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TACOMA, Wash., Aug. 19 -- Posttonsillectomy smoking nearly doubles the risk of hemorrhage, but it appears limited to patients who have uvulopalatopharyngoplasty, investigators here reported.

Smokers had a bleeding rate of 10.2% compared with 6.7% overall in a study of 1,010 patients, Sean M. Demars, M.D., of Madigan Army Medical Center, and colleagues, reported in the August issue of Archives of Otolaryngology Head and Neck Surgery.

Subset analysis showed that patients who smoked after combined tonsillectomy and uvulopalatopharyngoplasty accounted for the significantly increased risk of bleeding. The association held up in men (P=0.05) and women (P=0.03).

"Smoking does appear to increase the risk of posttonsillectomy hemorrhage in patients who undergo uvulopalatopharyngoplasty with tonsillectomy, but not in those who undergo tonsillectomy alone," the authors concluded. "This modifiable risk factor may help clinicians further counsel their patients before surgery, but further study is needed to ascertain that these findings apply to a broader patient base."

Despite technical improvements that have reduced perioperative morbidity, tonsillectomy and uvulopalatopharyngoplasty still involve an appreciable risk of complications, the most common of which is perioperative bleeding.

Although smoking has a well-recognized detrimental effect on wound healing, the effects of smoking on posttonsillectomy and postuvulopalatopharyngoplasthy bleeding had not been studied, the authors said.

"It has been our anecdotal experience that smokers have a higher rate of postoperative hemorrhage than do nonsmokers," the authors continued. "To evaluate whether smoking is truly a modifiable risk factor, we undertook a retrospective review of all patients who underwent tonsillectomy or [uvulopalatopharyngoplasty] at our center in the past five years."

The chart review identified 1,010 patients who underwent either procedure during the five year period and had complete information. The study population comprised 274 (27.1%) smokers and 736 (72.9%) nonsmokers. The patients' mean age was 29.4, and men accounted for 62% of the patients, including 70% of the smokers.

Tonsillectomy was performed alone in 569 cases and combined tonsillectomy-uvulopalatopharyngoplasty in 441.

Initial examination of the data showed that smokers' risk of postoperative bleeding was double that of nonsmokers (10.2% versus 5.4%, P=0.01). The risk of postoperative bleeding tripled in smokers who had the combined surgical procedure (10.9% versus 3.3%, P=0.006). After exclusion of patients who underwent uvulopalatopharyngoplasty, smoking after tonsillectomy alone was not associated with an increased risk of bleeding.

Noting the limitations of a retrospective, nonrandomized study, the authors said "the reasons for the variation between the tonsillectomy and [uvulopalatopharyngoplasty] subsets are not known."

Men who underwent tonsillectomy alone had a significantly greater risk of postoperative bleeding compared with women (11.2% versus 5.4%, P=0.02). The rate of bleeding among patients who underwent uvulopalatopharyngoplasty, however, was similar among men and women (P=0.51).

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