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.

Thermal welding tonsillectomy versus cold dissection tonsillectomy: A systematic review and meta-analysis of randomised controlled trials

OBJECTIVES

To evaluate the efficacy of thermal welding (TW) versus cold dissection (CD) strategies among tonsillectomy patients.

DESIGN AND SETTING

A systematic review and meta-analysis of randomised controlled trials (RCTs).

PARTICIPANTS

Patients undergoing tonsillectomy.

MAIN OUTCOME MEASURES

The outcomes were summarised as risk ratio (RR) or mean difference/standardised mean difference (MD/SMD) with 95% confidence interval (CI) in a random-effects model.

RESULTS

Fourteen RCTs were analysed. The mean operative time (n = 14 RCTs, MD = -7.99 min, 95% CI [-12.88, -3.10], p < .001), mean intraoperative blood loss (n = 11 RCTs, MD = -57.18 mL, 95% CI [-71.58, -42.78], p < .001) and postoperative pain score on day 1 (n = 15 RCTs, SMD = -0.40, 95% CI [-0.75, -0.06], p = .02) were significantly reduced in the TW group compared with the CD group. However, there was no significant difference between both groups regarding the rate of reactionary bleeding (n = 13 RCTs, RR = 0.62, 95% CI [0.23, 1.71], p = .36) and delayed bleeding (n = 13 RCTs, RR = 1.03, 95% CI [0.46, 2.30], p = .95).

CONCLUSION

Compared with CD, TW significantly reduced the operative time and intraoperative blood loss, without an impact on the rate of postoperative bleeding. The reduction in postoperative pain score provided by the TW strategy was not clinically meaningful in clinical practice. TW might appear superior to CD among tonsillectomy patients.

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.

Variation in pediatric outpatient adenotonsillectomy costs in a multihospital network

OBJECTIVES/HYPOTHESIS

Identify hospital costs for same-day pediatric adenotonsillectomy (T&A) surgery, and evaluate surgeon, hospital, and patient factors influencing variation in costs, and compare relationship of costs to complications for T&A.

STUDY DESIGN

Observational retrospective cohort study.

METHODS

A multihospital network's standardized activity-based accounting system was used to determine hospital costs per T&A from 1998 to 2012. Children 1 to 18 years old who underwent same-day T&A surgery were included. Subjects with additional procedures were excluded. Mixed effects analyses were performed to identify variation in mean costs due to surgeon, hospital, and patient factors. Surgeons' mean cost/case was related to subsequent complications, defined as any unplanned visit within 21 days in the healthcare system.

RESULTS

The study cohort included 26,626 T&As performed by 66 surgeons at 18 hospitals. Mean cost per T&A was $1,355 ± $505. Mixed effects analysis using patient factors as fixed effects and surgeon and hospital as a random effect identified significant variation in mean costs per surgeon, with 95% of surgeons having a mean cost/case between 67% and 150% of the overall mean (range, $874-$2,232/case). Similar variability was found among hospitals, with 95% of the facilities having mean costs between 64% to 156% of the mean (range, $1,029-$2,385/case). Severity of illness and several other patient factors exhibited small but statistically significant associations with cost. Surgeons' mean cost/case was moderately associated with an increased complication rate.

CONCLUSIONS

Significant variation in same-day pediatric T&A surgery costs exists among different surgeons and hospitals within a multihospital network. Reducing variation in costs while maintaining outcomes may improve healthcare value and eliminate waste.

LEVEL OF EVIDENCE

4.

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.

Effect of cold-water cooling of tonsillar fossa and pharyngeal mucosa on post-tonsillectomy pain

PURPOSE

Post-tonsillectomy pain is a notable concern and thermal injury produced by electric surgical devices is considered a main cause. Intraoperative cooling of the tonsillar fossa and pharyngeal mucosa with cold water has effectively reduced postoperative pain, but no studies have fully evaluated the effects of this technique with a proper study design. We assessed mucosal cooling in two groups of patients undergoing the same surgical technique by a single surgeon, with one group receiving cold-water cooling and the other group as a control.

METHODS

Forty patients who underwent monopolar electrocautery tonsillectomy were randomly assigned to two groups (n = 20 for each group). Group 1 received cooling of the tonsillar fossa and pharyngeal mucosa with 4 °C saline just after removal of each tonsil whereas Group 2 did not receive cooling. Postoperative pain was recorded on operation day and 1, 2, 4, 7, and 10 days postoperatively. Post-tonsillectomy pain, return to normal diet, and incidence of postoperative bleeding were compared between the groups.

RESULTS

Post-tonsillectomy pain on 6 selected days and overall pain during the 10-day follow-up period were significantly lower in Group 1. However, return to normal diet and incidence of postoperative bleeding did not differ significantly between the groups.

CONCLUSIONS

Intraoperative application of cold water after tonsillectomy significantly reduced postoperative pain. We recommend cooling the tonsillar fossa and pharyngeal mucosa with cold water during tonsillectomy to easily and effectively reduce post-tonsillectomy pain.

Surgeon Dependent Variation in Adenotonsillectomy Costs in Children

Objectives

To (1) identify the major expenses for same-day adenotonsillectomy (T&A) and the costs for postoperative complication encounters in a children’s hospital and (2) compare differences for variations in costs by surgeon.

Study Design

Observational cohort study.

Setting

Tertiary children’s hospital.

Subjects and Methods

A standardized activity-based hospital accounting system was used to determine total hospital costs per encounter (not including professional fees for surgeons or anesthetists) for T&A cases at a tertiary children’s hospital from 2007 to 2012. Hospital costs were subdivided into categories, including operating room (OR), OR supplies, postanesthesia care unit (PACU), same-day services (SDS), anesthesia, pharmacy, and other. Costs for postoperative complication encounters were included to identify a mean total cost per case per surgeon.

Results

The study cohort included 4824 T&As performed by 14 different surgeons. The mean cost per T&A was $1506 (95% confidence interval, $1492-$1519, with a range of $1156-$1828 for the lowest and highest cost per case per surgeon; P < .01). Including the cost for postoperative complications, the mean cost increased to $1599 ($1570-$1629). The largest cost categories included OR (31.9%), SDS (28.1%), and OR supplies (15.6%).

Conclusion

A large portion of T&A expenses are due to OR and supply costs. Significant differences in costs between surgeons for outpatient T&A were identified. Studies to understand the reasons for this variation and the impact on outcomes are needed. If this variation does not affect patient outcomes, then reducing this variation may improve health care value by limiting waste.

Intraoperative ice pack application for uvulopalatoplasty pain reduction: a randomized controlled trial

OBJECTIVES/HYPOTHESIS

Pain after uvulopalatoplasty continues to cause patients significant morbidity, especially from the tonsillectomy portion. The literature describes multiple techniques to reduce post-tonsillectomy pain, none being definitive. The purpose of this study was to evaluate the effect of intraoperative ice pack application on post-uvulopalatoplasty pain.

STUDY DESIGN

Single-blinded, randomized controlled trial.

METHODS

After inclusion and exclusion criteria were met, patients were enrolled and randomized, and subsequently underwent standard electrocautery uvulopalatoplasty. Packs were placed into the tonsillar fossae immediately following tonsil removal and into the palate after the palatoplasty. Patients then completed a questionnaire that evaluated their experience for 10 days following surgery. The primary outcome was pain rated on a visual analog scale. Return to work and return to normal diet were also assessed. T test and Mann-Whitney statistical analyses, as well as routine descriptive statistics, were conducted.

RESULTS

Eighteen subjects were recruited. Patients that received intraoperative cold packs experienced a statistically significant change in VAS average pain [3.4 ± 1.1 cm (p = 0.00001)] when compared with patients receiving room temperature packs. No difference in return to work (p = 0.16) and return to normal diet (p = 0.12) was identified.

CONCLUSIONS

Intraoperative ice pack administration results in significantly reduced pain following electrocautery uvulopalatoplasty.

The effects of desflurane and sevoflurane on the peri- and postoperative bleeding of adenotonsillectomy patients

OBJECTIVE

To compare the effects of, volatile anesthetics, desflurane and sevoflurane on intra-operative and postoperative bleeding in patients who underwent tonsillectomy and adenoidectomy.

MATERIAL AND METHOD

Totally 40 children (14 girl and 26 boys) aged between 2 and 16years were included in this prospective randomized double-blind clinical trial. The patients underwent conventional cold tonsillectomy and curettage adenoidectomy under general anesthesia. For the maintenance of anesthesia, the patients were randomized into two groups; desflurane group and sevoflurane group, each including 20 subjects. Desflurane concentration was set between 4% and 6% (0.7-0.9 MAC), whereas sevoflurane concentration was set between 2% and 2.5% (0.7-0.9 MAC). The amount of perioperative bleeding in milliliters was measured by using separate aspirator bags for each patient.

RESULTS

Desflurane caused significantly lower amount of perioperative bleeding compared to sevoflurane (p=0.03). No significant difference was observed between the two groups in terms of age, body mass index and operation duration, respectively (p=0.20, p=0.49, p=0.07).

CONCLUSION

Desflurane, which is one of the volatile anesthetics, leads to a lower amount of intraoperative bleeding than sevoflurane during tonsillectomy and adenoidectomy operations.

Double-blind, randomised, controlled study of post-operative pain in children undergoing radiofrequency tonsillotomy versus laser tonsillotomy

INTRODUCTION

In the last decade tonsillotomy has come into vogue again, whereas the number of tonsillectomies is decreasing rapidly. Currently, most tonsils are reduced by utilise electrosurgery, radiofrequency or carbon dioxide laser. However, it is not clear whether radiofrequency tonsillotomy is as effective as laser or other surgical techniques in respect of post-operative pain and haemorrhage.

MATERIAL AND METHODS

A prospective, randomised, double-blinded, controlled, clinical study was conducted in the otorhinolaryngology department of Ludwig Maximilians University, Munich, Germany. Twenty-six children with tonsillar hypertrophy were included. Exclusion criteria were: history of peritonsillar abscess, previous tonsil surgery, tonsillitis within two weeks, pain before surgery, psychiatric illness, asymmetrical tonsils, chronic analgesic usage, bleeding disorders and other surgical procedures during the same operation. Tonsillotomy was performed on one side with radiofrequency and on the other side with a carbon dioxide laser. All procedures were performed by a single surgeon, under general anaesthesia. A visual analogue scale was used to measure patients' pain on each side, administered by a 'blinded' nurse on the three post-operative mornings and evenings, within the hospital.

RESULTS

There was no difference in post-operative pain scores or haemorrhage, comparing laser versus radiofrequency tonsillotomy. Patient's overall reported pain was very modest compared with post-tonsillectomy pain. No haemorrhage or other adverse effects were observed.

The Sluder method in the Netherlands and the incidence of postoperative haemorrhage in a pediatric hospital

OBJECTIVE

Analysis of the method of tonsillectomy in use in the Netherlands and the incidence of postoperative haemorrhage in an academic tertiary pediatric referral hospital.

STUDY DESIGN AND SETTING

(A) An explorative study of the Sluder tonsillectomy method in the Netherlands and (B) a retrospective case file review at the Sophia Children's Hospital in Rotterdam.

METHODS

(A) A telephone and e-mail survey amongst 107 hospitals in the Netherlands. (B) A review of patients younger than 16 years who underwent a tonsillectomy or adenotonsillectomy between January 1, 1998, and February 22, 2008. This part of the study surveyed the intubated Sluder method and analyzed the incidence of primary and secondary haemorrhage in an academic tertiary pediatric referral hospital.

RESULTS

(A) The Sluder method was commonly used in 102 (95.32%) hospitals; the traditional dissection technique was exclusively used only in five hospitals (4.67%). Of the 102 hospitals using the Sluder method, 67 (65.68%) report using only inhalation mask anaesthesia, while the remaining 35 use intubation. (B) Of 1797 patients studied, 40 patients experienced postoperative tonsillar haemorrhage (2.23%), with 35 (1.95%) patients primary haemorrhage of which 32 (1.78%) within 6 h after the surgery. Secondary haemorrhage occurred in five (0.28%) patients.

CONCLUSIONS

The Sluder method is still generally used in the majority of hospitals in the Netherlands today. Because of the low incidence of especially secondary haemorrhage and most of the primary haemorrhages occurring within 6h after the surgery, this technique is ideally suited for day care 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.

Adjuvant use of liquid alginate suspension for post-tonsillectomy morbidity: Double-blind randomized clinical trial of efficacy

Objective: To evaluate the efficacy of liquid alginate suspension in alleviating post-tonsillectomy morbidity in adult patients.

Methods: A prospective, double-blind, randomized, placebo-controlled study comparing the effect of liquid alginate suspension with placebo was performed on 40 patients who underwent tonsillectomy at Derince State Hospital, Kocaeli, Turkey. The patients were randomly chosen, and each used liquid alginate suspension four times daily or a placebo solution at the same regimen. Tonsillectomy was performed under general anesthesia by cold dissection and suture ligation. Patients were examined at postoperative days 1, 3, 5, and 7 for healing, instructed to note the amount of analgesics used, and asked to mark the visual analog score of throat pain every day for a week.

Results: The study group had statistically significant lower pain scores at day 2 ( P = 0.03). Study group required less analgesic than the control group during the study period, but the difference was statistically different only on day 2 ( P = 0.003) day. Healing was statistically significant on day 5 ( P = 0.03) in the study group.

Conclusion: Use of the antireflux suspensions in patients undergoing tonsillectomy may be effective in reducing postoperative morbidity in adjunct with classic analgesics.