Pediatric tonsillectomy: A short-term and long-term comparison of intracapsular versus extracapsular techniques

Endoscopic Powered Intracapsular Tonsillectomy and Adenoidectomy in Pediatric Obstructive Sleep Apnea With High-Risk Comorbid Disease Conditions: A Case Series

OBJECTIVE

Pediatric obstructive sleep apnea (OSA) caused by adenoids or an enlarged palatine tonsil has a negative impact on physical and mental growth. Surgical removal of the tissue is effective but entails a life-threatening risk of postoperative bleeding, which is up to 30 times higher in chronic pediatric disease cases. However, endoscopes and resection devices provide safe, reliable surgical methods. Here, we report the efficacy and safety of endoscopic powered intracapsular tonsillectomy and adenoidectomy (PITA) for pediatric OSA in patients with high-risk comorbidities.

METHODS

This retrospective case series included pediatric patients with OSA who underwent PITA at a single tertiary medical center between April 2017 and May 2023. Ten patients (three males and seven females; mean age 6.4 years, range 2-12 years) were included; all met the Japanese criteria for complex chronic pediatric conditions.

RESULTS

The average operative time was 61 min; a microdebrider was used in eight cases and a coblator in two cases. Although there was no postoperative bleeding, one case experienced regrowth.

CONCLUSIONS

Our data show that an endoscopic PITA approach could reduce the risk of severe bleeding and relieve the sleeping conditions of pediatric patients with complex chronic OSA.

Coblation intracapsular tonsillectomy in a paediatric tertiary centre: Revision surgery rates over a nine-year period

OBJECTIVES

Coblation intracapsular tonsillectomy (ICT) is increasingly being used in the paediatric population because of the rapid recovery and low rates of complications associated with it. There is, however, a risk of symptomatic regrowth with this technique. The objective of our study is to establish the rate of, and risks for, revision surgery over time in a major tertiary referral centre with a large cohort of paediatric Coblation ICT cases.

METHODS

A retrospective review of all children (0-19 years) undergoing Coblation ICT from April 2013 to June 2022 was undertaken, using electronic databases and clinical records. Post-operative follow up was reviewed and revision cases were subsequently identified and examined. Statistical analysis was performed using a Chi-Squared test.

RESULTS

4111 patients underwent Coblation ICT during the studied period, with or without concomitant adenoidectomy. Of these, 135 (3.3 %) required revision tonsil surgery, primarily for recurrence of initial symptoms; two patients required two consecutive revision procedures (137 revision procedures in total). Eight-eight (n = 88) (64 %) of these were revised with a repeat Coblation ICT procedure and 49 (36 %) with bipolar diathermy extracapsular tonsillectomy (ECT) of remnant tonsil tissue. The revision rates after Coblation ICT declined steeply on a year-on-year basis since the commencement of this technique (from 10.6 % early on, to 0.3 % at the end of the study period P<0.001). A significantly higher revision rate was noted in children below the age of two at the time of primary surgery, compared to those older than two years of age (P<0.001).

CONCLUSIONS

This study demonstrates real-world departmental revision rates over a nine-year period from the technique's commencement of use. With Coblation ICT, symptomatic re-growth occurs rarely, but may be clinically significant, with higher rates of recurrent symptoms seen in children under two years of age at the time of primary surgery. The revision rate apparently drops over time in parallel with overall experience of surgeons and formalised training.

Associations Between Post-tonsillectomy Hemorrhage and Anatomical Subsites of the Tonsillar Fossa

OBJECTIVE

This study presents a novel classification of the anatomical subsites of the tonsillar fossa and discusses their associations with post-tonsillectomy hemorrhage (PTH) after extracapsular tonsillectomy.

MATERIALS AND METHODS

Coblation tonsillectomy was performed on three adult cadavers and the anatomical subsites of the tonsillar fossa based on the distribution of the tonsillar feeding artery: the upper pole (subsite A), most of the tonsil body (subsite B), the inferior tonsil body (subsite C), and components of the lower pole (subsites D and E). Extracapsular tonsillectomy was prospectively performed using various surgical techniques and PTH was evaluated.

RESULTS

A cadaveric study revealed that the intra- and extra-capsular vessel topographies were essentially identical. Although the demarcation lines varied either up or down by a few millimeters, the arterial vascular network was particularly dense at subsites D and E, and the vessel diameter at these subsites was significantly greater than at subsite C and also (especially) at subsite E. Of 680 patients who underwent tonsillectomy, PTH developed early in 13 (31.7%) and late in 28 (68.3%). Surgical interventions were required by 29/41 patients (70.7%). Subsites D and E were the most common subsites of late PTH and PTH that required intervention. Such intervention was rarely necessary when PTH developed at subsite A or B.

CONCLUSIONS

The new classification of the anatomical subsites of the tonsillar fossa aids inexperienced surgeons and provides an anatomical rationale for variation in surgical technique that minimizes vascular injury, thus improving safety.

Efficacy of endoscopic powered intracapsular tonsillectomy and adenoidectomy for pediatric obstructive sleep apnea: A retrospective case-control study

OBJECTIVE

Safe surgery for pediatric patients with obstructive sleep apnea (OSA) is important to decrease postoperative events and improve cost-effectiveness. Therefore, this study aimed to compare surgical efficacy and safety between powered intracapsular tonsillectomy and adenoidectomy (PITA) and extracapsular tonsillectomy and adenoidectomy for OSA in children.

METHODS

In this retrospective case-control study, patient characteristics and postoperative outcomes were compared between 93 children with OSA who underwent PITA and 81 children who underwent conventional extracapsular tonsillectomy and adenoidectomy at a tertiary hospital. Data analysis using multivariate, multiple regression, and binomial logistic regression analyses was performed.

RESULTS

PITA reduced the odds of postoperative hemorrhage by 8.95% (odds ratio [OR]: 5.69, p = 0.013) and of secondary hemorrhage by 8.8% (OR: 10.08, p = 0.006), decreased postoperative analgesia use by 0.35% (p < 0.001), and increased oral intake on postoperative day 1 by 17% (p < 0.001). There were no significant differences in early hemorrhage or regrowth rates between the groups.

CONCLUSION

PITA could reduce the risk of secondary hemorrhage and improve postoperative quality of life, which are ideal clinical benefits of surgery in pediatric patients with OSA.

A prospective, randomized, single-blind study comparing coblation and monopolar extracapsular tonsillectomy

Objective

The aim of this study was to compare intraoperative blood loss, postoperative pain, post-tonsillectomy hemorrhage (PTH), and medical costs associated with extracapsular tonsillectomy between coblation and monopolar electrocautery in children.

Materials and methods

This study included 293 patients aged 6-15 years planned to undergo extracapsular tonsillectomy. Data on estimated blood loss, postoperative pain score, operation time, PTH, and the cost of disposable equipment were collected.

Results

Coblation extracapsular tonsillectomy was associated with significantly lower mean pain scores than monopolar technique on postoperative days 1 (p <.001) and 2 (p = 0.02). However, the pain score was similar between the groups at all other time points. The monopolar group had a significantly shorter operation time compared to the coblation group (11.09 ± 7.53 vs. 17.12 ± 4.29 min, p <.001). Intraoperative estimated blood loss was not significantly different between the groups (p = .43).The cost of extracapsular tonsillectomy was significantly lower in the monopolar compared to the coblation group (US$ 28.18 vs. US$ 430.48, p <.001). PTH occurred in 17 patients (5.80%) and required a second surgery. Secondary PTH occurred in 6.16% (9/146) and 0.68% (1/147) of patients in the coblation and monopolar groups, respectively (p <.001). The PTH was significantly higher in the tonsillitis compared to in the tonsillar hypertrophy (12.37% vs. 2.55%, p = .002), However, the difference of PTH was not significant among mean pain scores subgroups. Of the 17 patients with PTH, the lower pole, middle portion, and upper pole were involved in 15 (88.24%), 2 (11.76%), and 0 cases, respectively.

Conclusions

Coblation and novel monopolar electrocautery extracapsular tonsillectomy are associated with similar postoperative pain scores except on postoperative days 1 and 2. However, monopolar technique offers significant advantages over coblation method with less operative time, decreased secondary PTH, and cost.Level of Evidence: NA.

Tonsillectomy and Adenoidectomy - Pediatric Clinics of North America

Tonsillectomy and adenoidectomy are among the most commonly performed major pediatric operations in the United States, with more than 500,000 procedures performed annually. This procedure can be performed with or without adenoidectomy. These procedures were traditionally performed for recurrent tonsillitis; however, the vast majority of tonsillectomies are currently performed for obstructive symptoms. When performed for appropriate indications, tonsillectomy and adenoidectomy can greatly improve a child's quality of life and general health. Given the prevalence of these conditions and subsequent surgical procedures, evidence-based recommendations are regularly evaluated and updated. As such, familiarity with these guidelines is necessary for pediatric practitioners. This review summarizes the indications, complications, and outcomes for tonsillectomy and adenoidectomy, as well as provides a brief overview of operative techniques.

Does perioperative ketorolac increase bleeding risk after intracapsular tonsillectomy?

IMPORTANCE

Conflicting evidence exists regarding the post-tonsillectomy bleed risk associated with perioperative ketorolac use in the pediatric population. Surgical technique for tonsillectomy can further confound this risk.

OBJECTIVE

The primary objective was to retrospectively quantify the post-tonsillectomy bleed rate after single-dose administration of ketorolac in pediatric patients following intracapsular tonsillectomy. The secondary objective was to determine if age, sex, body mass index, medical comorbidities, and indication for surgery increased post-tonsillectomy bleed risk.

DESIGN

Retrospective cohort study of 1920 children who underwent intracapsular tonsillectomies between January 2017 and December 2018.

SETTING

This study was completed at a tertiary-care pediatric referral center.

PARTICIPANTS

1920 children who underwent intracapsular tonsillectomies between January 2017 and December 2018 at a single tertiary-care children's hospital.

EXPOSURES

Patients were divided into two cohorts: 1458 patients (75.9%) received ketorolac (K+), and 462 (24.1%) did not (NK). Age, sex, body mass index, comorbidities, and indication for surgery also were evaluated for association with post-tonsillectomy bleed risk.

MAIN OUTCOME(S) AND MEASURE(S)

Primary study outcome for both cohorts was post-tonsillectomy hemorrhage requiring operative intervention.

RESULTS

1920 study participants were included with an average age of 6.5 years; 51.5% of participants were males; and, 63.9% were white. Overall, the postoperative bleeding rate was 1.5%. However, there was no significant difference when comparing bleeding rates for the ketorolac group and the non-keterolac group (1.4%-1.7%; P = .82) Age, chronic tonsillitis, higher body mass index Z-scores, attention-deficit/hyperactivity disorder, and behavioral diagnoses were statistically significant risk factors for post-tonsillectomy hemorrhage.

CONCLUSIONS AND RELEVANCE

Single-dose postoperative ketorolac does not appear to be associated with increased risk of post-tonsillectomy bleed in pediatric patients undergoing intracapsular tonsillectomy. Providers should not avoid using ketorolac in patients undergoing intracapsular tonsillectomy due to concerns over bleeding risk.

Coblation intracapsular tonsillectomy in children: A prospective study of 1257 consecutive cases with long-term follow-up

OBJECTIVES

Intracapsular tonsillectomy (ICT) is increasingly adopted by paediatric centres worldwide due to its association with reduced pain, fast recovery and low risks of post-operative complications. Questions still surround its role in patients with recurrent tonsillitis, as well as tonsillar regrowth requiring revision surgery.

DESIGN

Prospective consecutive case series from March 2013 to April 2020.

SETTING

Tertiary paediatric ENT referral centre.

PARTICIPANTS

Paediatric patients undergoing Coblation ICT, with or without adenoidectomy, for obstructive and/or infective indications.

MAIN OUTCOME MEASURES

Health-Related Quality of Life (HRQL), analgesia requirement, post-operative haemorrhage rates, time to return to normal diet and activity or school/nursery, and parental satisfaction. We report revision surgery rates and identify predictive factors for revision surgery.

RESULTS

A total of 1257 patients (median age 4.2 years) underwent Coblation ICT, with a median direct and implied follow-up of 101.5 and 1419 days, respectively. We noted significantly improved HRQL scores across all domains. Median analgesia requirement was six days, and no patients required a return to theatre for post-operative haemorrhage. The majority of patients were eating a normal diet within 24 hours and returned to normal activity/school within a week post-operatively. Revision surgery was required in 2.6% of cases, mainly due to recurrent obstructive symptoms from tonsillar regrowth. Being under two years old at initial surgery (OR 5.10), having severe OSA (OR 4.43) or severe comorbidities (OR 2.98) increased the risk of needing revision surgery.

CONCLUSIONS

Long-term data demonstrate the efficacy and safety of Coblation ICT in paediatric patients across a range of indications.

Efficacy of bupivacaine infiltration for controlling post-tonsillectomy pain, duration of surgery and post-operative morbidities: A systematic review and meta-analysis

The objective of the present review and meta-analysis was to evaluate the efficacy of bupivacaine during tonsillectomy in terms of reducing the mean operative procedure duration, post-operative pain and the onset of post-operative morbidities. The Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines were followed to perform a systematic literature search using the MEDLINE, Scopus, EMBASE and CENTRAL databases. The present meta-analysis sought to evaluate the efficacy of bupivacaine administered during tonsillectomy as compared to the administration of normal saline. The efficacy of the intervention was evaluated based on pain scores using the visual analogue scale, the duration of the operation and the occurrence of post-operative morbidities. Out of 1,427 records, 15 articles with 729 participants (mean age, 10.2±6.7 years) were included in the study. The present systematic review supported the use of bupivacaine during tonsillectomy at a level of evidence of 1b and confirmed beneficial effects of bupivacaine intervention by demonstrating small to large effect reductions in the visual analog scale score (Hedge's g, -1.48), the mean duration of the operative procedure (Hedge's g, -1.35) and the incidence of post-operative morbidity (Hedge's g, -0.23) in comparison to the placebo groups treated with normal saline. Based on these results, the administration of bupivacaine is recommended during tonsillectomies to reduce the perceived level of pain, the duration of the operation and the post-operative morbidity.