Comparison of three tonsillectomy techniques in children

Postoperative Morbidity of Different Tonsillectomy Techniques: A Systematic Review and Network Meta-Analysis

OBJECTIVE

To compare different tonsillectomy techniques in terms of postoperative bleeding incidence and postoperative pain.

METHODS

An arm-based network analysis was conducted using a Bayesian hierarchical model. The primary and secondary outcomes were postoperative bleeding incidence and mean postoperative pain score.

RESULTS

A total of 6464 patients were included for five different interventions (cold dissection tonsillectomy; extracapsular coblation tonsillectomy; intracapsular coblation tonsillectomy [ICT]; bipolar diathermy tonsillectomy [BDT]; monopolar diathermy tonsillectomy). ICT showed the lowest absolute risk (4.44%) of postoperative bleeding incidence (73.31% chance of ranking first) and the lowest mean postoperative pain score (1.74 ± 0.68) with a 94.0% chance of ranking first, whereas BDT showed both the highest absolute risk of bleeding incidence (10.75%) and the highest mean postoperative pain score (5.67 ± 1.43).

CONCLUSIONS

ICT seems to offer better postoperative outcomes, in terms of reduced risk of bleeding and reduced pain. Further prospective studies are advised to confirm these findings.

LEVEL OF EVIDENCE

NA Laryngoscope, 134:1696-1704, 2024.

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.

Comparison of Three Tonsillectomy Techniques: Cold Dissection, Monopolar Electrocautery, and Coblation

Introduction  Tonsillectomy is among the most common otolaryngological surgeries. Objective  To evaluate and compare three tonsillectomy techniques: cold steel dissection (CSD), monopolar electrocautery (MEC), and coblation. Methods  The present study retrospectively reviewed the medical records of patients who underwent tonsillectomy between January 2014 and January 2016. Postoperative visual analog scale (VAS) pain scores, analgesic use, surgical duration, time to return to normal activity, and postoperative bleeding status were noted. Results  The CSD group had less analgesic use and shorter return to normal activity than the MEC group ( p  = 0.037 and p  < 0.001, respectively). The coblation group had lower VAS pain scores than the MEC group only at 1 hour to 4 hours postsurgery ( p  < 0.016). The postoperative bleeding rate was similar in all groups ( p  = 0.096). Conclusion  Cold steel dissection tonsillectomy is associated with less postoperative pain and shorter recovery than MEC. Coblation is better than MEC in terms of postoperative pain at 1 hour to 4 hours only, whereas CSD is associated with less postoperative pain than coblation at 2 days to 7 days.

The Impact of Surgical Indication on Posttonsillectomy Hemorrhage: A Systematic Review and Meta-Analysis

OBJECTIVE

To investigate the impact of the surgical indication on posttonsillectomy bleed rates.

DATA SOURCES

PubMed, Scopus, CINAHL.

REVIEW METHODS

A systematic review was performed searching for articles published from the date of inception to July 6, 2022. English language articles describing posttonsillectomy hemorrhage rates in pediatric patients (age ≤ 18) stratified by indication were selected for inclusion. A meta-analysis of proportions with comparison (Δ) of weighted proportions was conducted. All studies were assessed for risk of bias.

RESULTS

A total of 72 articles with 173,970 patients were selected for inclusion. The most common indications were chronic/recurrent tonsillitis (CT/RT), obstructive sleep apnea/sleep-disordered breathing (OSA/SDB), and adenotonsillar hypertrophy (ATH). Posttonsillectomy hemorrhage rates for CT/RT, OSA/SDB, and ATH were 3.57%, 3.69%, and 2.72%, respectively. Patients operated on for a combination of CT/RT and OSA/SDB had a bleed rate of 5.99% which was significantly higher than those operated on for CT/RT alone (Δ2.42%, p = .0006), OSA/SDB alone (Δ2.30%, p = .0016), and ATH alone (Δ3.27%, p < .0001). Additionally, those operated on for a combination of ATH and CT/RT had a hemorrhage rate of 6.93%, significantly higher than those operated on for CT/RT alone (Δ3.36%, p = .0003), OSA/SDB alone (Δ3.01%, p = .0014), and ATH alone (Δ3.98%, p < .0001).

CONCLUSION

Patients operated on for multiple indications had significantly higher rates of posttonsillectomy hemorrhage than those operated on for a single surgical indication. Better documentation of patients with multiple indications would help further characterize the magnitude of the compounding effect described here.

An umbrella review of the surgical performance of Harmonic ultrasonic devices and impact on patient outcomes

BACKGROUND

For thirty years, the Harmonic scalpel has been used for precise dissection, sealing and transection. There are numerous meta-analyses on individual surgical procedures with Harmonic, but no overarching review covering all the areas. This umbrella review seeks to summarize the clinical results from the use of Harmonic across surgical fields and broadly quantify its effects on patient outcomes.

METHODS

MEDLINE, EMBASE, and Cochrane Databases were searched for meta-analyses (MAs) of randomized controlled trials (RCTs) comparing Harmonic devices to conventional techniques or advanced bipolar (ABP) devices. For each procedure type, the most comprehensive MAs were evaluated. RCTs not already analysed in a MA were also included. Operating time, length of stay, intraoperative blood loss, drainage volume, pain, and overall complications were evaluated, and the methodological quality and certainty of evidence were assessed.

RESULTS

Twenty-four systematic literature reviews were identified on colectomy, hemorrhoidectomy, gastrectomy, mastectomy, flap harvesting, cholecystectomy, thyroidectomy, tonsillectomy, and neck dissection. There were also 83 RCTs included. In every MA evaluated, Harmonic devices were associated with either statistically significant or numerical improvements in every outcome compared with conventional techniques; most MAs reported a reduction in operating time of ≥ 25 min. Harmonic versus ABP device MAs in colectomy and thyroidectomy showed no significant differences in outcomes.

CONCLUSION

Across surgical procedures, Harmonic devices demonstrated improved patient outcomes for operating time, length of stay, intraoperative bleeding, drainage volume, pain, and overall complications compared to conventional techniques. Additional studies are required to assess differences between Harmonic and ABP devices.

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.

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.