Abstract
Tonsillectomy is one of the most common ear, nose and throat surgical procedure, carried out worldwide1. Amongst the various method of tonsillectomy (diathermy, laser, harmonic scalpel, radiofrequency cautery cryosurgery and coblation), dissection and snare method is commonest procedure done by otorhinolaryngologist. To compare the post operative complications associated with coblation versus conventional cold-dissection steel tonsillectomy. We carried out the prospective study of complications associated with coblation versus conventional cold steel tonsillectomy in postoperative pain, anesthesia, hemorrhage, fever, pharyngitis, injury of adjacent structure & cautery burn. Average blood loss on Coblation side was 18.74 ml while on conventional side it was 44.2 ml. Post operative pain score, injury to adjacent structure and cautery burn were found to be significantly decreased in coblation. No such difference was observed in pharyngitis and fever in both methods. The use of coblator reduces the post-operative pain, peri or post-operative blood loss, injury to adjacent structure & cautery burn too.
Keywords: Tonsillectomy, Coblation, Conventional cold steel, Primary hemorrhage
Introduction
Infectious diseases of tonsils are common in otorhinolaryngological practice, be it in pediatric age group or adults. Tonsillectomy is one of the most common ear, nose and throat (ENT) surgical procedure, carried out worldwide [1].Ideally the procedure should be painless, bloodless and associated with rapid recovery. But in reality, no method of tonsillectomy is free from morbidity. Tonsillectomy despite being the commonest and simplest surgery, the surgeon is always shaken of its high risk of complications like intra and post operative hemorrhage which may lead to shock and sometimes even death. Oro-pharynx and tonsils are rich in blood supply so the risk of hemorrhage is very high in tonsillectomy. It causes significant short-term morbidities, such as the omnipresent postoperative pain and the possibility of both primary and secondary hemorrhage, anesthetic complication (anxiety, headache and palpitation), post op. fever, pharyngitis, otitis media, cautery-burn &injury of adjacent structure. Postoperative pain and difficulty in swallowing prevent the child to return to regular diet resulting in dehydration and prolonged hospital stay [2].
Amongst the operative methods available; dissection and snare method are the commonest procedure performed by otorhinolaryngologist. With coblation, the results have been promising. Coblation is a newer technique started in 1997, combining radiofrequency energy and normal saline, resulting in a plasma field of highly ionized particles. This dissociates intercellular bonds and thus melt tissue at low temperature (40–70 °C) and reduces tissue damage. This method is based on dissection of tonsil by production of plasma.
There are two different techniques used in tonsillectomy by coblation.
Subtotal, intra-capsular ablation
Total, sub-capsular dissection of tonsils.
Some studies [3] state that leaving a small tonsillar tissue may cause recurrence, a subtotal tonsillectomy may not be the best technique to use in adult with chronic tonsillitis. We used total Sub-capsular tonsillectomy in our institute for all the cases. Within our otorhinolaryngology department, we have done a Prospective controlled study to compare the two-method cold dissection and coblation assisted tonsillectomy in terms of intra-operative and post operative finding. The study was structured so that approximately 100 patients of bilateral tonsillitis who undergoes bilateral tonsillectomy. The cases were distributed between Coblation and conventional (cold dissection technique) as on random number table.
Material and Methods
A prospective study of complications associated with Coblation versus conventional cold- dissection steel tonsillectomy was done in the department of otorhinolaryngology, over 2 years. It was a prospective study with a sample size of 100.
Source of Data
100 patients aged between 3 to 60 years after being screened from outpatient department underwent a general physical examination, local ENT examination and laboratory investigations prior to tonsillectomy.
Inclusion Criteria
Patients of chronic tonsillitis attending outpatient department in the department of otorhinolaryngology in a tertiary care center of north central Bharat, age group 3 years to 60 years of both sexes willing to give consent for the study were registered.
Exclusion Criteria
Patients not willing to give consent for tonsillectomy, having uncontrolled systemic diseases including diabetes, cardiac disease, hypertension and asthma with bleeding disorders example e. g., leukemia, aplastic anemia, hemophilia and those with acute upper respiratory tract infections were excluded.
Methods of Collection of Data
All the patients were explained about the procedure in detail and voluntary consent was obtained followed by detailed history taking and examination related to ear, nose, throat. 100 Patients were randomly divided into two groups. In group one-tonsillectomy performed by cold dissection steel tonsillectomy and group two-by Coblation assisted tonsillectomy.
Preoperative Evaluation
All the patients posted for tonsillectomy were assessed for general anesthesia; and were given loading antibiotics, antacid, nasal-decongestion, mouthwashes (pre-operative and postoperative) and analgesics (postoperatively).
The patients were asked to choose the less painful side even if the difference was very small. The area of slough in each tonsillar fossa was assessed by direct visual examination. The extent of healing within the tonsillar fossa is estimated by recording the percentage of the fossa that had re-mucosalised (Grid scale measurement). The episodes of postoperative bleeding from the tonsillar fossa were documented including the side and day on which it occurred and intervention required to stop it.
Results
Patients with chronic tonsillitis identified as candidates for tonsillectomy were selected randomly and bilateral tonsillectomy was done using Coblation in 50 patients and by conventional dissection method in other 50 patients. All the patients were examined regularly after surgery on 7th day, 15th day and after 1 month.
All the patients were regularly followed up, the results were compared and analyzed using chi square testing and SPSS (statistical product and service solutions) Statistics 23 version.
It is seen that majority of patients were in the age group > 25 years. The next majority age group was 16 to 20 years (23%).
On comparison of hemorrhage, Mean & standard deviation was more in conventional then Coblation methods of tonsillectomy.
In conventional method Mean and Standard deviation of age 25.10 and 11.018. In coblation method Mean and Standard deviation of age is 18.94 and 10.279.
Post operative pain is less in Coblation then conventional methods of tonsillectomy.
Patients which underwent Coblation experienced less pain post operatively statistically in overall, than on which Coblation was not used. Pain was measured by VAS scale (visual analog scale). Under this scale the mean pain averaged in < 24,15thday and 1 month was 1.80, 0.24 and 0.14 with Coblation and 5.56, 1.80 and 0.24 with conventional method (p value is significantly lower < 0.05).
Post-operative pharyngitis is approximately similar in both methods on statistically. On 7th POD, 15thPOD and 1 Month chi square is 0.762, 4.000 and 0.000 and p value is > 0.05.
Post operative fever is not much lower in Coblation than conventional statistically (P value is > 0.05).
Pearson Chi Square = 28.972a a. 6 Cells (50.0%) Have Expected Count Less Than 5. The Minimum Expected Count is 0.50. P VALUE = < 0.001
Injury of adjacent structure is significantly lower in Coblation than Conventional (Pearson chi square = 28.972, p value = < 0.05).
Pearson Chi Square = 16.318a P Value = 0.001
Comparison of cautery burn in Coblation is significantly lower than Conventional statistically (Pearson chi square = 16.318, P value = 0.001).
Discussion
Tonsillectomy is a very common surgery now a days done worldwide by otorhinolaryngologist community. Among various techniques available for tonsillectomy, Coblation method is newer method of tonsillectomy for most surgeon. The main aim of this study is to compare the complication associated with Coblation vs conventional cold steel technique.
In our study it is found that 35% patient were in the age group > 25 years which was the predominant one. in other studies, 16–20 years’ age was predominant conducted by Paramasivam v k (2012) [3], Fried man (2004) [4].
Almost equal male to female distribution was found in the study. Most studies did not show much influence of gender.
In our study complication of local anesthesia during intra operative in conventional was 24 patients out of which 18 patients had anxiety and 6 patients had tachycardia. There are no present studies related to anesthetic complication till date, in this way our study is unique.
Paramasivam v k et al. (2012) [3] described conventional tonsillectomy to be associated with greater blood loss. Vangelin et al. (2013) [5] a meta-analysis report showed intra operative bleeding was significantly less in coblation tonsillectomy.
Hong sm et al. (2013) [6] conducted a study in pediatric patients undergoing tonsillectomy and demonstrated that coblation tonsillectomy has lesser blood loss. Similar results were reported in the studies done by Omrani et al. (2011) [7] and Sukesh et al. (2012) [8]. D’Eredita 2009 [9] and Elbadaway also showed blood loss to be significantly lower with coblation tonsillectomy than conventional tonsillectomy. Hong 2013 [10]&Kim 2013 [11] showed no significant difference in post operative hemorrhage.
Martin (2013) [12] showed less blood loss by 15 ml in coblation than conventional (blood loss 65 ml).
Mitic (2007) [13] also reported intra operative bleeding was significantly less in the coblation. Roje 2009 [14] show less blood loss significantly (< 0.004).
Omrani (2012) [7] show the post operative hemorrhage (p > 0.05) was not significantly. Wang (2009) [15] show less intra operative bleeding in coblation tonsillectomy (6.53 ± 3.36) ml than in conventional tonsillectomy (30.07 ± 7.04) ml.
In our study we found that conventional (44.2 ml) had more amount of blood loss compared to coblation (18.74 ml). P value < 0.001 statistically significant. primary (< 24 h) and secondary hemorrhage (> 24 h) is also less in coblation method of tonsillectomy than conventional method of tonsillectomy (P value < 0.001) (Table 1).
Table 1.
Primary and secondary hemorrhage in conventional and coablation tonsillectomy
| Coblation | Conventional | t-value | Degree of freedom | p value | |||
|---|---|---|---|---|---|---|---|
| Mean | SD | Mean | SD | ||||
| Primary (< 24 h) | 1.66 | 1.451 | 10.80 | 2.523 | 22.20 | 48 | < 0.001 |
| Secondary (> 24 h) | 0.10 | .505 | 1.72 | 1.841 | 6.00 | 48 | < 0.001 |
Initial studies on coblation tonsillectomy showed a significant decrease in post-operative pain score comparing with conventional method of tonsillectomy. On other hand some studies reported no significant reduction in pain with coblation surgery.
In our study, there is very low-quality evidence that patient in coblation group had less pain with standard mean difference of 0.79. This effect reduced to −0.44 at day 3 and day 7. This suggest that pain may be slightly less in coblation tonsillectomy as compared to conventional tonsillectomy. It suggested that post-operative pain was significantly lower with coblation tonsillectomy than with conventional tonsillectomy. Higher pain scores 1 and 3 post operatively (p = 0.044, p = 0.036) in coblator group of tonsillectomies. On 14th day follow up, no significant differences were found between two tonsillectomy techniques (Tables 2, 3).
Table 2.
Mean and standard deviation, standard Error Mean (Post-operative pain)
| Mean | Standard deviation | Standard error mean | |||
|---|---|---|---|---|---|
| Comp. of post-op pain Intra OP | Conventional | 50 | 5.06 | 2.795 | 0.395 |
| Coblation | 50 | 0.00 | 0.000 | 0.000 | |
| 24 h | Conventional | 50 | 5.56 | 1.541 | 0.218 |
| Coblation | 50 | 1.80 | 1.010 | 0.143 | |
| 15th Day | Conventional | 50 | 1.80 | 0.756 | 0.107 |
| Coblation | 50 | 0.24 | 0.517 | 0.073 | |
| 1 Month | Conventional | 50 | 0.24 | 0.431 | 0.061 |
| Coblation | 50 | 0.14 | 0.351 | 0.050 |
Table 3.
In dependent T test of post-operative pain in conventional and coblation
| Levene's test for equality of variances | t-test for equality of means | 95% Confidence interval of the difference | ||||||
|---|---|---|---|---|---|---|---|---|
| F | Sig | t | Sig (2-tailed) | Mean Difference | Lower | Upper | ||
| Intra operative | Equal variances assumed | 108.802 | .000 | 12.801 | .000 | 5.060 | 4.276 | 5.844 |
| Equal variances not assumed | 12.801 | .000 | 5.060 | 4.266 | 5.854 | |||
| 24 h | Equal variances assumed | 11.560 | .001 | 14.431 | .000 | 3.760 | 3.243 | 4.277 |
| Equal variances not assumed | 14.431 | .000 | 3.760 | 3.242 | 4.278 | |||
| 15th Day | Equal variances assumed | 12.102 | .001 | 12.042 | .000 | 1.560 | 1.303 | 1.817 |
| Equal variances not assumed | 12.042 | .000 | 1.560 | 1.302 | 1.818 | |||
| 1 Month | Equal variances assumed | 6.743 | .011 | 1.272 | .206 | .100 | −.056 | .256 |
| Equal variances not assumed | 1.272 | .206 | .100 | −.056 | .256 | |||
Kim (2013) [11] suggested that post-operative pain was less in coblation method of tonsillectomy. Omrani (2012) [7]reported that post-operative pain is less in Coblation method than conventional method of tonsillectomy. Parker (2009) [16] also show requirement of less potent analgesic in coblator group of tonsillectomies. (Figs. 1, 2, 3, 4, 5, 6, 7, 8 and 9)
Fig. 1.
Age distribution among patients
Fig. 2.
Intra operative hemorrhage mean, standard deviation and standard error in conventional and coblation
Fig. 3.
Mean and standard deviation of age
Fig. 4.
Mean and standard deviation of primary and secondary hemorrhage
Fig. 5.
Comparison of post-operative pain in < 24 h., 15th POD and 1 month
Fig. 6.
Comparison of post-operative pharyngitis on 7th, 15th and 1 Month in conventional and coblation method
Fig. 7.
Comparison of post-operative fever on 7th, 15th and 1 Month in conventional and coblation method
Fig. 8.
Comparison of injury of adjacent structure in conventional and Coblation
Fig. 9.
Comparison of Cautery burn in conventional and coblation method
In our study too we found post-operative pain was significantly lower in first 24 h in subjects undergone coblation tonsillectomy but there was less significant difference found between coblation and conventional technique of tonsillectomy on 15 pod and 1 month pod. Mean and P value was 0.00, 0.24, 0.14 and < 0.001, < 0.001, < 0.002 respectively and statistically overall the pain was significantly less.
In our study, post-operative pharyngitis was not observed to be having significant difference statistically between coblation and conventional method of tonsillectomy. On 7th pod, 15th pod and 1 month chi square was 0.762, 4.000 and 0.000 and P value is > 0.05. No comparative study could be recollected from the literature available.
Bhattacharya et al. (2014) [17] show post-operative fever is 2.2% after tonsillectomy in a retrospective study.In our study post- operative fever is present in both technique but there is no such difference present in both method of tonsillectomy (P value > 0.05).
Roje et al. (2009) [18] observed there is significant differences in the depth of thermal damage to adjacent structure in both technique (P value < 0.001).
In our study injury of adjacent was significantly lower in coblation method than conventional tonsillectomy (Pearson chi square = 28.972, p value = < 0.05). Most commonly injured adjacent structure in conventional method of tonsillectomy was tonsillar pillar (26%).
D. eredita (2009) [19] results showed significant reduced thermal injury with molecular resonance than with coblation tonsillectomy (P value = < 0.001).
In our study, thermal injury was seen to be less commonly associated with coblation tonsillectomy than conventional tonsillectomy statistically (Pearson chi square = 16.318, p value = 0.001). Only 6% cases suffered cautery burn in coblation method of tonsillectomy.
Conclusion
Coblation tonsillectomy is relatively easy technique to perform providing a near bloodless field and minimal surrounding tissue damage. The intra-operative blood loss and post-operative primary and secondary blood loss was significantly less on the coblation than conventional method of tonsillectomy. Most importantly, postoperative pain scores were significantly lower in the coblation method on post-operative day 1 and also 15th pod and 1 month of post-operative days. It helps the patients to resume their normal activities early.
Coblation tonsillectomy is easy to perform and it is safer with significant advantages in terms of intra operative and post-operative blood loss and post-operative morbidity, the only deterring factor in the regular usages of coblation is the cost factor which has to be overcome.
Funding
Not applicable.
Declarations
Conflict of interest
None of the authors have any conflict of interest.
Informed Consent
Informed written consent was taken from patients participating in the study.
Consent for Publication
The current work is neither submitted nor published anywhere.
Footnotes
Publisher's Note
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Change history
6/2/2023
A Correction to this paper has been published: 10.1007/s12070-023-03909-9
References
- 1.Wiatrak BJ, Woollley AL (2005) Pharyngitis and adenotonsillar diseases. In: Cummings CW, Flint PW, Harker LA, Haughey BH, Richardson MA, Robbins KT (eds) Cummings otolaryngology; head and neck surgery, 4th edn. Elsevier, Mosby, Baltimore, pp 4135–4165
- 2.Pang YT. Paediatric tonsillectomy: bipolar electro dissection and dissection/snare compared. J Laryngol Otol. 1995;109(8):733–736. doi: 10.1017/S0022215100131172. [DOI] [PubMed] [Google Scholar]
- 3.Paramasivam VK, et al. Randomised comparative study of adenotonsillectomy by conventional and coblation method for children with obstructive sleep apnea. Int J Pediatr Otorhinolaryngol. 2012;76(6):816–821. doi: 10.1016/j.ijporl.2012.02.049. [DOI] [PubMed] [Google Scholar]
- 4.Friedman M, Losavio P, Ibrahim H, Ramakrishnan V. Radiofrequency tonsil reduction; safety, morbidity and efficacy. Laryngoscope. 2003;113:882887. doi: 10.1097/00005537-200305000-00020. [DOI] [PubMed] [Google Scholar]
- 5.Vangelin G, et al (2012) Meta analysis of intra operative blood loss various methods of tonsillectomy, pp 12–14
- 6.Hong SM, et al (2013) Coblation tonsillectomy in pediatric patients, pp 22–28
- 7.Omrani M, Barati B, Omidifar N, Okhovvat AR, Hashemi SA. Coblation versus traditional tonsillectomy: a double blind randomized controlled trial. J res med sci. 2012;17:45–50. [PMC free article] [PubMed] [Google Scholar]
- 8.Parsf Sukesh ons SP, Cordes SR, Comer B. Comparison of post-tonsillectomy pain using the ultrasonic scalpel, coblator, and electrocautery. Otolaryngol Head neck surg. 2006;134:106–113. doi: 10.1016/j.otohns.2005.09.027. [DOI] [PubMed] [Google Scholar]
- 9.D’Eredita R, Bozzola L (2009) Molecular resonance versus coblation tonsillectomy in children. Laryngoscope. 10: 1897–1901 [DOI] [PubMed]
- 10.Hong SM, Cho JG, Chae SW, Lee HM, Woo JS. Coblation versus electrocautery tonsillectomy: a prospective randomized study comparing clinical outcomes in adolescents and adults. Clin exp otorhinolaryngol. 2013;6(2):90–93. doi: 10.3342/ceo.2013.6.2.90. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Kim NG, Oh HM, Kim JY, Kim DW, Kim WH, Choi DJ. Comparison of tonsillectomy by conventional dissection electrocautery laser and coblation. Korean J otorhinolaryngol Head Neck Surg. 2013;56(12):773–777. doi: 10.3342/kjorl-hns.2013.56.12.773. [DOI] [Google Scholar]
- 12.Martin, Micheal gleason, George G Browning, J Burton Scott Browns (2013) Otorhinolaryngology and neck surgery, 7th ed, 2: 1998 47
- 13.Mitic S, Tvinnereim M, Lie E, Saltyte BJ. A pilot randomized controlled trial of coblation tonsillectomy versus dissection tonsillectomy with bipolar diathermy hemostasis. Clin otolaryngol. 2007;32(4):261–267. doi: 10.1111/j.1365-2273.2007.01468.x. [DOI] [PubMed] [Google Scholar]
- 14.Roje Z, Racic G, Dogas Z, Pisac VP, Timms M. Postoperative morbidity and histopathologic characteristics of tonsillar tissue following coblation tonsillectomy in children: a prospective randomized single blind study. Coll Anthropol. 2009;33(1):293–298. [PubMed] [Google Scholar]
- 15.Wang J, Liu D, Huang Z, Zhong J, Tan Z, Qiu S. Low temperature coblation assisted versus conventional dissection tonsillectomy in surgeries for children. Lin Chaung Er Bi Yan Hou Ke Za Zhi J clin otolaryngol. 2009;23(15):690–692. [PubMed] [Google Scholar]
- 16.Parker D, Howe L, Unsworth V, Hilliam R. A randomized controlled trial to compare postoperative pain in children undergoing tonsillectomy using cold steel dissection with bipolar hemostasis versus coblation technique. Clin otolaryngol. 2009;34(3):225–231. doi: 10.1111/j.1749-4486.2009.01932.x. [DOI] [PubMed] [Google Scholar]
- 17.Bhattacharya N, Shapiro NL. Associations between socioeconomic status and race with complications after tonsillectomy in children. Pediatr otolaryngol. 2014;151:1055–1060. doi: 10.1177/0194599814552647. [DOI] [PubMed] [Google Scholar]
- 18.Roje Z, Racic G, Kardum G, Selimovic M. Is the systemic inflammatory reaction to surgery responsible for postoperative pain after tonsillectomy and is it technique related? Wien Klin Wochenschr. 2011;123:479–484. doi: 10.1007/s00508-011-0020-1. [DOI] [PubMed] [Google Scholar]
- 19.Eredita RD. Tonsillectomy in children: a five factor analysis among three techniques -reporting upon clinical results, anesthesia time, surgery time, bleeding and cost. Laryngoscope. 2010;120(12):2502–2507. doi: 10.1002/lary.21128. [DOI] [PubMed] [Google Scholar]