Abstract
Objective
To study the efficacy of coblation in the endoscopic surgery of sinonasal and skull base masses.
Study Design
Prospective Interventional Study.
Method
100 patients with signs and symptoms of nasal obstruction were enrolled for 14 months. On the basis of diagnosis they underwent endoscopic sinus surgery using coblator and their intra-operative blood loss, operation time, post-operative pain threshold using VAS(Visual analogue scale) were enlisted.
Result
80% had Sinonasal polyp followed by Inverted papilloma in 8%, Angiofibroma in 5%, Hemangioma in 3%, Esthesioneuroblastoma in 2% and Rhinosporidiosis in 2%. The Minimum blood loss was 50 ml and Maximum was 600 ml. 30% patients had no pain, 60% had Mild pain and 10% had Moderate pain post procedure. Mean Operation time was 112.86 min.
Conclusion
Coblation has proven to have reduced operation time, blood loss and faster wound healing. It has now established itself as an essential tool for advance tumours in nasal surgeries.
Keywords: Coblation, Sinonasal masses, Sinonasal polyp, Skull base masses, Endoscopic surgery
Introduction
Nose and para nasal sinus masses are commonly encountered in clinical practice either neoplastic or non-neoplastic. Many diseases affecting the region are due to several specialized tissues in the region and their aberrations [1]. The commonest nasal mass seen is polyp. Rhinosporidiosis is also one of the most common nasal mass in our country [2]. The presentation of sinonasal malignancy depends on the primary site, the direction, and the extent of spread. The most common initial symptoms are nasal obstruction, epistaxis, proptosis, epiphora, diplopia, loose teeth, facial pain & swelling, and buccal or palatal swelling [3]. Radiofrequency (RF) tissue ablation has been used safely and effectively for years in several surgical fields. Two distinct types of RF ablation exist, unipolar and bipolar. Most applications described here use bipolar RF technology. Works by creating a low-temperature sodium chloride RF plasma field between bipolar electrodes. This energy disrupts molecular bonds, allowing tissues to dissolve [4]. “Coblation,“ allows ablation of tissue to occur at relatively low temperatures (typically 60–70 C), which is thought to limit thermal damage to surrounding tissues with a depth of penetration of 2 to 4 mm. potential benefits of Coblation include reduced blood loss, improved visualization, and reduced thermal injury to surrounding tissue [5]. Coblator may help to limit blood loss and improve visualization in select skull base tumours. they used an additional surrogate marker, the 11-point Wormald endoscopic surgical field grading scale. This scale has been shown to have higher interrater and intrarater reliability than previously described surgical field grading scales [6].
Materials and Methods
It is a prospective interventional study of 100 patients with signs and symptoms of nasal obstruction who were enrolled in the study of 14 months from 1st January, 2021 to 31st march, 2022 in the Department of Otorhinolaryngology, Mahatma Gandhi Medical College & Hospital, Jaipur (Rajasthan).
Cases enrolled were patients who came to the ENT department with signs and symptoms of nasal obstruction. Patients with Sinonasal or skull base masses and age > 12years were included in the study.Patients excluded from the study were patients aged < 12 years,patients with adenoid hypertrophy and proven cases of OSAS(obstructive sleep apnea syndrome), patients with Sinonasal malignancy, patients with immunocompromised state,prior endoscopic endonasal surgery and patient unwilling for surgery.A detailed history of the patient was taken followed by complete clinical examination, diagnostic nasal endoscopy, routine blood investigations, Contrast CT/MRI of nose and paranasal sinus. A written and informed consent was obtained from the patients before the surgery and the patients were provided with the information which included the details of the disease, the surgical procedure, the risks of the procedure and possible outcomes. Surgical procedures were performed according to the given pathology of the patient. All surgeries were performed under general anaesthesia. Karl Storz 0degree, 30 degree and 70 degree angled endoscopes with diameter of 4 mm were used for the procedure. The patient‘s nasal cavity was packed with 4% xylocaine with adrenaline cotton pledgets for about 15–20 min for adequate nasal decongestion. For infiltration anesthesia 1% lidocaine with epinephrine 1:200,000 was used. The coblation was used during the surgical procedures.
Results
All the patients who underwent surgical procedure were evaluated and distributed on the basis of age, gender, diagnosis, blood loss during procedure, post-operative pain, total operative time, wound healing time, correlation between age and wound healing, blood loss and wound healing, Operative Time and wound healing, gender and wound healing.The Minimum age of participants was 12 years and Maximum age was 64 years.
the mean age of Participants was 33.52years. The male participants were 35 (35%) while female participants were 65 (65%).
The patients on the basis of pre-operative imaging and diagnostic nasal endoscopy were diagnosed. In Diagnosis most of participant had sinonasal polyp (80%) followed by Inverted papilloma (8%), Angiofibroma (5%), Hemangioma (3%), Esthesioneuroblastoma (2%), Rhinosporidiosis (2%). The distribution of patients according to their diagnosis is shown below Table 1.
Table 1.
Distribution of Diagnosis of Participants
| Diagnosis | Frequency | Percentage(%) |
|---|---|---|
| sinonasal polyp | 80 | 80 |
| Inverted Papiloma | 8 | 8 |
| Juvenile Nasopharyngeal Angiofibroma | 5 | 5 |
| Hemangioma | 3 | 3 |
| Esthesioneuroblastoma | 2 | 2 |
| Rhinosporidiosis | 2 | 2 |
| Total | 100 | 100 |
The intra-operative blood loss was calculated. The Minimum blood loss of Participants was 50 ml and Maximum blood loss was 600 ml. The mean Blood loss of Participants was 280.40 ± 166.39 ml. The post operative pain was calculated using the Visual Analogue Scale(VAS). The maximum pain was noted five in VAS Scale and Minimum was Zero. 30% had no pain, 60% had Mild pain and 10% had Moderate pain post procedure. No participant complained of severe post-operative pain. The detailed description of the same is given in the following Table 2.
Table 2.
Distribution of Pain of Participants
| Post Operative Pain (VAS) | No. of cases | Percentage(%) |
|---|---|---|
| 0 | 30 | 30 |
| 1 | 45 | 45 |
| 2 | 15 | 15 |
| 3 | 10 | 10 |
| 4 | 0 | 0 |
| 5 | 0 | 0 |
| Total | 100 | 100 |
The Operative time was calculated. Maximum (37) patients had a 91–120 min of operative time. The maximum time noted was between 181 and 240 min which was seen in 14 patients while the minimum time noted which was between 30 and 60 min was seen in 13 patients. The mean Operation time was 113.36 min with SD 45.65. The post operative wound healing time was noted. Most of the patients (52 cases) experienced wound healing in 3–4 weeks of time while 20 patients took 2 weeks and 28 patients took 5–6 weeks to heal.
The mean Wound healing time of participants was 3.8 weeks with SD 1.29. The minimum wound healing time was 2 weeks and the maximum wound healing time was 6 weeks.
The age of the patients was correlated with the wound healing time. It was observed that there was no significant correlation between Age and Wound Healing time (p > 0.05) on calculation of Pearson’s correlation coefficient. Similarly the blood loss during procedure was correlated with the wound healing time and it was observed that there was no significant correlation between Blood loss and Wound Healing time (p > 0.05) on calculation of Pearson’s correlation coefficient. On correlating the operating time with wound healing time we found that there was significant correlation between them (p < 0.05). A negative correlation was found on calculation of Pearson’s correlation coefficient between Operation time and Wound healing, it means increase in time of Operation can decrease wound healing time. The gender and wound healing were correlated and on application of T-test it was found that there was no significant association between the gender of the cases and the wound healing time.
Discussion
Open skull base surgery is the historic standard for complex sinonasal masses and is a well-characterized procedure dating back several decades. However, during the last two decades, there has been increased interest in the feasibility of using purely endoscopic approaches to achieve comparable rates of gross total resection when compared to open approaches [7].
In a study conducted in 2010 by Kostrzewa J et al. where they took Twenty-three patients (average age: 46 years) with sinonasal or skull base tumors treated with transnasal endoscopic techniques. Coblation was used in 10 cases. The sinus/skull base tumors included were esthesioneuroblastoma (n = 6), melanoma (n = 3), squamous cell carcinoma (n = 3), inverted papilloma (n = 3), adenocarcinoma (n = 2), intracranial dermoid cyst (n = 2), adenoid cystic carcinoma (n = 1), craniopharyngioma (n = 1), fibromyxosarcoma (n = 1) and undifferentiated carcinoma (n = 1). The use of the coblation device was associated with a significant decrease in all categories including Estimated Blood Loss (EBL) (350 vs. 1,000 ml; p = 0.0001), EBL per operative time (66 vs. 166 ml/h; p = 0.0001) and Wormald grade (3.3 vs. 6.4; p = 0.0001). They concluded that Radiofrequency coblation significantly decreased blood loss during endoscopic tumor removal and is a useful tool in the armamentarium of the endoscopic skull base surgeon [8]. In 2012, Mohammed Iqbal Syed et all at St. John’s Hospital at Livingston, a tertiary referral center that covers otolaryngology services for the southeast of Scotland, conducted a review of 15 adult patients with intranasal and or sinus tumors endoscopically treated with radio frequency coblation. Fifteen patients with intranasal and sinus tumors were treated with transnasal endoscopic resection using radiofrequency coblation. The tumors included inverted papilloma (seven), paraganglioma (one), glomangiopericytoma (one), capillary hemangioma (one), hemangiopericytoma (one), juvenile angiofibroma (one), juvenile ossifying fibroma (one), oncocytic adenoma (one), and transitional cell carcinoma (one). They found that radiofrequency coblation is a useful and safe tool associated with minimal blood loss (< 200 mL to 600 mL) in the resection of these tumors, and the average operating time was 1.67 h. They concluded that Coblation is a rapidly evolving technique and in the future will have an increasing role to play in the endoscopic resection of intranasal and sinus tumors [9].
Conclusion
Coblation is an established tool in ENT surgeries, more specifically in nasal surgeries for removal of sinonasal masses and skull base tumours. Coblation has proven to have reduced operation time, blood loss and faster wound healing. It has now established itself as an essential tool for advance tumours in nasal surgeries.
Declarations
Informed consent
Informed consent taken of all the patients.
Ethical approval
given.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
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