Paediatric coblation tonsillectomy

Abstract

Objective: Tonsillectomy has been described using a number of techniques. Recently Coblation Technology has been used to remove tonsils with anecdotal evidence of a reduction in post-operative morbidity. In this study we aim to see if there is any difference in post-operative pain, tonsillar fossae healing and return to a normal diet performing tonsillectomy, using tissue coblation compared with standard bipolar dissection. Methods: A double blind randomised control trial to compare the technique of tissue coblation with standard bipolar dissection to remove tonsils in 38 children on the waiting list for tonsillectomy, with a history of chronic tonsillitis or obstructive tonsils. Results: A significant reduction in post-operative pain was found in the children whose tonsils were removed by tissue coblation (P<0.0001). More rapid healing of the tonsillar fossae was found in the coblation group. Children who had their tonsils removed by coblation were found to return to their normal diet far sooner than those who underwent bipolar dissection. There were no episodes of primary or secondary haemorrhage in either group. Conclusions: This new technique using tissue coblation for tonsil removal offers significant advantages in the post-operative period, with rapid return to a normal diet and a drastic reduction in analgesic requirements following the surgery.

Introduction

A tonsillectomy continues to be one of the most common procedures performed by Otolaryngologists in recent years. Despite a range of different techniques, including blunt dissection, guillotine [1] diathermy [2] or laser [3] and the use of multiple analgesics, post-operative pain remains the major side effect of the operation. A prolonged period of post-operative recovery lasting up to 2 weeks is standard and there is always the risk of bleeding from secondary infection of the tonsil bed during this time. The debate about the least painful method for removing tonsils continues in the literature. Work by Homer et al. [4] has again explored the use of guillotine tonsillectomy in 86 children and found the procedure to be less painful than dissection tonsillectomy. They found no increased haemorrhage rate or increase in tonsil tissue remnants after guillotine tonsillectomy.

Many physicians use different post-tonsillectomy analgesic regimes. Ozkose [5] published an interesting article supporting the use of tramadol at anaesthetic induction for adenotonsillectomies in children, in which they found lower post-operative analgesic requirements in these children.

Coblation (cold ablation) [6] is a new technique in soft tissue surgery. Recently the use of this new technique in the treatment of snoring, nasal congestion and sleep apnoea has received considerable research interest [7], [8]. The system involves passing a radiofrequency bipolar electrical current, at a much lower frequency than standard bipolar diathermy, through a medium of normal saline which results in the production of a plasma field of sodium ions. These ions are able to breakdown intercellular bonds and in effect vaporize tissue at a temperature of only 60 °C. The presence of irrigating saline helps to limit the amount of heat delivered to the surrounding structures and hence reduce the amount of postoperative pain experienced by the patient. Coblation is a bipolar system and therefore requires no ground pads.

The operative technique of coblation tonsillectomy is based on a standard tonsillectomy with the use of a coblation wand to dissect in the peri-tonsillar plane, with the tip directed towards the body of the tonsil. We routinely use the operating microscope to clearly see the dissection plane and allow early identification of blood vessels which need coagulation thereby reducing intra-operative blood loss.

Anecdotal evidence suggests that there is considerably less pain and rapid healing of the tonsillar fossae achieved after a tonsillectomy using this technique. We aim to evaluate these aspects of tonsillectomy morbidity with this study.