Adolescents and Adults Undergoing Temperature-Controlled Surgical Instruments vs Electrocautery in Tonsillectomy: A Systematic Review and Meta-analysis of Randomized Clinical Trials

Post-Tonsillectomy Bleeding and Analgesic Use Before and After the FDA Boxed Warning Against Codeine

OBJECTIVE

The aim of this study was to investigate the trends in post-tonsillectomy analgesic utility and incidence of post-tonsillectomy hemorrhage before and after the 2013 FDA Boxed Warning against codeine use after pediatric tonsillectomy.

METHODS

A retrospective study was conducted using TriNetX. A search for patients up to 18 years from 2008 to 2022 within the US Collaborative Network identified 15,648,542 subjects. CPT and ICD-10 codes were used to identify children who experienced post-tonsillectomy hemorrhage within 14 days of a tonsillectomy. Analgesics given within 14 days of tonsillectomy were tabulated annually from 2008 to 2022, including codeine, ibuprofen, acetaminophen, oxycodone, ketorolac, and hydrocodone. Bleeding percentage and analgesic utility were grouped into events before and after 2013.

RESULTS

Mean age at tonsillectomy was 5.6 years (SD = 3.0). Before 2013, the median percentage of children who experienced postoperative bleeding was 1.8% with 0.73% returning to the OR for bleeding control. After 2013, the median percentage of children who experienced postoperative bleeding was 2.4% (p = 0.029), and 0.99% returned to the OR (p = 0.008). Use of post-tonsillectomy codeine fell from 10.4% to 0.5% (p = 0.003) whereas ibuprofen rose from 2.0% to 63.9% (p = <0.001), acetaminophen from 42.8% to 77.2% (p = <0.001), ketorolac from 1.2% to 9.2% (p = <0.001), and oxycodone from 2.0% to 30.9% (p = <0.001). No change was detected in use of hydrocodone.

CONCLUSION

Analgesics used post-tonsillectomy in children have changed since the FDA Boxed Warning against codeine. There has been a small but statistically significant increase in post-tonsillectomy bleeding.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:4783-4788, 2024.

Postoperative Complications in Lingual Versus Palatine Tonsillectomies

OBJECTIVE

The aim of this study was to investigate the risks of lingual tonsillectomy (LT) in a large cohort and compare these risks to those of palatine tonsillectomy (PT).

METHODS

A retrospective cohort study was conducted using data from the United States collaborative network within TriNetX. The LT group was defined using Current Procedural Terminology (CPT) code 42870 and PT group using CPT codes 42820, 42821, 42825, or 42826. Groups were further subdivided into pediatric and adult populations and matched based on propensity scores within the cohorts. Complications occurring within 14 days of procedure were compared within each cohort.

RESULTS

There were 1,357 adult patients (mean age, 42.9 years) and 863 pediatric patients (mean age, 8.1 years). Adults who had LT were more likely to experience postoperative dysphagia (OR = 2.6, p < 0.001) and require admission to the hospital (OR = 4.3, p < 0.001) or intensive care unit (OR = 6.1, p < 0.001). There was no significant difference in bleeding between adult PT and LT groups, occurring at rates of 3.8% and 4.4%, respectively (p = 0.50). Pediatric patients who had LT were also more likely to experience postoperative dysphagia (OR = 2.4, p = 0.017) and require admission to the hospital (OR = 8.2, p < 0.001) or intensive care unit (OR = 2.7, p = 0.012). The postoperative bleed rate was 3.2% in the pediatric PT cohort, which was 2.4 times higher compared to those who underwent LT (1.5%, p = 0.016).

CONCLUSION

Postoperative complications after lingual tonsillectomy are more common than after palatine tonsillectomy in both adults and children.

LEVEL OF EVIDENCE

III Laryngoscope, 2024.

Effect of perioperative ketorolac on postoperative bleeding after pediatric tonsillectomy

INTRODUCTION

Ketorolac is a frequently used anesthetic pain agent which is traditionally avoided during tonsillectomy due to concern for postoperative hemorrhage. Our goal was to assess the degree of risk associated with the use of Ketorolac following pediatric tonsillectomy.

METHODS

The TriNetX electronic health records research database was queried in January 2024 for patients undergoing tonsillectomy with or without adenoidectomy under the age of 18 years and without a diagnosed bleeding disorder. Patients were separated into two cohorts either having received or not having received ketorolac the same day as surgery. Propensity score matching was performed for age at the time of surgery, sex, race, ethnicity, and preoperative diagnoses. The outcomes assessed were postoperative hemorrhage requiring operative control within the first day (primary hemorrhage) and within the first month after surgery (secondary hemorrhage).

RESULTS

17,434 patients were identified who had undergone pediatric tonsillectomy with or without adenoidectomy and had received ketorolac the same day as surgery. 290,373 patients were identified who had undergone pediatric tonsillectomy with or without adenoidectomy and had not received ketorolac the same day as surgery. 1:1 propensity score matching resulted in 17,434 patients within each cohort. Receipt of ketorolac the same day as surgery resulted in an increased risk of primary hemorrhage OR 2.158 (95 % CI 1.354, 3.437) and secondary hemorrhage OR 1.374 (95 % CI 1.057, 1.787) requiring operative control.

CONCLUSION

Ketorolac use during pediatric tonsillectomy with or without adenoidectomy was associated with an increased risk of postoperative primary and secondary bleeding requiring surgery.

Effect of monopolar diathermy power settings on postoperative pain, wound healing, and tissue damage after tonsillectomy: a randomized clinical trial

This study aimed to assess the impact of varying monopolar diathermy power settings on postoperative pain, hemorrhage, and wound healing following tonsillectomy. A single-center, prospective, randomized, double-blinded, controlled clinical study was conducted. During bilateral tonsillectomy procedures, one tonsil received low-power settings (15 W, cutting/blend) while the other tonsil received high-power settings (35 W, cutting/blend). Postoperative pain scores (0-10) and wound healing scores (0-3) were evaluated immediately after surgery and at 1, 2, and 4 weeks postoperatively using the visual analog scale. Additionally, histological analysis was performed on electrically resected tonsil tissues to assess tissue damage in the tonsil bed. The allocation of high and low power settings to each side was randomized. Results showed that 1 week after the surgery, the high-power group experienced significantly higher pain scores (mean ± standard deviation: 4.84 ± 2.21) compared to the low-power group (3.56 ± 2.24, p = 0.049). Moreover, the high-power side exhibited slower wound healing during the initial 1-2 weeks postoperatively, as indicated by lower wound scores at 2 weeks (high-power: 1.96 ± 0.64; low-power: 2.43 ± 0.59, p = 0.008). Furthermore, histological analysis revealed significantly deeper tissue degradation on the high-power side compared to the low-power side (p < 0.001), with mean depths of 565.2 ± 291.0 µm and 156.0 ± 36.8 µm, respectively. In conclusion, these findings suggest that when employing monopolar diathermy in tonsillectomy, lower power settings can lead to improved outcomes in terms of postoperative pain, wound healing, and tissue damage.Trial registration: CRIS identifier: KCT0005670 (cris.nih.go.kr, registration date: 11/12/2020).

Effect of Cold-Water Irrigation on the Coblation Site for Post-Tonsillectomy Pain: A Prospective Randomized Clinical Study

OBJECTIVE

To explore the effect of cold-water irrigation on post-tonsillectomy pain after coblation.

METHODS

Data from 61 adult patients who underwent coblation tonsillectomy in our hospital from January 2019 to December 2020 were collected, and the patients were randomly divided into the cold-water irrigation group (Group 1) and the room-temperature irrigation group (Group 2). Group 1 was irrigated with ice water mixed saline with the help of a pressure band, and Group 2 was irrigated with room-temperature saline. During the operation, we monitored the temperature of the operating cavity in real time. We recorded the postoperative pain for 11 consecutive days from the day and the 10th day after the operation.

RESULTS

The postoperative pain score was significantly lower than that in Group 2, except on the 2nd, 3rd and 7th and 8th days after the operation.

CONCLUSION

The perfusion of cold water during coblation tonsillectomy is helpful to reduce postoperative pain.

Radiofrequency Versus Electrocautery in Pediatric Tonsillectomy: A Double-Blind, Randomized Controlled Trial

To compare radiofrequency and electrocauterization in reducing the degree of postoperative pain in pediatric patients undergoing tonsillectomy. A double-blind, parallel-group, randomized controlled trial. Pediatric patients with indications for tonsillectomy were randomized to receive either tonsillectomy with radiofrequency or electrocautery. Also recorded were intraoperative blood loss, duration of the surgery, length of hospital stays, and complications from the surgery. Forty pediatric patients participated in the study; 20 were randomized to each group. The participants' ages ranged from 3 to 14 years old, and 65% were male. The overall postoperative pain scale score during the early postoperative period was lower in the radiofrequency group compared to the electrocautery group (mean difference - 1.37 (95%CI - 1.72, - 0.12); p < 0.001). Also, the mean pain scale scores at 6 h, 1, and 2 days were significantly lower in the radiofrequency group. Intraoperative blood loss and length of hospital stay in the radiofrequency group were also significantly lower than in the electrocautery group, whereas the duration of the surgery and complication rate were not different between the two groups. Pediatric tonsillectomy using radiofrequency ablation could reduce the severity of early postoperative pain, intraoperative blood loss, and length of hospital stay compared to tonsillectomy with electrocautery. Therefore, tonsillectomy with radiofrequency may be considered a safe and effective operative option. Trial registration Thai Clinical Trials Registry (TCTR-20210303007), 03-March-2021.

Intracapsular tonsillectomy in the treatment of recurrent and chronic tonsillitis in adults: a protocol of a prospective, single-blinded, randomised study with a 5-year follow-up (the FINITE trial)

INTRODUCTION

The standard surgical treatment for recurrent or chronic tonsillitis is extracapsular tonsillectomy. Recent studies show that intracapsular tonsillectomy has the potential to reduce the postoperative morbidity of patients undergoing tonsil surgery. The Finnish Intracapsular Tonsillectomy (FINITE) trial aims to provide level I evidence to support the hypothesis that the recovery time from tonsil surgery can be reduced with intracapsular tonsillectomy. Additionally, from this trial, major benefits in quality of life, reduction of postoperative complications, treatment costs and throat symptoms might be gained.

METHODS AND ANALYSIS

The FINITE trial is a prospective, randomised, controlled, patient-blinded, three-arm clinical trial. It is designed to compare three different surgical methods being extracapsular monopolar tonsillectomy versus intracapsular microdebrider tonsillectomy versus intracapsular coblation tonsillectomy in the treatment of adult patients (16-65 years) suffering from recurrent or chronic tonsillitis. The study started in September 2019, and patients will be enrolled until a maximum of 200 patients are randomised. Currently, we are in the middle of the study with 125 patients enrolled as of 28 February 2022 and data collection is scheduled to be completed totally by December 2027. The primary endpoint of the study will be the recovery time from surgery. Secondary endpoints will be the postoperative pain scores and the use of analgesics during the first 3 weeks of recovery, postoperative haemorrhage, quality of life, tonsillar remnants, need for revision surgery, throat symptoms, treatment costs and sick leave. A follow-up by a questionnaire at 1-21 days and at 1, 6, 24 and 60 months will be conducted with a follow-up visit at the 6-month time point.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Medical Ethics Committee of the Hospital District of Southwest Finland (reference number 29/1801/2019). Results will be made publicly available in peer-reviewed scientific journals.

TRIAL REGISTRATION NUMBER

NCT03654742.

Intrapatient Comparison of Coblation versus Electrocautery Tonsillectomy in Children: A Randomized, Controlled Trial

Many surgical instruments have been introduced and compared for safety and surgical efficiency in tonsillectomy. This study aimed to compare postoperative pain between coblation and conventional monopolar electrocautery tonsillectomy by intrapatient comparison in children. Thirty pediatric patients over six years of age undergoing tonsillectomies were enrolled. Coblation and electrocautery were used to remove both tonsils in one patient; one was removed by coblation and the other by electrocautery. The coblation side was randomly selected, and it was blinded to the patients. Each side’s daily pain scores were collected on the visual analogue scale (VAS) during ten postoperative days. On the day of surgery, 22 (73%) patients identified less pain on the coblation side, while others felt similar pain. The mean pain scores were significantly lower on the coblation side during the postoperative ten days (except for the 6th and 8th) than on the electrocautery side. The duration of severe pain (VAS > 5) was significantly shorter on the coblation side than on the electrocautery side (2.0 versus 3.7 days, respectively; p = 0.042). Coblation tonsillectomy induced less pain than electrocautery in pediatric patients; therefore, surgeons could choose the coblator as a surgical instrument for tonsillectomy to improve the pediatric postoperative quality of life.

Acupuncture Analgesia in Patients with Postoperative Neck Pain: A Protocol for Systematic Review and Meta-Analysis

Background. There is a yearly increase in pain after neck surgery, which is accompanied by high consumption of opioids. However, the opioid addiction epidemic is one of the most serious public health problems worldwide. Therefore, it is important to find suitable alternatives for opioids. Acupuncture therapy has been found effective for some types of pain control. This protocol aims to evaluate the efficacy and safety of acupuncture therapy in the treatment of pain after neck surgery. Methods and Analysis. We will search eight electronic databases from their inception to April 2022. Only randomized controlled trials (RCTs) using manual acupuncture, auricular acupuncture, or electroacupuncture as major therapy will be included, regardless of whether the study was published in Chinese or English. The selection of studies and data extraction will be independently completed by at least two experienced reviewers with a master's degree. The methodological quality of the included studies will be assessed by the Cochrane risk-of-bias tool. For the meta-analysis, Review Manager Statistical (RevMan V.5.3) software will be used. The results will be presented as the risk ratio (RR) for the binary data and the mean difference (MD) or standardized mean difference (SMD) for the continuous data. Ethics and Dissemination. This protocol for a systematic review will be submitted to a peer-reviewed journal for publication and presented at a relevant conference, and there is no need to obtain formal ethical approval. Trial Registration Number. PROSPERO registration number CRD42021281722.

Transoral Endoscopic Resection of Oropharyngeal Pedunculated Giant Fibrolipoma Using Harmonic Scalpel: A Case Report

Lipoma is the most common soft tissue benign tumor in the body. It can occur in the head and neck area as well. Fibrolipoma is a variant of lipoma that contains fibrous tissue. Fibrolipomas of the head and neck are relatively rare, and their presentation depends largely on their size and location; some slowly growing tumors might go unnoticed until they reach significant size and become symptomatic. Here, we report a case of 64-year-old male who presented with large pedunculated oropharyngeal fibrolipoma that originated from the posterior oropharyngeal wall and extended downward into the postcricoid area and cervical esophagus. It was excised transorally using rigid endoscope, and ACE Harmonic scalpel was utilized to excise this 16.7 cm long mass. The postoperative pain was minimal, the surgical site showed complete healing, and oral diet was resumed easily in 5 days.

Comparative systematic review and meta-analysis of the therapeutic effects of coblation tonsillectomy versus electrocautery tonsillectomy

BACKGROUND

Surgical removal of the primary lesion is a common treatment for chronic tonsillitis, recurrent tonsillitis, and tonsillar hypertrophy, and is the most widely performed surgery in otorhinolaryngology. With the development and progress of medical science and technology, the methods of tonsillectomy have gradually diversified, and it is of great significance to seek the best tonsillectomy method. This meta-analysis explored the advantages and disadvantages of coblation tonsillectomy (CT) and electrocautery tonsillectomy (ET).

METHODS

The keywords "coblation", "radiofrequency ablation", "electrocautery", and "tonsillectomy" were used to search the PubMed, Embase, Cochrane library, Clinicaltrials.gov, and Google Scholar databases, and randomized controlled trials (RCTs) of the 2 procedures since the establishment of the database were included. After screening and bias risk assessment, a meta-analysis was performed using Stata 16.0 software.

RESULTS

A total of 10 articles met the inclusion criteria and entered the final meta-analysis. There were 1,056 participants, including 547 patients who underwent CT and 509 patients who underwent ET. There was no significant difference in the operation time between CT and ET [standard mean difference (SMD) =0.39, 95% CI: -0.35 to 1.13, Z=1.044, P=0.296]. CT resulted in less intraoperative blood loss than ET (SMD =-2.62, 95% CI: -4.83 to -0.41, Z=-2.322, P=0.020). The postoperative pain score of CT was less than ET, but the difference was not statistically significant (SMD =-0.28, 95% CI: -0.58 to 0.01, Z=-1.866, P=0.062). CT resulted in less time to return to normal diet after surgery than ET, and the difference was statistically significant (SMD =-0.36, 95% CI: -0.60 to -0.12, Z=-2.918, P=0.004).

DISCUSSION

CT resulted in less intraoperative blood loss and faster postoperative recovery than ET, but there was no significant difference in operation time, postoperative pain, and the incidence rate of postoperative complications between the 2 groups.

A novel electrosurgical divider: performance in a self-controlled tonsillectomy study

PURPOSE

Tonsillectomies are among the most common surgeries in otorhinolaryngology. A novel electrosurgical temperature-controlled instrument (device) promises rapid tonsillectomies and might reduce postoperative pain, but comparative studies to assess performance are warranted.

METHODS

This randomized self-controlled clinical trial was conducted from October 2019 to October 2020 at the Department of Otorhinolaryngology, Head and Neck Surgery of the Medical University of Vienna. Forty-eight patients underwent a tonsillectomy with the device on one side and using cold-steel with localized bipolar cauterization on the other side (control). Main outcomes were the time for tonsil removal (per side) and the time to stop bleeding (per side). Secondary measurements were postoperative pain, assessed once on day 0 and five times on days 1, 3, 5, 7, and 10. Postoperative bleeding episodes and consequences were recorded.

RESULTS

Device tonsillectomies were performed significantly faster than controls; the mean surgical time difference was 209 s (p < 0.001, 95% CI 129; 288). Intraoperative blood loss was significantly lower on the device side (all p < 0.05). Postoperative measurements of pain and bleeding were similar for both sides. Two return-to-theatre secondary bleeding events were recorded for the control side.

CONCLUSION

The novel electrosurgical temperature-controlled divider reduced the tonsillectomy surgical time and intraoperative blood loss, with no apparent negative effects on postoperative pain or bleeding, compared to a cold-steel tonsillectomy with localized bipolar cauterization. In time-restricted settings, the device could be beneficial, particularly after familiarization with device handling.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03793816.