Pediatric total tonsillectomy using coblation compared to conventional electrosurgery: a prospective, controlled single-blind study

Postoperative Morbidity of Different Tonsillectomy Techniques: A Systematic Review and Network Meta-Analysis

OBJECTIVE

To compare different tonsillectomy techniques in terms of postoperative bleeding incidence and postoperative pain.

METHODS

An arm-based network analysis was conducted using a Bayesian hierarchical model. The primary and secondary outcomes were postoperative bleeding incidence and mean postoperative pain score.

RESULTS

A total of 6464 patients were included for five different interventions (cold dissection tonsillectomy; extracapsular coblation tonsillectomy; intracapsular coblation tonsillectomy [ICT]; bipolar diathermy tonsillectomy [BDT]; monopolar diathermy tonsillectomy). ICT showed the lowest absolute risk (4.44%) of postoperative bleeding incidence (73.31% chance of ranking first) and the lowest mean postoperative pain score (1.74 ± 0.68) with a 94.0% chance of ranking first, whereas BDT showed both the highest absolute risk of bleeding incidence (10.75%) and the highest mean postoperative pain score (5.67 ± 1.43).

CONCLUSIONS

ICT seems to offer better postoperative outcomes, in terms of reduced risk of bleeding and reduced pain. Further prospective studies are advised to confirm these findings.

LEVEL OF EVIDENCE

NA Laryngoscope, 134:1696-1704, 2024.

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.

Adult tonsillectomy-increased pain scores are correlated with risk of bleeding: a retrospective cohort study

PURPOSE

Tonsillectomy is among the most common surgical procedures performed worldwide, and post-tonsillectomy bleeding is a serious complication. This study aims to investigate the role of post-operative pain as a risk factor for bleeding in adults.

METHODS

A retrospective cohort study of adults who underwent tonsillectomy in a tertiary referral center between 2015-2021. Medical records were reviewed for demographics, diagnoses, surgical technique, treatments, pain scores (measured by visual analogue scale 0-10), readmissions, and bleeding events. The primary outcome was return to the operating room for hemostasis, and secondary outcomes were bleeding events and consumption of additional analgesic doses.

RESULTS

Of the 274 patients, 137 (50%) were males, the mean age was 30.3 ± 12 years (range 18-82), and 33 (12%) were smokers. Indications for tonsillectomy were recurrent throat infections in 213 (77.7%) patients and obstructive sleep apnea in 61 (22.3%). Surgical technique was cold dissection in 238 (86.9%) patients and electrocautery in 36 (13.1%). Primary post-tonsillectomy bleeding (< 24 h of surgery) occurred in 6 (2%) patients, and secondary bleeding (later than 24 h from tonsillectomy) in 43 (15.7%). A total of 19 (7%) patients necessitated surgical hemostasis. After controlling for technique and other confounders, high pain scores (VAS ≥ 5) on post-operative days 1 and 2 were associated with increased risk of bleeding that necessitated surgical hemostasis (adjusted odds ratio 6.9, 95% confidence interval 1.7-44.5). Other independent risk factors were male sex, age < 30 years, smoking, and recurrent throat infections.

CONCLUSIONS

Higher pain scores following tonsillectomy are correlated with bleeding episodes requiring surgical intervention in adults. Further studies may explore the role of different intensive pain regimens in minimizing the risk of bleeding.

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

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

Comparison of outcomes between thermal welding forceps, controlled ablation and monopolar electrosurgery for tonsillectomy in children

OBJECTIVE

To compare recovery from tonsillectomy using thermal welding forceps (TWF), controlled ablation (CA), and monopolar electrosurgery (MES) in children.

METHODS

This was a prospective single blinded observational study using data from electronic medical record (EMR) and caregiver completed patient diary, conducted at a community-based children's hospital within an academic program with tonsillectomy performed by attending surgeons. Children aged 3-17 years undergoing tonsillectomy or adenotonsillectomy by TWF, CA, or MES over a 4-year period were included. Demographics, intraoperative time for tonsillectomy, blood loss, patient diary documentation of pain levels, analgesic doses, diet type and events per day were recorded. In addition, EMR documentation of morbidity events (bleeding, visits for bleeding, return to operating room [OR], total visits or admissions, poor oral intake or dehydration) were noted. To assess for differences in baseline characteristics, we utilized analysis of variance and Pearson's χ² test. To determine primary outcomes, we used a multilevel mixed-effect linear regression model.

RESULTS

A total of 369 children were enrolled, and 346 who met inclusion criteria underwent tonsillectomy. The children were categorized by the instrument used by the surgeons: CA 32.4% (n = 112), MES 36.7% (n = 127), and TWF 30.9% (n = 107). Mean age overall was 6.8 ± 3.2 years, with 57.4% female and 42.6% male. Diary return rate was 52.3% (n = 181) overall, with CA at 48.2% (n = 54), MES at 44.8% (n = 57), and TWF at 65.4% (n = 70). Average pain on the day of surgery was different between instruments with CA having the lowest level of 2.0 compared to 2.7 for TWF and MES (p = 0.001). Maximum pain level for day of surgery were lowest for CA at 2.7 compared to 3.4 for MES and 3.5 for TWF (p = 0.003). Pain levels were lowest for TWF after postoperative day (POD) 6. Overall rate of bleeding was 9.3%, with 2.6% return to surgery for control of bleeding. TWF had the lowest rate of bleeds (4.7% versus CA 11.6% and MES 11.0%), return to surgery (0.0% versus CA 2.7% and MES 4.7%), the earliest and final return to regular diet at POD 5.8 and 8.1, respectively without reaching statistical significance.

CONCLUSION

CA had significantly lowest early pain levels on day 0-1 and trended lowest up to POD 6, after which TWF was lowest but did not reach statistical significance. TWF had the earliest return to regular diet. Children undergoing CA and MES are more likely to have a postoperative bleed and a return to the OR than TWF suggesting improved ability to seal vessels with the latter instrument. Further study with a larger sample is needed.

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.

Monopolar electrocautery tip vs plasma ablation in tonsillotomy: A randomized case-control study comparing outcomes in pediatric population

BACKGROUND

The objective of this study was to compare the low-priced monopolar electrocautery to the high-priced, worldwide used, plasma ablation in tonsillotomy among children aged between three and twelve years, suffering from obstructive breathing disorders (OBD), with respect to post-operative pain, bleeding and related morbidities.

METHODS

A randomized case-control study was conducted in the Eye and Ear Hospital International- Lebanon. 103 children aged between three and twelve years suffering from OBD secondary to tonsillar hypertrophy were randomly assigned into two groups. Post-operative pain was evaluated using age-adequate validated scales: "FLACC-R" (Face, Legs, Activity, Cry, Consolability-Revised) for children aged less than five years, and "Wong Baker faces" for older children. Additional post-operative outcomes were evaluated using Pain-PROM (Patient reported Pain-Related Outcome Measures) and TAHSI (Tonsil and Adenoid Health Status Instrument) scales.

RESULTS

Significantly, higher rates of patients who underwent tonsillotomy via plasma ablation technique used analgesics and had severe pain compared to the monopolar electrocautery group. A longer operative duration was significantly associated with higher pain scores, and the plasma ablation technique yielded significantly higher operative mean durations. 10 days post-operatively, a significantly higher percentage of children reported an overall high pain severity and more than expected overall pain when using the plasma ablation technique compared to the monopolar electrocautery one. Overall bleeding rates were similar. No difference was reported one month post-operatively.

CONCLUSION

When compared to plasma ablation, monopolar electrocautery, can provide the same efficiency in relieving OBD in healthy children, with equal overall bleeding rates, but significantly lower cost, operating time, pain scores and need for analgesics.

Lateral rhinotomy and coblation for treatment of a nasal hamartoma in a dog

CASE DESCRIPTION

A 4-year-old spayed female French Bulldog was referred for treatment of a suspected right-sided nasal angiofibroma associated with a 4-month history of unilateral nasal discharge and stertor.

CLINICAL FINDINGS

The dog appeared healthy other than right-sided mucoid debris and decreased airflow through the right naris. The dog was anesthetized, and a large intranasal mass was observed obstructing the right nasal passage and abutting the nasal septum.

TREATMENT AND OUTCOME

A lateral rhinotomy was performed, and rigid endoscopes (0° and 30°) were used to examine the right nasal cavity. The mass filled the anterior aspect of the nasal cavity and involved a portion of the nasal turbinates with some erosion. A coblation unit was used to ablate tumor tissue laterally to remove the tumor in piecemeal fashion. Recovery was routine with only minor epistaxis after surgery, and the dog was discharged the next day. Eight months after surgery, follow-up CT revealed right-sided nasal turbinate and conchal atrophy consistent with prior mass ablation. No macroscopic recurrence was detected, and the owners reported only rare, clear rhinorrhea.

CLINICAL RELEVANCE

Findings suggested that coblation may be an alternative to radiation therapy for vascular tumors with minimal invasion and low metastatic potential.

Radiofrequency Ablation vs Electrocautery Blinded Randomized Trial: Impact on Clinically Meaningful Outcomes

OBJECTIVE

To analyze patients' return to normal activity, pain scores, narcotic use, and adverse events after undergoing tonsillectomy or adenotonsillectomy with monopolar electrocautery or radiofrequency ablation.

STUDY DESIGN

Randomized double-blinded clinical trial based on prospective parallel design.

SETTING

Academic medical center and tertiary children's hospital between March 2018 and July 2019.

METHODS

Inclusion criteria included patients aged ≥3 years with surgical indication of recurrent tonsillitis or airway obstruction/sleep-disordered breathing. Patients were randomly assigned to monopolar electrocautery or radiofrequency ablation. Patients were blinded to treatment assignment. Survey questions answered via text or email were collected daily until postoperative day 15. The primary outcome was the patient's return to normal activity. Secondary outcomes included daily pain score, total amount of postoperative narcotic use, and adverse events.

RESULTS

Of the 236 patients who met inclusion criteria and were randomly assigned to radiofrequency ablation or monopolar electrocautery, 230 completed the study (radiofrequency ablation, n = 112; monopolar electrocautery, n = 118). There was no statistically significant difference between the groups in the number of days for return to normal activity (P = .89), daily pain scores over 15 postoperative days (P = .46), postoperative narcotic use (P = .61), or return to hospital for any reason (P = .60), including bleeding as an adverse event (P = .13).

CONCLUSIONS

As one of the largest randomized controlled trials examining instrumentation in tonsillectomy, our data do not show a difference between monopolar electrocautery and radiofrequency ablation with regard to return to normal activity, daily pain scores, total postoperative narcotic use, or adverse events.

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.

Comparison of Endoscope-Assisted Coblation Adenoidectomy to Conventional Curettage Adenoidectomy in Terms of Postoperative Eustachian Tube Function

INTRODUCTION

Adenoidectomy is one of the most common surgical procedures performed in children in otorhinolaryngology practice. This study aims to compare the conventional curettage adenoidectomy (CCA) and the endoscope-assisted coblation adenoidectomy (EACA) in terms of the postoperative Eustachian tube function and the surgical outcomes.

METHODS

A prospective, randomized, controlled study was carried out at a tertiary referral center and private hospital. Seventy-two adenoid hypertrophy patients without middle ear disease were randomly assigned to 2 groups to be operated via CCA and EACA techniques prior to surgery. Parameters including middle ear pressure values (MEPV), operative time, intraoperative hemorrhage, postoperative residual adenoid tissue, and postoperative pain were compared between groups.

RESULTS

In the CCA group for both ears, there was a statistically significant difference between preoperative mean MEPV and mean MEPV of postoperative day 1, while MEPV returned to normal ranges at the postoperative day 7. No statistically significant differences were observed in mean MEPV on preoperatively and 1st and 7th postoperative days in the EACA group for both right and left ears. Mean operative time was significantly higher in the EACA group compared to the CCA group (P < 0.001). Eight (22.2%) out of 36 patients who underwent CCA had a residual adenoid tissue postoperatively, while there was no residual adenoid tissue in any patients who operated via the EACA technique. Mean pain score on postoperative day 1 and 2 and blood loss were significantly less in the EACA group than the CCA group.

CONCLUSION

Endoscope-assisted coblation adenoidectomy may serve a reasonable alternative to conventional curettage adenoidectomy because it provides Eustachian tube functions preserved, decreased intraoperative hemorrhage, complete resection of the adenoid tissue, and lower pain score.

Harmonic Scalpel Versus Coblation Tonsillectomy A Comparative Study

Tonsillectomy is an age old procedure in ENT practice. Though traditional dissection method is gold standard, we surgeons are trying different techniques like electrocautery, coblation, harmonic scalpel (HS) mainly to improve surgical convenience, to decrease operative time, post operative pain, intra and post operative bleeding and fast return to normal life. In this particular study we are comparing coblation and HS as surgical tool in tonsillectomy. It is a prospective double-blind randomized controlled trial where information was compared between two groups of coblation and HS tonsillectomy. A total number of 128 patients were compared over operation time, intra-operative blood loss, postoperative pain, time needed to regain the normal diet and activity and postoperative haemorrhage. We found statistically significant differences in operation time (p < 0.001) and intra operative blood loss (p < 0.001). Secondary haemorrhage rate was far better in HS (1.5%) group compared to coblation (7.8%). Whereas postoperative pain, time needed to go back to the normal diet and activity were better in HS group but the difference is not significant. This study revealed a significantly less operative time and intra-operative and post operative blood loss in harmonic scalpel tonsillectomy in comparison with coblation method. These findings addressed HS tonsillectomy as an advanced method.

Postoperative Pain and 14-Day Recovery in Children Undergoing Adenotonsillectomy: Low Thermal Damage Device Versus Electrosurgery

This was a randomized controlled trial of low thermal damage device versus traditional electrosurgery in children 3 to 17 years old with a clinical diagnosis of sleep disordered breathing, obstructive sleep apnea with adenotonsillar hypertrophy, or recurrent adenotonsillitis. Pain score (Wong-Baker FACES pain scale) was recorded each morning before eating, drinking, or administering pain medication for 14 days postoperatively. Seventy-five children were enrolled. There was no difference in the rate of decrease in pain scores. A significant interaction between rate of pain decrease and number of pain medication doses was present ( P < .0001). Median number of pain medication doses was greater with electrosurgery (36, range: 7-49) versus low thermal device (21, range: 2-124; P = .001). Pain scores reached 0 after a median of 7 days (95% confidence interval [CI], 5.2-8.6) for low thermal device and 9 days (95% CI, 8.0-10.0) for electrosurgery ( P = .67). One child randomized to electrosurgery was withdrawn due to hospitalization for postoperative bleed. In children, low thermal device results in significantly less pain medication used during the postoperative period than electrosurgery.

Comparative analysis of conventional cold curettage versus endoscopic assisted coblation adenoidectomy

Objective

To compare conventional cold curettage adenoidectomy with endoscopic assisted coblation adenoidectomy in terms of operative time, primary blood loss, post-operative residual tissue and post-operative pain.

Methods

This prospective non-randomised study was carried out on 60 patients aged 5–12 years. One group underwent conventional cold curettage adenoidectomy and the other underwent endoscopic assisted coblation adenoidectomy, with 30 patients per group.

Results

Mean operation duration was significantly higher for endoscopic assisted coblation adenoidectomy. Mean blood loss was 44.33 ml in conventional cold curettage adenoidectomy and 32.47 ml in endoscopic assisted coblation adenoidectomy. The pain grade was significantly lower in endoscopic assisted coblation adenoidectomy. Forty per cent of patients who underwent conventional cold curettage adenoidectomy had adenoid tissue post-surgery, while it was completely absent in endoscopic assisted coblation adenoidectomy patients.

Conclusion

Coblation adenoidectomy has significant advantages over conventional adenoidectomy in terms of reduced blood loss, no post-operative residual tissue and lower pain grade on day 1 after surgery.

Impact of coblation versus electrocautery on acute post-operative outcomes in pediatric tonsillectomy

Objective

Based on previous studies in the pediatric population, it remains unclear whether there is a difference in postoperative pain between two widely used tonsillectomy techniques: coblation and bovie electrocautery. This large prospective study investigates whether postoperative pain scores differ between these two surgical techniques for tonsillectomy.

Methods

Prospective, non‐randomized study of children aged 2–8 enrolled in a randomized controlled trial of single‐dose intravenous acetaminophen for pain associated with adenotonsillectomy. Included procedures occurred between October 2012 and June 2015 at a tertiary referral center. Only patients whose operations exclusively used coblation or electrocautery and who required postoperative admission for extended observation were included. Follow‐up period was the length of inpatient stay. Patients and nurses who recorded the pain scores were blinded to the tonsillectomy technique.

Results

A total of 183 patients were included: 117 coblation cases and 66 electrocautery cases. Pain scores in the surgical recovery unit and pain scores after admission to the floor unit were not significantly different between coblation and electrocautery, either before or after adjustment for patient age, body mass index, intravenous acetaminophen use, and surgeon. There was also no difference in length of stay, readmission rate, or post‐tonsillectomy hemorrhage.

Conclusions

Coblation and electrocautery tonsillectomy are associated with similar post‐operative pain scores in the recovery and inpatient units in the pediatric population. As coblation is costlier, the results of this study may affect which tool is used by otolaryngologists from a cost–benefit perspective.

Level of evidence

III

Reducing the exposure of the tonsillar fossa does not impact postoperative pain levels in children undergoing tonsillectomy: A double-blind randomized controlled trial

BACKGROUND

It is not established whether reducing the exposure of the tonsillar fossa would be an effective strategy for postoperative pain relief among the pediatric population submitted to tonsillectomy. We assessed the impact of closing this region using absorbable sutures on pain, on the resumption of normal diet and on the healing process until seven days after surgery.

METHODS

Randomized, double-blind, controlled trial comparing postoperative pain in 132 children between the ages of 5 and 12 years undergoing tonsillectomy having bilateral closure, unilateral closure or non-closure of the tonsillar fossa.

RESULTS

No differences in pain levels were reported both at discharge and on postoperative day 7. The day of resumption of normal diet was similar in all patients. Less granuloma and edema of the uvula were noted in patients with non-closure of the tonsillar fossa.

CONCLUSION

These results showed that reducing the exposure of the tonsillar fossa after the removal of the palatine tonsils was not an effective method for postoperative pain relief in children. Moreover, its closure was associated with slower healing.

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.

Utilization and trends in surgical instrument use in pediatric adenotonsillectomy

OBJECTIVE

Examine trends in surgical instrument usage for pediatric adenotonsillectomy.

METHODS

An online survey asking questions about current and previous surgical instrument use was created by the authors and distributed to 517 members of the American Society of Pediatric Otolaryngology in October 2015. The survey was designed to assess trends in the use of surgical instruments in pediatric adenotonsillectomy by comparing the results of our 2015 survey to data from a previously published 2005 study.

RESULTS

133 surveys were returned. The most common instruments for total tonsillectomy in 2015 were monopolar electrocautery (57.0%) and coblation (22.7%). The most common subtotal tonsillectomy instruments in 2015 were microdebrider with monopolar electrocautery (41.3%) and coblation (37.0%). The most common adenoidectomy instruments in 2015 were monopolar electrocautery alone (41.3%), coblation (15.1%), and microdebrider with electrocautery (15.1%).

CONCLUSION

As compared to our 2005 study, our 2015 study demonstrates that the instrument choice for total tonsillectomy, sub-total tonsillectomy, and adenoidectomy have shifted away from cold techniques toward monopolar electrocautery and coblation.

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.

Coblation tonsillectomy: a systematic review and descriptive analysis

Coblation is one of the more recent techniques for tonsillectomy; however, it remains unclear whether it exhibits any benefit or increased risk when compared to other techniques. This review provides an updated assessment of coblation tonsillectomy and how it compares to other tonsillectomy techniques. Systematic review and descriptive analysis of published literature. Electronic searches of MEDLINE, EMBASE, Web of Science and the Cochrane Database were performed. We included all randomized control trials comparing coblation tonsillectomy (not 'tonsillotomy') with any other tonsillectomy technique. Studies were excluded if tonsils, rather than individuals, were randomized. 16 eligible studies were identified, including a total of 567 patients, both adults and children. Coblation was compared with a variety of other tonsillectomy techniques. Outcomes included pain, primary and secondary haemorrhage, intraoperative bleeding and operation time. Postoperative pain was the primary outcome in most studies. There was a trend towards less pain in the coblation group in seven of the included studies. More recent studies appeared to fare more favourably in terms of pain outcomes and operating time. The coblation technique appears to be comparable with other commonly employed techniques for tonsillectomy; however, there is still no strong evidence to suggest that it possesses any definitive benefits. Findings would advocate further work being done through carefully designed randomised control trials, which compare coblation with cold dissection as the 'gold standard' and place an emphasis on reducing the amount of adjuvant electrocautery used so as to maximise the benefits of coblation and the lower temperature it generates.

Postoperative Bleeding and Associated Utilization following Tonsillectomy in Children

Objective To assess posttonsillectomy hemorrhage (PTH), associated nonoperative readmissions/revisits, and reoperations in children. Data Sources MEDLINE, EMBASE, and the Cochrane Library. Review Methods Two investigators independently screened studies against predetermined criteria and extracted key data. Investigators independently assessed study risk of bias and the strength of the evidence of the body of literature. We calculated unadjusted pooled estimates of PTH frequency and conducted a Bayesian meta-analysis to estimate frequency of primary and secondary PTH and PTH-associated reoperation and revisits/readmissions by partial and total tonsillectomy and surgical approach. Results In meta-analysis, the frequency of primary and secondary PTH associated with total and partial tonsillectomy was <4% for any technique and with overlapping confidence bounds. Pooled frequencies of PTH were also <5% overall (4.2% for total tonsillectomy, 1.5% for partial tonsillectomy) in comparative studies. Fewer PTH episodes occurred with tonsillectomy for obstructive sleep-disordered breathing than for throat infection. In meta-analysis, frequency of PTH-associated nonoperative revisits/readmission or reoperation ranged from 0.2% to 5.7% for total tonsillectomy and from 0.1% to 3.7% for partial tonsillectomy. At least 4 deaths were reported in case series including 1,778,342 children. Conclusions PTH occurred in roughly 4% of tonsillectomies in studies included in this review. Although studies typically did not report bleeding severity or amount, relatively few episodes of PTH necessitated reoperation for hemostasis. Nonetheless, tonsillectomy is not without risk of harm. Frequency of PTH across techniques was similar; thus, we cannot conclude that a given technique is superior.

Language and speech outcomes of children with hearing loss and additional disabilities: identifying the variables that influence performance at five years of age

OBJECTIVE

This study examined language and speech outcomes in young children with hearing loss and additional disabilities.

DESIGN

Receptive and expressive language skills and speech output accuracy were evaluated using direct assessment and caregiver report. Results were analysed first for the entire participant cohort, and then to compare results for children with hearing aids (HAs) versus cochlear implants (CIs).

STUDY SAMPLE

A population-based cohort of 146 five-year-old children with hearing loss and additional disabilities took part.

RESULTS

Across all participants, multiple regressions showed that better language outcomes were associated with milder hearing loss, use of oral communication, higher levels of cognitive ability and maternal education, and earlier device fitting. Speech output accuracy was associated with use of oral communication only. Average outcomes were similar for children with HAs versus CIs, but their associations with demographic variables differed. For HA users, results resembled those for the whole cohort. For CI users, only use of oral communication and higher cognitive ability levels were significantly associated with better language outcomes.

CONCLUSIONS

The results underscore the importance of early device fitting for children with additional disabilities. Strong conclusions cannot be drawn for CI users given the small number of participants with complete data.

Inside-Out Complete Tonsillectomy: Extended Intracapsular Tonsillectomy for Severe Sore Throat

Objectives:

This consecutive case series is presented to describe inside-out complete tonsillectomy and to assess its effects on postoperative pain and bleeding and its initial effectiveness in controlling recurrent sore throat and peritonsillar abscess formation.

Methods:

Bipolar electrosurgical scissors are used for bloodless resection of 90% of the tonsillar mass. During controlled resection, tonsil tissue is intentionally left at the superior and inferior poles and at the deepest part of the tonsillar fossa to provide coverage for nutrient arteries and the tonsillar plexus of veins. This tissue is then electrodesiccated and removed under direct vision and indirect mirror guidance to achieve complete tonsillectomy.

Results:

One hundred eighty-three consecutive tonsillectomies were performed by a single surgeon in a 16-month period, 47 of which were for the indication of recurrent sore throat (44) or recurrent peritonsillar abscess (3). Among these 47 children, there were 2 readmissions for dehydration. There were no immediate or delayed bleeding episodes. The average child required 4 days of narcotic pain medication. The mean annualized number of severe sore throats decreased from 5.24 before operation to 0.36 after operation (p <.0001, Student's paired t-test). There were no recurrent peritonsillar abscesses.

Conclusions:

Inside-out complete tonsillectomy achieves the surgical goal of complete tonsillectomy with the smallest possible wound and minimal injury to the surrounding tissue. The perioperative morbidity is markedly decreased compared to that of historical controls. The initial results suggest effectiveness similar to that of extracapsular tonsillectomy.

Hemorrhage following Coblation Tonsillectomy

Objectives:

We performed a prospective study to evaluate the incidence of post-tonsillectomy hemorrhage (PTH) in adults and children who underwent Coblation tonsillectomy (CTE) under general anesthesia.

Methods:

The data of 63 adults and children (mean age, 21.8 years) were analyzed.

Results:

There were 7 episodes of considerable bleeding (11.1%) that required surgical treatment under general anesthesia in 6 patients, of whom 5 experienced secondary bleeding (>24 hours). Moreover, bleeding and massive swelling of the pharynx required surgical treatment and prolonged intubation (35 hours) in 1 patient. None of the patients received blood transfusions. There was no case with a lethal outcome. Less intense bleeding (clots; blood-tinged sputum) was observed in 17 patients (27%) who required readmission or prolonged inpatient observation, 1 of whom had previously undergone surgical treatment of PTH. However, these 17 patients had an uneventful clinical course. In total, 22 patients experienced minor or major forms of PTH (34.9%).

Conclusions:

At least in our hands, CTE dramatically increased the frequency of PTH. The high rate of secondary bleeding contrasts with our documented experience using conventional methods, ie, cold dissection and suture ligation, to achieve hemostasis (7.9% with CTE versus <0.8% with conventional methods). Therefore, at our institution, tonsillectomy with conventional instruments remains the method of choice.

Post-Tonsillectomy Morbidity and Quality of Life in Pediatric Patients with Obstructive Tonsils and Adenoid: Microdebrider vs Electrocautery

OBJECTIVES: To prospectively compare outcomes in children over age 2 with obstructive adenotonsillar hypertrophy when tonsillectomy is performed utilizing an intracapsular microdebrider technique versus low-wattage electrocautery technique.

STUDY DESIGN AND SETTING: Prospective, single-blind, randomized controlled trial at a tertiary care children's hospital.

RESULTS: Among the 300 children, those treated with the microdebrider resumed normal activity faster, with a median recovery of 2.5 days, and stopped taking pain medication sooner, with the median time to the last dose of 4 days. The microdebrider group were 3 times more likely to no longer need pain medications at 3 days postoperatively and 2.5 times less likely to be still needing pain medication 7 days postoperatively. They were twice as likely to be at a normal activity level by 3 days postoperatively and were less likely to still not have attained normal activity and normal diet after 7 days. There was no difference between groups in median days to return to normal diet (3.0 to 3.5 days). At 1-month follow-up, children in the microdebrider group were 5 times more likely to have residual tonsil tissue.

CONCLUSIONS: Intracapsular tonsillectomy in children with obstructive adenotonsillar hypertrophy results in improved peri-operative outcomes. Residual tonsil tissue is more common with use of the microdebrider; however, the incidence of future obstruction or infection is unknown.

EBM rating: A-1b

Coblation Adenotonsillectomy: An Improvement Over Electrocautery Technique?

OBJECTIVES: To compare postoperative complication rates of coblation and electrocautery adenotonsillectomies.

STUDY DESIGN: Retrospective chart review.

RESULTS: From January 2000 to June 2004, 1997 pediatric patients underwent adenotonsillectomy. 745 coblation, and 1252 electrocautery tonsillectomies were performed. Primary bleed, secondary bleed, and dehydration were seen in 3, 35, and 23 coblation, and 9, 41, and 64 electrocautery tonsillectomies, respectively. Data analysis revealed no significant difference in primary and secondary hemorrhage rate, but a higher dehydration rate in the electrocautery group ( P = 0.0423). A total of 602 coblation, 763 curette/cautery, and 632 electrocautery adenoidectomies were performed. Neck pain was seen in 0, 17, and 3 patients, respectively. Data analysis showed a higher incidence of neck pain with the curette/cautery technique compared with coblator and cautery techniques ( P = 0.0006 and P = 0.0119, respectively).

CONCLUSIONS: Coblation tonsillectomy had similar rates of primary and secondary hemorrhage when compared with electrocautery tonsillectomy but a lower incidence of postoperative dehydration. Coblation adenoidectomy caused less postoperative neck pain than curette/cautery adenoidectomy without significant advantage over cautery adenoidectomy.

EBM rating: B-3b

Tonsillectomy and Adenoidectomy: Current Techniques and Outcomes

Tonsillectomy and Adenoidectomy continues to be one of the most commonly performed surgical procedures in the pediatric population with over 500,000 procedures performed annually. Decreasing pain, maintaining hydration, and minimizing the risk of post operative hemorrhage has brought attention to novel surgical technique and instrumentation. Electro-cautery remains the most common technique used across the United States, however newer technologies have evolved claiming improved recovery with expedited return to normal activity and diet. The current literature remains of significant debate as to the modality that offers the best outcomes. In this review, we describe some of the newer technologies and more common modalities used in practice and discuss the current literature findings.

How to cite this article

Sharma S, Andreoli S, Josephson GD. Tonsillectomy and Adenoidectomy: Current Techniques and Outcomes. Int J Head Neck Surg 2016;7(2):104-108.

Thermal necrosis induced by electrocauterization as a local adjuvant therapy in local aggressive bone tumors, what is the safe limit for surgical margins? An experimental study

OBJECTIVE

In the current study, it was aimed to investigate the temperature change in the cavity wall and pathologic necrosis occurred during cauterization, which was applied at different voltages and time intervals.

MATERIALS AND METHODS

The right tibias of 32 male rabbits were used. Three 2-mm-diameter holes were created on the cortical surface of the tibia using a hand-held drill. Using an electrocautery device, 55 mV was applied for 3 and 5 s and 65 mV was applied for 3 and 5 s. Maximum temperatures at 3 and 6 mm distance from the application site were measured. Biopsy specimens obtained at 3 and 6 mm distance from the application site were evaluated microscopically for bone cell viability and periosteal necrosis.

RESULTS

Thirty-two rabbits were divided into four groups. In all groups, periosteal bone cells located at the region, extending from the application site to 3 mm distance, died. In this region, application of 55 mV for 3 s caused peripheral necrosis. There were significant differences between the four groups in terms of maximum temperatures measured at 3 mm distance from the application site (p = 0.027). On the other hand, no significant differences were noted between the four groups in terms of maximum temperatures measured at 6 mm distance from the application site (p > 0.05).

CONCLUSIONS

Cauterization of the cavity wall in the spray mode at 55 mV for 3 s after tumor resection caused necrosis in the cavity wall, extending from the application site to 3 mm distance.

LEVEL OF EVIDENCE

Experimental animal study, Level II.

Appropriate dose of dexmedetomidine for the prevention of emergence agitation after desflurane anesthesia for tonsillectomy or adenoidectomy in children: up and down sequential allocation

Background

Dexmedetomidine can be used for the prevention of emergence agitation (EA) in children. However, an inadequate dose of dexmedetomidine can induce prolonged sedation and cardiovascular complications. The aim of this study was to evaluate the effective dose of dexmedetomidine for the prevention of EA after desflurane anesthesia for patients undergoing a tonsillectomy or adenoidectomy.

Methods

We enrolled 21 unpremedicated children, between 2 and 12 years, undergoing either a tonsillectomy or an adenoidectomy. General anesthesia was induced using sevoflurane and oxygen, and dexmedetomidine was administered before surgery. Anesthesia was maintained using desflurane resulting in a BIS range of 40–60. In the postanesthetic care unit (PACU), EA (agitation measured at level 4 or more at least once) was assessed on arrival in the PACU,15 min later, and 30 min later. The dose of dexmedetomidine for consecutive patients was determined by the response of the previous patient, using an increment or decrement of 0.1 μg/kg.

Results

The 50 % effective dose of dexmedetomidine for prevention of EA was 0.25 μg/kg (95 % confidence limits, 0.17–0.33 μg/kg), and the 95 % effective dose was 0.38 μg/kg (95 % confidence limits, 0.29–0.39 μg/kg).

Conclusions

For prevention of EA after desflurane anesthesia for 50 % and 95 % of children undergoing tonsillectomies or adenoidectomies, 0.25 μg/kg or 0.38 μg/kg of dexmedetomidine is suggested. Further study is needed to validate the suggested dose of dexmedetomidine to prevent the EA that was identified in the present study.

Trial registration

Clinical Research Information Service KCT0000126.

Bleeding following coblation tonsillectomy: a 10-year, single-surgeon audit and modified grading system

Objective:

Coblation tonsillectomy can be controversial. This study assessed post-tonsillectomy haemorrhage outcomes for patients operated on by a single experienced coblation-trained ENT surgeon.

Study design:

A retrospective audit of coblation tonsillectomies was performed using the Flinders modification of Stammberger criteria for post-tonsillectomy haemorrhage.

Method:

Case note review, interview and database interrogation were utilised to obtain the dataset. Haemorrhage results were compared to reports in the current literature.

Results:

Of those who underwent coblation tonsillectomy, 3.4 per cent were readmitted to hospital with haemorrhage and 1.3 per cent returned to the operating theatre (0.4 per cent primary haemorrhage and 0.9 per cent secondary haemorrhage). Younger children had a lower risk of returning to the operating theatre than older children or adults (0.3 per cent under the age of 12 years vs 2.0 per cent aged 12 years or older).

Conclusion:

Coblation can be a safe method for tonsillectomy with low complication rates when performed by an experienced ENT surgeon. The Flinders modification of the Stammberger criteria for post-tonsillectomy haemorrhage provides a simple system for data comparison.

Paediatric day case tonsillectomy: a safe, feasible and an economical way to treat patients – Yorkhill experience

Introduction

Day case surgery is widely encouraged as it has many benefits. In this study, we evaluate the feasibility of paediatric tonsillectomies as day case surgery procedures in a tertiary paediatric centre.

Methods

The outcome of paediatric tonsillectomy performed as day case procedures was studied for four months. We recorded complication rates in comparison to the standard in-patient practice.

Results

23 paediatric patients were included in this study. The age of the patients ranged from four to 11 years, with mean age of 6.5. No patients suffered post-operative complications within the first 24 h. Two patients were re-admitted due to a post-operative complication (8.6%) and one patient for a non-operative cause (4.3%) beyond the initial 24 h.

Conclusion

Paediatric Day Case Paediatric Tonsillectomy is a safe, feasible and an economical way to manage patients. It should be practised as a day case where appropriate and when criteria are met.

Coblation vs. Electrocautery Tonsillectomy: A Prospective Randomized Study Comparing Clinical Outcomes in Adolescents and Adults

OBJECTIVES

Coblation is operated in low temperature, so it is proposed that tonsillectomy with coblation involves less postoperative pain and allows accelerated healing of the tonsillar fossae compared with other methods involving heat driven processes. However, the results of the previous studies showed that the effect of coblation tonsillectomy has been equivocal in terms of postoperative pain and hemorrhage. Though, most of the previous studies which evaluated coblation tonsillectomy were performed in children. Recently, electrocautery tonsillectomy has been used most widely because of the reduced intraoperative blood loss and shorter operative time compared to other techniques. This prospective study compared intraoperative records and postoperative clinical outcomes in adolescents and adults following coblation and electrocautery tonsillectomies.

METHODS

Eighty patients over 16 years of age with histories of recurrent tonsillitis were enrolled. The patients were randomly allocated into coblation (n=40) and electrocautery tonsillectomy groups (n=40). All operations were performed by one surgeon who was skilled in both surgical techniques. Intraoperative parameters and postoperative outcomes were checked.

RESULTS

Postoperative pain and otalgia were not significantly different between the two groups; however, there was a tendency towards reduced pain and otalgia in the coblation group. More cotton balls for swabbing the operative field were used introoperatively in the electrocautery group (P=0.00). There was no significant difference in postoperative hemorrhage, wound healing, commencement of a regular diet, and foreign body sensation between the groups.

CONCLUSION

Only cotton use, which represented the amount of blood loss, was less in the coblation tonsillectomy group. Coblation tonsillectomy warrants further study with respect to the decreased postoperative pain and otalgia.

Antibiotics to reduce post-tonsillectomy morbidity

BACKGROUND

This is an update of a Cochrane Review first published in The Cochrane Library in Issue 2, 2008 and previously updated in 2010.Tonsillectomy continues to be one of the most common surgical procedures performed in children and adults. Despite improvements in surgical and anaesthetic techniques, postoperative morbidity, mainly in the form of pain, remains a significant clinical problem. Postoperative bacterial infection of the tonsillar fossa has been proposed as an important factor causing pain and associated morbidity, and some studies have found a reduction in morbid outcomes following the administration of perioperative antibiotics.

OBJECTIVES

To determine whether perioperative antibiotics reduce pain and other morbid outcomes following tonsillectomy.

SEARCH METHODS

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 20 March 2012.

SELECTION CRITERIA

All randomised controlled trials examining the impact of perioperative administration of systemic antibiotics on post-tonsillectomy morbidity in children or adults.

DATA COLLECTION AND ANALYSIS

Two authors independently collected data. Primary outcomes were pain, consumption of analgesia and secondary haemorrhage (defined as significant if patient re-admitted, transfused blood products or returned to theatre, and total (any documented) haemorrhage). Secondary outcomes were fever, time taken to resume normal diet and activities and adverse events. Where possible, we generated summary measures using random-effects models.

MAIN RESULTS

Ten trials, comprising a pooled total of 1035 participants, met the eligibility criteria. Most did not find a significant reduction in pain with antibiotics. Similarly, antibiotics were mostly not shown to be effective in reducing the need for analgesics. Antibiotics were not associated with a reduction in significant secondary haemorrhage rates (risk ratio (RR) 0.49, 95% CI 0.08 to 3.11, P = 0.45) or total secondary haemorrhage rates (RR 0.90, 95% CI 0.56 to 1.44, P = 0.66). With regard to secondary outcomes, antibiotics reduced the proportion of patients with fever (RR 0.63, 95% CI 0.46 to 0.85, P = 0.002).

AUTHORS' CONCLUSIONS

The present systematic review, including meta-analyses for select outcomes, suggests that although individual studies vary in their findings, there is no evidence to support a consistent, clinically important impact of antibiotics in reducing the main morbid outcomes following tonsillectomy (i.e. pain, need for analgesia and secondary haemorrhage rates). The limited benefit apparent with antibiotics may be a result of positive bias introduced by several important methodological shortcomings in the included trials. Based on existing evidence, therefore, we would advocate against the routine prescription of antibiotics to patients undergoing tonsillectomy. Whether a subgroup of patients who might benefit from selective administration of antibiotics exists is unknown and needs to be explored in future trials.

Coblation tonsillectomy in children: incidence of bleeding

OBJECTIVES/HYPOTHESIS

To evaluate the intraoperative and postoperative bleeding rate utilizing the Coblation device for total tonsillectomy in children.

STUDY DESIGN

Prospectively designed clinical study.

METHODS

Institutional review board approval was obtained to study patients undergoing Coblation tonsillectomy. Records of all children 1 to 18 years of age undergoing tonsillectomy or adenotonsillectomy from April 2003 to April 2010 were reviewed. All children underwent total tonsillectomy utilizing the Coblation device, and the intraoperative and postoperative bleeding complications were analyzed. The data were also analyzed to determine whether surgeon experience with the technique influenced the bleeding rate.

RESULTS

A total of 1,918 patients were evaluated. Intraoperative blood loss was <5 mL in >90% of the patients, with no patients experiencing >20 mL of blood loss. The postoperative bleeding rate was consistent with the literature (n = 87, 4.5%). Of the patients with bleeding following surgery, five (5.7%) experienced primary bleeding and 82 (94.3%) secondary bleeding. Postoperative bleeding that ceased spontaneously and did not require intervention was present in 56 (2.9%). The number of patients who actually required intervention to control postoperative bleeding was 31 (1.6%). The majority of bleeding occurred by postoperative day 7. There was no statistically significant difference in bleeding rates by age, and there was no evidence found to support a surgeon learning curve for performing Coblation tonsillectomy.

CONCLUSIONS

This study provides further support that Coblation total tonsillectomy in children is a reliable and safe procedure with a relatively low incidence of intraoperative and postoperative bleeding.

Post-operative pain following coblation or monopolar electrocautery tonsillectomy in children: a prospective, single-blinded, randomised comparison

OBJECTIVE

To compare post-operative pain following tonsillectomy by either coblation or monopolar electrocautery in children.

DESIGN

A parallel-designed, prospective, single-blinded, randomised trial.

SETTING

Ambulatory surgical facility.

STUDY PARTICIPANTS

Eighty otherwise healthy paediatric patients undergoing coblation or electrocautery tonsillectomy by a fellowship-trained paediatric otolaryngologist.

MAIN OUTCOME MEASURES

(i) The number of post-operative days with severe pain based on subjective qualification by the caretaker, (ii) post-operative days with pain rated ≥ 5 on a scale of 1-10, (iii) post-operative days requiring oral paracetamol/acetaminophen with codeine solution and (iv) post-operative days until resumption of a regular diet were assessed and recorded daily using a post-operative pain survey as a form of daily diary that was returned at the 2-week follow-up visit.

RESULTS

Patients were consecutively enrolled into two groups of 40 patients. Average ages were 5.2 years for coblation tonsillectomy and 6.0 years for electrocautery tonsillectomy. The average number of post-operative days with severe pain was 4.2 for coblation and 5.9 for electrocautery (P = 0.006), days rating pain ≥ 5 were 3.6 for coblation and 4.8 for electrocautery (P = 0.037), days of codeine use were 2.5 for coblation and 2.9 for electrocautery (P = 0.324), and days until resumption of a regular diet were 5.2 for coblation and 6.2 for electrocautery (0.329).

CONCLUSIONS

Coblation tonsillectomy may reduce post-operative pain and the time until resumption of a regular diet compared to electrocautery tonsillectomy.

A Prospective, Randomized, Double-Blind Study of Coblation versus Dissection Tonsillectomy in Adult Patients

This randomized double blind study was conducted prospectively to determine whether coblation tonsillectomy fared better than the conventional dissection method in terms of postoperative pain, bleeding, and rapidity of healing in adult Indian patients undergoing tonsillectomy. Sixty adult patients undergoing tonsillectomy for benign indications were randomized to have one tonsil removed by subcapsular radiofrequency ablation method and the other by conventional dissection method. The operative time and blood loss was noted for each side. Patients were evaluated at 6, 12, 24, 48, 72 h and then on 7th and 20th postoperative day for postoperative pain (by visual analog scale), bleeding, and tonsillar fossa healing. Statistical comparison was done using appropriate tests. The two groups were demographically matched. It took longer to perform the coblation procedure (15 vs 11 min) (P > 0.05). The operative blood loss on the radiofrequency side was 11 ml, vs 34 ml on the conventional side (P = 0.009). 77% patients said that the coblation side was less painful for the overall 20-day recovery period. There were significant differences seen at 6, 12, 24, 48, and 72 h in terms of postoperative pain scores. Beyond that, the pain was consistently less on the coblation side, but the difference was not significant. There was no case of reactionary or secondary hemorrhage in either arm. The healing took longer on the radiofrequency side. Coblation tonsillectomy is an easy to learn technique with significantly reduced operative blood loss and postoperative pain. Longer operative times maybe further reduced with experience.

Is the systemic inflammatory reaction to surgery responsible for post-operative pain after tonsillectomy, and is it "technique-related"?

AIMS

Investigate the influence of operative technique on post-operative morbidity and the systemic inflammatory response after tonsillectomy. In addition, our aim was to compare the systemic inflammatory reaction, post-operative pain severity, and required time before the resumption of normal physical activity between two groups of tonsillectomized children and to correlate characteristics of the systemic inflammatory reaction to post-operative morbidity.

PARTICIPANTS AND METHODS

This prospective, randomized, and single-blind study included 100 children between the ages of 3-16 years and who were scheduled for a tonsillectomy at our department for chronic tonsillitis and/or respiratory obstruction. The children were randomly assigned into one of two groups: either a conventional tonsillectomy with bipolar diathermy coagulation or a radiofrequency tonsillectomy procedure; both groups had a 14-day follow-up. We investigated the severity and duration of postoperative pain (based on the use of analgesics during the postoperative period), the postoperative day that they resumed normal physical activity, and the rate of postoperative hemorrhage. In order to assess the systemic inflammatory response, serum C-reactive protein (CRP) levels were measured before the surgery and seven days after the procedure.

RESULTS

After the surgery CRP levels increased to a statistically significant level (t = -4.7; p < 0.001) in conventional tonsillectomy group. There was a statistically significant correlation between increased blood CRP levels after the surgery and the level of post-operative analgesic consumption, which was based on an increased number of analgesic applications (r = 0.28; p < 0.01) and a greater number of days in which analgesics were consumed (r = 0.26; p < 0.01). There was also a correlation between increased blood CRP levels and a longer required time to resume normal physical activities (r = 0.30; p < 0.01).

CONCLUSION

Post-operative morbidity after tonsillectomy appears to depend on the systemic inflammatory response to surgery. This response is "technique-related," wherein a less-aggressive surgical technique produces a weaker post-operative inflammatory response and less post-operative morbidity.

Comparison of Postoperative Pain in Pediatric Patients Undergoing Coblation Tonsillectomy versus Cautery Tonsillectomy

Objective. To compare postoperative pain scores between monopolar electrocautery and coblation subcapsular tonsillectomy.

Study Design. Prospective double-blind randomized study.

Setting. Tertiary care children’s hospital.

Subjects and Methods. Between December 2004 and April 2008, 61 children, ages 4 to 20 years (mean age, 10 years; SD, 4 years), were randomized to have one tonsil removed by electrocautery and the other tonsil removed by coblation. Subjects used the FACES scale to rate pain on each side immediately postoperatively, 2 days postoperatively, and 2 weeks postoperatively. Postoperative hemorrhage was also tracked.

Results. Coblation tonsillectomy resulted in statistically less pain than electrocautery immediately after surgery, but this difference was not clinically significant.

Conclusions. Pediatric pain is similar following monopolar electrocautery or coblation subcapsular tonsillectomy.

Vessel sealing system uvulopalatoplasty versus uvulopalatal flap: a randomized, controlled study of efficacy and adverse effects

The objective of this randomized, controlled study is to compare intraoperative blood loss, operative time, postoperative pain and postoperative adverse effects (bleeding, velopharyngeal insufficiency and others) between vessel sealing system uvulopalatoplasty (VSSU) and uvulopalatal flap (UPF). The study was conducted at the Department of Otolaryngology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand. 31 subjects with sleep-disordered breathing and obstruction at the retropalatal level were enrolled consecutively. Intervention was randomized by mixed block randomization into 2 groups (UPF, VSSU). Stratification was also done by the presence or absence of concomitant tonsillectomy. Measured outcomes, which were blinded to patients and outcome assessor, were intraoperative blood loss, operative time, postoperative pain, postoperative bleeding, postoperative velopharyngeal insufficiency and other adverse effects. Median (IQR) of intraoperative blood loss from VSSU and UPF was 0.00 (0.00-1.00) and 6.00 (1.25-12.75) ml (p < 0.001). Median (IQR) of operative time from VSSU and UPF was 3.50 (3.00-5.00) and 15.00 (12.25-18.00) min (p < 0.001). There was significantly less pain in VSSU group on operative day (p = 0.001) and postoperative day 1 (p = 0.009). However, no significant difference of pain on postoperative day 2 to day 14 (p = 0.055-0.983) between both groups. Regarding postoperative bleeding, 1 case of immediate bleeding in UPF group and 1 case of delayed bleeding in VSSU group were found in this study. Postoperative velopharyngeal insufficiency and other adverse effects were not found in both groups. In conclusion, VSSU was better than UPF in terms of less intraoperative blood loss, less operative time and less pain in early postoperative period. Postoperative velopharyngeal insufficiency and other adverse effects were not found in both groups.

Hemorrhage rate after coblation tonsillectomy: a meta-analysis of published trials

After the surgical procedure of tonsillectomy, hemorrhage ranks among its serious postoperative complications. In this systematic review, we analyze hemorrhage following tonsillectomies performed using the coblation technique. 24 prospective, randomized, and controlled studies were included in the meta-analysis. Data of 796 patients who had undergone coblation tonsillectomy were analyzed. Hemorrhages occurred in 33 patients: 2 classified as primary and 26 as secondary hemorrhages. 5 could not be classified into either group. Overall, the total hemorrhage rate for the coblation procedure was 4.1% with a 95% confidence interval from 2.8 to 5.5%. The overall hemorrhage rate of 4.1% found in this meta-analysis shows that coblation is a safe and effective technique for tonsillectomies with a secondary bleeding rate similar to what is reported for comparable techniques such as bipolar diathermia.

Antibiotics to reduce post-tonsillectomy morbidity

BACKGROUND

This is an update of a Cochrane Review first published in The Cochrane Library in Issue 2, 2008.Tonsillectomy continues to be one of the most common surgical procedures performed in children and adults. Despite improvements in surgical and anaesthetic techniques, postoperative morbidity, mainly in the form of pain, remains a significant clinical problem. Postoperative bacterial infection of the tonsillar fossa has been proposed as an important factor causing pain and associated morbidity, and some studies have found a reduction in morbid outcomes following the administration of perioperative antibiotics.

OBJECTIVES

To determine whether perioperative antibiotics reduce pain and other morbid outcomes following tonsillectomy.

SEARCH STRATEGY

We searched the Cochrane ENT Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2009, Issue 4), MEDLINE (1950 to 2009) and EMBASE (1974 to 2009). The date of the last search was 30 October 2009.

SELECTION CRITERIA

All randomised controlled trials examining the impact of perioperative administration of systemic antibiotics on post-tonsillectomy morbidity in children or adults.

DATA COLLECTION AND ANALYSIS

Two authors independently collected data. Primary outcomes were pain, consumption of analgesia and secondary haemorrhage (defined as significant if patient re-admitted, transfused blood products or returned to theatre, and total (any documented) haemorrhage). Secondary outcomes were fever, time taken to resume normal diet and activities and adverse events. Where possible, we generated summary measures using random-effects models.

MAIN RESULTS

Ten trials, comprising a pooled total of 1035 participants, met the eligibility criteria. Most did not find a significant reduction in pain with antibiotics. Similarly, antibiotics were mostly not shown to be effective in reducing the need for analgesics. Antibiotics were not associated with a reduction in significant secondary haemorrhage rates (relative risk (RR) 0.49, 95% CI 0.08 to 3.11, P = 0.45) or total secondary haemorrhage rates (RR 0.90, 95% CI 0.56 to 1.44, P = 0.66). With regard to secondary outcomes, antibiotics reduced the proportion of subjects with fever (RR 0.63, 95% CI 0.46 to 0.85, P = 0.002).

AUTHORS' CONCLUSIONS

The present systematic review, including meta-analyses for select outcomes, suggests that although individual studies vary in their findings, there is no evidence to support a consistent, clinically important impact of antibiotics in reducing the main morbid outcomes following tonsillectomy (i.e. pain, need for analgesia and secondary haemorrhage rates). Limited benefit apparent with antibiotics may be a result of positive bias introduced by several important methodological shortcomings in the included trials. Based on existing evidence therefore, we would advocate against the routine prescription of antibiotics to patients undergoing tonsillectomy. Whether a subgroup of patients who might benefit from selective administration of antibiotics exists is unknown and needs to be explored in future trials.

Making sense out of the tonsillectomy literature

BACKGROUND

With the increase in new technology and changing indications for tonsillectomy, the literature has exploded during the last 20 years with scores of publications reporting the relative effectiveness of many different techniques. Despite this "wealth of information," no single technique has been adopted by most surgeons.

OBJECTIVES

To systematically analyze the usefulness of this literature of the past 20 years concerning tonsillectomy technique in children. To propose the use of specific study parameters that could optimize clinical decision-making and future research.

METHODS

Detailed review of the methodologies and findings in articles which compared one or more tonsillectomy techniques in clinical trials of children, ages 1-23 years from 1987 through 2007.

RESULTS

The Medline search revealed 255 papers of which 89 studies were suitable for inclusion in our review. In these 89 studies (found in 87 papers), 9 dissection techniques, 3 planes of dissection, 8 methods of hemostasis, and 41 different outcome measures were reported. Forty-four (49%) were described as randomized, 63 (71%) prospective, 25 retrospective (28%), 1 case report, 1 matched pair, and 9 case series papers. Sixteen (18%) trials were non-blind, 23 (26%) were single blind, 17 (19%) were double blind, and 7 (8%) were not stated. Seventy-five (84%) were comparative and 14 (16%) non-comparative. Eight (9%) studies reported power analyses. Twelve (13%) had no follow-up; 67 (75%) of the studies performed had short-term follow-up in the peri-operative period; 10 (11%) had follow-up for greater than 1 year. Eleven (12%) mentioned outcomes related to the effectiveness of the procedure itself in relieving symptoms for which the surgery was done.

CONCLUSIONS

Tonsillectomy technique research is of obvious interest to the otolaryngologist. We found deficits in: the precise reporting of surgical techniques, adequate study design and useful outcome measures, all of which make the literature less useful than it could be. Guidelines for study design parameters which could lead to more valuable information for the clinician are suggested.