Harmonic Scalpel Versus Coblation Tonsillectomy A Comparative Study

Evaluation and Risk Factor Analysis of Post-tonsillectomy Hemorrhage in an Adult Population: An Experience From a National Ear, Nose, and Throat (ENT) Center in Georgia

BACKGROUND

Tonsillectomy, a common surgical procedure for removing the palatine tonsils, is frequently performed in the otorhinolaryngology department. Tonsillectomy, with or without adenoidectomy, is considered a straightforward operation. However, serious complications, such as post-tonsillectomy hemorrhage, can complicate the recovery period. The research aims to analyze and estimate the factors associated with postoperative bleeding in the adult Georgian population.

METHOD

We conducted a cross-sectional study. The data was collected retrospectively from the medical records of adult patients aged 18 years and older, who underwent tonsillectomy in 2022 and 2023 at the National Center of Otorhinolaryngology, Japaridze-Kevanishvili Clinic, in Georgia. We performed univariate analysis using binary logistic regression and multivariate logistic regression analysis and calculated odds ratio (OR) to identify factors associated with postoperative bleeding among patients with tonsillectomy. A p-value of <0.05 was considered statistically significant.

RESULTS

A total of 778 adult patients with tonsillectomy were included in the study. Post-tonsillectomy hemorrhage occurred in 14.7% (n=114) of cases, with primary bleeding observed in 8.1% (n=63) of patients and secondary bleeding in 6.6% (n=51) of cases. The highest incidence of bleeding was observed on days 1 (8.1%, n=63) and 7 (1.3%, n=10). The statistical analysis revealed a statistically significant association between post-tonsillectomy hemorrhage and several factors: smoking status (OR=10.1, 95% CI: 6.1-16.7, p<0.001) and having a body mass index (BMI) greater than 25 (OR=3.6, 95% CI: 2.1-6.1, p<0.001).

CONCLUSION

The study confirmed several significant risk factors, including smoking and higher BMI, that are associated with an increased risk of bleeding among patients, undergoing tonsillectomy. Further research is needed to validate these findings in the Georgian population.

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.

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.

Unveiling the Enigmatic Adenoids and Tonsils: Exploring Immunology, Physiology, Microbiome Dynamics, and the Transformative Power of Surgery

Within the intricate realm of the mucosal immune system resides a captivating duo: the adenoids (or pharyngeal tonsils) and the tonsils (including palatine, tubal, and lingual variations), which harmoniously form the Waldeyer's ring. As they are strategically positioned at the crossroads of the respiratory and gastrointestinal systems, these exceptional structures fulfill a vital purpose. They function as formidable "gatekeepers" by screening microorganisms-both bacteria and viruses-with the mission to vanquish local pathogens via antibody production. However, under specific circumstances, their function can take an unsettling turn, inadvertently transforming them into reservoirs for pathogen incubation. In this review, we embark on a fascinating journey to illuminate the distinctive role of these entities, focusing on the local immune system inside their tissues. We delve into their behavior during inflammation processes, meticulously scrutinize the indications for surgical intervention, and investigate the metamorphosis of their microbiota in healthy and diseased states. We explore the alterations that occur prior to and following procedures like adenoidectomy, tonsillectomy, or their combined counterparts, particularly in pediatric patients. By comprehending a wealth of data, we may unlock the key to the enhanced management of patients with otorhinolaryngological disorders. Empowered with this knowledge, we can embrace improved therapeutic approaches and targeted interventions/surgeries guided by evidence-based guidelines and indications.

Efficacy of Levobupivacaine Versus Levobupivacaine Plus Dexmedetomidine Infiltration for Post-Tonsillectomy Analgesia: A Randomized Controlled Trial

Background. The study evaluated the analgesic effects of levobupivacaine infiltration in the tonsil bed, and a combination of levobupivacaine and dexmedetomidine in patients undergoing tonsillectomy. Methods. Ninety children (ages 3 to 7 years) who were scheduled for a tonsillectomy were allocated randomly into two groups. (L Group): peritonsillar infiltration with 0.25% levobupivacaine (2 ml + 0.5 ml saline 0.9% per tonsil). (LD Group): levobupivacaine 0.25% (2 ml) plus dexmedetomidine 1 μg/kg diluted in 1 ml saline 0.9% (0.5 ml in each tonsil), and administered by peritonsillar infiltration (2.5 ml per tonsil) following intubation 3–5 minutes before operation. To avoid bias, infiltrate a total volume of 2.5 ml in each tonsil. The first analgesic request time was the primary outcome, with postoperative pain score, total analgesic consumption, total oral intake, sedation, and side effects as secondary outcomes. Results. The first rescue analgesia time in the LD group was longer (644.31 ± 112.89 min) than in the L group (551.51 ± 146.16 min, $P$ -value <0.001). The number of patients who required >1 analgesic dose in the L group (n = 13) was higher than in the LD group (n = 5). The LD group consumes a lower total dose of IV paracetamol in the first 24 hours postoperatively (321.89 ± 93.25 mg) than the L group (394.89 ± 183.71 mg, $P<0.00$ -value < 0.050). On the first day postoperatively, patients in the LD group had a higher total oral intake ( $P<0.001$ ). Except for a slight increase in laryngospasm in the L group, there were no side effects. Conclusions. The Children’s peritonsillar infiltration of levobupivacaine and dexmedetomidine improved postoperative pain after adenotonsillectomy. The topically applied levobupivacaine and dexmedetomidine were concomitant with no systemic effects, greater total oral intake on the first day postoperative, and higher family satisfaction.

Coblation Versus Diode Laser Tonsillectomy: A Comparative Study

Introduction

The study aimed to compare the intra-individual 2 procedures of tonsillectomy (Coblation and diode laser) concerning the operative time, the amount of blood loss, postoperative pain, and other complications.

Materials and Methods

A comparative study was conducted at many Private Hospitals, Baghdad, Iraq from February 2019- February 2020. Coblation and diode laser tonsillectomy were performed on the same patient (one for each side) which was blinded to the patients or their caregivers and the surgeon who did the tonsillectomy. A double blinded randomization process of 1 to 1 of these two procedures according to the side involved was performed. Data concerning the age, gender, indications for tonsillectomy, operative time, the amount of the blood loss, post-tonsillectomy pain by VAS scores, and other complications were recorded for each patient.

Results

Out of 62 participants, there were 34 (54.8%) females. The majority were from the age group ≤18 years (n = 54, 87.1%). The operative time and amount of the intraoperative blood loss were significantly lower in the Coblation than a diode laser tonsillectomy. However, the postoperative pain scores in the diode laser were a statistically significant difference less than the Coblation group at the periods 3 hours, 8 hours, 24 hours, and 7 days (P-value < 0.05).

Conclusions

Coblation was better than diode laser because of shorter operative time and less intraoperative blood loss. However, the diode laser technique had lesser postoperative pain at the postoperative periods 3 hours, 8 hours, 24 hours, and 7 days than Coblation.

Comparison of three tonsillectomy techniques in children

PURPOSE

Tonsillectomy is still one of the most common surgical procedures worldwide performed by otorhinolaryngologists. This single-blind randomized study aimed to compare cold dissection tonsillectomy, coblation tonsillectomy, and harmonic scalpel tonsillectomy in pediatric patients in respect of intraoperative blood loss, operating time, and postoperative pain and bleeding.

METHODS

This single-blind randomized clinical trial evaluated 82 pediatric patients aged 3-16 years (mean age: 7.23 ± 3.26 years) applied with tonsillectomy between April 2017 and March 2020. Harmonic scalpel tonsillectomy was applied to 33 (40.2%) patients, the cold knife technique to 25 (30.5%), and coblation tonsillectomy to 24 (29.3%).

RESULTS

There was no statistically significant difference between the three techniques in respect of postoperative pain levels and post-tonsillectomy bleeding rates. The intraoperative bleeding rate and mean operating time were determined to be significantly lower in the harmonic scalpel group (p < 0.05).

CONCLUSION

Harmonic scalpel tonsillectomy is associated with a shorter operating time and lower intraoperative bleeding rates and similar postoperative pain score and postoperative bleeding rates compared with coblation tonsillectomy and cold dissection tonsillectomy. Harmonic scalpel tonsillectomy is a fast, safe, and effective method for tonsillectomy in children.

Plasma Ablation vs Other Hot Techniques for Tonsillectomy: A Meta-analysis

OBJECTIVE

To evaluate whether plasma ablation tonsillectomy is superior to other hot techniques in reducing postoperative morbidity.

DATA SOURCES

The databases of PubMed, EMBASE, and Web of Science were used to search the literature, from inception to January 2, 2020. Randomized controlled trials (RCTs) that compared plasma ablation tonsillectomy with any other hot techniques were eligible.

REVIEW METHODS

A modified Cochrane tool was used to assess the risk of bias. The standardized mean difference (SMD) and 95% confidence interval (CI) were used to estimate pooled effects of postoperative pain, and the risk ratio (RR) was used for postoperative bleeding. Subgroup analysis was prespecified to explore the source of heterogeneity. The evidence quality of each outcome was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

RESULTS

A total of 15 RCTs were included (n = 1293). Comparing with other hot techniques, plasma ablation tonsillectomy may cause less pain on postoperative day 7 (SMD, -0.53; 95% CI, -0.84 to -0.23). However, the magnitude of the difference may be clinically meaningless. There were no significant differences not only in terms of postoperative pain on day 1 and day 3 but also in the incidence of postoperative bleeding, reoperation hemostasis, and return to normal diet and activities between the 2 groups.

CONCLUSION

There is still substantial uncertainty on postoperative pain, bleeding, and recovery. The current evidence is insufficient to demonstrate that plasma ablation is superior to other hot techniques for tonsillectomy.

The applicability and efficacy of magnetic resonance-guided high intensity focused ultrasound system in the treatment of primary trigeminal neuralgia

Primary trigeminal neuralgia is a common clinical refractory neuralgia characterized by an onset of excruciating pain that can severely affect patients' quality of life. Long-term suffering from this pain may lead to depression, anxiety, and suicide. Current treatments, however, are associated with high recurrent rates and severe complications. We hypothesize that both the applicability and efficacy of magnetic resonance-guided high intensity focused ultrasound (MR-HIFU) treatment in primary trigeminal neuralgia can be achieved under the following conditions: a specific target focus and incident channel, a temperature measurement system that does not incur damage to surrounding tissues, and an optimal radiation dose. Successful non-invasive treatment of primary trigeminal neuralgia by MR-HIFU systems could represent a breakthrough of this technology applied to the oral and maxillofacial region.