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Epithelial separation theory for post-tonsillectomy secondary hemorrhage: evidence in a mouse model and potential heparin-binding epidermal growth factor-like growth factor therapy

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Abstract

Objective

To provide histological evidence to investigate a theory for post-tonsillectomy secondary hemorrhage (PTH) in a mouse model and to evaluate the potential for heparin-binding epidermal growth factor-like growth factor (HB-EGF) treatment on wound healing in this model.

Methods

A prospective randomized single-blinded cohort study. A uniform tongue wound was created in 84 mice (day 0). Mice were randomized to HB-EGF (treatment, n = 42) or saline (control, n = 42). In treatment mice, HB-EGF 5 µg/ml was administered intramuscularly into the wound daily (days 0–14). In control mice, normal saline was administered daily. Three mice from each group were sacrificed daily through day 14 and the wounds evaluated histologically by blinded reviewers.

Results

Key stages of wound healing, including keratinocyte proliferation and migration, wound contraction, epithelial separation, and neoangiogenesis, are defined with implications for post-tonsillectomy wound healing. Epithelial separation (59 vs. 100%, p = 0.003) and wound reopening (8 vs. 48%, p < 0.001) were reduced with HB-EGF. Epithelial thickness (220 vs. 30 µm, p = 0.04) was greater with HB-EGF. Wound closure (days 4–5 vs. day 6, p = 0.01) occurred earlier with HB-EGF.

Conclusions

In healing of oral keratinocytes on muscle epithelial separation secondary to muscle, contraction occurs concurrently with neoangiogenesis in the base of the wound, increasing the risk of hemorrhage. This potentially explains why post-tonsillectomy secondary hemorrhage occurs and its timing. HB-EGF-treated wounds showed greater epithelial thickness, less frequent epithelial separation and wound reopening, and earlier wound closure prior to neovascularization, suggesting that HB-EGF may be a potential preventative therapy for PTH.

Level of evidence

NA—animal studies or basic research.

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Illustration © Chris Gralapp

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References

  1. Boss EF, Marsteller JA, Simon AE (2012) Outpatient tonsillectomy in children: demographic and geographic variation in the United States, 2006. J Pediatr 160:814–819

    Article  PubMed  Google Scholar 

  2. Cullen KA, Hall MJ, Golosinskiy A (2006) Ambulatory surgery in the United States. Natl Health Stat Rep 2009:1–25

    Google Scholar 

  3. Lafortune G, Balestat G, Durand A (2012) Comparing activities and performance of the hospital sector in Europe: how many surgical procedures performed as inpatient sand day cases? Directorate for Employment, Labour and Social Affairs, OECD, final report on work package II

  4. Bhattacharyya N, Kepnes LJ (2014) Revisits and postoperative hemorrhage after adult tonsillectomy. Laryngoscope 124:1554–1556

    Article  PubMed  Google Scholar 

  5. Seshamani M, Vogtmann E, Gatwood J, Gibson TB, Scanlon D (2014) Prevalence of complications from adult tonsillectomy and impact on health care expenditures. Otolaryngol Head Neck Surg 150:574–581

    Article  PubMed  Google Scholar 

  6. Johnson LB, Elluru RG, Myer CM 3rd (2002) Complications of adenotonsillectomy. Laryngoscope 112:35–36

    Article  PubMed  Google Scholar 

  7. Gysin C, Dulguerov P (2013) Hemorrhage after tonsillectomy: does the surgical technique really matter? ORL J Oto-rhino-laryngol Relat Spec 75:123–132

    Article  Google Scholar 

  8. Isaacson G (2012) Tonsillectomy healing. Ann Otol Rhinol Laryngol 121:645–649

    Article  PubMed  Google Scholar 

  9. Glim JE, van Egmond M, Niessen FB, Everts V, Beelen RH (2013) Detrimental dermal wound healing: what can we learn from the oral mucosa? Wound Repair Regen 21:648–660

    Article  PubMed  Google Scholar 

  10. Casteleyn C, Breugelmans S, Simoens P, Van den Broeck W (2011) The tonsils revisited: review of the anatomical localization and histological characteristics of the tonsils of domestic and laboratory animals. Clin Dev Immunol 2011:472460

    Article  PubMed  PubMed Central  Google Scholar 

  11. Garber JC, Barbee RW, Bielitzki JT et al (2016) The guide for the care and use of laboratory animals. ILAR J 57

  12. Santa Maria PL, Kim S, Varsak YK, Yang YP (2015) Heparin binding-epidermal growth factor-like growth factor for the regeneration of chronic tympanic membrane perforations in mice. Tissue Eng Part A 21:1483–1494

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  13. Santa Maria PL, Weierich K, Kim S, Yang YP (2015) Heparin binding epidermal growth factor-like growth factor heals chronic tympanic membrane perforations with advantage over fibroblast growth factor 2 and epidermal growth factor in an animal model. Otol Neurotol 36:1279–1283

    Article  PubMed  PubMed Central  Google Scholar 

  14. Gwet K (2016) Handbook of inter-rater reliability: the definitive guide to measuring the extent of agreement among multiple reviewers. Advanced Analytics, Gaithersburg

    Google Scholar 

  15. Collison PJ, Mettler B (2000) Factors associated with post-tonsillectomy hemorrhage. Ear Nose Throat J 79:640–642 (644, 646 passim)

    CAS  PubMed  Google Scholar 

  16. Krishna P, Lee D (2001) Post-tonsillectomy bleeding: a meta-analysis. Laryngoscope 111:1358–1361

    Article  CAS  PubMed  Google Scholar 

  17. Lowe D, van der Meulen J, National Prospective Tonsillectomy A (2004) Tonsillectomy technique as a risk factor for postoperative haemorrhage. Lancet 364:697–702

    Article  CAS  PubMed  Google Scholar 

  18. Watson MG, Dawes PJ, Samuel PR et al (1993) A study of haemostasis following tonsillectomy comparing ligatures with diathermy. J Laryngol Otol 107:711–715

    Article  CAS  PubMed  Google Scholar 

  19. Blakley BW (2009) Post-tonsillectomy bleeding: how much is too much? Otolaryngol Head Neck Surg 140:288–290

    Article  PubMed  Google Scholar 

  20. Heidemann CH, Wallen M, Aakesson M, Skov P, Kjeldsen AD, Godballe C (2009) Post-tonsillectomy hemorrhage: assessment of risk factors with special attention to introduction of coblation technique. Eur Arch Oto-rhino-laryngol 266:1011–1015

    Article  Google Scholar 

  21. Sarny S, Ossimitz G, Habermann W, Stammberger H (2011) Hemorrhage following tonsil surgery: a multicenter prospective study. Laryngoscope 121:2553–2560

    Article  PubMed  Google Scholar 

  22. Shires CB, Saputra JM, King L et al (2012) Histopathological and postoperative behavioral comparison of rodent oral tongue resection: fiber-enabled CO2 laser versus electrocautery. Otolaryngol Head Neck Surg 147:716–721 (Epub 2012 Apr 2024)

    Article  PubMed  PubMed Central  Google Scholar 

  23. Lee SK, Lee SS, Song IS et al (2004) Paradoxical effects of elastase inhibitor guamerin on the tissue repair of two different wound models: sealed cutaneous and exposed tongue wounds. Exp Mol Med 36:259–267

    Article  PubMed  Google Scholar 

  24. Dorr W, Spekl K, Farrell CL (2002) The effect of keratinocyte growth factor on healing of manifest radiation ulcers in mouse tongue epithelium. Cell Prolif 35:86–92

    Article  CAS  PubMed  Google Scholar 

  25. Usui ML, Underwood RA, Mansbridge JN, Muffley LA, Carter WG, Olerud JE (2005) Morphological evidence for the role of suprabasal keratinocytes in wound reepithelialization. Wound Repair Regen 13:468–479

    Article  PubMed  Google Scholar 

  26. Evrard L, Nammour S, Dourov N (1996) Scanning electron microscopic and immunocytochemical studies of contraction during secondary CO2 laser wound healing in rat tongue mucosa. J Oral Pathol Med 25:72–77

    Article  CAS  PubMed  Google Scholar 

  27. Marikovsky M, Vogt P, Eriksson (1996) Eet al. Wound fluid-derived heparin-binding EGF-like growth factor (HB-EGF) is synergistic with insulin-like growth factor-I for Balb/MK keratinocyte proliferation. J Investig Dermatol 106:616–621

    Article  CAS  PubMed  Google Scholar 

  28. Shirakata Y, Kimura R (2005) Nanba Det al. Heparin-binding EGF-like growth factor accelerates keratinocyte migration and skin wound healing. J Cell Sci 118:2363–2370

    Article  CAS  PubMed  Google Scholar 

  29. Johnson NR, Wang Y (2015) Coacervate delivery of HB-EGF accelerates healing of type 2 diabetic wounds. Wound Repair Regen 23:591–600

    Article  PubMed  Google Scholar 

  30. Besner G, Higashiyama S, Klagsbrun M (1990) Isolation and characterization of a macrophage-derived heparin-binding growth factor. Cell Regul 1:811–819

    CAS  PubMed  PubMed Central  Google Scholar 

  31. Davis-Fleischer KM, Besner GE (1998) Structure and function of heparin-binding EGF-like growth factor (HB-EGF). Front Biosci J Virtual Libr 3:d288–d299

    Article  CAS  Google Scholar 

  32. Murayama Y, Miyagawa J, Higashiyama S et al (1995) Localization of heparin-binding epidermal growth factor-like growth factor in human gastric mucosa. Gastroenterology 109:1051–1059

    Article  CAS  PubMed  Google Scholar 

  33. Nakagawa T, Hayase Y, Sasahara M (1997) Distribution of heparin-binding EGF-like growth factor protein and mRNA in the normal rat kidneys. Kidney Int 51:1774–1779

    Article  CAS  PubMed  Google Scholar 

  34. Santa Maria PL, Kim S, Yang YP (2016) No systemic exposure of transtympanic heparin-binding epidermal growth factor like growth factor. Drug Chem Toxicol 39:451–454

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  35. Solares CA, Koempel JA, Hirose K et al (2005) Safety and efficacy of powered intracapsular tonsillectomy in children: a multi-center retrospective case series. Int J Pediatr Otorhinolaryngol 69:21–26

    Article  PubMed  Google Scholar 

  36. Lowe D, van der Meulen J, Cromwell D et al (2007) Key messages from the national prospective tonsillectomy audit. Laryngoscope 117:717–724

    Article  PubMed  Google Scholar 

  37. Tomkinson A, Harrison W, Owens D, Harris S, McClure V, Temple M (2011) Risk factors for postoperative hemorrhage following tonsillectomy. Laryngoscope 121:279–288

    Article  PubMed  Google Scholar 

  38. Praveen CV, Parthiban S, Terry RM (2013) High incidence of post-tonsillectomy secondary haemorrhage following coblation tonsillectomy. Indian J Otolaryngol Head Neck Surg 65:24–28

    Article  CAS  PubMed  Google Scholar 

  39. Setabutr D, Adil EA, Adil TK, Carr MM (2011) Emerging trends in tonsillectomy. Otolaryngol Head Neck Surg 145:223–229

    Article  PubMed  Google Scholar 

  40. Koltai PJ, Solares CA, Mascha EJ, Xu M (2002) Intracapsular partial tonsillectomy for tonsillar hypertrophy in children. Laryngoscope 112:17–19

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Otolaryngology, Head and Neck Surgery, Stanford University, Palo Alto, CA, USA

    Daniel M. Beswick, Chloe Santa Maria, Noel F. Ayoub, Robson Capasso & Peter Luke Santa Maria

  2. Ear Sciences Centre, The University of Western Australia, Nedlands, Australia

    Peter Luke Santa Maria

  3. Ear Science Institute Australia, Subiaco, Australia

    Peter Luke Santa Maria

Authors
  1. Daniel M. Beswick
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  2. Chloe Santa Maria
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  3. Noel F. Ayoub
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  4. Robson Capasso
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  5. Peter Luke Santa Maria
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Corresponding author

Correspondence to Daniel M. Beswick.

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Funding

This project was funded by the Garnett Passe and Rodney Williams Memorial Foundation, Stanford’s SPARK, and the Stanford Child Health Research Institute.

Conflict of interest

Authors DMB, CSM, RC, and PSM are inventors on a patent, owned by Stanford University, which covers subject matter in this study. Author NFA has no conflict of interest.

Ethical standards

All applicable international, national, and/or institutional guidelines for the care and use of animals were followed. This article does not contain any studies with human participants performed by any of the authors.

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Beswick, D.M., Santa Maria, C., Ayoub, N.F. et al. Epithelial separation theory for post-tonsillectomy secondary hemorrhage: evidence in a mouse model and potential heparin-binding epidermal growth factor-like growth factor therapy. Eur Arch Otorhinolaryngol 275, 569–578 (2018). https://doi.org/10.1007/s00405-017-4810-6

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  • DOI: https://doi.org/10.1007/s00405-017-4810-6

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