Postoperative tonsillectomy pain in pediatric patients: electrocautery (hot) vs cold dissection and snare tonsillectomy--a randomized trial

Alternative surgical dissection techniques

The bipolar scissors, coblator, harmonic scalpel, and somnoplasty techniques are widely available and offer new choices for the operating arena. There are advantages and disadvantages to all four techniques. With time, these dissection methods will prove their lasting power. Otolaryngologists have already begun to expand their applications and will surely play a role in their use and development.

Postoperative bleeding after diathermy and dissection tonsillectomy

OBJECTIVE

To analyze the incidence and pattern of bleeding after tonsillectomy performed by either cold dissection or diathermy.

DESIGN

A prospective, nonrandomized cohort study of postoperative hemorrhage after tonsillectomy.

METHODS

Monthly reporting of the number of tonsillectomies and postoperative bleeds from otolaryngologists working in rural areas of Victoria, Australia over a 2.5 year period. Criteria for bleeding were either 1) repeat anesthesia and surgery because of hemorrhage (including return to theater from the recovery room), or 2) readmission to hospital because of bleeding, or 3) blood transfusion to replace blood loss. Main outcome measures were the incidence, volume, and time course of postoperative hemorrhage.

RESULTS

The number of bilateral tonsillectomies with removal by cold-blunt dissection was 3,087. In this group, there were 57 (1.85%) bleeds. The number of bilateral tonsillectomies with removal by diathermy dissection was 1,557. In this group, there were 37 (2.38%) bleeds. If cold dissection is taken as the "control" and diathermy tonsillectomy as the "treatment" group, the relative risk of bleeding after diathermy tonsillectomy is 1.30 (95% confidence interval 0.88-1.93). The pattern of bleeding after each technique differs significantly over time, with more reactionary bleeds in the dissection group and more bleeds between 4 to 7 postoperative days after diathermy. When bleeding occurred, it was in excess of 500 mL in 16% of dissection cases and 43% of diathermy tonsillectomies.

CONCLUSIONS

The difference in the risk of bleeding after each technique did not reach statistical significance, but the temporal pattern of hemorrhage differed, and more bleeds exceeding 500 mL were seen in the diathermy group.

Randomized controlled trial of Coblation versus electrocautery tonsillectomy

OBJECTIVE

To compare the postoperative recovery of patients receiving Coblation-assisted (Arthrocare, Sunnyvale, CA) intracapsular tonsillectomy with that of patients receiving traditional subcapsular electrocautery tonsillectomy.

STUDY DESIGN AND SETTING

This was a prospective, randomized, double-blinded, controlled study. One hundred one children, aged 2 to 16 years, were randomized to Coblation or to conventional electrocautery tonsillectomy. Only patients with the operative indication of obstructive sleep apnea were entered into the study. Intracapsular tonsillectomy was performed on the Coblation group, and traditional subcapsular dissection was performed on the electrocautery group. Adenoidectomy was performed with the curette in both groups. Outcome measures were assessed on days 1, 3, and 5 after surgery. These included child and parental rating of pain by using the Wong Faces pain scale, analgesic use, oral intake, and activity level. Patients, parents, and the nurse practitioner obtaining the outcome data were blinded to treatment arm.

RESULTS

Treatment groups were similar in age, gender, and weight. Surgical time and estimated blood loss were similar. There were no complications in either group. Coblation patients had less pain and greater oral intake at all 3 time points. Percentage of normal activity level returned to >70% earlier and more frequently in Coblation patients. There was slightly decreased analgesic use on postoperative day 5 in the Coblation group.

CONCLUSIONS AND SIGNIFICANCE

Children with obstructive sleep apnea undergoing tonsillectomy and adenoidectomy demonstrate significantly better postoperative recovery after Coblation-assisted intracapsular tonsillectomy.

Harmonic Scalpel versus Conventional Tonsillectomy: A Double-Blind Clinical Trial

We conducted a prospective, double-blind clinical trial to evaluate the differences in operating time, intraoperative blood loss, postoperative pain at 3 hours and 1 week, and delayed (> 24 hr) bleeding associated with ultrasonic harmonic scalpel tonsillectomy and conventional tonsillectomy. The study was carried out on 28 patients with recurrent tonsillitis and/or adenotonsillar hypertrophy who underwent harmonic scalpel tonsillectomy on one side and cold dissection tonsillectomy with suction electrocautery hemostasis on the other. The harmonic scalpel was associated with significantly less intraoperative blood loss (mean: 6.2 vs. 58.8 ml; p < 0.0001) and less early (3 hr) postoperative pain as determined by scores on a 10-point visual analog scale (mean: 3.5 vs. 4.4; p = 0.0042); although the difference in early pain scores is statistically significant, it is probably not clinically significant. Pain scores at 1 week were nearly identical (mean: 2.7 vs. 2.6; p = 0.9246). The length of operating time was similar (mean: 10.9 vs. 7.7 min; p = 0.0022). An unanticipated finding was the fact that delayed bleeding, which occurred in 3 patients (10.7%), occurred only on the harmonic scalpel side. We conclude that the only clearly demonstrable advantage that the harmonic scalpel had over cold dissection was that it caused less intraoperative blood loss.

Pediatric total tonsillectomy using coblation compared to conventional electrosurgery: a prospective, controlled single-blind study

OBJECTIVE

Postoperative recovery after tonsillectomy using Coblation excision (CES) was compared with conventional electrosurgery (ES).

STUDY DESIGN AND SETTING

Patients aged 3 to 12 years from 3 clinical sites were randomly assigned and blinded to receive tonsillectomy using CES (n = 44) or ES (n = 45).

RESULTS

Operative parameters did not differ between groups. Return to normal diet, activity, and pain-free status were similar, although fewer CES patients contacted the physician regarding postoperative complications (33% vs 54%; p = 0.081), experienced nausea (35% vs 62%, p = 0.013), or had localized site-specific swelling (p < 0.05) during the 2 weeks after surgery. In addition, CES children tended to discontinue prescription narcotics 1 day earlier than ES patients (7 vs 8 days, p = 0.071) and took one half as many daily doses. More CES than ES parents rated the postoperative experience as 'better than expected' (79% vs 60%, p = 0.055).

CONCLUSION AND SIGNIFICANCE

Children who received CES tonsillectomy appeared to experience a better quality postoperative course, with no detriment to operative benefits of conventional electrosurgery.

Current practice patterns in tonsillectomy and perioperative care

OBJECTIVES

Tonsillectomy is one of the most commonly performed otolaryngologic procedures in the United States. Many options and controversies exist regarding techniques and peri-operative management. The purpose of the study was to examine current practice patterns among otolaryngologists regarding tonsillectomy.

METHODS

A 13 question survey regarding tonsillectomy techniques and peri-operative management was mailed to 10% of randomly selected board certified otolaryngologists of the AAO-HNS in the spring of 2002. Four hundred and eighteen anonymously completed questionnaires were returned, for a response rate of 58.5%. Statistical analysis of survey data was performed by means of cross tabulation and Pearson Chi-Square Calculation.

RESULTS

Monopolar electrocautery was the most common technique used among those surveyed (53.5%). There was a significant correlation between choice of monopolar electrocautery and the cited reason for choice of technique being decreased blood loss (P < 0.001). There was no relationship between pediatric fellowship training and choice of technique. 97.7% routinely admitted sleep apnea patients for post-operative observation. There was no significant correlation between practice setting (tertiary versus community) and type of post-operative monitoring for sleep apnea patients, with patients most commonly admitted to an intermediate care setting.

CONCLUSION

In our survey, the most common surgical technique for tonsillectomy was monopolar electrocautery, chosen for the reason of decreased blood loss.

Treating pediatric patients with obstructive sleep disorders: an update

Obstructive sleep apnea syndrome in children continues to be an important subject for otolaryngologists because of the high prevalence of the disease. The evaluation of a child with OSAS remains controversial, although there is little controversy that T&A is the optimal treatment for these children. The search for the optimal T&A technique is ongoing, although now either "cold" tonsillectomy or "hot" tonsillectomy is standard. Quality-of-life studies confirm the significant benefit gained after a child undergoes a T&A.

Radiofrequency tonsil reduction: safety, morbidity, and efficacy

OBJECTIVES

To evaluate the safety, morbidity, and efficacy of radiofrequency tissue volume reduction of tonsils using two different surgical techniques and to compare these two techniques with each other and with classic tonsillectomy.

STUDY DESIGN

A nonrandomized retrospective review of tonsil reductions was made between 2000 and 2002 using in vivo studies associated with tonsil reduction and tonsillectomy performed either in the hospital operating room or in the outpatient treatment area.

METHODS

We studied 150 patients and divided them into three main groups based on surgical technique. Group A consisted of 50 consecutive patients who underwent tonsil "ablation," Group B contained another 50 consecutive individuals who received tonsil "coblation," and Group C consisted of 50 patients who underwent classic tonsillectomy (cold dissection). Each group consisted of two subcategories of children (age range, 1-12 y) and adults (age range, 12-60 y) with chronic tonsillar hypertrophy. Most of the pediatric patients underwent adenoidectomy during the same surgical procedure. Indications for tonsillectomy were those listed by the American Academy of Otolaryngology-Head and Neck Surgery. A retrospective chart review was used to assess procedures, safety, morbidity, and efficacy of tonsil reduction and tonsillectomy. Four specific end points of morbidity were investigated: pain, return to normal diet, return to normal activity, and use of pain medication. Efficacy of tonsillectomy was determined by the clinical observation of the remaining tonsillar tissue and compared with pretreatment photographs of the tonsils.

RESULTS

There were no complications in any of the groups. Efficacy was assessed based on the mean tonsil reduction and was found to be 100% for tonsillectomy, 86% for the tonsil coblation technique, but only 53.6% for the ablation technique. Morbidity was minimal in groups A and B and significantly greater in Group C. The number of pain days, narcotic-use days, and days before return to normal diet and activity were greatly reduced in groups A and B when compared with classic tonsillectomy (group C). Pain levels on day 1 were less than 3 (on a scale of 1-10) in groups A and B. The number of pain days and narcotic-use days was less than 4 days in groups A and B. Similarly, most patients returned to solid diet and normal activity by day 4. Pain levels, number of narcotic-use days, and number of days to return to normal diet and activity were significantly higher for classic tonsillectomy.

CONCLUSIONS

Tonsil coblation has distinct advantages when compared with tonsil ablation and standard tonsillectomy. Tonsil coblation resulted in greater than 86% elimination of tonsillar tissue in both children and adults. In most patients, pain levels were minimal and limited to the first 48 hours after surgery. Return to normal diet and activity was much earlier in the coblation group versus classic tonsillectomy.

Tonsillectomy: cold dissection versus bipolar electrodissection

OBJECTIVES

to compare the technique and post-operative morbidity of two different tonsillectomy methods: cold dissection and bipolar electrodissection.

MATERIAL AND METHODS

prospective study including children (3> age <14) undergoing tonsillectomy in ORL Department of the main hospital in Azores, Portugal, from September 2000 to March 2001. Patients alternately selected to cold dissection tonsillectomy group (CDT) or bipolar electrodissection tonsillectomy group (BET). Duration of surgery; amount of blood loss; duration of hospitalization; aspect of tonsillar fossa on 10th post-operative day and intensity of pain after surgery were recorded and compared.

RESULTS

Sixty tonsillectomies were performed. Blood loss and duration of surgery were significantly decreased in BET group (P<0.001), but the healing process, directly assessed by the aspect of tonsillar fossa on the 10th day was markedly delayed. The intensity of pain was slightly higher in the BET group compared with the CDT group, and no difference on duration of hospitalization was found between the two groups. Two post-operative hemorrhages occurred (one in each group), and no major complications were registered.

CONCLUSIONS

BET reduces the duration of surgery and amount of blood loss when compared with cold dissection, but post-operative morbidity is increased. We believe the best patient indication for this method are small children where total circulating blood volume is reduced and patients with bleeding disorders.

Post tonsillectomy morbidity: following the introduction of single-use-instruments

OBJECTIVE

Following the introduction of single-use-instruments (SUI) for tonsillectomy in January 2001 in UK, the Medical Devices Agency (MDA) received reports of significant increase in secondary haemorrhage in some centres. This was believed to be related to electrosurgical (diathermy) forceps. The aim of this study is to compare post tonsillectomy morbidity before (year 2000) and after (year 2001) the introduction of SUI in a unit where bipolar dissection is the most popular method of dissection.

METHOD

The case notes of all tonsillectomy patients between 20 April and 31 October for the years 2000 (145 patients) and 2001 (166 patients) were reviewed. The patients' age and sex, other concurrent operations, grade of surgeon, dissection and haemostasis methods, length of post operative hospital stay and the reason for prolonged stay (if more than one night) were noted. Readmitted cases were analysed to identify the cause and the management.

RESULTS

There was no case of reactionary haemorrhage in both the non SUI (year 2000) and the SUI (year 2001) groups. For the non SUI versus SUI group, 6.2 versus 4.8% stayed more than one night post operatively; 4.8 versus 5.4% were readmitted for secondary haemorrhage with 1.4 versus 2.4% return to theatre to control bleeding, respectively. The average hospital stay for the readmitted cases were 2.1 versus 1.6 days and the average time lapse between tonsillectomy and secondary haemorrhage were 6.7 versus 6 days respectively.

CONCLUSION

There was no significant difference in post tonsillectomy morbidity following the introduction of SUI.

A comparison of tonsillectomy with the harmonic scalpel versus electrocautery

OBJECTIVE

We sought to test whether the use of the harmonic scalpel would cause less pain and more rapid recovery in tonsillectomy patients versus the use of electrocautery.

DESIGN AND SETTING

In a private practice community hospital, we conducted a prospective nonrandomized comparison of 156 pediatric tonsillectomy cases. Local anesthetic infiltrations and steroids were used at the discretion of the surgeon. Outcome variables consisted primarily of immediate- and mid-term pain, pain medications required, time to eating, morbidities and charges.

RESULTS

There were no differences between the groups on an intention-to-treat basis except for costs, which were higher in the harmonic scalpel group. When rescue use of electrocautery was required to control bleeding in the in the harmonic scalpel patients, more pain and longer times to taking food were noted.

CONCLUSIONS

Used with discretion the harmonic scalpel is equivalent to electrocautery for tonsillectomy.

SIGNIFICANCE

The harmonic scalpel does not provide a major benefit over more conventional methods of tonsillectomy.

Monopolar electrocautery in adenoidectomy as a possible risk factor for Grisel's syndrome

OBJECTIVES/HYPOTHESIS

Grisel syndrome is a nontraumatic atlantoaxial subluxation after an inflammatory process in the upper cervical region. It results from a peripharyngeal infection as well as a rare complication following adenotonsillectomy. After the introduction of monopolar suction electrocautery in adenoidectomy, an increased incidence of Grisel's syndrome has been observed. The purpose of the study was to evaluate monopolar suction electrocautery as a possible risk factor.

STUDY DESIGN

Retrospective chart review along with current measurements of monopolar and bipolar electrocautery during adenoidectomy.

METHODS

The charts of 1431 consecutive cases of adenoidectomy were reviewed before (n = 710) and after (n = 721) the introduction of monopolar suction electrocautery for intraoperative hemostasis. Moreover, energy of delivered current of electrocautery was measured in 30 pediatric patients during adenoidectomy.

RESULTS

Three cases of Grisel's syndrome occurred as a postoperative complication in 721 adenoidectomies (0.4%) after the introduction of monopolar suction electrocautery. In contrast, no Grisel's syndrome was observed in 710 procedures before the use of monopolar electrocautery. Current measurements demonstrate an almost fourfold higher level of electrical energy using monopolar electrocautery compared with bipolar coagulation for bleeding control in adenoidectomy.

CONCLUSION

Monopolar suction cautery in adenoidectomy may be considered as a risk factor for Grisel's syndrome.

Electrosurgery for tonsillectomy

OBJECTIVE

To describe the electrophysical principles, techniques, and morbidity associated with electrosurgical tonsillectomy.

STUDY DESIGN

Review.

METHODS

In electrosurgery, radiofrequency energy is applied directly to tissues to generate heat. Electrosurgery devices are radiofrequency generators coupled with application handpieces. The most common electrosurgery techniques are the monopolar blade, monopolar suction, bipolar, and microscopy-assisted procedures. Several studies have compared electrosurgery with other methods for performing tonsillectomy.

RESULTS

Electrosurgery has been found to be equivalent to or better than other methods used for tonsillectomy with respect to perioperative and delayed bleeding, postoperative pain, operating time, and time to return to normal activity.

CONCLUSION

Several safe and effective techniques are available for tonsillectomy, including electrosurgery. The choice of method depends on the surgeon's training, comfort with the technology, experience, and impressions concerning morbidity.

The effect of ketoprofen on recovery after tonsillectomy in children: a 3-week follow-up study

OBJECTIVE

To evaluate recovery after tonsillectomy in children, and to determine the safety and efficacy of ketoprofen in pain treatment after discharge.

STUDY DESIGN

A prospective, longitudinal study in 102 children undergoing tonsillectomy.

METHODS

All children underwent tonsillectomy under a same general anesthesia. At discharge, all patients were prescribed ketoprofen capsules at a dose of 3-5 mg(-1) kg(-1) per 24 h for postoperative pain control at home, with paracetamol or paracetamol-codeine tablets for rescue analgesia. At home, the patients recorded pain and analgesic consumption each day for the first week after surgery. At 3 weeks, patients recorded the total analgesic requirement, duration of pain, and all adverse events during recovery and return to normal daily activities.

RESULTS

The median of pain cessation was 9 days (range 1-20 days) and the median duration of analgesic treatment was 10 days (4-19 days). More than 50% of the patients needed rescue analgesic daily during the first week after tonsillectomy. Ketoprofen combined with paracetamol or paracetamol-codeine provided sufficient analgesia for most children. However, the analgesic action of drugs was too short to achieve pain relief, which allow undisturbed sleep during the first postoperative nights. A return back to normal daily activities took place after 9 days (2-26 days). The influence of age for pain pattern was negligible. Five patients needed electrocautery to stop postoperative bleeding. No other serious adverse-events occurred.

CONCLUSIONS

The main problem after tonsillectomy is significant pain that may last 9 days or longer after surgery. Ketoprofen combined with paracetamol-codeine seems to provide a sufficient analgesia, but before ketoprofen may be recommended for children during tonsillectomy a larger study is needed to show whether or not ketoprofen increases the hemorrhage rate.

Evaluation of Post-tonsillectomy Bleeding in the Adult Population

A retrospective review of a consecutive series of 685 adult patients undergoing tonsillectomy was conducted. Determinations were made of the post-tonsillectomy bleeding rate, the need for intervention to control bleeding, and the blood transfusion rate. Statistical analysis was used to determine whether bleeding rates differed according to three criteria: gender, indication for tonsillectomy, and age. Post-tonsillectomy bleeding occurred in 35 patients (5.1%); five of these patients experienced bleeding during the first 24 hours postoperatively, and the remaining 30 experienced delayed bleeding. When it occurred, the mean time lapse between tonsillectomy and bleeding was 6.9 days (±4.1). Twenty of the 35 patients (57.1%) required a procedure to control their bleeding, but no patient required a transfusion. There was no statistically significant difference in bleeding rates based on gender, the indication for surgery (chronic tonsillitis, obstructive sleep apnea syndrome, or to rule out neoplasia), and age. These results indicate that (1) post-tonsillectomy bleeding occurs in approximately 1 of 20 adults independent of individual patient characteristics, (2) more than half of patients who bleed are likely to require a procedure to control their hemorrhage, and (3) the need for transfusion is distinctly unlikely.

Dissection versus diathermy for tonsillectomy

BACKGROUND

Tonsillectomy is a commonly performed surgical procedure. There are several operative methods currently in use, but the superiority of one over another has not been clearly demonstrated.

OBJECTIVES

To compare the morbidity associated with tonsillectomy by two different techniques - dissection and diathermy.

SEARCH STRATEGY

Cochrane Controlled Trials Register, Medline (1966-2000), Embase (1974-2000). Reference lists were scanned for additional material.

SELECTION CRITERIA

Randomised controlled trials of children and adults undergoing tonsillectomy or adenotonsillectomy by dissection or diathermy techniques. Trials were assessed for methodological quality according to the method outlined in the Cochrane Reviewers Handbook.

DATA COLLECTION AND ANALYSIS

The reviewers assessed each trial and extracted data independently.

MAIN RESULTS

Twenty-two potential studies were identified for further assessment. Twenty trials were not included because they did not meet the inclusion criteria for randomisation methods, controls or outcome criteria. Two trials met the inclusion criteria, one comparing monopolar dissection diathermy with conventional cold dissection in children, and the other comparing microscopic bipolar dissection with cold dissection in children and adults. These studies demonstrate reduced intraoperative bleeding, but increased pain in the diathermy group. There was no difference in the rate of secondary bleeding overall, although the power of both studies to detect a small difference was insufficient.

REVIEWER'S CONCLUSIONS

There are insufficient data to show that one method of tonsillectomy is superior. There is evidence that pain may be greater after monopolar dissection. Large, well designed randomised controlled trials are necessary to determine the optimum method for tonsillectomy.

A randomised controlled trial of the effect of regional nerve blocks on immediate post-tonsillectomy pain in adult patients

Post-operative pain is the main cause of morbidity following tonsillectomy. The efficacy of glossopharyngeal and lesser palatine nerve blocks in controlling postoperative pain in adult patients was investigated prospectively. Patients 16 years and older admitted for elective tonsillectomy were randomised to one of three groups to receive a pre-incisional oropharyngeal injection of 0.5% bupivicaine, a 'dummy' injection of saline or no injection. Dissection tonsillectomy and general anaesthetic techniques were standardized. Postoperative pain was monitored for 24 h. ANOVA, chi2 and Fisher's exact test were used for intergroup comparisons. Ninety-two patients (72 women and 20 men), mean age 22 years were studied. Twenty-nine patients received 0.5% bupivicaine, 30 saline and 33 no pre-incisional injection. The overall mean pain scores of 2.1, 1.9 and 1.9 in the bupivicaine, saline and no injection groups were similar. Glossopharyngeal and lesser palatine 0.5% bupivicaine nerve blocks are not effective in reducing early post-tonsillectomy pain.