Diathermy power settings as a risk factor for hemorrhage after tonsillectomy

Effect of monopolar diathermy power settings on postoperative pain, wound healing, and tissue damage after tonsillectomy: a randomized clinical trial

This study aimed to assess the impact of varying monopolar diathermy power settings on postoperative pain, hemorrhage, and wound healing following tonsillectomy. A single-center, prospective, randomized, double-blinded, controlled clinical study was conducted. During bilateral tonsillectomy procedures, one tonsil received low-power settings (15 W, cutting/blend) while the other tonsil received high-power settings (35 W, cutting/blend). Postoperative pain scores (0-10) and wound healing scores (0-3) were evaluated immediately after surgery and at 1, 2, and 4 weeks postoperatively using the visual analog scale. Additionally, histological analysis was performed on electrically resected tonsil tissues to assess tissue damage in the tonsil bed. The allocation of high and low power settings to each side was randomized. Results showed that 1 week after the surgery, the high-power group experienced significantly higher pain scores (mean ± standard deviation: 4.84 ± 2.21) compared to the low-power group (3.56 ± 2.24, p = 0.049). Moreover, the high-power side exhibited slower wound healing during the initial 1-2 weeks postoperatively, as indicated by lower wound scores at 2 weeks (high-power: 1.96 ± 0.64; low-power: 2.43 ± 0.59, p = 0.008). Furthermore, histological analysis revealed significantly deeper tissue degradation on the high-power side compared to the low-power side (p < 0.001), with mean depths of 565.2 ± 291.0 µm and 156.0 ± 36.8 µm, respectively. In conclusion, these findings suggest that when employing monopolar diathermy in tonsillectomy, lower power settings can lead to improved outcomes in terms of postoperative pain, wound healing, and tissue damage.Trial registration: CRIS identifier: KCT0005670 (cris.nih.go.kr, registration date: 11/12/2020).

Very-Low Energy Monopolar Reduces Post-Tonsillectomy Hemorrhage Versus Standard Energy Techniques

OBJECTIVES/HYPOTHESIS

To compare rates of post-tonsillectomy hemorrhage (PTH) between a very-low energy transfer monopolar technique (VLET) and standard energy techniques.

STUDY DESIGN

Retrospective controlled cohort study.

METHODS

All tonsillectomies performed by practice physicians during the period January 1, 2010 to August 31, 2019 were identified. Three groups were created based on surgeon technique utilization: the study group (VLET) and two control groups (exclusive standard energy monopolar [Standard]; exclusive "hot" technique without exclusive monopolar use [Mixed "Hot"]). Each group's PTH occurrences requiring surgical intervention (PTHRSI) were identified and rates compared.

RESULTS

During the study period 11,348 tonsillectomies were performed (4,427 Standard, 1,374 VLET, 5,547 Mixed "Hot"), and 167 (1.47%) PTHRSI events identified (14 primary (<24 hours), 153 secondary (>24 hours), 12 repeat (>1PTHRSI/patient). Compared to the Standard group secondary and total PTHRSI rates (1.47%, 1.60%), the Mixed "Hot" group experienced similar rates (1.57%, P = .54; 1.68%, P = .64), but the VLET group experienced significantly lower rates (0.15%, P = .0026, adjusted odds ratio [OR] 0.114 [0.028-0.469]; 0.22%, P = .0016, adjusted OR 0.155 [0.048-0.494]). Age was a significant risk factor for both secondary and total PTHRSI (P = .0025, P = .0024, adjusted OR 1.02/year [1.01-1.03]). No significant difference in rate of primary PTHRSI was seen collectively or in any age group. The <12VLET Group experienced 0 episodes of secondary PTHRSI and a total PTHRSI rate of 0.09% in 1060 tonsillectomies.

CONCLUSIONS

Standard energy techniques had an adjusted odds ratio over 8-fold higher for secondary PTHRSI and over 6-fold higher for total PTHRSI compared to the minimized energy transfer VLET technique.

LEVEL OF EVIDENCE

3 Laryngoscope, 2021.

Predictors of Occurrence and Timing of Post-Tonsillectomy Hemorrhage: A Case-Control Study

OBJECTIVE

To describe cases and timing of pediatric post-tonsillectomy hemorrhage (PTH), to evaluate predictors of PTH, and to determine the optimal amount of postoperative care unit (PACU) monitoring time.

STUDY DESIGN

Using the Pediatric Health Information System (PHIS) database and electronic medical records, a matched case-control study from 2005 to 2015 was performed.

SETTING

A single, tertiary-care institution.

SUBJECTS AND METHODS

Each case of PTH was matched with 1 to 4 controls for the following factors: age, sex, surgeon, and time of year. A total of 124 cases of PTH and 479 tonsillectomy controls were included. The rate and timing of postoperative bleeding were assessed, and matched pair analysis was performed using conditional logistic regression.

RESULTS

Our institutional PTH rate of 1.9% (130 of 6949) included 124 patients; 15% (19) were primary (≤24 hours), with 50% (9) occurring within 5 hours. Twenty-one percent (4 of 19) of primary PTH patients received operative intervention. Eighty-five percent (105 of 124) of all cases were secondary PTH, and 47% (49) of those patients received operative intervention. Cold steel (OR 1.9, 95% CI 1.1-3.3) and Coblation (OR 1.9, 95% CI 1.2-3.1) techniques and tonsillectomy alone (OR 3.7, 95% CI 1.9-7.2) increased odds of PTH. Patients who developed PTH had 4 times the odds of having a preceding postoperative respiratory event than controls (OR 4.0, 95% CI 1.6-10.0).

CONCLUSION

We conducted a rigorous case-control study for PTH, finding that PTH was associated with use of cold steel and Coblation techniques and with tonsillectomy alone. Patients with a postoperative respiratory event may be more likely to develop a PTH and should be counseled accordingly. A PACU monitoring time of 4 hours is sufficient for outpatient tonsillectomy.

Do changing trends in tonsil surgery affect hemorrhage rates? A longitudinal study covering 1,452,637 procedures

PURPOSE

To evaluate whether changing trends in tonsil surgery between 2005 and 2017 in Germany were associated with different age- and gender-specific hemorrhage rates.

METHODS

A longitudinal population-based inpatient cohort study was performed including all patients who had undergone tonsillectomy (with or without adenoidectomy), tonsillotomy, abscess-tonsillectomy, removal of tonsillar remnants and surgical treatment to achieve hemostasis following tonsil surgery. The population was stratified by age (groups of 5 years) and gender. Operation rates were calculated in relation to the end-year population number according to the German Federal Office of Statistics.

RESULTS

The surgical rates per 100,000 had significantly decreased from 170.39 to 90.95 (46.62%) in female patients and from 147.33 to 88.19 (40.14%) in male patients within the study period (p < 0.001). A total of 42.352 female patients had required surgical treatment to achieve hemostasis following 783,005 procedures (5.41%). In contrast, only 669,632 operations were performed in male patients but were complicated by hemorrhage in 51.185 cases (7.64%) which was significantly different (p < 0.001). The male-to-female ratio of the surgical rates had increased from 0.86:1 to 0.93:1. Hemorrhage rates differed significantly between age groups (p < 0.001). Male gender is a significant risk factor for bleeding at all ages < 85 years with greatest differences in 20- to 25-year-old patients (12.19% male vs. 6.26% female).

CONCLUSIONS

Changing trends in tonsil surgery are not associated with increased rates of bleeding complications. Hemorrhage following tonsil surgery is significantly related to age and gender and this should be noted when reported hemorrhage rates in the literature are appraised by the reader.

Is weight a predictive risk factor of postoperative tonsillectomy bleed?

Objective

To determine if a correlation exists between weight-for-age percentile and post-tonsillectomy hemorrhage in the pediatric population.

Study Design

Retrospective study.

Methods

1418 patients under the age of 15 who underwent tonsillectomy with or without adenoidectomy at a tertiary children's hospital between June 2012 and March 2015 were included in this retrospective study. Patient demographic information, operative and postoperative variables, as well as category and day of postoperative tonsillectomy bleed, if one occurred, were recorded. Fisher's exact and ordinal logistic regression analyses were performed on the full cohort.

Results

The overall post-tonsillectomy hemorrhage prevalence was found to be 2.2%, with primary and secondary rates of 0.78% and 1.34%, respectively. Weight-for-age percentile, sex, indication for or method of tonsillectomy, or postoperative use of NSAIDs, antibiotics or narcotics were not significantly associated with post-tonsillectomy hemorrhage. There was a significant relationship between postoperative use of dexamethasone and higher rate of Category 3 post-tonsillectomy hemorrhage (P = .028).

Conclusion

The post-tonsillectomy hemorrhage rate in our study is consistent with that cited in the literature. No correlation was demonstrated between weight-for-age percentile and occurrence of post-tonsillectomy hemorrhage. Postoperative administration of dexamethasone was associated with a significant increased rate of post-tonsillectomy hemorrhage requiring surgical intervention, a novel finding.

Level of Evidence

4.

Does Microscope Assistance in Cold Steel Tonsillectomy Reduce the Risk of Postoperative Hemorrhage? Results of a Prospective Cohort Study

Background

Posttonsillectomy hemorrhage (PTH) is the most feared complication. Dissection near the tonsillar capsule under microscopic view (TE_mic) could be assumed to decrease PTH compared to traditional tonsillectomy (TE_trad).

Methods

In this study, patients were evaluated with respect to the need for surgical control (R/N: return/no return to theater (RTT): the day of surgery [0] or thereafter [1]). The findings at resection site and pain were measured.

Results

869 patients were included (183 TE_mic; 686 TE_trad). PTH requiring RTT was not seen in the TE_mic group on the day of surgery (R0) while PTH requiring RTT subsequently (R1) was seen in 1.1% of the cases. In the TE_mic group, hemorrhages without a need for surgical control were observed in 0.6% (N0) and 3.4% (N1), respectively. The corresponding rates for TE_trad were as follows: R0, 0.3%; R1, 1.7%; N0, 0.6%; and N1, 3.6% (p > 0.05). Postoperative edema and local infection at resection site were proven to be predictive of PTH (p = 0.007).

Conclusion

Microscope assistance in tonsillectomy did not statistically have an influence on the PTH even though there was a trend towards lower PTH rate in the TE_mic group. Benefit for TE_mic was observed in high-volume and long experienced surgeons.

Postoperative Bleeding and Associated Utilization following Tonsillectomy in Children

Objective To assess posttonsillectomy hemorrhage (PTH), associated nonoperative readmissions/revisits, and reoperations in children. Data Sources MEDLINE, EMBASE, and the Cochrane Library. Review Methods Two investigators independently screened studies against predetermined criteria and extracted key data. Investigators independently assessed study risk of bias and the strength of the evidence of the body of literature. We calculated unadjusted pooled estimates of PTH frequency and conducted a Bayesian meta-analysis to estimate frequency of primary and secondary PTH and PTH-associated reoperation and revisits/readmissions by partial and total tonsillectomy and surgical approach. Results In meta-analysis, the frequency of primary and secondary PTH associated with total and partial tonsillectomy was <4% for any technique and with overlapping confidence bounds. Pooled frequencies of PTH were also <5% overall (4.2% for total tonsillectomy, 1.5% for partial tonsillectomy) in comparative studies. Fewer PTH episodes occurred with tonsillectomy for obstructive sleep-disordered breathing than for throat infection. In meta-analysis, frequency of PTH-associated nonoperative revisits/readmission or reoperation ranged from 0.2% to 5.7% for total tonsillectomy and from 0.1% to 3.7% for partial tonsillectomy. At least 4 deaths were reported in case series including 1,778,342 children. Conclusions PTH occurred in roughly 4% of tonsillectomies in studies included in this review. Although studies typically did not report bleeding severity or amount, relatively few episodes of PTH necessitated reoperation for hemostasis. Nonetheless, tonsillectomy is not without risk of harm. Frequency of PTH across techniques was similar; thus, we cannot conclude that a given technique is superior.

Readmission rates and financial penalties after ear, nose and throat surgery: how can we improve?

INTRODUCTION

Since April 2011, all patient readmissions within 30 days have resulted in a financial penalty to the hospital trust, and therefore the responsible department. These costs may be substantial and potentially preventable.

METHODS

A service evaluation of readmissions within 30 days of discharge, over a 12-month period (January-December 2012), was performed in the ear, nose and throat department of a district general hospital, and findings were used as a basis to suggest areas for potential quality improvement.

AIMS

To determine the number of readmissions, causes of readmission and resulting costs, and to explore how these readmissions may be prevented.

RESULTS

The departmental 30-day readmission rate over the study period was 3.12% (81/2606). The commonest causes of readmission (33.3%) were complications following tonsillectomy (27/81) such as pain, infection or bleeding. Over a third of these patients (30/81) were readmitted for less than 24 hours, with the average length of stay being less than 2.5 days. Financial implications: In 2011 the trust had 7526 emergency readmissions which were eligible for penalty within the 30-day time frame. This resulted in a loss of income of more than £60 000 to the ear, nose and throat department.

CONCLUSIONS

Optimizing postoperative care and improving patient understanding of common complications may reduce readmission rates, thus limiting the financial burden on the trust. These areas could serve as a basis for future quality improvement projects.

Bipolar cautery tonsillectomy using different energy doses: pain and bleeding

OBJECTIVE

Tonsillectomies are the most frequently applied operations in the ENT practice. Even though different surgical tonsillectomy techniques have been used, bipolar cautery is the most frequently used one. Our aim was to compare postoperative bleeding rates, pain scores and recovery times in tonsillectomies performed by using bipolar cautery in Joules (1Watt·sec or Ws) calculated by multiplying Watts by the duration of cauterization.

METHODS

Adenotonsillectomy and tonsillectomy patients, admitted to the Department of otorhinolaryngology of Izmir Ataturk Training and Research Hospital and Mardin State Hospital, between January 2007 and December 2012 constituted the study group prospectively. The patients divided into 4 groups due to the energy they exposed.

RESULTS

Patients in Group 1 recovered most rapidly (mean recovery time, 13.9 ± 1.8 days). Statistically significant results were obtained between Groups 1 and 4 and also Groups 2 and 4 when recovery times of the patient groups were evaluated with Bonferroni correction test.

CONCLUSION

As a result, for hemostatic control, electrocauterization should be used at lower doses and short-term as possible so as to decrease frequency of bleeding episodes, alleviate postoperative pain and accelerate wound healing.

Cold versus hot tonsillectomy: state of the art and recommendations

An investigation of the risk factors for haemorrhage after tonsillectomy with particular reference to the use of bipolar diathermy for tonsillar dissection and haemostasis, diathermy power settings and coblation tonsillectomy. The findings of the National Prospective Tonsillectomy Audit and subsequent related research are summarised and discussed with reference to the issue of use of hot versus cold tonsillectomy techniques. Additional unpublished data on coblation tonsillectomy is presented. Overall, increased haemorrhage rates were noted for diathermy dissection tonsillectomy (adjusted odds ratio 2.47, p < 0.0001) and coblation tonsillectomy (adjusted odds ratio 3.07, p < 0.0001) compared to the reference category of cold steel tonsillectomy. Use of bipolar diathermy for haemostasis only carried an intermediate risk of haemorrhage (adjusted odds ratio 1.57, p = 0.004). Further investigation of diathermy power settings demonstrated a quantitative relationship between increasing power usage and subsequent haemorrhage. Use of diathermy for haemostasis at the lowest effective setting may carry a comparable risk of haemorrhage to that of cold steel tonsillectomy. Recommendations are given on the optimum tonsillectomy technique for both the older child or adolescent and the particularly young or low weight child.

Hemorrhage after tonsillectomy: does the surgical technique really matter?

A thorough review of the publications on surgical techniques used for tonsillectomy is provided, emphasizing randomized studies and meta-analysis. In the assessment of the data it is important to clearly define and categorize the types of posttonsillectomy bleeding (PTB), as well as the various factors that have been associated with increased PTB. In recent audits of a large number of tonsillectomies, the PTB rates seem to concur: 1% early and 2.5% delayed PTB; 10% anamnestic, 2% objective, and 2% re-operation PTB. Objective PTB rates beyond 10% should require an audit. The bipolar technique seems associated with the least early PTB, while the cold technique is associated with the least delayed PTB. Because of the lack of large well-conducted randomized trials, it is difficult to conclude which technique is the best. With electrocautery techniques, the current power should be adjusted to the minimal level providing hemostasis. Surgical techniques for tonsillectomy that should probably be abandoned include monopolar electrocautery, Coblation, various lasers, and the harmonic scalpel. Vessel-sealing systems might hold promise and deserve further evaluation. Tonsillotomy might be associated with less postoperative pain, but the hemorrhagic advantage in randomized studies is not obvious. Tonsil regrowth rates and efficacy to treat obstruction need also further evaluation.

Six years of evidence-based adult dissection tonsillectomy with ultrasonic scalpel, bipolar electrocautery, bipolar radiofrequency or 'cold steel' dissection

OBJECTIVE

To conduct an adequately powered, prospective, randomised, controlled trial comparing adult dissection tonsillectomy using either ultrasonic scalpel, bipolar electrocautery, bipolar radiofrequency or 'cold steel' dissection.

METHODS

Three hundred patients were randomised into four tonsillectomy technique groups. The operative time, intra-operative bleeding, post-operative pain, tonsillar fossa healing, return to full diet, return to work and post-operative complications were recorded.

RESULTS

The bipolar radiofrequency group had a shorter mean operative time. The mean intra-operative blood loss during bipolar radiofrequency tonsillectomy was significantly less compared with cold dissection and ultrasonic scalpel tonsillectomy. Pain scores were significantly higher after bipolar electrocautery tonsillectomy. Patients undergoing bipolar electrocautery tonsillectomy required significantly more days to return to full diet and work. The bipolar electrocautery group showed significantly reduced tonsillar fossa healing during the first and second post-operative weeks.

CONCLUSION

In this adult series, bipolar radiofrequency tonsillectomy was superior to ultrasonic, bipolar electrocautery and cold dissection tonsillectomies. This method combines the advantages of 'hot' and 'cold' tonsillectomy.

Adenoidectomy Technique in the United Kingdom and Postoperative Hemorrhage

Objective. To investigate the incidence of postoperative hemorrhage and its risk factors after adenotonsillectomy.

Study Design. A prospective cohort study as part of the National Prospective Tonsillectomy Audit.

Setting. National Health Service and private hospitals in England and Northern Ireland.

Subjects and Methods. National Prospective Tonsillectomy Audit methodology was followed with a nonrandomized prospective observational cohort methodology and data collection.

Results. A total of 33,921 patients underwent tonsillectomy; of these, 9900 underwent adjunctive adenoidectomy. Traditional curette adenoidectomy (without any diathermy use at all) was performed in 6871 patients. Suction diathermy technique was used in 1489 patients. Hemorrhage rates were calculated for these main adenoidectomy technique groups and compared by calculation of risk ratios. Both early and late hemorrhage rates for suction diathermy were found to be 0.07% (n = 1 in each case). In the traditional curette group, these rates were 0.3% (n = 19) and 0.2% (n = 14), respectively. The risk ratio for hemorrhage overall was 3.6 for curette adenoidectomy compared with suction diathermy (95% confidence interval, 0.86-14.9; P = .06). The data suggest comparable hemorrhage rates in both adenoidectomy technique groups and fail to demonstrate diathermy usage as a risk factor for hemorrhage following adenoidectomy despite a clear interaction between diathermy usage and subsequent hemorrhage in tonsillectomy.

Conclusion. Use of suction diathermy in adenoidectomy appears to have a similar safety profile to conventional techniques and may offer additional benefits over traditional adenoid curettage. Further clinical and laboratory-based research into the complex interaction between diathermy usage and both adenoid and tonsillar tissue is warranted.