Lasers in Tonsillectomy: Revisited With Systematic Review

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.

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.

[The role of tonsillectomy in the treatment of chronic tonsillitis]

The problem of chronic tonsillitis remains one of the urgent problems of modern otorhinolaryngology. The article discusses the statistics and complications of chronic tonsillitis, provides indications for tonsillectomy and its main complications.

OBJECTIVE

Generalization and systematization of data on the impact of surgical treatment on the quality of life of patients with chronic tonsillitis.

MATERIAL AND METHODS

Search for literary sources, carried out using the search engines of the RSCI, PubMed, Web of Science, and eLibrary.

RESULTS

A review of literature sources demonstrates a significant improvement in the quality of life of patients after tonsillectomy; however, data from some studies show a trend towards a decrease in the number of planned tonsillectomies and an associated increase in the detection of local purulent-septic complications.

[Comparison of pain after laser and traditional extracapsular tonsillectomy]

OBJECTIVE

To compare the pain during the postoperative period after the extracapsular tonsillectomy, performed with the 1.94 µm laser and cold steel tonsillectomy.

MATERIAL AND METHODS

Sixty patients with chronic decompensated tonsillitis were enrolled in the study. Patients were randomized into two groups: the first one was subjected to cold steel tonsillectomy; in the second group tonsillectomy was done using a laser with 1.94 µm wavelength at pulsed mode. Patients' anamnesis was evaluated (the presence of signs of a toxic-allergic form of the disease, peritonsillar abscesses, the duration of the disease and the frequency of exacerbations of tonsillitis per year). In the postoperative period patients filled out questionnaires: the severity of pain was assessed for 10 days in points from 0 to 10, and painkiller use frequency per day.

RESULTS

Statistical analysis revealed that the pain after tonsillectomy depends on the presence of peritonsillar abscesses in the anamnesis. In patients with abscesses, the pain and the need for anesthesia are significantly lower with the laser technique compared with cold steel. The tonsillectomy technique does not affect the risk of postoperative bleeding (in both groups - 1/30).

CONCLUSION

The postoperative period after extracapsular laser tonsillectomy is characterized by significantly less pain than traditional tonsillectomy with cold instruments in patients with a history of peritonsillar abscess. Laser tonsillectomy does not have an increased risk of bleeding compared to traditional tonsillectomy.

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.

Time to Functional Recovery After Laser Tonsillotomy Performed Under Local Anesthesia vs Conventional Tonsillectomy With General Anesthesia Among Adults: A Randomized Clinical Trial

IMPORTANCE

Carbon dioxide laser tonsillotomy performed under local anesthesia may be an effective and less invasive alternative than dissection tonsillectomy for treatment of tonsil-related afflictions.

OBJECTIVE

To compare functional recovery and symptom relief among adults undergoing tonsillectomy or tonsillotomy.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial was conducted at 5 secondary and tertiary hospitals in the Netherlands from January 2018 to December 2019. Participants were 199 adult patients with an indication for surgical tonsil removal randomly assigned to either the tonsillectomy or tonsillotomy group.

INTERVENTIONS

For tonsillotomy, the crypts of the palatine tonsil were evaporated using a carbon dioxide laser under local anesthesia, whereas tonsillectomy consisted of total tonsil removal performed under general anesthesia.

MAIN OUTCOMES AND MEASURES

The primary outcome was time to functional recovery measured within 2 weeks after surgery assessed for a modified intention-to-treat population. Secondary outcomes were time to return to work after surgery, resolution of primary symptoms, severity of remaining symptoms, surgical complications, postoperative pain and analgesics use, and overall patient satisfaction assessed for the intention-to-treat population.

RESULTS

Of 199 patients (139 [70%] female; mean [SD] age, 29 [9] years), 98 were randomly assigned to tonsillotomy and 101 were randomly assigned to tonsillectomy. Recovery within 2 weeks after surgery was significantly shorter after tonsillotomy than after tonsillectomy (hazard ratio for recovery after tonsillectomy vs tonsillotomy, 0.3; 95% CI, 0.2-0.5). Two weeks after surgery, 72 (77%) patients in the tonsillotomy group were fully recovered compared with 26 (57%) patients in the tonsillectomy group. Time until return to work within 2 weeks was also shorter after tonsillotomy (median [IQR], 4.5 [3.0-7.0] days vs 12.0 [9.0-14.0] days; hazard ratio for return after tonsillectomy vs tonsillotomy, 0.3; 95% CI, 0.2-0.4.). Postoperative hemorrhage occurred in 2 patients (2%) in the tonsillotomy group and 8 patients (12%) in the tonsillectomy group. At 6 months after surgery, fewer patients in the tonsillectomy group (25; 35%) than in the tonsillotomy group (54; 57%) experienced persistent symptoms (difference of 22%; 95% CI, 7%-37%). Most patients with persistent symptoms in both the tonsillotomy (32 of 54; 59%) and tonsillectomy (16 of 25; 64%) groups reported mild symptoms 6 months after surgery.

CONCLUSIONS AND RELEVANCE

This randomized clinical trial found that compared with tonsillectomy performed under general anesthesia, laser tonsillotomy performed under local anesthesia had a significantly shorter and less painful recovery period. A higher percentage of patients had persistent symptoms after tonsillotomy, although the intensity of these symptoms was lower than before surgery. These results suggest that laser tonsillotomy performed under local anesthesia may be a feasible alternative to conventional tonsillectomy in this population.

TRIAL REGISTRATION

Netherlands Trial Register Identifier: NL6866 (NTR7044).

Respiratory obstruction due to tonsillar lymphoglandular polyp in a brachycephalic dog: a case report

BACKGROUND

Respiratory distress is one of the most common afflictions of brachycephalic dogs. Dogs in respiratory distress usually present to the emergency service with a constellation of clinical signs including but not limited to: stertorous breathing, dyspnea, gagging, cyanotic mucus membranes, hyperthermia, and commonly a history of gastrointestinal signs. While Brachycephalic Obstructive Airway Syndrome is the most common cause of respiratory distress in dogs with brachycephalic conformation, any condition eliciting an inflammatory response in the oropharynx, can result in obstruction. There is no previous report of respiratory obstruction leading to emergency tonsillectomy caused by tonsillar polyps.

CASE PRESENTATION

A 9-month-old male intact English bulldog presented to the emergency service in severe respiratory distress. Due to continued severe dyspnea and cyanosis the patient was induced with propofol (Propofol, Hospira) 4 mg/kg intravenously titrated to effect and tracheal intubation performed. Intubation was noted to be difficult due the presence of two, large, inflamed masses in the oropharynx region. The remainder of his physical exam was unremarkable. Minimum database blood work and chest radiographs revealed only minor abnormalities. The patient was placed under anesthesia and the masses were transected sharply using a carbon dioxide (CO2) laser (Aesculight, Bothell, WA, USA). Anesthesia and recovery were uneventful, and the patient was discharged the following day. Histopathology results of the masses revealed them to be benign lymphoglandular polyps.

CONCLUSIONS

This is the first report of bilateral tonsillar polyps causing life-threatening respiratory obstruction in a dog. Both masses were excised safely and completely with the CO2 laser. Difficulties inherent to oropharyngeal surgery include the hemorrhage, small working space, tissue swelling and difficult visualization. Surgical excision of these polyps alleviated all emergent and chronic clinical signs, and the patient's remains healthy 12-months post-treatment.