Tonsillectomy Techniques Research Articles

Guillotine versus dissection tonsillectomy: randomised, controlled trial

This trial aimed to compare the guillotine technique of tonsillectomy with 'cold steel' dissection, the current 'gold standard'. A single centre, randomised, controlled trial. One hundred children aged 3 to 11 years who were listed for bilateral tonsillectomy were recruited. Patients had one tonsil removed by each technique, and were blinded to the side. The operative time, intra-operative blood loss, haemostasis requirement and post-operative pain scores were recorded and compared. Operative time and intra-operative blood loss were both significantly less for the guillotine technique (p < 0.001) and there was a significantly reduced haemostasis requirement (p < 0.001). Pain was also less on the guillotine side (p < 0.001). There were no tonsillar remnants or palatal trauma for either technique. There was no significant difference between techniques in the frequency of secondary haemorrhage. This study provides level Ib evidence that guillotine tonsillectomy in children with mobile tonsils is an effective and time-efficient procedure which produces less intra-operative blood loss and post-operative pain than cold steel dissection.

Comparison of three techniques in pediatric tonsillectomy

The objective of this study was to compare the thermal welding technique (TWT), classic dissection (CD) tonsillectomy and bipolar cautery dissection (BCD) for pediatric tonsillectomy. Three hundred and five consecutive children with chronic tonsillitis and/or upper airway obstruction were alternately assigned to the TWT, CD, or BCD tonsillectomy groups. Age, gender, operation time, intraoperative blood loss, early postoperative pain, time to regain normal diet, and extent of healing of the tonsillar fossa on the tenth postoperative day were evaluated. The rate of intraoperative blood loss was significantly lower in the thermal welding and BCD groups (p < 0.001). The difference between mean operative time of TWT and BCD groups was not statistically significant (p > 0.001). The difference between mean operative time of the two groups against cold dissection group was statistically significant (p < 0.001). No significant difference was found in the incidence of posttonsillectomy hemorrhage between the three patient groups (p > 0.001). The mean pain score was 4.8 ± 1.2 (median 5, range 4-6) in the TWT group, 8.3 ± 1.3 (median 8, range 7-10) in the BCD group, and 5.1 ± 1.2 (median 5, range 4-7) in the CD group 6 h to 7 days post-surgery. The difference between mean pain score between TWT and CD was not statistically significant (p > 0.001). The difference between mean pain score of the two groups against BCD group was statistically significant (p < 0.001). The results showed TWT as a new tonsillectomy technique with advantages such as shorter operation time and minimal intraoperative blood loss for children patient's post operative comfort. When we compared TWT with the cold dissection and bipolar cautery tonsillectomy, we found that TWT tonsillectomy offered an innovative new tonsillectomy method with significantly reduced blood loss and reduced surgical time and without any increase in the postoperative pain.

Rate of post-tonsillectomy hemorrhage after elective bipolar microcauterization of nonbleeding vessels

The objective of this paper is to describe an extended microscopic hemostasis technique involving cauterization of exposed blood vessels that were not actively bleeding in tonsillar fossa after bipolar tonsillectomy and to assess the rate of post-tonsillectomy hemorrhage with this technique in children who had bipolar tonsillectomy. The medical records of children who underwent microscopic bipolar tonsillectomy with extended hemostasis between June 2008 and January 2011 were reviewed. Relevant history and physical examination, diagnosis, and characteristics of postoperative hemorrhage were recorded; 994 children (531 males, 463 females), aged between 1 and 18 years (6 ± 3 years), underwent tonsillectomy; of the 994 patients, 11 (1.1%) developed post-tonsillectomy hemorrhage. No primary post-tonsillectomy hemorrhage occurred. The hemorrhage was seen 6-13 days after the surgery. One patient had bleeding after having trauma to the neck on postoperative day 13. Of the 11 patients with post-tonsillectomy bleeding, 3 had blood clot with no active bleeding and 8 exhibited active bleeding after removal of blood clot. Of the 994 patients, 8 (0.8%) needed intervention to control active bleeding. Compared to previous studies of bipolar tonsillectomy, extended microscopic hemostasis achieved by cauterization of tonsil fossa non-bleeding blood vessels appeared to reduce bleeding rate after bipolar cautery tonsillectomy. The present study did not include a control arm; further randomized controlled studies are needed to establish the definite effect of extended microscopic hemostasis technique on the rate of hemorrhage rates after tonsillectomy techniques.

Thermal welding versus cold knife tonsillectomy: A prospective randomized study

This is a prospective randomized study conducted in a group of children who underwent two methods of tonsillectomy: thermal welding or cold knife tonsillectomy. Parameters, such as postoperative pain scores, intraoperative blood loss, operation time, and postoperative bleeding rates, were analyzed to find out which technique is better. Ninety-one children (aged between 2 years and 13 years) with recurrent tonsillitis, obstructive sleep apnea syndrome, or both were included in the study. According to the type of tonsillectomy procedure, the patients were divided into two groups: cold knife and thermal welding procedure. The two groups were compared on the basis of postoperative pain scores, intraoperative blood loss, operation time, and postoperative bleeding. Fifty-seven patients underwent thermal welding tonsillectomy and 34 had cold knife tonsillectomy. The mean pain score in thermal welding group was significantly lower (p<0.001). There was no remarkable blood loss intraoperatively in the thermal welding procedure. The operation time was not significantly different between two groups. No postoperative bleeding was encountered in the thermal welding group. Compared with the cold knife technique, thermal welding was found to be a relatively new and safe technique for tonsillectomy as it results in significantly less postoperative pain and no remarkable blood loss.

On the history of modern tonsillectomy: the contribution of Nikolaos Taptas

The earliest reports on removal of the entire tonsil using a method of careful dissection came in the early 1900 s by American and British otorhinolaryngologists. These descriptions are credited as the first of the so-called modern tonsillectomy. In this report we present a technique of tonsillectomy conceived by Nikolaos Taptas, a Greek physician and citizen of the Ottoman Empire, which was introduced at the same period with the ones previously mentioned. Taptas practiced his technique in the very early 1900 s. He used his own instruments and reported excellent post-operative results with very few complications. He should therefore be considered among the pioneers of modern tonsillectomy.

A randomised controlled trial of two analgesic techniques for paediatric tonsillectomy*

Investigators from Bristol described a fentanyl- and diclofenac-based analgesic technique for tonsillectomy with low postoperative nausea and vomiting rates and low pain scores. This study compared the effectiveness of a modified Bristol technique with a codeine-based regimen with respect to PONV and analgesia. Sixty-five children, ASA 1-2, were randomly assigned to either the Bristol group (fentanyl 1-2 μg.kg(-1) and diclofenac 1-2 mg.kg(-1)) or codeine group (codeine 1.5 mg.kg(-1)). All children received paracetamol 15 mg.kg(-1) and dexamethasone 0.1 mg.kg(-1) . Postoperative nausea and vomiting and pain scores were recorded hourly, and fitness for discharge was assessed at 4 h. The overall incidence of postoperative nausea and vomiting was 21% with no difference between groups (Bristol group 8/30, codeine group 5/32, p = 0.29). Children in the Bristol group required analgesia earlier than those in the codeine group (p < 0.005), but maximum pain scores were not different (Bristol group median (IQR [range) 4.5 (3-5 [0-5]), codeine group 4.0 (2-5 [1-5]), p = 0.15). Twenty-three per cent of children were assessed as not fit for discharge at 4 h. The codeine-based regimen may have a small advantage over the Bristol regimen, but neither technique seems ideally suited for a day-case service without a longer period of observation. You can respond to this article at http://www.anaesthesiacorrespondence.com.

The Outcomes of 4 Different Techniques of Tonsillectomy

Objective: Compare 4 different techniques of tonsillectomy reagarding operative time, intra-operative blood loss, and pain scores. Method: A total of 160 patients were randomly assigned to the cold dissection tonsillectomy (CDT), bipolar elecrocautery tonsillectomy (BPT), Harmonic Scalpel tonsillectomy (HST), and Thermal Welding tonsillectomy (TWT) groups. Patients underwent tonsillectomy where intraoperative blood loss and time were evaluated. Patients where then followed for pain analysis. Results: Operative time varied from 6 to 31 minutes, and mean operative time was 13.76 ± 5.28 minutes. Operative time in the HST group was significantly shorter than in the CDT and TWT groups (p = 0.001). Highest intraoperative bleeding was observed in the CDT group (68.6 ± 35.3 ml) and was significantly higher than in the HST (9.4 ± 3.1ml) and BPT groups (13.4 ± 3.8 ml) ( P = .001, resp P = .022). Pain scores in the HST group were much lower than in the CDT and BPT groups ( P = .022, resp P = .001). Pain scores between other groups did not show any statistically significant difference ( P &gt; .05). Conclusion: The 4 techniques compared all show different attributes useful during surgery, but considering long learning curves and high prices we believe that cold dissection tonsillectomy still has the upper hand.

Postoperative pain after adult tonsillectomy with plasmaknife compared to monopolar electrocautery

Monopolar cautery is the most commonly used technique for tonsillectomy. The aim of the present study is to compare postoperative pain using a new technology, PlasmaKnife tonsillectomy (PKT), in comparison with monopolar cautery tonsillectomy (MCT). Prospective, randomized, single-blinded, self-controlled study using paired organs. Thirty-two adult patients, aged 18 to 30 years, scheduled for tonsillectomy for recurrent tonsillitis were included. Patients were randomly assigned to undergo PKT on one side and MCT on the opposite side. The primary outcome was self-rated daily pain assessed by using a 10-point scale. Patients were provided 21-day pain diaries and were phoned twice weekly by a research assistant to assess pain and remind them to complete diaries. Secondary outcomes included comparisons of operative time, blood loss, and postoperative complications. Repeated measures analysis of variance comparing PKT to MCT during the 21-day postoperative period revealed no difference in postoperative pain between the two groups (P = .131). In addition, total operative time (P = .276) and blood loss (P = .418) did not differ significantly between PKT and MCT. Adult subjects undergoing PKT do not experience less postoperative pain in comparison to MCT.

Robotic-assisted lingual tonsillectomy

INTRODUCTION This report presents a new technique of transoral robotic-assisted lingual tonsillectomy (RALT). The lingual tonsil area is difficult to visualize and access in the oropharynx. When a lingual tonsillectomy is performed to obtain diagnostic tissue, visualization of this area is important. Transoral robotic surgery (TORS) has been reported to be feasible and safe in other areas of the oral cavity and is reported frequently in resection of tonsillar squamous cell carcinomas. We report a single institution’s experience with RALT, including the feasibility, safety, utility of the procedure, as well as functional and quality-of-life (QOL) data.

Coblation tonsillectomy: is it inherently bloody?

The aim of the study was to compare a single surgeon's post-tonsillectomy haemorrhage rates using cold steel dissection and coblation tonsillectomy techniques. Retrospective study on patients, who underwent tonsillectomy at West Wales General Hospital (WWGH) performed by a single surgeon from 2006 to 2010 employing both cold steel and coblation tonsillectomies. Data were analysed using Mann-Whitney and Chi-squared tests. The nominated surgeon performed 239 tonsillectomies at WWGH from 2006 to 2010. 119 patients underwent cold steel dissection and 120 had coblation tonsillectomy. There was no demographic difference between the two groups. There was no statistically significant difference in the length of hospital stay between the two groups (median 1 day in each group). 6/119 (5.0%) patients in the cold steel group, and 7/120 (5.8%) in the coblation group had post-operative bleeding (p = 1.00). The return to theatre rate for cold steel dissection was 1/119 (0.84%) and for coblation surgery was 1/120 (0.83%) (p = 1.00). Among the first 60 cases of coblation tonsillectomies, 4 patients (6.6%) had post-operative haemorrhage and the latter 60 cases had 3 patients (5%). There was no evidence of a difference in the overall post-operative bleeding between those who had cold steel dissection and coblation tonsillectomies. These data suggest that higher post-operative haemorrhage is not inherent to coblation tonsillectomy.

Emerging Trends in Tonsillectomy

To describe the tonsillectomy techniques and management used by practicing otolaryngologists in the United States. Anonymous 18-question postal survey of pediatric and general otolaryngologists on their current tonsillectomy practices. Tertiary academic medical center. Current preoperative, perioperative, and postoperative practices in tonsillectomy were queried with multiple-choice and open-ended questions. Pediatric otolaryngologists and general otolaryngologists were compared. 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. Coblation is becoming a more commonly used instrument for tonsillectomy. Pediatric otolaryngologists perform more tonsillectomies than do general otolaryngologists and manage their patients differently.

The Cardiff Cup: A Model for Tonsillectomy Tie Training

Tonsillectomy is a procedure commonly performed by otolaryngologists. The National Prospective Tonsillectomy Audit [1] reported reduced postoperative haemorrhage rates using cold steel dissection combined with ligation for haemostasis in comparison to hot tonsillectomy techniques. Accordingly, there is growing emphasis on the need for ENT surgical trainees to develop competence in tonsillectomy ties for haemostasis. Tonsillectomy tie technique is an important skill that requires good manual dexterity and one that is difficult to learn under the pressure of a bleeding patient. Furthermore, in the UK, opportunities for junior surgical trainees to undertake tonsillectomy tie training in the operating theatre have been limited by the enforcement of the European Working Time Directive [2]. Thus, there is a growing need for the use of simulation to practise tonsillectomy ties. We present a simple, readily available and economical simulation model for surgical trainees to practise tonsillectomy ties.

Clinical Profile of Post-Tonsillectomy Bleeding: A 30-Month Institutional Review

Objective: To determine the prevalence of post-tonsillectomy bleeding in our institution and to describe the clinical characteristics, tonsillectomy techniques and post-tonsillectomy bleeding intervention in these patients.&#x0D; Methods: &#x0D; Study Design: Observational descriptive study&#x0D; Setting: Tertiary private hospital&#x0D; Population: All patients who were treated for post-tonsillectomy bleeding were retrospectively reviewed from medical records of all patients who had undergone tonsillectomy between January 1, 2007 and June 30, 2009. Age and sex, indication for surgery, tonsil grade, Body Mass Index (BMI), surgical technique, post-operative medications, length of hospital stay, interval between tonsillectomy and onset of bleeding and interventions to address post-operative bleeding were noted.&#x0D; Results: Of the 662 patients who underwent tonsillectomy, 37 (5.6%) were managed for post-operative hemorrhage. Most had grade 2 or 3 tonsils (18 or 48.6% and 16 or 43.2% respectively) and were obese (25 or 67.5%). The highest proportion of post-operative bleeding was 9.2% for bipolar cauterization technique (18 of 196 patients) followed by 7.4% with cold knife, monopolar cauterization and suturing (11 of 148 patients); 6.9% with harmonic scalpel (2 of 29 patients); 6.5% with monopolar and bipolar cauterization (3 of 46 patients), and 2.8% for cold knife or Fischer knife (3 of 109 patients). Seven patients (18.9%) required blood transfusion. Onset of bleeding occurred between 4-12 days following surgery (mean: 8 days). Possible causes of bleeding included heavy physical activity and cough but most had no identifiable cause. Majority of the patients (29 out of 37) required surgical exploration under general anesthesia.&#x0D; Conclusion: Post tonsillectomy bleeding is still a clinically significant complication despite advances in surgical techniques. Surgeons must always consider trade-offs between benefits and risks of the procedure and be continually vigilant of this potentially serious complication.&#x0D; &#x0D; Key Words: Post-tonsillectomy bleeding, tonsillectomy techniques

Complications of adenotonsillectomy

Tonsillectomy and adenoidectomy are two of the most commonly performed pediatric surgical procedures. As with all surgical intervention, tonsillectomy and adenoidectomy are associated with a host of potential complications. Fortunately, for most children undergoing adenotonsillectomy (T&A), complications are rare. This review is intended to summarize recent reports, which may lead to prevention and treatment of T&A complications. The presented reports of complications and risk factors for complications in children undergoing T&A highlight perioperative medical management as a means to decrease perioperative complications. Certain tonsillectomy techniques, such as microdebrider intracapsular tonsillectomy, may lead to decreased posttonsillectomy hemorrhage and dehydration. Despite published recommendations, preoperative assessments for bleeding diatheses vary among practitioners. Conversely, guidelines for evaluation of posttonsillectomy hemorrhage are lacking. Some pediatric populations, such as children with coagulopathy, neurologic disease, and obesity, have increased risk of perioperative complications, and recent reports regarding their care are presented. We present recent data pertinent to the contemporary management of medical and surgical complications of T&A, with particular focus on specific at-risk pediatric populations. In the patient groups illustrated in this review, anticipation of complications may decrease complications or lead to improved management of complications when they occur.

Clinical Profile of Post-Tonsillectomy Bleeding - A 30-Month Institutional Review

Objective:&nbsp; To determine the prevalence of post-tonsillectomy bleeding in our institution and to describe the clinical characteristics, tonsillectomy techniques and post-tonsillectomy bleeding intervention in these patients. Methods:&nbsp; Study Design:&nbsp; Observational descriptive study Setting: Tertiary private hospital Population:&nbsp; All patients who were treated for post-tonsillectomy bleeding were retrospectively reviewed from medical records of all patients who had undergone tonsillectomy between January 1, 2007 and June 30, 2009.&nbsp; Age and sex, indication for surgery, tonsil grade, Body Mass Index (BMI),&nbsp; surgical technique, post-operative medications, length of hospital stay, interval between tonsillectomy and onset of bleeding and interventions to address post-operative bleeding were noted. Results:&nbsp; Of the 662 patients who underwent tonsillectomy, 37 (5.6%) were managed for post-operative hemorrhage. Most had grade 2 or 3 tonsils (18 or 48.6% and 16 or 43.2% respectively) and were obese (25 or 67.5%). The highest proportion of post-operative bleeding was 9.2% for bipolar cauterization technique (18 of 196 patients) followed by 7.4%&nbsp; with cold knife, monopolar cauterization and suturing (11 of 148 patients); 6.9% with harmonic scalpel (2 of 29 patients); 6.5%&nbsp; with monopolar and bipolar cauterization (3 of 46 patients), and 2.8% for cold knife or Fischer knife (3 of 109 patients). Seven patients (18.9%) required blood transfusion. Onset of bleeding occurred between 4-12 days following surgery (mean: 8 days). Possible causes of bleeding included heavy physical activity and cough but most had no identifiable cause. &nbsp;&nbsp;Majority of the patients (29 out of 37) required surgical exploration under general anesthesia. Conclusion:&nbsp; Post tonsillectomy bleeding is still a clinically significant complication despite advances in surgical techniques. Surgeons must always consider trade-offs between benefits and risks of the procedure and be continually vigilant of this potentially serious complication. &nbsp; Key Words: Post-tonsillectomy bleeding, tonsillectomy techniques

Analyzing factors associated with major complications after adenotonsillectomy in 4776 patients: Comparing three tonsillectomy techniques

Objective To compare the rates of major complications (postoperative hemorrhage requiring return to the operating room or cauterization in the emergency department and dehydration requiring intravenous fluids or readmission) in a large cohort of children undergoing adenotonsillectomy by three different techniques. Study Design Case series with chart review, case-controlled study. Setting Regional children's hospital. Subjects and Methods Subjects comprised patients aged 1 to 18 years undergoing adenoidectomy, tonsillectomy, or adenotonsillectomy by microdebrider, coblator, or Bovie over a 36-month period. Major complications identified were compared to two case-matched controls to try to identify patients at risk for major postoperative complications. Results The overall complication rate was 80 of 4776 (1.7 ± 0.4% [percent ± 95% confidence interval]). Of the 3362 patients who received either an adenotonsillectomy or tonsillectomy alone, 80 had a complication (2.3 ± 0.5%). Major complication rates differed among tonsil removal techniques: 34 of 1235 (2.8 ± 0.9%) coblation; 40 of 1289 (3.1 ± 0.9%) electrocautery; six of 824 (0.7 ± 0.7%) microdebrider ( P < 0.001). Postoperative hemorrhage occurred in older children (8.5 vs 5.5 years; P < 0.001), while age did not influence postsurgical dehydration (5.33 vs 5.49 years). The case-control portion of the study did not find any reliable way to identify patients at risk for complications during adenotonsillectomy. Identity of the surgeon was not a confounding independent variable, nor was participation by resident surgeons. Conclusion In this “real life” teaching hospital surgical setting in which three different techniques of tonsillectomy are routinely performed by a variety of resident and attending surgeons, microdebrider intracapsular tonsillectomy is associated with lower rates of post-tonsillectomy hemorrhage and dehydration when compared to coblation and electrocautery complete tonsillectomy technique.

Comparison of Three Common Tonsillectomy Techniques: A Prospective Randomized, Double-Blinded Clinical Study

Comparison of Three Common Tonsillectomy Techniques: A Prospective Randomized, Double-Blinded Clinical Study

New techniques for tonsillectomy and adenoidectomy

New techniques for adenotonsillectomy offer reduced morbidity and improved recovery by limiting tissue injury. The authors review three new instrument-based approaches to adenotonsillectomy and offer data to demonstrate the prevalence of technique and device use across several different geographic regions. New techniques for adenotonsillectomy offer reduced morbidity and improved recovery by limiting tissue injury. The authors review three new instrument-based approaches to adenotonsillectomy and offer data to demonstrate the prevalence of technique and device use across several different geographic regions.

Guillotine tonsillectomy: a neglected technique

Increased post-operative tonsillectomy haemorrhage rates have been observed following 'hot' tonsillectomy techniques, compared with 'cold steel' dissection. Post-tonsillectomy haemorrhage rates and the degree of blood loss during guillotine tonsillectomy have not been reported in the recent literature. This retrospective case note review assessed the degree of blood loss during guillotine tonsillectomy, as measured by the number of tonsil swabs used, and the post-tonsillectomy haemorrhage rate. In a group of 168 patients, no tonsil swabs were used in 13.1 per cent of cases, and less than two tonsil swabs were used in 41.1 per cent of cases. Guillotine tonsillectomy, when performed by the method described in this article, resulted in minimal intra-operative blood loss in 54 per cent of cases, and appeared to have comparable post-tonsillectomy haemorrhage rates to cold steel dissection techniques.

Comparing the effectiveness of “plasma knife” tonsillectomy with two well-established tonsillectomy techniques: Cold dissection and bipolar electrocautery. A Prospective randomized Study

Objective To evaluate the effectiveness of a new device “plasma knife” for tonsillectomy by comparing to two well-established tonsillectomy techniques: cold dissection, and bipolar electrocautery. Methods A prospective, randomized study conducted on 110 patients undergoing tonsillectomy. Subjects were randomized to plasma knife (PKT), cold dissection (CDT) and bipolar electrocautery (BET) groups. Operative time, intraoperative blood loss and postoperative complications were recorded. Pain/discomfort level of patients and healing time of the tonsillar fossae were assessed postoperatively. Data were recorded and statistically analyzed. Results Operative time with plasma knife and bipolar electrocautery were associated with a significant decrease in operative time compared to cold dissection ( p < 0.05). Intraoperative blood loss was significantly decreased with plasma knife, compared to cold dissection and bipolar electrocautery ( p < 0.05). Less postoperative pain was observed with plasma knife compared to bipolar electrocautery but more postoperative pain was observed with both compared to CDT ( p < 0.05). Postoperative healing time was longer with plasma knife and bipolar electrocautery, compared to cold dissection ( p < 0.05). Conclusion Plasma knife is a useful and safe device in tonsillectomy. Its use reduces intraoperative blood loss and provides a fast tonsillectomy with acceptable morbidity.