Past and Present Instrument Use in Pediatric Adenotonsillectomy

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Effect of monopolar diathermy power settings on postoperative pain, wound healing, and tissue damage after tonsillectomy: a randomized clinical trial

This study aimed to assess the impact of varying monopolar diathermy power settings on postoperative pain, hemorrhage, and wound healing following tonsillectomy. A single-center, prospective, randomized, double-blinded, controlled clinical study was conducted. During bilateral tonsillectomy procedures, one tonsil received low-power settings (15 W, cutting/blend) while the other tonsil received high-power settings (35 W, cutting/blend). Postoperative pain scores (0-10) and wound healing scores (0-3) were evaluated immediately after surgery and at 1, 2, and 4 weeks postoperatively using the visual analog scale. Additionally, histological analysis was performed on electrically resected tonsil tissues to assess tissue damage in the tonsil bed. The allocation of high and low power settings to each side was randomized. Results showed that 1 week after the surgery, the high-power group experienced significantly higher pain scores (mean ± standard deviation: 4.84 ± 2.21) compared to the low-power group (3.56 ± 2.24, p = 0.049). Moreover, the high-power side exhibited slower wound healing during the initial 1-2 weeks postoperatively, as indicated by lower wound scores at 2 weeks (high-power: 1.96 ± 0.64; low-power: 2.43 ± 0.59, p = 0.008). Furthermore, histological analysis revealed significantly deeper tissue degradation on the high-power side compared to the low-power side (p < 0.001), with mean depths of 565.2 ± 291.0 µm and 156.0 ± 36.8 µm, respectively. In conclusion, these findings suggest that when employing monopolar diathermy in tonsillectomy, lower power settings can lead to improved outcomes in terms of postoperative pain, wound healing, and tissue damage.Trial registration: CRIS identifier: KCT0005670 (cris.nih.go.kr, registration date: 11/12/2020).

Coblator adenoidectomy in pediatric patients: a state-of-the-art review

INTRODUCTION

Adenoid hypertrophy is one of the main causes of nasal obstruction in 'children. Adenoid hypertrophy can be approached either with nasal corticosteroids, or surgically when medical treatment fails. Different adenoidectomy techniques have been proposed to reduce morbidity and surgical risks, with a consequent marked increase in the use of new surgical procedures in recent years, with a progressive increase in the use of coblation. This state-of-the-art review aims to systematically review the current literature on the role of coblation in adenoidectomy.

METHODS

The selection criteria included children submitted to adenoidectomy with coblator vs other techniques. 11 research questions were defined. 4 databases were explored by four authors: PubMed (Medline), the Cochrane Library, EMBASE and SciELO. The level of evidence and quality of the selected articles were assessed according to assessed according to the Quality Assessment Checklist of the National Institute for Health and Clinical Excellence.

RESULTS

20 studies met the inclusion criteria: 2 metanalysis, 12 randomized clinical trial, 2 non-randomized clinical trial, 1 prospective cohort study, and 3 retrospective cohort study. It encompassed a total population of 8375 participants. Regarding the different surgical techniques, 18 studies (excluding metanalysis) performed coblation (n = 1550), 6 microdebridement (n = 883), 15 curettage (n = 4016), and 1 suction coagulation (n = 1926).

CONCLUSION

Coblator adenoidectomy appears to offer better adenoid control compared to curettage, with a possible, although not confirmed lower rate of revision surgery. Similarly, this greater resection of adenoid tissue seems to be related to a greater reduction of nasal obstruction. The advantages of this technique are mainly less surgical bleeding-although it is not clear this is a clinically relevant difference, and less postoperative pain compared to cold curettage. The difference in pain is small, as adenoidectomy is not a painful surgery in general. There is little evidence on the control of OME and comparison with other techniques such as microdebrider adenoidectomy.

Postoperative Outcomes Following KTP-532 LASER Versus Coblation Assisted Paediatric Tonsillectomy

Aim: The aim of the study was to compare postoperative outcomes such as pain, healing of tonsillar fossa and return to normal diet following KTP-532 LASER versus Coblation assisted tonsillectomy. Methods: A prospective randomised clinical study was conducted over a 24-month period at a tertiary referral centre. Children aged 3-16 years underwent KTP-532 LASER assisted versus Coblation assisted tonsillectomy. A total of 60 children were randomly allocated into two groups-Group A underwent KTP-532 LASER assisted tonsillectomy, and Group B underwent Coblation assisted tonsillectomy (n = 30 in each). Postoperative pain and tonsillar fossa slough formation was evaluated on postoperative day 0, 1, 7, 14 and 28, and average duration taken to resume regular diet. Result: There was no statistically significant difference in postoperative pain between the two groups. There was significantly lesser slough formation in Group B on 1st postoperative day (p < 0.000), 7th postoperative day (p < 0.014), and 14th postoperative day (p < 0.010) when compared with Group A. Complete mucosalisation was achieved significantly earlier in Group B when compared to Group A (p < 0.01). Average duration for resumption of normal diet was 13.5 days for Group A and 12.6 days for Group B postoperatively, which was statistically insignificant (p < 0.830). Conclusion: There was no significant difference in postoperative pain between the two groups. Postoperative slough formation was significantly lesser and tonsillar fossa mucosalisation was faster in Group B. There was no statistical difference in time taken to resume normal diet.

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.

Coblation versus microdebrider in pediatric adenoidectomy

OBJECTIVE

To compare and contrast coblation and microdebrider with touch-up electrocautery (ME) for adenoidectomy in children.

METHODS

Patients <18 years old undergoing adenoidectomy without tonsillectomy were selected for this prospective, single-blinded, randomized controlled trial. Participants were enrolled into one of two groups based on birth date: coblation or ME. The surgeons completed a standard survey about intraoperative factors for each method. Recovery nurses filled out a standardized survey postoperatively. A third standardized survey was completed via a phone interview with the parent or patient caregiver on postoperative day 3 to assess procedure outcomes. The survey results were then compared using ANOVA statistical analysis.

RESULTS

50 patients were enrolled in the coblation group and 51 were enrolled in the ME group. There was no significant difference in mean age between the coblation (4.96 years) and ME groups (4.58 years) (p = 0.525). The mean time (in minutes) for coblation (5.50) was significantly lower than ME (9.47) when controlling for the confounder: surgical site exposure (p < 0.001). The surgical time was significantly influenced by the quality of exposure/visualization (p = 0.037). The coblator method had significantly less intraoperative blood loss compared to ME (p < 0.001). There was a statistically significant difference between coblation (1.53) and ME (2.05) for days of pain (p = 0.045) when controlling for the confounder adenoid size.

CONCLUSION

In our study we found that coblation demonstrated significantly less intraoperative time and less blood loss, as well as a shorter duration of postoperative pain, when compared to ME for adenoidectomy.

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.

Guidelines (short version) of the French Oto-Rhino-Laryngology--Head and Neck Surgery Society (SFORL) for the management of post-tonsillectomy pain in adults

OBJECTIVES

The present clinical practice guidelines cover the entire field of management of post-tonsillectomy pain. Given the French and European regulatory restrictions on the use of codeine, an update appears necessary to clarify the management of post-tonsillectomy pain in adults.

METHOD

A work group approached the issue of pain management, following the chronological pathway from initial consultation to postoperative period. As exhaustive a study of the literature as possible assessed the pain impact of the various surgical techniques and the efficacy of the various analgesia schedules.

RESULTS

Guidelines on the management of post-tonsillectomy pain in adults were drawn up and graded, based on the levels of evidence of selected articles and on work group consensus. The guidelines stress the importance of patient information and seek to harmonize practice, reduce the risk of postoperative complications and above all improve control of post-tonsillectomy pain in adults.

Adenotonsillectomy in obese children with obstructive sleep apnea syndrome: magnetic resonance imaging findings and considerations

OBJECTIVE

The reasons why adenotonsillectomy (AT) is less effective treating obese children with obstructive sleep apnea syndrome (OSAS) are not understood. Thus, the aim of the study was to evaluate how anatomical factors contributing to airway obstruction are affected by AT in these children.

METHODS

Twenty-seven obese children with OSAS (age 13.0 ± 2.3 y, body mass index Z-score 2.5 ± 0.3) underwent polysomnography and magnetic resonance imaging of the head during wakefulness before and after AT. Volumetric analysis of the upper airway and surrounding tissues was performed using commercial software (AMIRA®).

RESULTS

Patients were followed for 6.1 ± 3.6 mo after AT. AT improved mean obstructive apnea-hypopnea index (AHI) from 23.7 ± 21.4 to 5.6 ± 8.7 (P < 0.001). Resolution of OSAS was noted in 44% (12 of 27), but only in 22% (4 of 18) of those with severe OSAS (AHI > 10). AT increased the volume of the nasopharynx and oropharynx (2.9 ± 1.3 versus 4.4 ± 0.9 cm(3), P < 0.001, and 3.2 ± 1.2 versus 4.3 ± 2.0 cm(3), P < 0.01, respectively), reduced tonsils (11.3 ± 4.3 versus 1.3 ± 1.4 cm(3), P < 0.001), but had no effect on the adenoid, lingual tonsil, or retropharyngeal nodes. A small significant increase in the volume of the soft palate and tongue was also noted (7.3 ± 2.5 versus 8.0 ± 1.9 cm(3), P = 0.02, and 88.2 ± 18.3 versus 89.3 ± 24.4 cm(3), P = 0.005, respectively).

CONCLUSIONS

This is the first report to quantify volumetric changes in the upper airway in obese children with OSAS after adenotonsillectomy showing significant residual adenoid tissue and an increase in the volume of the tongue and soft palate. These findings could explain the low success rate of AT reported in obese children with OSAS and are important considerations for clinicians treating these children.

Tonsillectomy care for the pediatrician

Pediatricians play an important role in the perioperative care of hospitalized children after tonsillectomy and are often called upon to manage posttonsillectomy problems in the outpatient setting. The tonsillectomy operation has changed in recent years. More children are operated upon for sleep disordered breathing and fewer for recurrent pharyngitis. New instruments now permit less invasive surgery. Systematic reviews by the Cochrane Collaboration and others have helped define best practices for preoperative assessment and postoperative care. This article will outline these practices as defined in the 2011 American Academy of Otolaryngology-Head and Neck Surgery Foundation clinical practice guideline "Tonsillectomy in Children." It will describe the different tonsillectomy operations, discuss patterns of normal healing, and review management of pain and posttonsillectomy hemorrhage to form a foundation for improved pediatric care.

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.

The effects of an antistick phospholipid solution on pediatric electrocautery adenoidectomy

We conducted a study to determine if coating a suction cautery tip with an antistick phospholipid solution would decrease the amount of time required to complete primary pediatric adenoidectomies. The aim of the study was focused on two main criteria: the amount of surgical time required to complete each procedure and the number of times an operation had to be interrupted because the suction cautery tip needed to be cleaned (each interruption was called a "handback"). We obtained data prospectively during 61 pediatric adenoidectomies performed at our institution from February through June 2009. These patients were randomized to undergo surgery either with (n = 31) or without (n = 30) the use of the antistick phospholipid solution (Electro Lube; Mectra Labs; Bloomfield, Ind.). The overall mean amount of time needed to complete an adenoidectomy was 6 minutes and 39 seconds (6:39); use of the antistick solution shortened the amount of surgical time by 1:45-a decrease of 23.2% (p = 0.0360). Likewise, surgeries performed with Electro Lube required an average of 3.0 fewer handbacks for cleaning during the operation (p < 0.0001). The benefits of the antistick solution were even more pronounced in patients with larger adenoids than in those with smaller adenoids.

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.

[Coblation tonsillectomy under surgical microscopy]

Numbers of tonsillectomies may be decreasing in Japan due to troublesome bleeding involved in managing in a small viewing field and relatively low national health insurance point for tonsillectomy. We found coblation tonsillectomy to have advantages of less bleeding, shorter operating time, and less postoprerative pain than conventional tonsillectomy. We found that 40% of those on whom a coblator was used reported no postoperative throat pain, and noted a quick learning curve in decreasing postoperative bleeding in coblation tonsillectomy.

Suction cautery adenoidectomy (SCA): is the additional cost justified?

OBJECTIVES

Adenoidectomy is one of the oldest and most frequent ENT procedures. This study aimed to compare adenoidectomy using suction-cautery adenoidectomy (SCA) to curettage with respect to operative time, postoperative complications, and cost-effectiveness.

METHODS

The data for this retrospective case control study were retrieved from the Medical Records Department at one of the few medical centers that perform this technique in the Kingdom of Saudi Arabia. The data for each case included the following: patient demographic features, type of procedure, time of operation, occurrence of any postoperative complications, length of hospital stay and cost of the procedure. To minimize the sources of variance in our data, all adenoidectomies were performed by the same consultant otolaryngologist, using either SCA or curettage.

RESULT

Of the 86 patients who underwent adenoidectomy in this study, SCA was performed in half of them (43) and curettage in the other half. The two groups were well matched with no significant group differences in either age or gender (p=0.2 and p=0.19, respectively). There was a significant reduction in operative time (p<0.001) in the SCA group. There were no cases of postoperative hemorrhage after SCA, but there was one case of hemorrhage in the curette group that required a 2nd surgery to control the bleeding. Regarding cost, there were additional profits of more than 700,000 SR (US$180,000) each month with SCA as compared to curettage.

CONCLUSIONS

The suction cautery technique was superior at reducing operative time, increasing cost-effectiveness and decreasing the risk of postoperative complications. Therefore, we suggest suction cautery as the most appropriate method for adenoidectomy.

Tonsillectomy in children: a five-factor analysis among three techniques--reporting upon clinical results, anesthesia time, surgery time, bleeding, and cost

OBJECTIVES

Improved technology claims better clinical results for adenotonsillectomy (T&A) in children, and promoters of each technique announce many virtues over one another, year after year. However, cost remains one variable that is not always thoroughly addressed. In this study, monopolar cautery (MPC) T&A was compared with coblation (CAT) and molecular resonance (MR) techniques in a pediatric population.

STUDY DESIGN

Prospective analysis of 96 patients (32 for each surgical modality: MPC, MR, or CAT).

SETTING

Tertiary care pediatric institution.

SUBJECTS AND METHODS

Clinical results, anesthesia and surgery time, bleeding, and cost among these three established techniques were compared. P-values of P < .05 were considered significant for all comparisons.

RESULTS

The CAT and MPC had similar operative times (mean 19.2 and 21.1 minutes, respectively, P = NS), whereas the MR group had overall saving of 7.8 minutes in surgery (P < .05). In terms of cost of technology, the cost of the MPC and MR groups was 90.6% and 83.7% less than the CAT group, respectively.

CONCLUSIONS

This study demonstrated that MR technique of T&A enabled the surgical team to save a significant amount of time, whereas CAT added substantial costs, compared to MR and standard cautery techniques.

Comparison of Intraoperative Bleeding between Microdebrider Intracapsular Tonsillectomy and Electrocautery Tonsillectomy

Objectives:

We sought to assess the quantity of intraoperative bleeding from microdebrider intracapsular tonsillectomy (IT) relative to electrocautery tonsillectomy (ET).

Methods:

Intraoperative tonsil bleeding was measured prospectively for all children younger than 19 years of age who underwent primary tonsillectomy for recurrent tonsillitis or adenotonsillar hypertrophy at a tertiary care academic children's hospital. We performed IT in 57 patients (33 male, 24 female; mean age, 64.3 months) and ET in 51 patients (20 male, 31 female; mean age, 92.4 months).

Results:

Microdebrider IT resulted in more intraoperative bleeding than ET (27.9 versus 8.7 mL, p = 0.003; and 1.2 versus 0.2 mL/kg, p < 0.001). The median and maximum blood losses, respectively, were 0.6 and 9.5 mL/kg for IT and 0 and 2.0 mL/kg for ET. Blood loss for ET was not related to whether a resident versus an attending physician was the operating surgeon (p = 0.11). A linear regression model did not demonstrate greater bleeding with recurrent tonsillitis (IT, p = 0.39; ET, p = 0.89) or with increased patient age (IT, p = 0.08; ET, p = 0.62).

Conclusions:

Microdebrider IT produces more intraoperative bleeding than ET. The difference in blood loss is statistically but not clinically significant. Microdebrider IT causes bleeding within acceptable limits, and thus patients and physicians should not be discouraged from choosing this procedure solely on the basis of the amount of intraoperative blood loss.

Avoiding airway obstruction after pediatric adenotonsillectomy

OBJECTIVE

To evaluate the efficacy of a protocol designed to prevent post-adenotonsillectomy airway obstruction in small children with obstructive sleep apnea.

DESIGN

Computerized retrospective review of single surgeon case series.

SETTING

Tertiary children's medical center.

METHODS

Children with sleep study proven obstructive sleep apnea or children under the age of 3 years with clinically suspected obstructive sleep apnea were treated according to a protocol that included: (1) rapid bloodless tonsillectomy; (2) repeated release of the tonsillar retractor; (3) avoidance of uvular edema; (4) routine intra-operative intranasal oxymetazoline, and placement of nasal airway; (5) extended recovery room observation. Primary outcome measures were (1) avoidance of unexpected intensive care unit admission; (2) post-extubation pulmonary edema; (3) aspiration pneumonia.

RESULTS

During the period March 2004-August 2007, 864 children underwent adenotonsillectomy by a single surgeon-604 for the indication of obstructive sleep apnea or adenotonsillar hypertrophy with obstruction. Two hundred and ten were under the age of 3 years or had sleep study proven obstructive sleep apnea. There were two unexpected admissions to the pediatric intensive care unit for persistent upper airway obstruction-none required intubation. No child developed post-obstructive pulmonary edema. Three children were treated for infiltrates consistent with aspiration pneumonitis.

CONCLUSION

Most cases of post-extubation pulmonary edema and pneumonia can be avoided in young children and those with mild-to-moderate obstructive sleep apnea following a protocol that anticipates and avoids precipitating causes of upper airway obstruction.

Diathermy power settings as a risk factor for hemorrhage after tonsillectomy

OBJECTIVE

To investigate bipolar diathermy power settings as a risk factor for postoperative hemorrhage following tonsillectomy.

STUDY DESIGN AND SETTING

A prospective cohort study was undertaken between July 2003 and September 2004 in National Health Service (NHS) and independent hospitals in England and Northern Ireland. Data were collected on patient characteristics, tonsillectomy technique, and postoperative hemorrhage within 28 days of surgery.

RESULTS

Among the 9572 patients who had a tonsillectomy performed with bipolar diathermy dissection and hemostasis, the overall rate of hemorrhage was 4.6 percent and the risk of hemorrhage was not associated with the diathermy power setting. Among the 8465 patients who had tonsillectomy with cold steel dissection and bipolar diathermy hemostasis, the rate of hemorrhage increased from 1.8% in patients with the lowest power settings (6 to 8 watts) to 3.7% in those with settings above 18 watts (P value for trend = 0.005).

CONCLUSION

In tonsillectomies using cold steel dissection and bipolar diathermy for hemostasis, the risk of postoperative hemorrhage becomes greater as diathermy power increases.

Electrocautery adenoidectomy outcomes: A meta-analysis

Objective: Review the published literature regarding clinical outcomes of suction electrocautery adenoidectomy (ECA) in pediatric patients.

Data Source: The MEDLINE database was systematically reviewed for articles reporting on the use of ECA.

Review Methods: Each study was independently reviewed by each investigator. Inclusion criteria included English language, sample size greater than five, and presentation of extractable data regarding outcomes with ECA. Random-effects modeling was used to estimate summary outcomes.

Results: Nine studies met the inclusion criteria. The mean sample size was 276 patients with a grand mean age of 6.0 years. Random-effects modeling of intraoperative hemorrhage (4.1 cc vs 24.0 cc, 95 percent CI of difference = 16.5–23.1, P < 0.001) and operative time (10.0 minutes vs 18.4 minutes, 95 percent CI of difference = 0.82–2.90, P < 0.001) favored ECA vs curette adenoidectomy. Subjective success was reported in 95.0 percent (95% CI = 92.7%-97.3%, P < 0.001) of ECA patients with a grand mean of 5.8 months of follow-up. Adenoid regrowth was evaluated objectively (endoscopy or x ray) in only 116 of 2132 patients (5.4%), with an observed regrowth rate of 2.8 percent that (95% CI = 0%-5.5%, P = 0.052).

Conclusions: The preponderance of available evidence favors ECA vs curette adenoidectomy in terms of decreased intraoperative hemorrhage and operative time. Long-term outcome data for ECA are scarce but suggest a low regrowth and complication rate.

Efficacy of powered intracapsular tonsillectomy and adenoidectomy

OBJECTIVES/HYPOTHESIS

We sought to determine the effectiveness of powered intracapsular tonsillectomy and adenoidectomy (PITA) in the treatment of children with moderately severe obstructive sleep apnea and to measure changes in quality of life that occur with such treatment.

STUDY DESIGN

Prospective, nonrandomized clinical trial in an academic pediatric otolaryngology practice.

METHODS

Convenience sample of children ages 3 to 12 years diagnosed with obstructive sleep apnea of moderate severity, defined as an apnea-hypopnea index (AHI) between 5 and 20 on polysomnography. Children with recurrent streptococcal pharyngitis, chromosomal abnormalities, craniofacial abnormalities, neuromotor disease, sickle cell disease, obesity, or coagulopathy were excluded. PITA was performed by using the microdebrider. Polysomnography was performed before surgery and repeated 4 to 8 weeks after surgery. The Obstructive Sleep Apnea (OSA)-18 questionnaire was completed at surgery and at the time of postoperative polysomnography to assess quality of life changes. The main outcome measure was cure of obstructive sleep apnea, as defined by a postoperative AHI of 1 or less for complete cure and less than 5 for partial cure. Improvements in quality of life were assessed by changes in the OSA-18 questionnaire.

RESULTS

Nineteen children underwent PITA for moderate obstructive sleep apnea syndrome (OSAS), and 14 completed postoperative polysomnography. All 14 subjects who completed the study achieved at least partial cure. Thirteen of 14 (93%) subjects had a complete cure of OSAS after PITA. The median preoperative AHI was 7.9, and the median AHI after surgery was 0.1. The mean number of arousals per hour before surgery was 9.5, and this was reduced to a mean of 5.6 after surgery. Quality of life measures on OSA-18 also improved, with large improvements in total quality of life scores and in all five domains seen after surgery.

CONCLUSIONS

PITA cures otherwise healthy children with obstructive sleep apnea of moderate severity, at least in the short-term, as documented by postoperative polysomnography. Improvements in quality of life measures, as documented by changes in OSA-18, were seen in all children as well.

Suction cautery and electrosurgical risks in otolaryngology

BACKGROUND

Flash fires, mucosal injuries and commissure burns during otolaryngology procedures have been largely attributed to anesthetic and surgical errors. Reports of direct electrosurgical device related events are rare. The discovery of thermal damage to the oral commissure during routine suction cautery adenoidectomy at our institution prompted a detailed investigation of the device's thermal properties. We complement this analysis with a review of electrocautery device related injuries reported in otolaryngology literature.

METHODS

FLIR Systems Thermovision A40 infrared camera was used to evaluate temperature changes along the electrosurgical wand of suction cautery devices. Shaft temperatures were measured at specific times of continuous use, distances along the shaft, and cautery settings. A literature search of electrocautery-associated injuries during upper aerodigestive procedure was then performed. Nine pediatric otolaryngologists were then interviewed for historical experience with electrocautery injuries.

RESULTS

Temperatures exceeding 60 degrees C, and sufficient to cause thermal soft tissue damage, occurred along the suction cautery wand at a setting of 40 Watts (W). These temperatures traveled far enough to appose the oral commissure when the device was simultaneously in continuous use, in the fulgurate mode, and with the suction turned off. Literature review identified eleven articles specifically pertaining to electrosurgical injuries during routine oropharyngeal procedures. Flash fires and their associated burns were the most frequently reported complication. Conversely, seven of ten cases elicited from peer interviews were oral or commissure burns attributed to improper insulation of electrocautery devices.

CONCLUSIONS

Inadvertent electrosurgical injuries during routine otolaryngology procedures can result from inadequate equipment insulation. Techniques to reduce the likelihood of these events are discussed.

Intracapsular versus subcapsular coblation tonsillectomy

OBJECTIVE

To compare the postoperative recovery of patients who undergo intracapsular to subcapsular Coblation tonsillectomy.

STUDY DESIGN AND SETTING

This was a prospective, randomized, double-blinded study. A total of 69 children, aged 2 to 16 years, were randomized to intracapsular (n = 34) or subcapsular (n = 35) tonsillectomy. The Coblation technique was used with both groups. Outcomes measures were assessed on postoperative day 1 or 2 and 5 or 6. These included child and parental rating of pain with the Wong Faces pain scale, analgesic use, oral intake, and activity level.

RESULTS

Intracapsular tonsillectomy patients had similar levels of pain to subcapsular tonsillectomy patients on day 1 or 2. However, at day 5 or 6, intracapsular tonsillectomy patients had significantly less pain than the subcapsular tonsillectomy patients. Intracapsular patients ate more and were more active at both time points.

CONCLUSION AND SIGNIFICANCE

Children with obstructive sleep apnea who undergo tonsillectomy demonstrate better postoperative recovery after intracapsular tonsillectomy. The intracapsular versus subcapsular difference may be best appreciated at a delayed time point (day 5 or 6) rather than early (day 1 or 2).