Yet despite its commonality, adenotonsillectomy is often associated with many serious complications, including post tonsillectomy hemorrhage (PTH), pain, nausea, vomiting and dehydration. Post tonsillectomy hemorrhage (PTH) is considered a surgical emergency and can be classified into two major classes; immediate (primary) post tonsillectomy hemorrhage which occurs within the first 24 hours after operation and delayed (secondary) post tonsillectomy hemorrhage which occurs after 24 hours. In published reports, the rate of primary hemorrhage (within 24 hours of surgery) has ranged from 0.2 to2.2 and is generally known to be related to surgical technique, the rate of secondary hemorrhage (further than 24 hours after surgery) from 0.1 to3.35. Secondary hemorrhage is associated with detachment of the crust from the point of the removed tonsils. The preliminarily reported risk factors for post tonsillectomy hemorrhage include gender, age, indication of tonsillectomy, procedure technique and device, and the surgeon experience level, this bleeding complication constantly requires a re-admission for medical observation or surgery to control the bleeding. Despite the significant morbidity and potential mortality associated with hemorrhage, continued trials to reduce this complication rate, with changes in surgical procedure technique and advanced means and materials for perfect hemostasis, post-tonsillectomy hemorrhage remains a persistent threat and no management practice guidelines persists. The aim of this study is to evaluate and identify the possible risk factors for secondary post tonsillectomy hemorrhage in children. The summary of our results According to patient related risk factors for secondary post tonsillectomy hemorrhage in children, the summary of our results are:- • Regarding demographic data of the studied patients, age ranged from 3 – 18 years with a mean of 8.5 ± 4.45 years. There were 45 (64.29%) patients with a range of age of 3-5 years and 25 (35.71%) patients with a range of age of 6-18 years. There were 26 (37.14%) males and 44 (62.86%) females. • Regarding ABO grouping of the studied patients, 32 (45.71%) patients were O+, 21 (30%) patients were A+, 9 (12.86%) patients were B+, 4 (5.71%) patients were AB+, 2 (2.86%) patients were O-, 1 (1.43%) patients were A-, 1 (1.43%) patients were B- and none of the studied patients were AB-. • Per year 3 (4.29%) patients had 1-4 tonsillitis attacks and 67 (95.71%) patients had 5-8 tonsillitis attacks. The indication for the operation was chronic tonsillitis in 68 (97.14%) patients and was other indications in 2 (2.86%) patients. Recurrent attacks were significant predictors for bleeding . • History of gastroesophageal reflux was a risk factor in 48 (68.57%) patients and history of any other comorbidities was a risk factor in 45 (64.29%) patients. Regarding the preoperative laboratory investigations, the Hb level ranged from 10 - 12.4 g/dL with a mean of 11.3 ± 0.76 g/dL. The PLT count ranged from 290 – 400 *109 cell/L with a mean of 337.4 ± 31.77 *109 cell/L. INR ranged from 1 - 1.2 with a mean of 1.1 ± 0.09. • Regarding the postoperative complications, fever occurred in 42 (60%) patients and infection occurred in 35 (50%) patients. According to procedure related risk factors for secondary post tonsillectomy hemorrhage in children, the summary of our results are:- • Warm season was a risk factor of bleeding in 31 (44.29%) whereas cold season was a risk factor in 39 (55.71%) patients. History of OSA was a risk factor in 46 (65.71%) patients • Regarding the operative technique, 33 (47.14%) patients underwent monopolar surgery which is a risk factor, 25 (35.71%) patients underwent bipolar surgery, and 12 (17.14%) patients underwent cold dissection. • Regarding the surgeon experience level, the operation was done by a senior in 38 (54.29%) patients and was done by a junior in 32 (45.71%) patients. According to secondary post tonsillectomy hemorrhage in children and its management, the summary of our results are:- • After operation, the 1st attack of bleeding occurred on the 5th day in 2 (2.9%) patients, on the 6th day in 3 (4.3%) patients, on the 7th day in 15 (21.4%) patients, on the 8th day in 9 (12.9%) patients, on the 9th day in 5 (7.1%) patients, on the 10th day in 10 (14.3%) patients, on the 11th day in 6 (8.6%) patients, on the 12th day in 3 (4.3%) patients, on the 13th day in 5 (7.1%) patients, on the 14th day in 7 (10.0%) patients, and ≥ 14th up to 21 days in 5 (7.1%) patients. • Postoperative Hb level ranged from 4 - 10.5 g/dL with a mean of 8.01 ± 1.58 g/dL. Among the studied patients, 49 (70%) patients required blood transfusion. • Postoperatively, among the studied patients, 33 (47.14%) patients received combination of Penicillins and 37 (52.86%) patients received cephalosporins. 48 (68.57%) patients received Ibuprofen and 22 (31.43%) patients received Paracetamol. • Postoperative admission ranged from 5 – 7 days with a mean of 5.96 ± 0.82 days. Postoperative management of bleeding was performed through conservation in 43 (61.43%) patients and surgical intervention in 27 (38.57%) patients. • On univariate logistic analysis, Regarding patient related risk factors, young age (3-5 years), female gender, number of attacks/ year and postoperative Hb level, regarding procedure related risk factors, cold season, Hot techniques of tonsillectomy (unipolar tonsillectomy) and regarding medications related risk factors, analgesic (ibuprofen) were significant predictors of secondary post tonsillectomy hemorrhage requiring management either conservative or second surgical intervention whereas other parameters were insignificant predictors.