This is a retrospective study of 1369 patients who underwent tonsillectomy at “Mother Teresa” Hospital from January 2016 to March 2022. All surgeries were performed by physicians in the ENT department or by residents under the supervision of senior physicians. To minimize variability, all surgeries were performed using cold steel dissection, with electrocautery for hemostasis (monopolar or bipolar). Surgeon experience (resident vs attending) was not considered. The interventions were performed under general anesthesia, with the Crowe-Davis mouth gag for better visualization of the tonsils. All patients were discharged without hemorrhage.

The study data was obtained from the archives of the Statistics Service for the ENT department. All patient records with a diagnosis of “post-tonsillectomy hemorrhage” were reviewed, resulting in 104 patients with this complication. Their characteristics (age, gender), risk factors for hemorrhage, the grade and frequency of hemorrhage, the day the complication occurred, average hospital stay, readmission to the operating room, and need for transfusion were analyzed.

Inclusion Criteria:

Exclusion Criteria:

After creating the base dataset with data extracted from the University Hospital Center’s Statistics, the data was transferred to the SPSS 26 statistical software. SPSS 26 software was used for all statistical analyses. Figures and graphs were created in Microsoft Excel. A base table with descriptive data was constructed to show patient characteristics. Results were presented in numbers and percentages, and for continuous parameters, the mean and standard deviation were calculated.

Most parameters in the dataset were categorical, and to test the relationship/association between them, the Chi-square test and cross-tabulations were used. A logistic regression model, T-test and Fisher’s Exact Test were also performed.

In our study, the trend of tonsillectomies gradually decreased from 2016 to 2019, with a significant reduction—nearly sixfold—in 2020. This decline was primarily due to the COVID-19 pandemic and secondarily, due to a shift toward patients choosing surgical treatment in private clinics.

Although many studies have evaluated post-tonsillectomy hemorrhage, reported rates vary widely. Reference [2] conducted a review of 63 studies and concluded that the incidence of secondary hemorrhage should be on average 4.5% and not more than 13.9%. In the UK, a study involving 34,000 patients showed a hemorrhage rate of 3.5%, with only 0.9% requiring reoperation [3] . By comparison, our study found a 7.6% hemorrhage rate and a 1.53% reoperation rate. This discrepancy may reflect broader inclusion criteria in our study, which also captured patients with documented bleeding that did not necessarily require surgical intervention. Additionally, limited patient education may have led some to interpret normal post-operative membrane sloughing as hemorrhage, prompting unnecessary visits to the emergency department.

Secondary hemorrhage in our cohort occurred between post-operative days 2 and 23, with a peak incidence on day 6, followed by days 5 and 10. This trend is consistent with prior findings as in [4] , who attributed the peak incidence to the sloughing of fibrin from the tonsillar fossa.

Age emerged as a statistically significant risk factor, with the majority of cases corresponding to patients over 15 years, although the ages ranged from 3 to 66 years old. These conclusions align with prior international studies [5] - [8] . Adults tend to have a longer history of chronic tonsillitis, resulting in increased fibrosis and adhesions that complicate dissection and may increase the risk of intraoperative and delayed bleeding.

References [8] [9] both emphasize that increased fibrosis and adhesions in adult patients may contribute to a more challenging dissection and greater bleeding risk. While our overall hemorrhage rate (7.6%) is slightly above the average reported in literature (4.5% to 6.4%) [3] [4] . This discrepancy may reflect broader criteria for identifying hemorrhage in our study, including cases not requiring surgical intervention.

Clinically, the findings suggest that age is a significant independent risk factor and should guide both perioperative counseling and post-operative care. In particular, adults undergoing tonsillectomy for chronic tonsillitis or peritonsillar abscess may benefit from enhanced monitoring and early follow-up. Most hemorrhages occurred around post-operative day 6, supporting previous research linking bleeding to the sloughing of fibrin from the tonsillar fossa.

To reduce the incidence and severity of hemorrhage, we recommend the following: clear patient instructions on diet and physical activity during the first 10 post-operative days, early identification of at-risk individuals (e.g., adults, those with chronic tonsillitis), and consideration of meticulous intraoperative hemostasis techniques. Where possible, the use of standardized surgical methods and improved patient education could play a key role in reducing late post-operative complications. Additionally, creating structured follow-up protocols, particularly between days 5 and 10, may help in the early detection and management of bleeding episodes.

A significant association was also found between age and the indication for surgery. Children under 15 were more commonly operated on for hypertrophic tonsils, while patients over 15 were typically treated for chronic tonsillitis or peritonsillar abscess—again consistent with findings in [9] [10] .

There was no significant gender difference in hemorrhage rates, although other studies as in [11] and [8] , have suggested that male patients may be more prone to post-operative bleeding due to hormonal factors and behavioral tendencies such as less cautious eating during recovery.

Chronic tonsillitis was the most frequent indication for surgery in hemorrhage cases (61.5%), followed by peritonsillar abscess (19.2%) and tonsillar hypertrophy (18.3%). Our results differ slightly from [9] , which reported a lower rate of hemorrhage associated with peritonsillar abscess. This may be due to our older patient population. Notably, our analysis found no relationship between surgical indication and the grade of hemorrhage.

Importantly, no deaths occurred in our cohort. This is consistent with data from the USA and Europe, where mortality rates following tonsillectomy are extremely low ranging from 0.01% to 0.03% as in [12] . Further supporting the conclusion that tonsillectomy remains a safe procedure.

Hospital stays ranged from a few hours to seven days, with an average of 2.08 days. Most patients (46.2%) were hospitalized for one day. A statistically significant association was observed between age and hospital stay length, with older patients tending to require longer admission. This likely reflects their increased risk of bleeding and slower recovery. Reference [13] reported similar trends in Austria, with an average hospital stay of 2.9 days.

This study has several limitations inherent to its retrospective design.

In summary our findings show that the incidence of secondary hemorrhage increases with age, but there was no significant difference between genders. No hemorrhage in our study resulted in death. In most cases, it occurred on the 6th post-operative day. The most common indication for tonsillectomy is chronic tonsillitis. The grade of hemorrhage is not affected by the surgical indication. It is important to highlight these risk factors so that the mortality and morbidity of hemorrhages will be reduced.

We would like to extend our gratitude to all our patients who participated in this study and to the staff of Otorhinolaryngology Department in “Mother Teresa” University Hospital.