High incidence of post-tonsillectomy secondary haemorrhage following coblation tonsillectomy

A comparison of coblation and modified monopolar tonsillectomy in adults

OBJECTIVE

To compare the intraoperative records and postoperative clinical outcomes of adults who underwent coblation and modified monopolar tonsillectomy tonsillectomies.

MATERIALS AND METHODS

Adult patients with tonsillectomy were randomly divided into the coblation and modified monopolar tonsillectomy groups. The estimated blood loss, postoperative pain score, operation time, post-tonsillectomy hemorrhage (PTH), and cost of disposable equipment were compared.

RESULTS

Pain intensity in the coblation and monopolar groups was similar on postoperative days 3 and 7. However, the mean maximum pain score in the monopolar group was significantly higher compared to the coblation group on postoperative days 1 (P < 0.01) and 2 (P < 0.05).Secondary PTH occurred in 7.1% (23/326) of patients in the coblation group and 2.8% (9/327) of patients in the monopolar group (P < 0.05).

CONCLUSION

Although pain was significantly increased on postoperative days 1 and 2 in the modified monopolar tonsillectomy group, the operation time, secondary PTH, and medical costs were significantly decreased compared to the coblation technique group.

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.

Coblation Versus Cold Dissection Tonsillectomy: A Comparative Study

Tonsillectomy is the most frequently performed surgery in the recent years. Many techniques have been advocated to improve surgical efficacy and decrease postoperative morbidity. Probably the most update was coblation tonsillectomy. This is a comparative study which was conducted on 50 patients (23 females and 27 males) who underwent tonsillectomy operations, 25 patients using cold steel dissection method whereas coblation technique was used for the rest 25 patients. Follow up was done at day 1, 3, 7 and 14 and the related parameters were calculated. The mean age of patients was 11.6 years with a mean of 2.2-40 years. There were 27 (54%) males out of 50 and 23 (46%) were females. Male to female ratio was 54%:46% ≈ 1.17:1. The current study revealed significant difference between coblation versus cold dissection tonsillectomy. Postoperative pain was significantly less at day 3 and day 7 using coblation technique. Moreover, there were less intraoperative bleeding, less time in days to return to normal diet and less time to return to normal activities. We believe that coblation tonsillectomy carries less morbidity than cold steel dissection, hence we recommend it to be applied at our hospital.

A single center retrospective comparison of post-tonsillectomy hemorrhage between BiZact and Coblator

INTRODUCTION

Over 550,000 tonsillectomies are performed every year. While post-tonsillectomy hemorrhage (PTH) has been studied in the coblator, bovie, and cold steel technique, there is a dearth of studies examining the post-tonsillectomy outcome using BiZact. This study examines the rate of BiZact PTH requiring control of hemorrhage in the OR and assess resident comfort using the device.

METHODS

Retrospective chart review for all tonsillectomies performed between January 2018 and December 2020 were performed. Rates of PTH were analyzed. In addition, a 7-question BiZact resident experience survey was administered to 25 otolaryngology residents.

RESULTS

1384 patients were included in this study; 444 (32%) Bizact and 940 (68%) Coblation. 11 (2.48%) BiZact patients had PTH requiring OR for control of hemorrhage, compared to 44 (4.68%) Coblation patients. There were no patient deaths because of PTH. The mean age of patients with PTH was 7.44 (SD 4.07) years old. 22 (88%) residents responded to the survey. 17 (77.27%) felt more confident with Coblator while performing tonsillectomy most commonly reported for ease of use, followed by BiZact 4 (18.18%), most commonly reported for improved surgical plane.

CONCLUSION

BiZact is a safe and effective addition. At our institution, the rate of secondary PTH requiring OR intervention for BiZact is comparable to the national average for other tonsillectomy devices. The rate of BiZact PTH requiring OR intervention in our experience was nearly half of those done with Coblator. Overall residents at SCHC preferred Coblator over BiZact mainly attributed to Coblator's versatility and ability to control intraoperative tonsil bleeding without additional instruments despite BiZact's shorter operative time.

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.

Significantly reducing post-tonsillectomy hemorrhage requiring surgery by double-layer suture: A retrospective analysis

BACKGROUND

Although tonsillectomies carry a low-risk for adverse events, postoperative hemorrhage has been reported as the most common complication.

AIM

To compare the rates of postoperative secondary hemorrhage for tonsillectomy with or without double-layer suture.

MATERIAL AND METHODS

This is a retrospective study of 5087 patients who underwent coblation tonsillectomy with or without suture from 2006 to 2016. All cases had been followed up 3 weeks and severe secondary hemorrhage cases requiring operation were analyzed.

RESULTS

The severe secondary hemorrhage rate was statistically higher in group without suture (1.96%) as compared with the group with suture (1.08%). The surgery time (36.55 ± 7.45) was longer in patients with suture as compared to patients without suture (31.50 ± 6.23). In the age between 18 and 49 years group, the higher secondary hemorrhage rate (2.44%) was found in patients without suture. The rate of postoperative hemorrhage (0.96%) was significantly higher in patients without suture as compared with patients with suture (0.36%) on postoperative 5th day.

CONCLUSIONS

The risk of severe secondary hemorrhage is reduced in coblation tonsillectomy with suture. The rate of secondary hemorrhage is lower in patients with suture in 18 to 49 years old group and on the 5th day after surgery.

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.

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.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

NA-animal studies or basic research.

The debate continues: a prospective, randomised, single-blind study comparing Coblation and bipolar tonsillectomy techniques

OBJECTIVES

Tonsillectomy is a common procedure with significant post-operative pain. This study was designed to compare post-operative pain, returns to a normal diet and normal activity, and duration of regular analgesic use in Coblation and bipolar tonsillectomy patients.

METHODS

A total of 137 patients, aged 2-50 years, presenting to a single institution for tonsillectomy or adenotonsillectomy were recruited. Pain level, diet, analgesic use, return to normal activity and haemorrhage data were collected.

RESULTS

Coblation tonsillectomy was associated with significantly less pain than bipolar tonsillectomy on post-operative days 1 (p = 0.005), 2 (p = 0.006) and 3 (p = 0.010). Mean pain scores were also significantly lower in the Coblation group (p = 0.039). Coblation patients had a significantly faster return to normal activity than bipolar tonsillectomy patients (p < 0.001).

CONCLUSION

Coblation tonsillectomy is a less painful technique compared to bipolar tonsillectomy in the immediate post-operative period and in the overall post-operative period. This allows a faster return to normal activity and decreased analgesic requirements.

Comparison of Cold Technique Tonsillectomy and Thermal Welding Tonsillectomy at Different Age Groups

The aim of this study is to compare objectively advantages and disadvantages of cold technique tonsillectomy and thermal welding tonsillectomy at the same case. A total of 100 patients, 53 patients younger than 12 years of age and 47 patients elder than 12 years of age, were included in this study. Tonsillectomy was performed by using cold technique on the right side of the palatine tonsils and thermal welding on the left side. Right and left sides were compared regarding perioperative bleeding, surgical dissection time, postoperative pain scale at the 1st and 7th day and postoperative bleeding parameters. Perioperative bleeding was found to be higher in cold technique side in patients younger than 12 years of age (p&lt;0.001). Postoperative pain score on the day 1 was significantly higher in cold technique side, whereas it was found to be higher in thermal welding side at postoperative day 7 (p&lt;0.001). Perioperative bleeding was found to be significantly higher in cold technique side (p&lt;0.001) and surgical dissection time of thermal welding was found to be longer (p&lt;0.001) in patients elder than 12 years of age. Postoperative pain score at the day 1 and day 7 was found to be higher in thermal welding side (p&lt;0.001). Postoperative pain score at the day 1 and day 7 were statistically significantly higher in patients elder than 12 years of age. As a result, both techniques have its unique superior aspects and both can be applied as a routine tonsillectomy technique.

Postoperative Pain in Adult Tonsillectomy: Is There Any Difference Between the Technique?

Tonsillectomy is one of the most common surgical procedures performed worldwide. Several techniques have been developed to reduce morbidity and enhance recovery after tonsillectomy. Our study was designed to compare post-operative pain with three different techniques: cold dissection (CD), monopolar-bipolar dissection (MBD) and coblation dissection (CBD). 103 adults were scheduled for elective tonsillectomy from September 2014 to December 2015, and were randomized to CD, MBD and CBD. Post-operative pain was assessed using visual analogue scale (VAS) and Lattinen Test (LT). We did not find significant differences between the groups in the VAS pain scores (p > 0.05), except for the first day, when CBD tonsillectomy showed a higher pain score (p < 0.05). The differences in LT scores between the three techniques were not statistically significant (p > 0.05). Comparison of analgesic consumption between CD, MBD and CBD did not found any significant differences irrespective of the technique used. When first and second week after surgery were compared, differences in analgesics requirements were statistically significant (p < 0.05). Seventeen cases (16.5%) of secondary haemorrhage were reported, but there were no statistical differences in the rate of postoperative bleeding between the three groups (p > 0.05). We conclude that in our study comparison of the three techniques, CD, MBD and CBD, did not show significant differences in the post-tonsillectomy pain scores and bleeding rate.

Postoperative tonsillectomy bleeding complications in children: A comparison of three surgical techniques

OBJECTIVE & HYPOTHESIS

Stated in the Null form: There will be no difference in primary or secondary hemorrhage rate in children undergoing tonsillectomy or adenotonsillectomy across three surgical techniques: PEAK Plasmablade, electric monopolar cautery, coblation.

STUDY DESIGN

Retrospective chart analysis.

SETTING

Academic Medical Center: Children's Hospital.

SUBJECTS & METHODS

Electronic chart data were collected from patient's age 2-18 years who underwent tonsillectomy, with or without adenoidectomy, at a tertiary pediatric hospital between June 2011 to May 2013 by electric monopolar cautery, coblation, or PEAK PlasmaBlade. Treatment outcomes following each of these surgical approaches, relative to rate of post-operative primary and secondary bleeding, hospital admission, and emergency department visits were compared.

RESULTS

A total of 1780 patients that had tonsillectomy or adenotonsillectomy were evaluated. There was a significant difference in bleed rate by age with older patients having more bleeding post-procedure than their younger counterparts. There was also a difference in bleeding frequency by diagnosis. Patients with a diagnosis of OSA were less likely to experience a postoperative bleed than children with either recurrent tonsillitis or both. Significance was evident between post-op hemorrhage rate and instrumentation (χ(2) = 11.17, df = 2, p = 0.004). The majority of bleeds occurred with coblation (58.9%), while PEAK had only 17.8% and cautery 23%.

CONCLUSION

The null hypothesis was rejected. That is, PEAK PlasmaBlade was safe and effective, with statistically less postoperative bleeding and ED visits, especially when compared to coblation techniques. Coblation patients had the highest rates of postoperative bleeding.