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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

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

OBJECTIVE

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

DATA SOURCES

Medline, Embase, and the Cochrane Library.

REVIEW METHODS

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

RESULTS

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

CONCLUSION

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

Harmonic Scalpel Tonsillectomy Versus Coblation Tonsillectomy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Aim

This systematic review and meta-analysis of randomized controlled trials (RCTs) aimed to comprehensively evaluate the efficacy of coblation versus harmonic scalpel methods among patients undergoing tonsillectomy.

Methods

PubMed, Cochrane Central Register of Controlled Trials, Scopus, Web of Science, and Google Scholar databases were systematically screened from inception until October 2022. The outcomes were summarized as risk ratio (RR) or mean difference/standardized mean difference (MD/SMD) with 95% confidence interval (CI) in a random-effects model.

Results

Six RCTs were analyzed, encompassing a sum of 461 patients (harmonic scalpel = 233 patients and coblation = 228 patients). The overall quality assessment was low risk of bias in two RCTs, some concerns of bias in three RCTs, and high risk of bias in one RCT. There was no significant difference between harmonic scalpel and coblation groups regarding the mean operative time (n = 6 RCTs, MD=-7.45 min, 95% CI [-15.26, 0.01], p = 0.06) mean intraoperative blood loss (n = 5 RCTs, MD=-36.03 ml, 95% CI [-77.46, 5.41], p = 0.09), and rate of postoperative hemorrhage (n = 5 RCTs, RR = 0.59, 95% CI [0.25, 1.39], p = 0.23). The overall postoperative pain score was significantly reduced in favor of the coblation group compared with the harmonic scalpel group (n = 5 RCTs, MD = 0.40, 95% CI [0.10, 0.69], p = 0.009)".

Conclusions

The harmonic scalpel and coblation techniques share equal efficacy among patients undergoing tonsillectomy. The reduction in postoperative pain score provided by the coblation method is not clinically meaningful in clinical practice. Additional RCTs are needed to consolidate the power and quality of the presented evidence.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-04022-7.

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

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

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Coblation tonsillectomy versus laser tonsillectomy: a systematic review and meta-analysis of randomized controlled trials

AIM

This systematic review and meta-analysis of randomized controlled trials (RCTs) evaluated coblation versus laser (carbon dioxide and diode) tonsillectomy, with regard to various surgical and clinical outcomes.

METHODS

We searched PubMed, CENTRAL, Scopus, and Web of Science for relevant from inception until March 2021. We evaluated risk of bias using the Cochrane Collaboration Tool. We summarized the outcomes as risk ratio (RR) or mean difference/standardized mean difference (MD/SMD) with 95% confidence interval (CI). We conducted subgroup analysis based on the day of postoperative pain (day 1, day 7, and day 14) and type of postoperative hemorrhage (reactionary and secondary). In addition, we conducted subgroup analysis according to the type of laser.

RESULTS

Five RCTs were analyzed. Three and two RCTs were evaluated as having "some concerns" and "low risk of bias", respectively. Coblation tonsillectomy correlated with lower intraoperative blood loss (MD = -5.08 ml, 95% CI [- 7.33 to - 2.84], P < 0.0001) and lower operative time (MD = - 4.50 min, 95% CI [- 6.10 to - 2.90], P < 0.0001) compared with the laser tonsillectomy. However, there was no significant difference between both groups regarding the postoperative pain score (SMD = - 0.27, 95% CI [- 0.72 to 0.17], P = 0.27) and rate of postoperative hemorrhage (RR = 0.95, 95% CI [0.27-3.40], P = 0.23). Subgroup analysis reported similar insignificant difference between both groups according to the day of postoperative pain and type of postoperative hemorrhage.

CONCLUSIONS

Coblation tonsillectomy correlated with a significant reduction in intraoperative blood loss and operative time compared with the laser technique. Nevertheless, these effects do not seem clinically meaningful in surgical practice.

Intrapatient Comparison of Coblation versus Electrocautery Tonsillectomy in Children: A Randomized, Controlled Trial

Many surgical instruments have been introduced and compared for safety and surgical efficiency in tonsillectomy. This study aimed to compare postoperative pain between coblation and conventional monopolar electrocautery tonsillectomy by intrapatient comparison in children. Thirty pediatric patients over six years of age undergoing tonsillectomies were enrolled. Coblation and electrocautery were used to remove both tonsils in one patient; one was removed by coblation and the other by electrocautery. The coblation side was randomly selected, and it was blinded to the patients. Each side’s daily pain scores were collected on the visual analogue scale (VAS) during ten postoperative days. On the day of surgery, 22 (73%) patients identified less pain on the coblation side, while others felt similar pain. The mean pain scores were significantly lower on the coblation side during the postoperative ten days (except for the 6th and 8th) than on the electrocautery side. The duration of severe pain (VAS > 5) was significantly shorter on the coblation side than on the electrocautery side (2.0 versus 3.7 days, respectively; p = 0.042). Coblation tonsillectomy induced less pain than electrocautery in pediatric patients; therefore, surgeons could choose the coblator as a surgical instrument for tonsillectomy to improve the pediatric postoperative quality of life.

Paediatric tonsillectomy in England: A cohort study of clinical practice and outcomes using Hospital Episode Statistics data (2008-2019)

Objectives

To assess the safety of paediatric tonsillectomy procedures conducted in NHS hospitals in England between 2008 and 2019.

Design

Retrospective observational cohort study using Hospital Episode Statistics (HES) data.

Setting

Acute NHS trusts in England conducting paediatric tonsillectomy procedures.

Participants

Children (≤16 years old) undergoing bilateral tonsillectomy.

Main outcome measures

Number of tonsillectomies performed per year by procedural method. In‐hospital complications including return to theatre for arrest of haemorrhage. Readmission within 28 days, including those for pain, haemorrhage and surgical arrest of haemorrhage. Long‐term outcomes: all‐cause mortality, revision tonsillectomy.

Results

A total of 318 453 paediatric tonsillectomies were performed from 2008 to 2019:278,772 dissection (87.5%) and 39 681 coblation (12.5%). The proportion of tonsillectomy performed using coblation increased from 7% in 2008/9 to 27% in 2018/9. Five patients died in hospital (including 4 due to respiratory complications). In‐hospital complications occurred in 4202 children (1.3%), with the most frequent being haemorrhage. Within 28 days of tonsillectomy, 28 170 patients (8.8%) were readmitted and 7 deaths occurred. Readmission rates for haemorrhage and pain have increased since 2008. The proportion of children undergoing revision tonsillectomy procedures within 5 years following coblation tonsillectomy (1.4%) was approximately double that of dissection (0.6%).

Conclusions

Clinical practice of paediatric tonsillectomy has changed in England over the past 11 years. The overall mortality rate associated with the procedure is 0.0037%. Differences in outcomes have been identified for different procedural methods. However, routine administrative data are limited in differentiating procedural detail (eg we are unable to differentiate intra or extra‐capsular techniques from current clinical coding of tonsillectomy procedures). Therefore, prospective national data collection or more granular clinical coding is essential to capture relative outcomes of the different tonsillectomy methods and techniques being used in the NHS.