Eur Arch Otorhinolaryngol DOI 10.1007/s00405-011-1777-6
HEAD AND NECK
Comparison of three techniques in pediatric tonsillectomy Mahmut ÖzkÂrÂo
Received: 28 May 2011 / Accepted: 13 September 2011 © Springer-Verlag 2011
Abstract 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 Wve 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 signiWcantly lower in the thermal welding and BCD groups (p < 0.001). The diVerence between mean operative time of TWT and BCD groups was not statistically signiWcant (p > 0.001). The diVerence between mean operative time of the two groups against cold dissection group was statistically signiWcant (p < 0.001). No signiWcant diVerence 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 diVerence between mean pain score between TWT and CD was not statistically signiWcant (p > 0.001). The diVerence between mean pain score of the
M. ÖzkÂrÂo Department of Otolaryngology, Head and Neck Surgery, Tekden Medical Center, Kayseri, Turkey M. ÖzkÂrÂo (&) Köok Mah. Ãncirli Sok. No:36 Mühendisler Sitesi D Blok D:16, Melikgazi, Kayseri, Turkey e-mail:
[email protected]
two groups against BCD group was statistically signiWcant (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 oVered an innovative new tonsillectomy method with signiWcantly reduced blood loss and reduced surgical time and without any increase in the postoperative pain Keywords Thermal welding technique · Classic dissection · Bipolar cautery dissection · Tonsillectomy
Introduction Tonsillectomy is one of the most frequently applied and oldest surgical procedures in otorhinolaryngology [1]. Various surgical techniques are used to perform this operation, including classic blunt dissection, guillotine excision, electrocautery, cryosurgery, coblation, ultrasonic removal, laser removal, monopolar and bipolar dissection, thermal welding tonsillectomy and ligature tonsillectomy [2]. Common targets of these new techniques have been to reduce the incidence of potential complications by shortening the operative time and increasing the safety and comfort of the patient. The thermal welding technique (TWT), which is a new technique for tonsillectomy, diVers from other electrosurgical procedures in several respects, including the use of direct thermal heating applied to the tissue to achieve the desired protein denaturation eVect. A simple resistance heating wire driven by low-voltage direct current produces heat at the tip of
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bayonet forceps; no electrical current is applied to the tissue [3, 4]. In this prospective study, classic dissection (CD), TWT and bipolar cautery dissection (BCD) methods were compared with respect to peri/postoperative parameters under the light of current literature.
Materials and methods A prospective study was conducted on 305 consecutive children undergoing tonsillectomy plus adenoidectomy from January 2008 through March 2010. Each child was alternately assigned to CD, TWT or BCD group as they appeared on the surgery list. Patients were enrolled for the intended treatments by M.Ö. Parents were blinded to the assigned surgical technique. Inclusion criteria were chronic tonsillitis and/or upper airway obstruction (248 patients have chronic tonsillitis and 57 patients have upper airway obstruction). Children younger than 3 years and older than 12 years of age and/or children who had a history of tonsillitis within 3 weeks, with signs of acute upper airway infection, peritonsillar abscess and hematological disorders were excluded from the study. All procedures were performed by the same surgeon (M.Ö) under general anesthesia through endotracheal intubation. According to our study protocol, each patient was placed in the Rose position and a DavisBoyle mouth gag supported by DraYn bipods was inserted into the mouth. A tongue retractor of suitable size was used depending on the age of the patient. First, adenoidectomy was performed and packed, and then the tonsil was grasped with tonsil-seizing forceps and gently retracted medially. In TWT, a power supply mounted with an ultraslim bayonet forceps and foot pedal is used. Without incision, both tonsils are retracted to the midline, and the anterior plica is grasped with an ultraslim bayonet forceps and coagulated using 3–4 level thermal energy. Subsequent dissection is accomplished through to the lower pole with the same forceps using 8-level thermal energy. The lower pole is coagulated with the same forceps and the tonsil is extracted. Hemostatic control is done with the same forceps switching the power supply to level 3–4. In the CD group, the tonsil is grasped and medialized with an Allis clamp. After incising the anterior plica, the tonsil is separated from its upper pole with a dissection spoon through to its lower pole. Tamponade of the fossa is maintained till extraction of the other tonsil. After completion of the procedure, hemostasis is achieved with technique of suture of all bleeding points. In the group of BCD tonsillectomy patients, a Statome 900 (EMC Industries, Guyancourt-Cedex, France) diathermy machine set at 30 W was used. After retracting the tonsil medially to identify the pericapsular dissection plane, a palatoglossal incision was performed along the border of anterior tonsillar pillar with bipolar cautery forceps. The
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pericapsular dissection was carried out with great care from the superior to inferior poles of the tonsil. This dissection with bipolar forceps was mostly blunt throughout the procedure, unless a blood vessel was identiWed. The vessel was Wrst cauterized and then dissected away from the tonsillar capsule. After removal of the tonsil, point coagulation for bleeding foci was used, if necessary. After absolute hemostasis was achieved, the Davis-Boyle mouth gag was removed and the patient was extubated. Operation time was measured from the time of insertion of the Davis-Boyle mouth gag to the time of its removal. The Wrst cold liquid diet was given to the child 4–6 h after the operation. Blood loss was estimated and recorded for each patient from the suction bottle, as well as by weighing the used sponges. Children were examined for bleeding, blood clot or residual tissue in tonsil beds and discharged on the Wrst postoperative day. Paracetamol was recommended for pain relief as needed. Antibiotic (amoxicillin/clavulanic acid) was prescribed routinely in weight-related doses. Children were asked to Wll out a pain diary for postoperative days 1, 4, 7 and 10 using a visual analog scale of 0–10 correlating faces from happy to crying. The diary should be completed in the morning of the given day before taking any analgesic. Parents were instructed to feed their child on a normal diet at the 7th postoperative day. If the child could not take a normal diet by this time, a soft diet was continued until the child was able to receive his/her normal diet. The time to return to normal diet was recorded by the parents. Ten days later, another surgeon (C.M.) who was blinded to the operation technique performed, visited the children. The condition of the tonsillar fossa was noted. If there was no slough in the tonsillar fossa 10 days after surgery, it was accepted as “good healing”. Data were analyzed by the Chi-square test, Student’s t test, Kolmogorov–Smirnov test, and Mann–Whitney U test using SPSS 11.5 software. The study was approved by the local ethics committee. Written informed consent was obtained from all parents.
Results A total of 305 children were enrolled in the study. Bilateral tonsillectomy was performed; 104 (50 male, 54 female) patients, whose age ranged from 4 to 12 years (mean age 8.24 years) underwent TWT, 99 (45 male, 44 female) patients whose age ranged from 4 to 13 years (mean age 7.77) underwent the cold dissection technique and 102 (54 male, 48 female) patients whose age ranged from 4 to 13 years (mean age 7.21) underwent the BCD. The three groups were similar for demographic parameters. No statistically signiWcant diVerence was noted for age (p = 0.092) and gender (p = 0.108). There were no adverse events during surgery.
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Operation time
Table 1 Descriptive data about cases that developed post-tonsillectomy bleeding in TWT group, BCD group and in the CD group
Mean operative time was 13.92 § 3.66 min for TWT, 13.13 § 2.98 min for BCD and 25.75 § 12.10 min for CD group. The diVerence between mean operative time of TWT and BCD groups was not statistically signiWcant (p > 0.001). The diVerence between mean operative time of the two groups against cold dissection group was statistically signiWcant (p < 0.001).
Cases
Intraoperative blood loss Mean intraoperative blood loss was 3.77 § 3.04 ml for TWT group, 3.41 § 3.79 ml for BCD group and 32.08 § 12.05 ml for CD group. The diVerence between mean intraoperative blood loss of TWT group and BCD group was not statistically signiWcant (p > 0.001). The diVerence between mean intraoperative blood loss of the two groups against CD group was statistically signiWcant (p < 0.001). Postonsillectomy hemorrhage
Age
Sex
Operation
Time of bleeding (days)
Case 1 (T*)
5
Male
T&A
13
Case 2 (T*)
4
Female
T&A
5
Case 3 (T*)
7
Male
T
7
Case 4 (T*)
5
Male
T&A
8
Case 5 (T*)
11
Female
T&A
11
Case 6 (B*)
9
Female
T
Case 7 (B*)
3
Male
T&A
6
Case 8 (B*)
8
Female
T&A
8
4
Case 9 (B*)
5
Male
T&A
7
Case 10 (B*)
9
Male
T&A
12
Case 11 (B*)
6
Case 12 (C*)
10
Case 13 (C*)
4
Female
T&A
6
Male
T
5
Female
T&A
7
T* Thermal welding group, B* bipolar cautery disection group, C* cold disection group, T tonsillectomy, T & A tonsillectomy and adenoidectomy
None of the patients in the three groups experienced primary hemorrhage. Secondary hemorrhage was seen in Wve patients (5, 7, 8, 11, 13 postoperative days) in the TWT group, only one patient’s hemostatic control was done under general anesthesia. Secondary hemorrhage was seen in six patients (4, 6, 7, 8, 12 postoperative days) in the BCD group; hemostatic control was done with conventional method. Secondary hemorrhage was seen in two patients (5, 7 postoperative days) in the cold dissection group, and in one patient hemostatic control was done under general anesthesia. No signiWcant diVerence was found in the incidence of posttonsillectomy hemorrhage between the three patient groups (p > 0.001) (Table 1). Postoperative nausea and vomiting No patient required hospitalization or intravenous Xuids for more than 24 h. Few patients experienced nausea and vomiting after operation (mainly during the Wrst postoperative day). No signiWcant diVerence was found in the incidence of these symptoms between the three patient groups (p > 0.001). Postoperative pain 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 diVerence between mean pain score between TWT and CD were not statisti-
Fig. 1 Mean posttonsillectomy pain scores. Postop postoperative, CD group cold disection group, BCD group bipolar cautery disection group, TWT group thermal welding group, h hours, d days
cally signiWcant (p > 0.001). The diVerence between mean pain score of the two groups against BCD group were statistically signiWcant (p < 0.001). The mean time to regain normal diet was 7.3 § 0.7 (median 7, range 7–9) days in the TWT group and 7.0 § 1.5 (median 8, range 6–9) days in the CD group; this diVerence, although statistically signiWcant (p = 0.015, Mann–Whitney U test), is not clinically relevant. The mean time to regain normal diet was 9.3 § 1.7 (median 9, range 9–11) days in the BCD group. The diVerence between mean pain score of the two groups against BCD group were statistically signiWcant (p < 0.001) (Fig. 1).
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Discussion Tonsillectomy is one of the most common surgical procedures performed worldwide [1]. Each method has its own advantages and disadvantages. However, the main target is to establish a method which can reduce operative time, minimalise per-/postoperative risk of bleeding, decrease number of complications and enhance postoperative comfort of the patient as well [1–4]. Cold dissection and electrodissection are the two mostly used techniques. As a matter of fact, beginners learn the procedure utilizing the cold dissection method in most of the units [2]. Thermal welding technique is distinct from other electro surgical techniques because it is eVective through the application of direct heat energy instead of electrical current. Tissue injury is minimal with TWT, and the procedure is suitable for tonsillectomy [5]. A lot of experience has been gained with cold knife dissection and bipolar electrocautery through the years [1, 2]. But comparative studies of cold knife dissection, bipolar electrocautery and thermal welding tonsillectomy are rarely mentioned in literature. Pizzuto et al. [6] suggested there was not any diVerence in the healing time of tonsillar fossae between electrosurgical and classical dissection tonsillectomy, whereas other authors have stated that healing of the tonsillar fossa occurred much sooner with the CD method [7, 8]. Weinstock [9] has stated that healing after TWT lasted 1 week and that no eschar was left in the tonsillar fossa after 7 days. The healing time with the thermal welding technology should be faster than with the cold dissection technique. In our study, the amount of remucosalization of the tonsillar fossae was greater in the TWT and CD groups, compared with the bipolar electrocautery dissection technique. The most common serious complication of tonsillectomy is delayed hemorrhage, which occurs in 2–4% of all patients. Most of these bleeds are primary. Secondary bleeds can occur at any time during the Wrst two postoperative weeks [10]. Lee et al. [11], reported that there was no signiWcant diVerence in secondary hemorrhage rate between cold and hot dissection in pediatric population. Yasar et al. [12, 13] compared the TWT with cold dissection for pediatric and adult tonsillectomy in two diVerent studies. They did not detect any primary or secondary hemorrhage in either group, a result similar to those of several other studies after tonsillectomy [2, 9]. Raut et al. [8] reported rates of primary and secondary hemorrhage after tonsillectomy of 3.1 (1/32) and 12.5% (4/32), respectively, using the CD method on 32 cases, and 5.5 (1/18) and 16.6% (3/18), respectively, with the bipolar scissors method on 18 cases. The incidence of post-tonsillectomy hemorrhage in a large pediatric group studied by Windfuhr and Chen [14]
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was 1.6% after CD. We did not detect any primary hemorrhage in three groups, a result similar to those of several other studies after tonsillectomy. Secondary hemorrhage was seen in Wve patients in the TWT group (in one patient hemostatic control was done under general anesthesia), six patients in the BCD group (hemostatic control was done with conventional method) and two patients in the cold dissection group (one patient’s hemostatic control was done under general anesthesia). Karatzias et al. reported the record of 50 patients who had undergone thermal welding tonsillectomy, and there was no measurable bleeding during surgery in any case. Postoperative hemorrhage and other complications were not seen [3]. The second study of Karatzias et al. [4] which compared TWT and bipolar electrocautery, showed no signiWcant diVerence regarding mean operative time. In our study, intraoperative bleeding and operation time were signiWcantly lower with the TWT and BCD technique. Although the diVerence in blood loss and operation time between the two techniques against CD group were statistically signiWcant, both values are clinically acceptable. During tonsillectomy, surrounding tissue undergoes mechanical or thermal damage that results in severe pain due to inXammation, spasm of the exposed pharyngeal muscles and nerve irritation [6]. Pain is reported to be the main cause for seeking outpatient medical attention in the Wrst 2 weeks after surgery [4]. Raut et al. [8] found the degree of postoperative pain to be lower with the CD method compared with the bipolar scissors method. In a systematic review by Leinbach et al. [15], electrodissection caused increased postoperative pain in comparison with cold dissection tonsillectomy. Weinstock [9] claimed the degree of pain to be low in patients who underwent thermal welding tonsillectomy. Sezen et al. [16] compared TWT with the conventional ‘cold’ dissection tonsillectomy, and they found that TWT tonsillectomy oVered an innovative new tonsillectomy method with signiWcantly reduced blood loss and reduced surgical time and without any increase in the postoperative pain. Celebi et al. [17] studied acoustic, aerodynamic and perceptual voice and speech parameters in thermal welding system tonsillectomy and cold knife tonsillectomy patients in order to determine the impact of operation technique on voice and speech. They showed that surgical technique, whether it was cold knife or thermal welding system, did not appear to aVect voice and speech in tonsillectomy patients. In our study, we found higher pain scores for BCD and CD than TWT. There is no thermal energy in CD, meaning that there is no thermal injury to adjacent structures which is one of the causes for pain. The forceps used in thermal welding are disposable and therefore the method should have a very low risk of transmitting slow virus infection disease. This potential beneWt
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could be factored in when weighing the higher cost of TWT compared with CD and BCD. Thermal welding forceps costs about 204 Euro. Thermal welding technique is much more expensive than other two techniques. Thermal welding technique is 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 oVered an innovative new tonsillectomy method with signiWcantly reduced blood loss and reduced surgical time without any increase in the postoperative pain. It was a useful method for tonsillectomy. Finally, the number of individuals in the subgroups is rather small and conclusions drawn from the study are therefore limited. Acknowledgments with the study.
6.
7.
8.
9.
10.
11.
We thank Prof. Dr. Cemil Mutlu for assistance
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