Coblation tonsillectomy: a systematic review and descriptive analysis

Intraoperative cryoanalgesia on reducing post-tonsillectomy pain scales: a meta-analysis of randomized controlled trials

OBJECTIVE

To assess the effect of intraoperative cryoanalgesia on subjective pain scores of patients after tonsillectomy.

METHODS

A systematic review of PubMED, Web of Science, EMBASE was performed using the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) standards. For the first time, we included and quantitative synthesized English-language randomized controlled trials (RCT) evaluating patients of all age groups with benign pathology who underwent tonsillectomy with intraoperative cryoanalgesia versus without.

RESULTS

A total of 835 publications were identified, and 7 articles with 463 participants met our criteria were selected for meta-analysis. The standard mean difference for overall subjective pain score, subjective pain scores at postoperation Day1 (POD1), POD7 were -1.44 with 95% confidence interval (CI) [-2.17, -0.72], P = .0001; -1.20 with 95% CI [-1.89, -0.50], P = .0007; -0.90 with 95% CI [-1.46, -0.35], P = .001 respectively, both in favor of cryoanalgesia. Nevertheless, subgroup analysis by surgical technique showed no robust effect between hot technique and "relative" hot technique on overall pain: (-1.72, 95% CI [-2.71, -0.73]) vs. (-1.06, 95% CI [-2.20, 0.07]), p=.39; on POD1: (-1.56, 95% CI [-2.78, -0.33]) vs. (-0.97, 95% CI [-1.83, -0.11]), p=.39; and on POD7 (-1.11, 95% CI [-1.81, -0.40]) vs. (-0.89, 95% CI [-2.02, 0.25]), p=.13. The standard mean difference for postoperative secondary bleeding rate was 1.29 with 95% CI 0.37,4.52], p = .06, no difference in 2 groups.

CONCLUSION

Limited evidence suggests that intraoperative cryoanalgesia during tonsillectomy leads to lower subjective pain score on overall, POD1 and POD7 without differences on post-operation bleeding rate.

Surgical arrest of post-tonsillectomy haemorrhage: hospital episode statistics 2016-2022

INTRODUCTION

Return to theatre for arrest of post-tonsillectomy haemorrhage represents a significant complication of a commonly performed Ear, Nose and Throat procedure. We used Hospital Episode Statistics data to quantify this risk. This method has been used previously for data from 2002-2004 and again for 2010-2016. In this article, coblation tonsillectomy was considered separately as it had not been analysed in previous studies.

METHODS

We used Hospital Episode Statistics data provided by the Department of Health to determine the risk of return to theatre for patients undergoing tonsillectomy between 2016 and 2022. Adults and children were analysed separately.

RESULTS

Between 1 April 2016 and 30 April 2022, 179,172 tonsillectomies were performed (not including coblation tonsillectomy), 4,311 (2.41%) of which returned to theatre for control of postoperative bleeding. In children, 1.16% returned to theatre, whereas in adults, 3.80% returned (p<0.05). When including coblation tonsillectomy, the return to theatre rate was 0.82% in children, 3.46% in adults and 1.92% overall.

CONCLUSIONS

This study shows that adults remain more than three times more likely than children to require a return to theatre for arrest of haemorrhage following tonsillectomy. The rates of post-tonsillectomy haemorrhage decrease when coblation tonsillectomies are added to the analysis. The rate of return to theatre for post-tonsillectomy haemorrhage seems to have stabilised compared with previous work carried out. The authors recommend further work to assess the complication rate of tonsillectomy in the UK and to compare coblation tonsillectomy with other techniques.

A comparative study of BiZact™ tonsillectomy versus cold steel dissection technique in adults: Analysis of operating time, intraoperative blood loss, postoperative bleeding rate and pain

OBJECTIVES

To analyse operating time, intraoperative blood loss, postoperative bleeding rate and pain when using the relatively new BiZact™ tonsillectomy device compared to the commonly used cold steel dissection technique with bipolar cautery in adults.

DESIGN

Retrospective case control study. Parameters analysed for significant association with technique were operating time, intraoperative blood loss, wound pain on postoperative days 1-4 and rate of post-tonsillectomy bleeding (PTB).

SETTING

Monocentric study at a department of otolaryngology and head and neck surgery at a tertiary centre in Germany.

PARTICIPANTS

A total of 183 patients who underwent a bilateral tonsillectomy with either the BiZact™ tonsillectomy device or the cold dissection technique with bipolar cautery for haemostasis.

MAIN OUTCOME MEASURES

Operating time, intraoperative blood loss, postoperative pain on the first to fourth postoperative day (numeric rating scale: 0-10) (PTB, primary bleeding ≤24 h, secondary bleeding >24 h postoperative; Stammberger scale).

RESULTS AND CONCLUSION

The BiZact™ tonsillectomy device leads to a significant shorter operating time with less intraoperative blood loss compared to cold steel dissection with bipolar haemostasis. No benefits with regards to PTB or postoperative pain could be observed. The use of the BiZact™ device provides major benefits in clinical routine and stands up to conventional tonsillectomy techniques.

Endoscopic transcanal coblation excision of glomus tympanicum: a novel technique

OBJECTIVE

To evaluate the feasibility of coblation in excision of glomus tympanicum tumors.

PATIENTS AND METHODS

A retrospective study carried out over 28 patients with types I and II glomus tympanicum tumors according to GLASSCOCK-JACKSON classification. Preoperative radiological and endocrinal evaluation were performed. All patients underwent endoscopic transcanal excision of their glomus tympanicum tumors using coblation.

RESULTS

None of the patients developed recurrence during the 1-year follow up period proved radiologically. None of the patients developed facial palsy postoperatively. Differences between preoperative and postoperative dizziness and taste disturbance were statistically non-significant. Tinnitus disappeared completely in 22 patients postoperatively. A statistically significant reduction in Tinnitus Handicap Inventory (THI) after surgery was found. Statistically significant reductions in postoperative air conduction (AC) threshold and air bone gap (ABG) were recorded while bone conduction (BC) threshold showed statistically non-significant change.

CONCLUSION

Coblation is an effective and safe tool in excision of glomus tympanicum tumors. Further studies comparing coblation with laser and piezosurgery are strongly recommended.

Postoperative Outcomes of Intracapsular Tonsillectomy With Coblation: A Systematic Review and Meta-Analysis

OBJECTIVE

Following tonsillectomy, postoperative pain and hemorrhage from the tonsillar bed are causes of significant morbidity. Intracapsular tonsillectomy with Coblation is suggested to minimize such morbidity while remaining efficacious in long-term outcomes. This systematic review and meta-analysis assessed short-term morbidity and long-term outcomes from intracapsular tonsillectomy with Coblation, focusing primarily on posttonsillectomy hemorrhage.

DATA SOURCES

Medline, Embase, and the Cochrane Library.

REVIEW METHODS

Guided by PRISMA guidelines, studies on intracapsular tonsillectomy with Coblation published between December 2002 and July 2022 evaluating frequency of posttonsillectomy hemorrhage were screened. Studies without primary data were excluded. Meta-analysis was conducted using the random-effect model. The primary outcome was the proportion of patients who experienced posttonsillectomy hemorrhage. The secondary outcomes were posttonsillectomy pain, the proportion requiring revision tonsillectomy, and severity of sleep-disordered breathing measured by polysomnography outcomes.

RESULTS

From 14 studies there were 9821 patients. The proportion of total posttonsillectomy hemorrhage was 1.0% (95% confidence interval [CI] 0.5%-1.6%, n = 9821). The proportion experiencing primary hemorrhage, secondary hemorrhage, and those requiring further tonsil surgery were 0.1% (95% CI 0.0%-0.1%; study n = 7), 0.8% (95% CI 0.2%-1.4%; study n = 7), and 1.4% (95% CI 0.6%-2.2%; study n = 6), respectively. Mean reduction in apnea-hypopnea index was -16.0 events per hour (95% CI -8.8 to -23.3, study n = 3) and mean increase in oxygen nadir was 5.9% (95% CI 2.6%-9.1%, study n = 3).

CONCLUSION

Intracapsular tonsillectomy with Coblation has been demonstrated to have a low rate of posttonsillectomy hemorrhage. Data regarding long-term tonsil regrowth and need for reoperation were encouraging of the efficacy of this technique.

Comparison of Three Tonsillectomy Techniques: Cold Dissection, Monopolar Electrocautery, and Coblation

Introduction  Tonsillectomy is among the most common otolaryngological surgeries. Objective  To evaluate and compare three tonsillectomy techniques: cold steel dissection (CSD), monopolar electrocautery (MEC), and coblation. Methods  The present study retrospectively reviewed the medical records of patients who underwent tonsillectomy between January 2014 and January 2016. Postoperative visual analog scale (VAS) pain scores, analgesic use, surgical duration, time to return to normal activity, and postoperative bleeding status were noted. Results  The CSD group had less analgesic use and shorter return to normal activity than the MEC group ( p  = 0.037 and p  < 0.001, respectively). The coblation group had lower VAS pain scores than the MEC group only at 1 hour to 4 hours postsurgery ( p  < 0.016). The postoperative bleeding rate was similar in all groups ( p  = 0.096). Conclusion  Cold steel dissection tonsillectomy is associated with less postoperative pain and shorter recovery than MEC. Coblation is better than MEC in terms of postoperative pain at 1 hour to 4 hours only, whereas CSD is associated with less postoperative pain than coblation at 2 days to 7 days.

Is Laser Better than Cold Steel (Dissection and Snare) for Tonsillectomy?

OBJECTIVE

To analyse the surgical outcome of CO2 laser assisted tonsillectomy with the cold steel (conventional dissection and snare) tonsillectomy.

MATERIALS AND METHODS

This prospective, non-randomised, single blind study was conducted in 25 cases suffering with recurrent tonsillitis. The left tonsillectomy was performed with CO2 laser while the right tonsil was excised using cold steel method (conventional dissection and snare method). The surgical time, blood loss and post-operative pain for each method was recorded and analysed.

RESULTS

CO2 laser tonsillectomy had highly significant less intra-operative blood loss (41.8ml vs. 78.8ml with p = 0.001) and postoperative pain levels on postoperative day 1,3, and 5 ( p value of 0.013, 0.006 and 0.000 respectively) as compared to cold steel method. However; there was no statistically significant difference in operative time between the two techniques (p > 0.05).

CONCLUSION

CO2 laser tonsillectomy appeared to be better technique than cold steel in terms of intra-operative haemorrhage and pain.

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.

Multicentre clinical study of haemorrhage after coblation tonsillectomy in children: a prospective study protocol

INTRODUCTION

Post-tonsillectomy haemorrhage (PTH) is the most common and significant life-threatening complication following tonsillectomy, especially in children. Coblation tonsillectomy (CTE) at low temperature is extensively used in China and has gradually replaced conventional tonsil dissection. However, risk of late PTH has been shown to increase with the use of hot instruments. The aim of this study is to detect post-CTE haemorrhage (PCTH) rates and analyse risk factors of PCTH in China, through a nationwide multicentre prospective study.

METHODS AND ANALYSIS

This investigator-initiated, prospective, multicentre clinical trial will involve children with tonsil disease who will undergo CTE from 22 research centres in different cities in China. All operations will be performed using the same technique of extracapsular tonsillectomy. Data will be collected for all patients enrolled in this study through a preoperative visit, intraoperative data and a postoperative visit. The measurement data conforming to a normal distribution will be expressed by means±SDs, and a Student's t-test will be used for comparison. The comparison among groups of counting data will be expressed by percentage or rate, and a χ² test will be used for comparison. Non-conditional logistic regression analysis will be used to analyse the preoperative, intraoperative and postoperative risk factors for haemorrhage rate after CTE. P<0.05 will be considered statistically significant.

ETHICS AND DISSEMINATION

This study protocol was approved by the Ethics Committee of Shanghai Children's Hospital/Shanghai Jiao Tong University (reference number 2021R096-E01). All patients will provide written informed consent. Results of this study are to be published in respected, peer-reviewed journals and findings presented at scientific conferences in the field of paediatric otorhinolaryngology.

TRIAL REGISTRATION NUMBER

NCT05206799.

A novel classification and grading scale of palatine tonsil anatomy in children

PURPOSE

The influence of tonsil anatomical differences on post-tonsillectomy hemorrhage and pain has not been studied yet. This study aimed to establish a classification and grading scale of palatine tonsil anatomy, not size, for personalized post-tonsillectomy care.

METHODS

Between August 2020 and August 2021, 337 children who underwent extracapsular tonsillectomy were recruited. The images of tonsil anatomy during the surgery were recorded and then classified and graded. Postoperative hemorrhage was recorded, and the degree of pain was measured using a visual analog scale (VAS). The primary outcomes were the associations between postoperative hemorrhage, pain, and the classification and grade of tonsil anatomy, analyzed by univariable and multivariable analyses.

RESULTS

186 of the 337 patients (55.2%) were male and 151 (44.8%) were female; the mean age was 5.59 years. The overall postoperative hemorrhage rate was 4.1%. The mean postoperative VAS score was 4.96. By univariable analysis with logistic regression model, significant associations were found between postoperative hemorrhage and the grade 2 and grade 3 tonsillar lower pole, and grade 3 tonsillar bed. Multivariable analysis with binary logistic regression model also revealed significant associations between postoperative hemorrhage and the grade 2 and grade 3 lower pole (OR: 8.23, 95% CI 1.01-67.37, P = 0.049; OR: 23.86, 95% CI 2.22-56.47, P = 0.009, respectively) and grade 3 tonsillar bed (OR: 14.25, 95% CI 1.46-18.75, P = 0.022). Linear regression analysis showed the associations between postoperative pain and grade 2 and grade 3 lower pole (β: 0.88, 95% CI 0.31-1.32, P = 0.002; β: 1.56, 95% CI 1.29-3.29, P = 0.001, respectively) and grade 3 anterior surface (β: 0.85, 95% CI 0.30-3.07, P = 0.004). Age and upper pole were not associated with the postoperative hemorrhage and pain neither.

CONCLUSION

In the present study, we established a novel classification and 3-grade scale of palatine tonsil anatomy, based on upper pole, anterior surface, lower pole, and tonsillar bed. Furthermore, we revealed for the first time that some anatomical characteristics of tonsils were associated with post-tonsillectomy complications.

Long-Term Clinical Outcome of Low-Temperature Plasma Ablation Treatment for Recurrent Corneal Erosions

Purpose: To observe the therapeutic effect of low-temperature plasma ablation in treating patients with recurrent corneal erosions (RCEs). Materials and Methods: From 2020 to 2022, 35 participants with unilateral RCEs voluntarily enrolled. Here, 35 eyes of 35 patients were treated with low-temperature plasma ablation (coblation). All surgeries were performed by the same doctor (X.H.). The coblation went back and forth over the entire erosion area around five times for about five minutes. After the operation, patients were scheduled for follow-up visits at the outpatient clinic after 1 month, 3 months, 6 months, and 12 months, and at the end of the trial. During every visit, each patient underwent an evaluation of their ocular symptoms utilizing the following: pain score, intraocular pressure, slit lamp biomicroscopic examination, dry eye analysis, corneal topography, and corneal in vivo confocal microscopy (IVCM). Results: The mean follow-up time was 12.4 ± 6.1 months, ranging from 6 to 29 months. Of the 35 patients who had low-temperature plasma ablation, 32 eyes (91.43%) were completely symptom-free and three (8.57%) eyes had repeated episodes of recurrent corneal erosions after the surgery, at 3, 10, and 12 months, respectively. The typical RCE morphologic abnormalities observed in IVCM included the deformation and relaxation of the corneal epithelium, disorganized stromal fibers, reduced nerve fiber density, and disordered organization. After low-temperature plasma ablation, the loose cysts disappeared, and the epithelium became solid and tight. There was no obvious difference in the intraocular pressure (p = 0.090) or corneal astigmatism (p = 0.175) before and after treatment. The mean pain score decreased significantly, with a preoperative score of 7.7 ± 2.4 and postoperative score of 1.1 ± 1.8 (p < 0.001). The mean corneal thickness decreased from 562.6 ± 42.2 mm to 549.6 ± 26.9 mm (p = 0.031). The mean non-invasive keratograph tear meniscus height (NIKTMH) decreased from 0.210 ± 0.054 mm to 0.208 ± 0.045 mm (p = 0.001), and the mean TBUT decreased from 6.191 ± 2.811 s to 5.815 ± 2.802 s (p < 0.001), which manifested as a slight worsening of dry eyes. In one case, the patient’s corneal astigmatism became more severe, which may be related to the high instantaneous energy when the operation did not flush in a timely manner, and it was recovered after 6 months. Conclusions: Low-temperature plasma ablation is an effective and safe procedure to treat patients with recurrent corneal erosions.

Coblation Versus Bipolar Diathermy Hemostasis in Pediatric Tonsillectomy Patients: Systematic Review and Meta-Analysis

This study aimed to compare the outcomes of coblation versus bipolar diathermy in pediatric patients undergoing tonsillectomy. A systematic review and meta-analysis were performed per the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Guidelines. An electronic search of information was conducted to identify all Randomized Controlled Trials (RCTs) comparing the outcomes of coblation versus bipolar in pediatric patients undergoing tonsillectomy. Primary outcome measures were intraoperative bleeding, reactionary hemorrhage, delayed hemorrhage, and post-operative pain. Secondary outcome measures included a return to a normal diet, effects on the tonsillar bed, operation time, and administration of analgesia. Fixed and random-effects models were used for the analysis. Seven studies enrolling 1328 patients were identified. There was a significant difference between coblation and bipolar groups in terms of delayed hemorrhage (Odds Ratio [OR] = 0.27, P = 0.005) and post-operative pain (standardized mean difference [MD] = -2.13, P = 0.0007). Intraoperative bleeding (MD = -43.26, P = 0.11) and reactionary hemorrhage did not show any significant difference. The coblation group improved analgesia administration, diet and tonsillar tissue recovery, and thermal damage for secondary outcomes. No significant difference was reported in terms of operation time. In conclusion, coblation is comparable to a bipolar technique for pediatric patients undergoing tonsillectomy. It improves postoperative pain and delayed hemorrhage and does not worsen intraoperative bleeding and reactionary hemorrhage.

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.

What the blogosphere has to say about adult tonsillectomy

OBJECTIVES

Tonsillectomy has generated extensive comment on the internet, but this content has not been examined in a scientific manner. This study aimed to determine what the blogosphere has to say about adult tonsillectomy and to report whether this information can be used to improve post-surgical care.

METHODS

The internet was searched to find personal blogs relating to tonsillectomy. A retrospective review of data collected on these blogs was carried out and the blogs were conceptually analysed by the authors.

RESULTS

Fifty blogs were included. Seventy per cent of patients had read blogs prior to their procedure. The average pain score where available was 7.2. Complications occurred in 10 per cent of patients. Only 1 patient (2 per cent) regretted having a tonsillectomy.

CONCLUSION

It is important for otolaryngologists to stay in tune with the blogosphere as this unregulated and easily accessible source of information is both friend and foe but will ultimately help in pre-operative counselling and post-operative management.

Primary and secondary postoperative hemorrhage in pediatric tonsillectomy

BACKGROUND

Tonsillectomy is the most common procedure for treatment of pediatric recurrent acute tonsillitis and tonsillar enlargement that contributes to obstructive sleep apnea hypopnea syndrome. Postoperative hemorrhage of tonsillectomy is a life-threatening complication.

AIM

To identify the risk factors that may contribute to primary and secondary post-operative hemorrhage in pediatric tonsillectomy.

METHODS

The clinical data from 5015 children, 3443 males and 1572 females, aged 1.92-17.08 years, with recurrent tonsillitis and/or tonsil hypertrophy who underwent tonsillectomy in our hospital from January 2009 to December 2018 were retrospectively collected. The variables including sex, age, time of onset, diagnosis, method of tonsillectomy, experience of surgeon, time when the surgery started and monthly average air temperature were abstracted. The patients with postoperative hemorrhage were classified into two groups, the primary bleeding group and the secondary bleeding group, and their characteristics were compared with those of the nonbleeding group separately. Statistical analysis was performed by chi-square test with SPSS 20.

RESULTS

Ninety-two patients had post-tonsillectomy hemorrhage, and the incidence rate of post-tonsillectomy hemorrhage was 1.83%. The mean age was 5.75 years. Cases of primary hemorrhage accounted for approximately 33.70% (31/92), and cases of secondary hemorrhage occurred in 66.30% (61/92). The rate of reoperation for bleeding was 0.92%, and the rate of rehospitalization for bleeding was 0.88% in all patients. Multiple hemostasis surgery was performed in 6.52% (3/46) of patients. The method of tonsillectomy (coblation tonsillectomy) and experience of the surgeon (junior surgeon with less than 5 years of experience) were significantly associated with primary hemorrhage (χ² = 5.830, P = 0.016, χ²= 6.621, P = 0.010, respectively). Age (over 6 years old) and time of onset (more than a 1-year history) were significantly associated with secondary hemorrhage (χ²= 15.242, P = 0.000, χ²=4.293, P = 0.038, respectively). There was no significant difference in sex, diagnosis, time when the surgery started or monthly average air temperature. There was a significant difference in the intervention measures between the primary bleeding group and the secondary bleeding group (χ²= 10.947, P = 0.001). The lower pole and middle portion were the common bleeding sites, followed by the upper pole and palatoglossal arch.

CONCLUSION

The incidence rate of post-tonsillectomy hemorrhage is low. Coblation tonsillectomy and less than 5 years’ experience of surgeon contribute to the tendency for primary hemorrhage. Age and time of onset are responsible for secondary hemorrhage.

PROSPECT guideline for tonsillectomy: systematic review and procedure-specific postoperative pain management recommendations

Tonsillectomy is one of the most frequently performed surgical procedures; however, pain management remains challenging. Procedure‐specific efficacy as well as specific risks of treatment options should guide selection of pain management protocols based on evidence and should optimise analgesia without harm. The aims of this systematic review were to evaluate the available literature and develop recommendations for optimal pain management after tonsillectomy. A systematic review utilising preferred reporting items for systematic reviews and meta‐analysis guidelines with procedure‐specific postoperative pain management (PROSPECT) methodology was undertaken. Randomised controlled trials published in the English language up to November 2019 assessing postoperative pain using analgesic, anaesthetic or surgical interventions were identified. Out of the 719 potentially eligible studies identified, 226 randomised controlled trials met the inclusion criteria, excluding the studies examining surgical techniques. Pre‐operative and intra‐operative interventions that improved postoperative pain were paracetamol; non‐steroidal anti‐inflammatory drugs; intravenous dexamethasone; ketamine (only assessed in children); gabapentinoids; dexmedetomidine; honey; and acupuncture. Inconsistent evidence was found for local anaesthetic infiltration; antibiotics; and magnesium sulphate. Limited evidence was found for clonidine. The analgesic regimen for tonsillectomy should include paracetamol; non‐steroidal anti‐inflammatory drugs; and intravenous dexamethasone, with opioids as rescue analgesics. Analgesic adjuncts such as intra‐operative and postoperative acupuncture as well as postoperative honey are also recommended. Ketamine (only for children); dexmedetomidine; or gabapentinoids may be considered when some of the first‐line analgesics are contra‐indicated. Further randomised controlled trials are required to define risk and combination of drugs most effective for postoperative pain relief after tonsillectomy.

Plasma Ablation vs Other Hot Techniques for Tonsillectomy: A Meta-analysis

OBJECTIVE

To evaluate whether plasma ablation tonsillectomy is superior to other hot techniques in reducing postoperative morbidity.

DATA SOURCES

The databases of PubMed, EMBASE, and Web of Science were used to search the literature, from inception to January 2, 2020. Randomized controlled trials (RCTs) that compared plasma ablation tonsillectomy with any other hot techniques were eligible.

REVIEW METHODS

A modified Cochrane tool was used to assess the risk of bias. The standardized mean difference (SMD) and 95% confidence interval (CI) were used to estimate pooled effects of postoperative pain, and the risk ratio (RR) was used for postoperative bleeding. Subgroup analysis was prespecified to explore the source of heterogeneity. The evidence quality of each outcome was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

RESULTS

A total of 15 RCTs were included (n = 1293). Comparing with other hot techniques, plasma ablation tonsillectomy may cause less pain on postoperative day 7 (SMD, -0.53; 95% CI, -0.84 to -0.23). However, the magnitude of the difference may be clinically meaningless. There were no significant differences not only in terms of postoperative pain on day 1 and day 3 but also in the incidence of postoperative bleeding, reoperation hemostasis, and return to normal diet and activities between the 2 groups.

CONCLUSION

There is still substantial uncertainty on postoperative pain, bleeding, and recovery. The current evidence is insufficient to demonstrate that plasma ablation is superior to other hot techniques for tonsillectomy.

Coblation versus cold dissection in paediatric tonsillectomy: a systematic review and meta-analysis

BACKGROUND

Cold dissection is the most commonly used tonsillectomy technique, with low post-operative haemorrhage rates. Coblation is an alternative technique that may cause less pain, but could have higher post-operative haemorrhage rates.

OBJECTIVE

This study evaluated the peri-operative outcomes in paediatric tonsillectomy patients by comparing coblation and cold dissection techniques.

METHODS

A systematic review was conducted of all comparative studies of paediatric coblation and cold dissection tonsillectomy, up to December 2018. Any studies with adults were excluded. Outcomes such as pain, operative time, and intra-operative, primary and secondary haemorrhages were recorded.

RESULTS

Seven studies contributed to the summative outcome. Coblation tonsillectomy appeared to result in less pain, less intra-operative blood loss (p < 0.01) and a shorter operative time (p < 0.01). There was no significant difference between the two groups for post-operative haemorrhage (p > 0.05).

CONCLUSION

The coblation tonsillectomy technique may offer better peri-operative outcomes when compared to cold dissection, and should therefore be offered in paediatric cases, before cold dissection tonsillectomy.

A multifunctional dexamethasone-delivery implant fabricated using atmospheric plasma and its effects on apoptosis, osteogenesis and inflammation

Implant-based local drug delivery is a unique surgical therapy with many clinical advantages. Atmospheric pressure plasma is a novel non-thermal surface biotechnology that has only recently been applied in enhancing a surgical implant. We are the first to use this technology to successfully create a dexamethasone-delivery metallic implant. Irrespective of the loaded medication, the surface of this novel implant possesses advantageous material features including homogeneity, hydrophilicity, and optimal roughness. UV-vis spectroscopy revealed much more sustainable drug release compared to the implants produced using simple drug attachment. In addition, our drug-releasing implant was found to have multiple biological benefits. As proven by the ELISA data, this multi-layer drug complex provides differential regulation on the cell apoptosis, as well as pro-osteogenic and anti-inflammatory effects on the peri-implant tissue. Furthermore, using the pathway-specific PCR array, our study discovered 28 and 26 upregulated and downregulated genes during osteogenesis and inflammation on our newly fabricated drug-delivery implant, respectively. The medication-induced change in molecular profile serves as a promising clue for designing future implant-based therapy. Collectively, we present atmospheric pressure plasma as a potent tool for creating a surgical implant-based drug-delivery system, which renders multiple therapeutic potentials. Graphical abstract Schematic of the APP-facilitated Dex-delivery implant. This layer-by-layer drug-releasing complex consisted of bottom plasma activation layer, middle medication layer, and top absorbable polymer layer.

Customizable Implant-specific and Tissue-Specific Extracellular Matrix Protein Coatings Fabricated Using Atmospheric Plasma

Progression in implant science has benefited from ample amount of technological contributions from various disciplines, including surface biotechnology. In this work, we successfully used atmospheric plasma to enhance the biological functions of surgical implants by coating them with extracellular matrix proteins. The developed collagen and laminin coatings demonstrate advantageous material properties. Chemical analysis by XPS and morphological investigation by SEM both suggested a robust coating. Contact angle goniometry and dissolution study in simulated body fluid (SBF) elicited increased hydrophilicity and physiological durability. Furthermore, these coatings exhibited improved biological interactions with human mesenchymal and neural stem cells (NSCs). Cell adhesion, proliferation, and differentiation proved markedly refined as shown by enzymatic detachment, flow cytometry, and ELISA data, respectively. Most importantly, using the pathway-specific PCR array, our study discovered dozens of deregulated genes during osteogenesis and neurogenesis on our newly fabricated ECM coatings. The coating-induced change in molecular profile serves as a promising clue for designing future implant-based therapy. Collectively, we present atmospheric plasma as a versatile tool for enhancing surgical implants, through customizable implant-specific and tissue-specific coatings.

Coblation tonsillectomy versus coblation tonsillectomy with ties in adults

Objective

This study was performed to compare the intraoperative and postoperative courses of coblation tonsillectomy and coblation tonsillectomy with ties in adults.

Methods

All patients who underwent tonsillectomy from July 2012 to September 2016 were retrospectively reviewed. Intraoperative and postoperative bleeding, pain, and return to normal food intake were compared between patients who underwent coblation tonsillectomy and those who underwent coblation tonsillectomy with ties.

Results

Of 515 patients, 300 (58.3%) underwent coblation tonsillectomy and 215 (41.7%) underwent coblation tonsillectomy with ties. Twenty-five (4.9%) patients developed postoperative hemorrhage, 22 (88.0%) of whom had undergone coblation tonsillectomy and 3 (12.0%) of whom had undergone coblation tonsillectomy with ties. Patients who underwent coblation tonsillectomy reported less pain than those who underwent coblation tonsillectomy with ties. Patients who underwent coblation tonsillectomy with ties resumed a normal diet significantly later than those who underwent coblation tonsillectomy (10.0 ± 3.2 vs. 8.2 ± 1.9 days, respectively).

Conclusion

Coblation tonsillectomy is associated with less intraoperative bleeding, a shorter surgery time, less postoperative pain, and fewer days to recovery of a normal diet than is coblation tonsillectomy with ties. However, coblation tonsillectomy with ties is associated with remarkably reduced postoperative hemorrhage.

Coblation tonsillectomy versus cold steel dissection tonsillectomy: a morphological study

Objective

To compare the extent of tissue damage produced by conventional cold steel and coblation tonsillectomy.

Methods

Twenty patients underwent conventional and 18 underwent coblation tonsillectomy. The removed tonsils were histopathologically evaluated.

Results

Analgesic use was lower in the coblation group during the early post-operative period. Histological investigation of tonsils removed by the conventional method showed intensive haemorrhage and hyperaemia in the tonsillar capsules, which was not seen in the coblation group. Furthermore, in the coblation group, there was less mast cell degranulation (p = 0.0081) and a smaller amount of skeletal muscle tissue (p = 0.0043) in the tonsillar capsules, indicating less tissue damage.

Conclusion

Compared to the cold steel technique, coblation tonsillectomy is superior in terms of less early post-operative pain and less damage to surrounding tissues. Significantly lower mast cell degranulation in coblation tonsillectomy may contribute to the reduction of post-operative pain.

Argon plasma coagulation tonsillectomy versus coblation tonsillectomy: a comparison of efficacy and safety

BACKGROUND

Tonsillectomy is one of the most common otolaryngological procedures. Nonetheless, there is still no universally approved 'gold standard' technique.

OBJECTIVE

To compare the safety and efficacy of argon plasma coagulation and coblation techniques in tonsillectomy.

METHODS

A multi-institutional, retrospective cohort study was conducted, comprising 283 patients who underwent bilateral tonsillectomies performed by a single surgeon between 2014 and 2017. The outcome measures included: operative time, intra-operative blood loss, post-operative pain and post-operative haemorrhage.

RESULTS

In the argon plasma coagulation group, mean operative time and post-operative haemorrhage rate were significantly reduced, p = 0.0006 and p = 0.003 respectively. There was no statistically significant difference between the two groups in terms of post-operative pain and intra-operative blood loss.

CONCLUSION

The argon plasma coagulation technique is easy, safe and efficacious. Argon plasma coagulation tonsillectomy seems cost-effective compared to coblation tonsillectomy: the single-use disposable electrode tip and wand used in this study cost AUD$76.50 and AUD$380 respectively. Argon plasma coagulation appears to be a favourable alternative to current modalities such as coblation.

Cost-effectiveness of Coblation compared with cold steel tonsillectomies in the UK

Objective

This study aimed to estimate the cost-effectiveness of Coblation compared with cold steel tonsillectomy in adult and paediatric patients in the UK.

Method

Decision analysis was undertaken by combining published clinical outcomes with resource utilisation estimates derived from a panel of clinicians.

Results

Using a cold steel procedure instead of Coblation is expected to generate an incremental cost of more than £2000 for each additional avoided haemorrhage, and the probability of cold steel being cost-effective was approximately 0.50. Therefore, the cost-effectiveness of the two techniques was comparable. When the published clinical outcomes were replaced with clinicians’ estimates of current practice, Coblation was found to improve outcome for less cost, and the probability of Coblation being cost-effective was at least 0.70.

Conclusion

A best-case scenario suggests Coblation affords the National Health Service a cost-effective intervention for tonsillectomy in adult and paediatric patients compared with cold steel procedures. A worst-case scenario suggests Coblation affords the National Health Service an equivalent cost-effective intervention for adult and paediatric patients.

Postoperative Tonsillectomy Hemorrhage

Post-tonsillectomy hemorrhage represents a potentially life-threatening condition that occurs in up to 5% of pediatric patients. Minor bleeding often precedes severe hemorrhage. Patients with minor or self-resolving bleeding should be observed in the emergency department or admitted for monitoring. Patients with severe bleeding should be immediately assessed for airway and hemodynamic stability. Management of severe bleeding includes immediate surgical consultation or initiation of the transfer process to a center with surgical capabilities, direct pressure to the site of hemorrhage with or without the additional of a hemostatic agent, possible rapid sequence intubation, and management of hemodynamic instability with volume resuscitation.

Coblation versus other surgical techniques for tonsillectomy

BACKGROUND

Tonsillectomy is a very common operation and is performed using various surgical methods. Coblation is a popular method because it purportedly causes less pain than other surgical methods. However, the superiority of coblation is unproven.

OBJECTIVES

To compare the effects of coblation tonsillectomy for chronic tonsillitis or tonsillar hypertrophy with other surgical techniques, both hot and cold, on intraoperative morbidity, postoperative morbidity and procedural cost.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2017, Issue 3); PubMed; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 20 April 2017.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of children and adults undergoing tonsillectomy with coblation compared with any other surgical technique. This review is limited to trials of extracapsular (traditional) tonsillectomy and excludes trials of intracapsular tonsil removal (tonsillotomy).

DATA COLLECTION AND ANALYSIS

We used the standard Cochrane methods. Our primary outcomes were: patient-reported pain using a validated pain scale at postoperative days 1, 3 and 7; intraoperative blood loss; primary postoperative bleeding (within 24 hours) and secondary postoperative bleeding (more than 24 hours after surgery). Secondary outcomes were: time until resumption of normal diet, time until resumption of normal activity, duration of surgery and adverse effects including blood transfusion and the need for reoperation. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics.

MAIN RESULTS

We included 29 studies, with a total of 2561 participants. All studies had moderate or high risk of bias. Sixteen studies used an adequate randomisation technique, however the inability to mask the surgical teams and/or provide adequate methods to mitigate the risk of bias put nearly all studies at moderate or high risk of detection and measurement bias for intraoperative blood loss, and primary and secondary bleeding. In contrast most studies (20) were at low risk of bias for pain assessment. Most studies did not report data in a manner permitting meta-analysis.Most studies did not clearly report the participant characteristics, surgical indications or whether patients underwent tonsillectomy or adenotonsillectomy. Most studies reported that tonsillitis (infection) and/or tonsillar hypertrophy (obstruction) were the indication for surgery. Seven studies included only adults, 16 studies included only children and six studies included both. Pain At postoperative day 1 there is very low quality evidence that patients in the coblation group had less pain, with a standardised mean difference (SMD) of -0.79 (95% confidence interval (CI) -1.38 to -0.19; 538 participants; six studies). This effect is reduced a SMD of -0.44 (95% CI -0.97 to 0.09; 401 participants; five studies; very low-quality evidence) at day 3, and at day 7 there is low quality evidence of little or no difference in pain (SMD -0.01, 95% CI -0.22 to 0.19; 420 participants; five studies). Although this suggests that pain may be slightly less in the coblation group between days 1 and 3, the clinical significance is unclear. Intraoperative blood loss Methodological differences between studies in the measurement of intraoperative blood loss precluded meta-analysis. Primary and secondary bleeding The risk of primary bleeding was similar (risk ratio (RR) 0.99, 95% CI 0.48 to 2.05; 2055 participants; 25 studies; low-quality evidence). The risk of secondary bleeding was greater in the coblation group with a risk ratio of 1.36 (95% CI 0.95 to 1.95; 2118 participants; 25 studies; low-quality evidence). Using the median of the control group as the baseline risk, the absolute risk in the coblation group was 5% versus 3.6% in the control group. The difference of 1.3% has a 95% CI of 0.2% lower in the coblation group to 3.5% higher. Secondary outcomes Differences in study design and data reporting precluded the identification of differences in the time to resumption of normal diet or activity, or whether there was a difference in the duration of surgery.Although we could not feasibly compare the costs of equipment or operative facility, anaesthetic and surgical fees across different healthcare systems we used duration of surgery as a proxy for cost. Although this outcome was commonly reported in studies, it was not possible to pool the data to determine whether there was a difference.Adverse events other than bleeding were not well reported. It is unclear whether there is a difference in postoperative infections or the need for reoperation.

AUTHORS' CONCLUSIONS

The coblation technique may cause less pain on postoperative day 1, but the difference is small and may be clinically meaningless. By postoperative day 3, the difference decreases further and by postoperative day 7 there appears to be little or no difference. We found similar rates of primary bleeding but we cannot rule out a small increased risk of secondary bleeding with coblation. The evidence supporting these findings is of low or very low quality, i.e. there is a very high degree of uncertainty about the results. Moreover, for most outcomes data were only available from a few of the 29 included studies.The current evidence is of very low quality, therefore it is uncertain whether or not the coblation technique has any advantages over traditional tonsillectomy techniques. Despite the large number of studies, failure to use standardised or validated outcome measures precludes the ability to pool data across studies. Therefore, well-conducted RCTs using consistent, validated outcome measures are needed to establish whether the coblation technique has a benefit over other methods. In the included studies we identified no clear difference in adverse events. However, given the rarity of these events, randomised trials lack the power to detect a difference. Data from large-scale registries will provide a better estimate of any difference in these rare outcomes.