A pilot randomized controlled trial of coblation tonsillectomy versus dissection tonsillectomy with bipolar diathermy haemostasis

Comparative Study of Complications Associated with Coblation Versus Conventional Tonsillectomy

Tonsillectomy is one of the most common ear, nose and throat surgical procedure, carried out worldwide1. Amongst the various method of tonsillectomy (diathermy, laser, harmonic scalpel, radiofrequency cautery cryosurgery and coblation), dissection and snare method is commonest procedure done by otorhinolaryngologist. To compare the post operative complications associated with coblation versus conventional cold-dissection steel tonsillectomy. We carried out the prospective study of complications associated with coblation versus conventional cold steel tonsillectomy in postoperative pain, anesthesia, hemorrhage, fever, pharyngitis, injury of adjacent structure & cautery burn. Average blood loss on Coblation side was 18.74 ml while on conventional side it was 44.2 ml. Post operative pain score, injury to adjacent structure and cautery burn were found to be significantly decreased in coblation. No such difference was observed in pharyngitis and fever in both methods. The use of coblator reduces the post-operative pain, peri or post-operative blood loss, injury to adjacent structure & cautery burn too.

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.

Traditional and Coblation Tonsillectomy in Pediatrics Population: A Comparative Study

Tonsillectomy is still surrounded by controversy, especially regarding choice of surgical technique. Despite numerous surgical techniques are present, post-operative pain remains significant postoperative morbidities. An ideal method would lessen complications and minimize operative time and costs. This is a randomized double blinded interventional study. We enrolled 70 subjects and divided into two groups of 35 subjects in each. One group underwent traditional tonsillectomy and another underwent coblation tonsillectomy. We compared operating time, intraoperative blood loss, post-operative pain, return to normal activities and diet and post-operative hemorrhage. Mean operating time in coblation group was 18.24 ± 5.37 min and in traditional group 30.04 ± 7.08 min. The mean blood loss in coblation tonsillectomy group was 82.79 ± 21.13 ml and in traditional tonsillectomy 150.4 ± 37.91 ml. The mean of post-operative pain score in coblation tonsillectomy group was 3.2 ± 1.47 and in traditional tonsillectomy group 6.11 ± 1.61. The mean day of regaining activity in coblation tonsillectomy group was 6.26 ± 0.92 days and in traditional tonsillectomy group 8.26 ± 1.09 days. Mean time by which patients of coblation tonsillectomy group regained their diet was 4.11 ± 0.87 days whereas in traditional tonsillectomy group it was 6.14 ± 1.14 days. There was no case observed with episode of primary or secondary hemorrhage. We conclude from this study that coblation tonsillectomy takes less operating time with less blood loss, also associated with less post-operative pain, less time taken to achieve normal diet and activities.

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.

Coblation Versus Bipolar Diathermy Hemostasis in Pediatric Tonsillectomy Patients: Systematic Review and Meta-Analysis

This study aimed to compare the outcomes of coblation versus bipolar diathermy in pediatric patients undergoing tonsillectomy. A systematic review and meta-analysis were performed per the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Guidelines. An electronic search of information was conducted to identify all Randomized Controlled Trials (RCTs) comparing the outcomes of coblation versus bipolar in pediatric patients undergoing tonsillectomy. Primary outcome measures were intraoperative bleeding, reactionary hemorrhage, delayed hemorrhage, and post-operative pain. Secondary outcome measures included a return to a normal diet, effects on the tonsillar bed, operation time, and administration of analgesia. Fixed and random-effects models were used for the analysis. Seven studies enrolling 1328 patients were identified. There was a significant difference between coblation and bipolar groups in terms of delayed hemorrhage (Odds Ratio [OR] = 0.27, P = 0.005) and post-operative pain (standardized mean difference [MD] = -2.13, P = 0.0007). Intraoperative bleeding (MD = -43.26, P = 0.11) and reactionary hemorrhage did not show any significant difference. The coblation group improved analgesia administration, diet and tonsillar tissue recovery, and thermal damage for secondary outcomes. No significant difference was reported in terms of operation time. In conclusion, coblation is comparable to a bipolar technique for pediatric patients undergoing tonsillectomy. It improves postoperative pain and delayed hemorrhage and does not worsen intraoperative bleeding and reactionary hemorrhage.

The safety of bipolar mode radiofrequency (BMRF) on cochlear implant integrity test; a clinical prospective study

PURPOSE

We aimed to assess the effect of bipolar mode radiofrequency (BMRF) tonsillectomy as a model of oro-pharyngeal surgical maneuver on the integrity of the internal device in patients with cochlear implants (CIs).

MATERIALS AND METHODS

This prospective case series included 15 consecutive pediatric patients with CIs (age range 4 to 8 years, mean 5.2 years) who underwent BMRF tonsillectomy. The postoperative integrity of the internal device was evaluated by comparing the electric current response tested preoperatively with that tested 2 days postoperatively.

RESULTS

There were differences in the current levels in the main regions of the cochlea; (the apical, mid-turn, and basal) after comparing preoperative and postoperative values, but they were not statically significant.

CONCLUSION

BMRF seems to be safe for tonsillectomy in children with CIs without negative impact on the integrity of the internal device.

Comparison of three tonsillectomy techniques in children

PURPOSE

Tonsillectomy is still one of the most common surgical procedures worldwide performed by otorhinolaryngologists. This single-blind randomized study aimed to compare cold dissection tonsillectomy, coblation tonsillectomy, and harmonic scalpel tonsillectomy in pediatric patients in respect of intraoperative blood loss, operating time, and postoperative pain and bleeding.

METHODS

This single-blind randomized clinical trial evaluated 82 pediatric patients aged 3-16 years (mean age: 7.23 ± 3.26 years) applied with tonsillectomy between April 2017 and March 2020. Harmonic scalpel tonsillectomy was applied to 33 (40.2%) patients, the cold knife technique to 25 (30.5%), and coblation tonsillectomy to 24 (29.3%).

RESULTS

There was no statistically significant difference between the three techniques in respect of postoperative pain levels and post-tonsillectomy bleeding rates. The intraoperative bleeding rate and mean operating time were determined to be significantly lower in the harmonic scalpel group (p < 0.05).

CONCLUSION

Harmonic scalpel tonsillectomy is associated with a shorter operating time and lower intraoperative bleeding rates and similar postoperative pain score and postoperative bleeding rates compared with coblation tonsillectomy and cold dissection tonsillectomy. Harmonic scalpel tonsillectomy is a fast, safe, and effective method for tonsillectomy in children.

Endoscope holder-assisted endoscopic coblation tonsillectomy

BACKGROUND

Tonsillectomy is being performed either with a headlight, surgical loupe magnification or with microscopic aid. We report the technique of endoscope holder-assisted endoscopic tonsillectomy using coblation. Coblation tonsillectomy has the primary advantage of limited thermal damage compared with alternative forms of surgery.

METHODS

Our endoscope holder, primarily designed for endoscopic ear surgery, has been extrapolated for the use in two-handed technique of tonsillectomy. The method is described in detail.

CONCLUSION

Endoscope gives a panoramic view, better optics, magnified image of the bleeders and hence there is applicability of the endoscope holder for endoscopic tonsillectomy.

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

BACKGROUND

Cold dissection is the most commonly used tonsillectomy technique, with low post-operative haemorrhage rates. Coblation is an alternative technique that may cause less pain, but could have higher post-operative haemorrhage rates.

OBJECTIVE

This study evaluated the peri-operative outcomes in paediatric tonsillectomy patients by comparing coblation and cold dissection techniques.

METHODS

A systematic review was conducted of all comparative studies of paediatric coblation and cold dissection tonsillectomy, up to December 2018. Any studies with adults were excluded. Outcomes such as pain, operative time, and intra-operative, primary and secondary haemorrhages were recorded.

RESULTS

Seven studies contributed to the summative outcome. Coblation tonsillectomy appeared to result in less pain, less intra-operative blood loss (p < 0.01) and a shorter operative time (p < 0.01). There was no significant difference between the two groups for post-operative haemorrhage (p > 0.05).

CONCLUSION

The coblation tonsillectomy technique may offer better peri-operative outcomes when compared to cold dissection, and should therefore be offered in paediatric cases, before cold dissection tonsillectomy.

Postoperative Pain and Wound Healing After Coblation-Assisted Barbed Anterior Pharyngoplasty (CABAPh): An Observational Study

Despite the numerous progresses in the palatal surgery, one of the critical aspect of snoring and OSA surgery is the postoperative pain. Over the last decades several surgical palatal procedures have been proposed. Our aim was to evaluate the tolerability of the coblation-assisted barbed anterior pharyngoplasty (CABAPh) in terms of postoperative pain and wound healing, compared with bipolar assisted barbed anterior pharyngoplasty (BAPh). An observational study on 20 patients with simple snoring was conducted. The outcomes measured to assessing pain were a 10 cm visual analog scale (VAS) and the dose of paracetamol + codeine administrated postoperatively. The wound healing was evaluated using a 3-point scale. The other parameters indicative of both pain and surgical repair were food intake and weight loss postoperatively. The mean overall pain (VAS scale) was significantly less in the CABAPh group (M 3.7; CI 3.34-4.06) compared with the BAPh (M 4.73; CI 4.28-5.19) with a P = 0.003. The mean wound healing after 4 weeks was significantly less in CABAPh group (M 2.7; CI 3.12-2.28) compared with the BAPh (M 2.1; CI 2.45-1.75) with a P = 0.02. There were no statistically significant difference with regard to food intake (P = 0.09) and weight loss (P = 0.94). The CABAPh was able to achieve a greater pain reduction and a faster wound healing compared with bipolar forceps.

Comparative Post-operative Pain Analysis Between Coblator Assisted and Bipolar Diathermy Tonsillectomy in Paediatric Patients

Tonsillectomy is one of the commonly performed otolaryngological operations. Despite a range of different techniques post-operative pain remains a major side-effect of this operation. Coblation assisted tonsillectomy is a latest technique of tonsillectomy. This technique is said to be associated with less intra-operative bleeding and less postoperative morbidity. We conducted a study in 100 patients to compare the pain scores between coblation assisted and bipolar diathermy tonsillectomy by FLACC score and Wong Baker scale score. The data so collected was statistically analysed using a t test and p values were calculated. The p value was highly significant (p < 0.001) for both scores in coblation assisted tonsillectomy 6 h postoperatively and on 1st postoperative day (p < 0.05). On 7th post-operative day however there was no significant difference in post-operative pain score using FLACC score in both groups but Wong baker scale scores were still significant. We concluded that post-operative pain was less with coblator assisted tonsillectomy as compared to bipolar diathermy tonsillectomy at least in early post-operative period.

Cost-effectiveness of Coblation compared with cold steel tonsillectomies in the UK

Objective

This study aimed to estimate the cost-effectiveness of Coblation compared with cold steel tonsillectomy in adult and paediatric patients in the UK.

Method

Decision analysis was undertaken by combining published clinical outcomes with resource utilisation estimates derived from a panel of clinicians.

Results

Using a cold steel procedure instead of Coblation is expected to generate an incremental cost of more than £2000 for each additional avoided haemorrhage, and the probability of cold steel being cost-effective was approximately 0.50. Therefore, the cost-effectiveness of the two techniques was comparable. When the published clinical outcomes were replaced with clinicians’ estimates of current practice, Coblation was found to improve outcome for less cost, and the probability of Coblation being cost-effective was at least 0.70.

Conclusion

A best-case scenario suggests Coblation affords the National Health Service a cost-effective intervention for tonsillectomy in adult and paediatric patients compared with cold steel procedures. A worst-case scenario suggests Coblation affords the National Health Service an equivalent cost-effective intervention for adult and paediatric patients.

Safety of radiofrequency ablation for adenotonsillectomy after cochlear implantation

OBJECTIVE

While a cadaveric animal study has suggested that radiofrequency ablation can be safely used in patients with cochlear implants, no in vivo studies have been published to confirm that radiofrequency ablation does not alter the integrity of the cochlear implant device.

METHODS

Cochlear implant impedance and functional performance were studied through a prospective case series in five children with seven functioning multichannel implants before and after radiofrequency ablation adenotonsillectomy.

RESULTS

There were 4 females and 1 male patient, aged 6-10 years (mean 8.5 ± 1.95 years) with 7 functioning implants. Pre- and post-surgical impedance testing revealed all electrodes were within normal operating limits. There was no statistically significant difference between the mean pre and post-operative impedances in 5 of the 7 tested implants (P = 0.2-0.8). The other two implants showed statistically significant improvement in impedance values which were not clinically significant (P = 0.02 and P < 0.001). Speech perception was unchanged as was functional performance for all 7 tested implants.

CONCLUSIONS

We found that radiofrequency ablation used in the oropharynx during adenotonsillectomy did not alter the integrity of the cochlear implant devices when assessed using electrode impedance testing, audiometry and speech perception evaluation. These results confirm those reported in previous in vitro studies and confirm the safety of radiofrequency ablation adenotonsillectomy for children who have undergone previous cochlear implant placement.

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.

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.

Coblation tonsillectomy under surgical microscopy: A retrospective study

Objective

A retrospective study to compare surgical parameters and postoperative pain in patients undergoing coblation tonsillectomy with or without microscopic guidance.

Methods

Data regarding duration of surgery and hospital stay, intraoperative blood loss, incidence of haemorrhage and postoperative pain scores were retrieved from the medical records of adult patients undergoing coblation tonsillectomy under direct vision or with microscopic guidance.

Results

The incidence of secondary haemorrhage (>24 h postoperatively) was significantly lower and the duration of hospital stay was significantly shorter in the microscope group (n = 92) than the direct vision group (n = 76). Pain scores both at rest and while swallowing reached ≤3 (no significant impact on quality-of-life) significantly faster in the microscope group than the direct vision group.

Conclusions

Microscope-assisted coblation tonsillectomy decreases the duration of hospital stay and the incidence of postoperative secondary haemorrhage, and results in an early improvement in postoperative pain scores.

WITHDRAWN: Diclofenac for acute pain in children

At December 2014, this review has been withdrawn from the Cochrane Library. This review is out of date, although it is correct at the date of publication. The review may be misleading as new studies could alter the original conclusions. All previous versions of the review can be found in the ‘Other versions’ tab. We are seeking additional authors to support the updating of this review. For further information, please contact PaPaS Managing Editor, Anna Hobson [Contact Person].

The editorial group responsible for this previously published document have withdrawn it from publication.

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.

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.

Emerging trends in tonsillectomy

OBJECTIVE

To describe the tonsillectomy techniques and management used by practicing otolaryngologists in the United States.

STUDY DESIGN

Anonymous 18-question postal survey of pediatric and general otolaryngologists on their current tonsillectomy practices.

SETTING

Tertiary academic medical center.

SUBJECTS AND METHODS

Current preoperative, perioperative, and postoperative practices in tonsillectomy were queried with multiple-choice and open-ended questions. Pediatric otolaryngologists and general otolaryngologists were compared.

RESULTS

Eighty percent of respondents perform subcapsular (total tonsillectomy) dissection. Most otolaryngologists trained with either monopolar cautery (52%) or cold steel (42%). The Coblator (ArthroCare ENT, Austin, Texas) is the most common single instrument used for tonsillectomy (27.5%), followed by monopolar cautery (26%), but in combination with other instruments, monopolar cautery was still more common (33.5%) than coblation (28.9%). Coblation was more common among private practice and general otolaryngologists. The majority of those surveyed do not use intraoperative local anesthesia, but most do use intraoperative steroids (67%). Compared with generalists, pediatric otolaryngologists were less likely to use coblation, were less likely to use local anesthetic, managed postoperative pain slightly differently, and were more likely to recommend diet ad libitum after surgery. Otolaryngologists were more likely to admit medically compromised patients postoperatively.

CONCLUSIONS

Coblation is becoming a more commonly used instrument for tonsillectomy. Pediatric otolaryngologists perform more tonsillectomies than do general otolaryngologists and manage their patients differently.

Argon plasma coagulation versus cold dissection in pediatric tonsillectomy

PURPOSE

Argon plasma coagulation (APC) is a new surgical procedure based on a conductive plasma of ionized argon between an activating electrode and a tissue surface. It is a good alternative for tonsillectomy because of its effective hemostasis and limited penetration depth of the coagulation beam. The aim of this prospective, randomized trial was to evaluate the operative time, intraoperative bleeding, and postoperative morbidity of the "hot" APC tonsillectomy compared with a traditional "cold" dissection tonsillectomy in children.

MATERIALS AND METHODS

Two hundred eighteen pediatric patients (aged 4-15 years; mean, 7,2 years) were randomized into 2 groups: treatment A (tonsillectomy with APC, n = 109) and treatment B (conventional tonsillectomy, n = 109). The outcome measures were as follows: (1) operative time, (2) intraoperative blood loss, (3) postoperative pain (evaluated using a visual analogue scale with a range score 0-10 on postoperative days 1, 3, 5, 8, and 15), and (4) postoperative primary and secondary hemorrhage. Statistical analysis was carried out using the Student t test.

RESULTS

In treatment A group, the mean duration of operative time and the intraoperative blood loss were significantly reduced (P < .001). There was no statistical significant difference between 2 groups in the intensity of postoperative pain and the incidence of postoperative hemorrhage (P > .05).

CONCLUSIONS

Argon plasma coagulation tonsillectomy in children is a new, easy, and safe technique that offers a complete eradication of the tonsillar disease, short operating time, minimal intraoperative blood loss, and a suitable cost with no additional increase in postoperative pain and hemorrhage when compared with the conventional "cold dissection."

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.

The art of tonsillectomy: the UK experience for the past 100 years

Tonsillectomy is one of the commonest ear, nose, and throat procedures performed in the United Kingdom. In the drive to reduce complication rates and improve patients' satisfaction, numerous adaptations to the traditional technique have evolved. In this article, the authors explore the changes that have been happening in the United Kingdom during the past 100 years and conclude that revisiting the traditional techniques may still be the answer to a successful procedure.

Prospective, controlled clinical trial of Ankaferd Blood Stopper in children undergoing tonsillectomy

OBJECTIVES

This is a prospective study evaluating the efficacy of Ankaferd Blood Stopper as a hemostatic agent compared to hemostasis by means of knot-tie after cold knife dissection tonsillectomy.

METHODS

Study design was the use of ABS and the KT to reach hemostasis for patients undergoing tonsillectomy. ABS is applied on right side tonsil fossa and KT is used on left side tonsil fossa. Measured outcomes such as blood loss, surgical time, and complication will be assessed. In total, 47 consecutive patients undergoing cold knife dissection tonsillectomy were studied, in all of whom Ankaferd Blood Stopper wet tampon was used for right side tonsil hemorrhage and knot-tie technique for left side tonsil hemorrhage. Data were collected intraoperatively. Follow-up visits of all patients were completed at postoperative days 1, 3, 7, and 10.

RESULTS

Ankaferd Blood Stopper side had shorter hemostasis time after tonsil removal than knot-tie side (3.19+/-0.74 min vs 7.29+/-2.33 min [mean+/-SD], p<0.01) and less blood loss (1.57+/-2.26 ml vs 14.04+/-7.23 ml [mean+/-SD], p<0.01). In addition, KT number was less with ABS side as compared to KT side (p<0.01).

CONCLUSIONS

The side on which Ankaferd Blood Stopper was used had statistically significant differences in hemostasis time, blood loss, and knot-tie number in the operation period. Ankaferd Blood Stopper is safe and efficient, and it decreases intraoperative bleeding, reduces operating time, as compared to the traditional hemostasis methods after cold knife dissection tonsillectomy.

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.

Diclofenac for acute pain in children

BACKGROUND

Diclofenac is commonly used for acute pain in children, but is not licensed for this indication in all age groups.

OBJECTIVES

1) Assess the efficacy of diclofenac for acute pain in children. 2) Assess the safety of diclofenac for short-term use in children. 3) Identify gaps in the evidence to direct future research.

SEARCH STRATEGY

Seventeen databases indexing clinical trial reports were searched in February 2005 (with an update search as part of this first review in May 2008). A hand search of Paediatric Anaesthesia was undertaken and summaries obtained of adverse reaction reports from the UK Yellow Card Scheme and World Health Organization (WHO) Monitoring Centre. The reference lists of included studies were also searched.

SELECTION CRITERIA

Any published report, in any language, involving the administration of diclofenac to a patient aged 18 years or younger for acute pain and detailing either monitoring of efficacy or safety.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study quality and extracted the data. Authors were contacted where necessary. Review Manager version 5 was used for analysis.

MAIN RESULTS

1) EFFICACY: randomised controlled trials (RCTs) comparing diclofenac with placebo/any other treatment by using pain scores (assessed or reported), or need for rescue analgesia.2) SAFETY: any type of study seeking adverse events (regardless of cause). An adverse event was defined as any reported adverse or untoward happening to a patient being treated with diclofenac for acute pain.Seven publications on diclofenac efficacy and 79 on safety (74 studies plus five case reports) were included in the final analysis. Compared with placebo/no treatment, diclofenac significantly reduced need for post-operative rescue analgesia (relative risk [RR] 0.6; number needed to treat to benefit [NNT] 3.6; 95% confidence interval [CI] 2.5 to 6.3).Compared with any other non-NSAID, patients receiving diclofenac suffered less nausea or vomiting, or both (RR 0.6; NNT 7.7 [5.3 to 14.3]). There appeared to be no increase in bleeding requiring surgical intervention in patients receiving diclofenac in the peri-operative period. Serious diclofenac adverse reactions occurred in fewer than 0.24% of children treated for acute pain. The types of serious adverse reactions were similar to those reported in adults.

AUTHORS' CONCLUSIONS

Diclofenac is an effective analgesic for perioperative acute pain in children. It causes similar types of serious adverse reactions in children as in adults, but these are rare. More research on optimum dosing and safety in asthmatic children is required.

A randomised controlled trial to compare postoperative pain in children undergoing tonsillectomy using cold steel dissection with bipolar haemostasis versus coblation technique

OBJECTIVE

To measure postoperative pain levels in children undergoing tonsillectomy, by two different techniques, cold steel dissection and coblator dissection. The hypothesis - that coblator dissection may be associated with less postoperative pain.

DESIGN

Prospective, randomised, double blind trial.

SETTING

Single centre, secondary care Children's Hospital.

PARTICIPANTS

Children aged between 4 and 16 years, undergoing tonsillectomy, or adeno-tonsillectomy.

EXCLUSION CRITERIA

children already taking regular analgesia and those who experienced postoperative bleeding. Seventy-nine children were recruited, nine were excluded.

MAIN OUTCOME MEASURES

We compared analgesia requirements during the first 10 days, and also the return to normal eating and drinking. These were assessed, using a validated pain scale. All analgesic administration in hospital and at home was compared. The return to normal eating & drinking patterns, was also compared.

RESULTS

Whilst in the 24 h postoperatively there was no significant difference in the pain scores between the two groups, the coblator group required less potent analgesia. No statistical difference was identified between the two groups following discharge, except on the sixth postoperative day, when the coblator group had lower pain scores. This may represent chance, rather than a clear difference.

CONCLUSION

The findings do not confirm the hypothesis that tonsillectomy undertaken in children, with the coblator device, is associated with lower levels of postoperative pain, but do indicate that less analgesia is required by the coblator patients in the first 12 h postoperatively.

A prospective multi-centre randomised controlled trial comparing PlasmaKnife with bipolar dissection tonsillectomy: evaluating an emerging technology

OBJECTIVE

To clinically evaluate and compare the PlasmaKnife to bipolar electrocautery in paediatric tonsillectomy.

METHODS

A prospective, multi-centred, double-blinded randomised controlled trial, conducted in central London teaching hospitals. The participants were 100 patients aged 2-16 years with recurrent tonsillitis or obstructive adenotonsillar hypertrophy awaiting a tonsillectomy were recruited in to the study. The primary outcome measures were throat, ear and swallowing pain scores over two weeks. Secondary outcome measures were return to normal diet, return to normal activity, analgesic requirements, operation time and intra-operative blood loss.

RESULTS

Surgical dissection was similar between the two groups with minimal blood loss and comparable overall operative times. We found that PlasmaKnife tonsillectomy caused more throat pain at 24 h (p=0.02). There was a tendency for a higher proportion in the bipolar dissection group to return to a normal diet, at day 3 (p=0.05) and at day 7 (p=0.04). The bipolar dissection returned to normal activities in a larger proportion than the PlasmaKnife group at day 3 (p=0.02) and at day 7 (p=0.01). There is some evidence of an association between use of analgesia at day 14 and method of tonsillectomy (p=0.03); the PlasmaKnife group tended to use less analgesia. During the study, four secondary bleeds occurred in the PlasmaKnife group and one in the bipolar dissection group, and all were managed conservatively.

CONCLUSION

Our study has found no significant advantage to PlasmaKnife over bipolar diathermy tonsillectomy. However, this preliminary study finds PlasmaKnife to be an interesting instrument and may warrant a larger randomised study to evaluate the potential advantages.