Rare electrosurgical complications in tonsillectomy: Analysis of national adverse event reporting

Adverse events related to suction electrocautery devices in adenotonsillectomy: Analysis of the MAUDE database

OBJECTIVE

To identify adverse events (AEs) related to suction electrocautery use during adenotonsillectomy.

METHODS

The US Food and Drug Administration (FDA) Manufacturer and User Facility Device Experience (MAUDE) database was searched using the terms "suction cautery," "suction electrocautery," "suction Bovie," and "suction coagulator" from January 2014 to December 2023.

RESULTS

165 AE reports were gathered from the MAUDE database medical device reports (MDRs). 36 met inclusion criteria. Patient injuries were found in 22 (61.1 %) reports and device malfunction events were found in 14 (38.9 %) reports. All patient injuries were thermal burns (N = 22, 100 %). Location of burn injuries included the lip (N = 6, 27.3 %), oral commissure (N = 5, 22.7 %), and tongue (N = 4, 18.2 %). The most common cause of an AE was inadequate device insulation (N = 7, 19.4 %).

CONCLUSION

The suction electrocautery apparatus may malfunction and cause patient burn injuries. Device failures mainly result from inadequate device insulation, coagulation problems, and detachment of device components. Surgeons must be aware of these potential complications and counsel parents and patients regarding AEs.

The Safety of the Laryngeal Mask Airway in Adenotonsillectomy: A Systematic Review and Meta-Analysis

BACKGROUND

Adenotonsillectomy is one of the most common surgical procedures worldwide. The current standard for securing the airway in patients undergoing adenotonsillectomy is endotracheal tube (ETT) intubation. Several studies have investigated the use of the laryngeal mask airway (LMA) in this procedure. We conducted a systematic review and meta-analysis to compare the safety and efficacy of the LMA versus ETT in adenotonsillectomy.

METHOD

Databases were searched from inception to 2022 for randomized controlled trials and comparative studies. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. The primary outcome is the rate of perioperative respiratory adverse events (PRAEs). Secondary outcomes included the rate of conversion to ETT, desaturations, nausea/vomiting, and surgical time. A subgroup analysis, risk of bias, publication bias, and Grading of Recommendations Assessment, Development, and Evaluation (GRADE) assessments were also performed.

RESULTS

Twelve studies were included in the analysis (4176 patients). The mean overall conversion to ETT was 8.36% [95% confidence interval (CI) = 8.17, 8.54], and for the pediatric group 8.27% (95% CI = 8.08, 8.47). The mean rate of conversion to ETT secondary to complications was 2.89% (95% CI = 2.76, 3.03) while the rest was from poor surgical access. Overall, there was no significant difference in PRAEs [odds ratio (OR) 1.16, 95% CI = 0.60, 2.22], desaturations (OR 0.79, 95% CI = 0.38, 1.64), or minor complications (OR 0.89, 95% CI = 0.50, 1.55). The use of LMA yielded significantly shorter operative time (mean difference -4.38 minutes, 95% CI = -8.28, -0.49) and emergence time (mean difference -4.15 minutes, 95% CI = -5.63, -2.67).

CONCLUSION

For adenotonsillectomy surgery, LMA is a safe alternative to ETT and requires less operative time. Careful patient selection and judgment of the surgeon and anesthesiologist are necessary, especially given the 8% conversion to ETT rate.

Microdebrider complications in sinus surgery: Analysis of the openFDA database

Objective

Functional endoscopic sinus surgery is a commonly performed otolaryngologic procedure that often uses the microdebrider device for tissue removal. Given the ubiquitous nature of the instrument, we sought to better define the patterns of device failure using the postmarket surveillance openFDA database.

Methods

The openFDA database was queried for all microdebrider-related adverse events from January 1, 2000 to November 1, 2020. Descriptive information on the nature of device failure and any associated patient injury was compiled. Reports not directly related to device failure were excluded from the analysis.

Results

A total of 641 events were included in the analysis. The most common device failure was overheating (n = 348, 54.3%), followed by material separation (n = 173, 27%), and inconsistent device activation (n = 52, 8.1%). Of the reported events, the vast majority did not result in patient harm (n = 579, 90.3%). On review of the remaining cases, only 24 events (3.7%) resulted in true harm to the patient, defined as a temporary or permanent injury or >30 min of additional anesthesia time. Of these cases, the need to reschedule surgical cases (n = 5, 0.8%), retained foreign body (n = 5, 0.8%), and thermal tissue injury (n = 3,0.5%) were the most common. Five patients suffered an injury due to surgeon error unrelated to device malfunction (n = 5, 0.8%).

Conclusions

Microdebrider device failures are extremely rare. When they do occur, less than 10% result in patient harm. In cases of patient harm related to microdebrider failure, preoperative testing of the device before use could prevent many of the reported malfunctions.

Comparing nationally reported adverse events associated with coblation vs. PlasmaBlade for tonsillectomy

OBJECTIVE(S)

Coblation, or radiofrequency ablation, and pulsed-electron avalanche knife (PEAK) plasmablade are newer approaches for tonsillectomy that reduce exposure to thermal heat. This study aims to describe and compare adverse events related to these devices for tonsillectomy.

STUDY DESIGN

Retrospective cross-sectional study.

SETTING

The US Food and Drug Administration's Manufacture and User Facility Device Experience (MAUDE) database.

METHODS

The MAUDE database was queried for reports involving coblation devices and the PEAK plasmablade from 2011 to 2021. Data were extracted from reports pertaining to tonsillectomy with and without adenoidectomy.

RESULTS

There were 331 reported adverse events for coblation and 207 for the plasmablade. For coblation, 53 (16.0 %) of these involved patients and 278 (84.0 %) were device malfunctions. Similarly for the plasmablade, 22 (10.6 %) involved patients and 185 (89.4 %) were device malfunctions. The most frequent patient-related adverse event was burn injury, which was significantly more common with the plasmablade compared to coblation (77.3 % vs. 50.9 %, respectively, p = 0.042). For both the coblator and plasmablade, the most common device malfunction was intraoperative tip or wire damage (16.9 % vs. 27.0 %, respectively, p = 0.010). The Plasmablade tip caught fire in five reports (2.7 %) with one causing burn injury.

CONCLUSIONS

While coblation devices and the plasmablade have demonstrated utility in tonsillectomy with or without adenoidectomy, they are associated with adverse events. Plasmablade use may require greater caution for intraoperative fires and patient burn injuries compared to coblation use. Interventions to improve physician comfort with these devices may help reduce adverse events and inform preoperative discussions with patients.

Patient injuries from tonsil and adenoid surgery in Finland

Objectives

The aims of this national register-based study were to examine patient injury claims related to tonsil and adenoid surgery injuries and to compare the frequency of claims between tonsillectomies and tonsillotomies in Finland.

Methods

We analyzed the complaints related to tonsil and adenoid surgery received by the Finnish Patient Insurance Center (PIC) between the years 2000 and 2019. One hundred seventy-two cases were included in the analysis. The annual surgery rates between the years 2000 and 2018 were acquired from the Finnish Institute for Health and Welfare.

Results

During the years 2000 to 2018, a total of 292,679 patients had tonsil and/or adenoid surgery nationwide. For tonsil or adenoid surgeries, the national average was 5.3 cases and 1.8 cases per 10,000, respectively, resulting in patient injury claims and compensations. A total of 33.1% of the claims regarding tonsil or adenoid surgery processed by the PIC were compensated. Most of the claims were made after a tonsillectomy (87.8%), and few were made after a tonsillotomy (1.7%). Seven deaths were recorded.

Conclusion

Patient injuries from tonsil and adenoid surgeries were mostly related to traditional extracapsular tonsillectomies. Most surgeries, along with most complications, involved specialists, who performed routine operations in high-volume centers. Surgeries for acute or recurrent infections resulted in more claims. Severe complications arising from tonsil and adenoid surgeries were rare.

Level of Evidence

4.

Does length of time between cases affect resident operative time for tonsillectomy and adenoidectomy?

OBJECTIVE

To evaluate the effect of prolonged time intervals between tonsillectomy and adenoidectomy (TA) on resident operative time and complications.

STUDY DESIGN

Retrospective cohort.

SETTING

Tertiary academic hospital.

METHODS

This retrospective study covers a five-year period from 2015 to 2020. Time intervals between isolated pediatric TA cases performed by eight otolaryngology residents were reviewed to assess effect on operative time (defined as prolonged if ≥ 30 min and non-prolonged if < 30 min). Intervals including a procedure involving either a tonsillectomy or adenoidectomy that was a non-isolated TA were excluded.

RESULTS

A total of 309 isolated TAs were identified with 67.3% of procedures performed under 30 min. The mean surgical time interval between procedures was 5.83 ± 10.02 days (range 0.02-69.82). Most TAs were performed on patients aged 7 years or younger. Surgical time interval between TA was not a significant factor in determining prolonged operative time on univariable logistic regression, OR 1.01 (CI: 0.98 to 1.03) (p = 0.63). Patient age at surgery, adenoid grade, tonsil size and total number of TAs performed to date were significant factors in determining prolonged operative time in both univariable and multivariable logistic regression models. Prolonged operative time did not have a significant effect on readmission, reoperation, or post-operative bleeding.

CONCLUSION

Extended time interval (up to 3 months) between routine TA does not affect operative time. Expansion of our methodology to more complex cases would be beneficial in designing resident training curriculum.

Complications associated with PlasmaBlade TnA during tonsillectomy and adenoidectomy from 2010 to 2020: A MAUDE study

PURPOSE

The pulsed-electron avalanche knife (PEAK) PlasmaBlade TnA (Medtronic, n.d.) is a relatively new electrosurgical technology that is used widely in head and neck surgery (Medtronic Manuals, n.d.). This study aims to summarize device malfunctions, patient complications, and subsequent interventions related to PEAK PlasmaBlade TnA during tonsillectomy and adenoidectomy.

MATERIALS AND METHODS

The US Food and Drug Administration's Manufacture and User Facility Device Experience database was queried for reports of PlasmaBlade TnA adverse events from June 6, 2009, to August 30, 2020. Data were extracted from reports pertaining to tonsillectomy with or without adenoidectomy.

RESULTS

128 reports were identified, from which 163 adverse events were extracted. Of these, 23 (14.6%) were related to patients, and 140 (85.4%) were related to device malfunction. The most frequently reported patient-related adverse event was a burn injury (17 [73.9%]). The most common device malfunctions were dislodgment of device component (39 [27.9%]), followed by tip ignition (32 [22.9%]), damaged tip or wire during operation (28 [20%]), and melted device (24 [17.1%]).

CONCLUSIONS

PEAK PlasmaBlade TnA have demonstrated utility in tonsillectomy with or without adenoidectomy but are associated with adverse events. Interventions aimed at improving both physician and patient education may help reduce adverse events attributed to improper use. Further study is needed to clarify optimal approaches to education.