Short-Term Outcomes of Tonsillectomy in Large Paediatric Case Series

Abstract

Tonsillectomy is a commonly performed procedure in pediatric ENT departments worldwide. To comprehensively evaluate the morbidity associated with tonsillectomy techniques and potential factors that impact outcomes The present study examined the entirety of pediatric patients who underwent tonsillectomy or adenotonsillectomy at CUCH during the years 2021 and 2022. Comprehensive scrutiny was conducted on admissions and readmission data, which encompassed hospital episode statistics, operative notes, patient questionnaires, and electronic records. A total of 690 procedures were identified in our records, with 399 males and 291 females ranging in age from 1 to 13 years. The main indications for surgery included sleep-disordered breathing and recurrent tonsillitis. Among the patients, 233 underwent the surgery as a day case. Coblation intracapsular technique was used in 52% of cases, dissection method in 37%, and coblation extracapsular method in 10%. The incidence of post tonsillectomy bleeding (&infection) was 8.19%( 1.75%),14.89%(2.08%), 1.65%(1.65%) for dissection, coblation extracapsular and coblation intracapsular techniques respectively. Coblation intracapsular tonsillectomy has shown the lowest rate of postoperative hemorrhage compared to other techniques. Senior surgeons (consultants) had the lowest rate of post-tonsillectomy hemorrhage; however, this difference did not reach statistical significance.

Introduction

Surgical techniques for tonsil removal have undergone significant advancements in the past decade. As one of the most frequently performed surgical procedures, there has been an ongoing discourse surrounding the optimal technique to employ. The advent of minimally invasive surgery and the emphasis on minimizing collateral tissue damage has prompted surgeons to seek out more gentle approaches for tonsil removal, especially among pediatric patients, with a primary objective of reducing postoperative complications [1].

In recent years, there has been growing interest in a technique called intracapsular tonsillectomy, which involves the removal of the tonsil within its capsule. Research suggests that this technique offers similar short-term benefits as traditional tonsillectomy, but may not provide long-term relief [2]. Furthermore, it is believed that intracapsular tonsillectomy carries a lower risk of bleeding and allows for faster recovery compared to other methods [3].

Complications arising from tonsillectomy encompass primary and secondary bleeding, throat pain, and infection. Post-tonsillectomy hemorrhage poses a life-threatening risk [4]. This study aims to showcase our experiences at a tertiary pediatric hospital with regards to tonsillectomy surgery. We will examine the different techniques employed and present postoperative morbidity in relation to various potential factors that influence surgical outcomes.

Materials and Methods

Data were obtained from hospital records of children who underwent tonsillectomy and/or adenotonsillectomy at Cairo University Children’s Hospital in 2021 and 2022. A total of 820 procedures were identified, with exclusion criteria applied to exclude cases with incomplete documentation and patients with significant medical comorbidities that may affect surgical outcomes. As a result, 130 cases were excluded, leaving a study population of 690 tonsillectomies, the majority of which (74%) were indicated for sleep-disordered breathing. The collected data included patient demographics, tonsillectomy technique, surgeon grade, and length of hospital stay. In addition, we investigated emergency department records as regards postoperative complications such as bleeding or pain or infection (pain, pyrexia and local signs of tonsillar bed infection) within 4 weeks after the operation.

Data were coded and entered using the statistical package for the Social Sciences (SPSS) version 28 (IBM Corp., Armonk, NY, USA). Data were summarized using mean, standard deviation, median, minimum, and maximum. Comparisons between groups were done using the unpaired t-test in normally distributed quantitative variables while the non-parametric Mann-Wh itney test was used for non-normally distributed quantitative variables. P-values less than 0.05 were considered statistically significant [5].

Ethical Considerations

The study received approval from the scientific committee of the ENT department. Additionally, it was approved by our institute’s research ethics committee under reference number N-299-2023. Informed consent was obtained from all patients, and strict adherence to ethical principles outlined in the Declaration of Helsinki was followed. The data presented in this report are completely anonymous and do not allow for patient identification.

Results

The study enrolled a total of 690 procedures, with patients ranging in age from 1 to 13 years and a mean age of 5. Among the cases, there were 399 males and 291 females. The majority of cases (approximately three-quarters) underwent the procedure for sleep-disordered breathing, while around one-quarter had recurrent tonsillitis as their indication. Less than 1% received the procedure for other reasons. In terms of techniques used, coblation extracapsular was utilized in approximately 10% of cases, coblation intracapsular in about 52%, and dissection with variable use of cold steel and bipolar electrocautery in 37%, as depicted by chart 1.

Chart 1.

Tonsillectomy techniques

In relation to the results of tonsillectomy procedures (chart 2), a total of 630 cases had no complications, while there were 29 cases of secondary bleeding, 6 cases of primary bleeding, and 13 cases with throat pain. Additionally, there were 12 reported instances of infection characterized by pain and fever along with local signs indicating throat infection. Although overall complications were more common in males, the percentage of bleeding incidents was slightly higher among females at rates of 6.5% compared to 4.1% for males (Table 1).

Chart 2.

Post tonsillectomy outcomes (number of cases)

Table 1.

Complications in males and females

Sex	Total	Bleeding	Pain	Infection (pain and pyrexia)
M	399	16	10	6
F	291	19	3	6

Regarding the need for further surgical interventions due to post-tonsillectomy bleeding, it was observed that 6 cases required surgery. Out of these, 3 patients experienced secondary bleeding following dissection tonsillectomy, 2 cases had primary bleeding after extracapsular coblation, and one case had primary bleeding after dissection. Chart 3 displays the proportion of cases with both primary and secondary bleeds categorized by each specific tonsillectomy technique. Additionally, Chart 4 illustrates the percentage of cases reporting throat infection (characterized by throat pain and fever) and throat pain associated with each technique.

Chart 3.

Shows percentage of cases who had primary and secondary bleeding for each tonsillectomy technique

Chart 4.

Shows the percentage of cases who had throat infection (presented with throat pain and fever) and pain per technique

Table 2 presents the incidence rates of pain, infection, and bleeding for each surgical technique. The cases included in the table are those who required emergency department visits or readmission due to post-tonsillectomy complications such as bleeding, severe pain, difficulty eating or drinking, fever, and signs of infection. Interestingly, extracapsular coblation showed no reported cases of pain but had the highest percentage (14.89%) of post-tonsillectomy bleeding.

Table 2.

Illustrates the percentage of pain, infection and bleeding per technique

Technique	Percentage of Pain	Infection	Bleeding
Dissection (variable use of cold steel and bipolar)	3.5% 9 /256	1.56% 4 /256	7% 19 /256
Extracapsular coblation	0% 0 /71	2.8% 2 /71	14% 10 /71
Intracapsular coblation	1.1% 4/363	1.65% 6/363	1.6% 6 /363

According to Table 3, the intracapsular coblation technique has the lowest percentage of day cases among all techniques.

Table 3.

Shows the percentage of day cases per technique

Technique	Day case
Dissection (variable use of cold steel and bipolar)	44.44% 114/256
Extracapsular coblation	38.29% 27/71
Intracapsular coblation	25.20% 92/363
Total for all techniques /all cases	233/690 33.76%

The surgeons who conducted tonsillectomy surgeries were categorized into three groups: consultants, training grades (residents and fellows), and non-training grades. Complications per surgeon grade are displayed in Table 4. A statistically significant association was found between post-tonsillectomy hemorrhage and surgical technique (P value 0.0002). However, no significance was observed regarding pain and surgical technique or surgeon grade and bleeding.

Table 4.

Illustrates tonsillectomy complications per surgeon grade

	Total cases	Primary bleeding	Secondary bleeding	Bleeding total	Pain	Infection
NTG	87	1	6	7(8%)	4(4.59%)	4
CG	465	4	17	21(4.5%)	7(1.5%)	6
TG	138	1	6	7(5%)	2(1.49)	2

NTG: non training grade, CG: consultant grade, TG : training grade

Discussion

Tonsillectomy, considered one of the oldest and most frequently performed surgical procedures in medical history, has evolved over time. According to historical accounts by Cornelius Celsus in Rome, inflamed tonsils were manually removed using fingers [6]. Various instruments including guillotines, snares, forceps, and dissectors have been utilized for tonsillectomy surgery throughout the years.

In subsequent years, the cold knife technique emerged as a prominent procedure that has remained widely practiced for several decades. This was subsequently followed by the adoption of electrocautery techniques to effectively address dissection and ensure efficient hemostasis. In recent times, further advancements in medical technology have introduced alternative approaches such as laser-based procedures, microdebriders, ultrasonic devices, and coblation techniques into clinical practice. [7]

The field of medical technology has witnessed significant advancements in tonsillectomy surgical methods, leading to improved outcomes for both surgeons and patients. In recent years, there has been a notable shift in the indications for tonsillectomy procedures, with a greater emphasis on addressing obstructive symptoms rather than recurrent tonsillitis. This change is particularly evident at our hospital where pediatricians are increasingly encountering patients presenting with symptoms of obstructive sleep apnea and its associated complications.

Tonsillectomy surgery can have significant and potentially fatal complications, such as severe bleeding and throat pain that may lead to dehydration. To address these concerns, a variety of techniques and devices have been developed aimed at reducing these devastating complications. One emerging technology is Coblation, which involves the use of radiofrequency energy passed through a conductive medium like isotonic sodium chloride to create a plasma field. This results in low-temperature molecular disintegration of the tissue compared to traditional electrosurgery (40ºC to 70ºC versus > 100ºC). The coblation wand is utilized in this procedure to dissect the tonsils within the created plasma field. It has been suggested that operating at lower temperatures with Coblation leads to reduced postoperative pain when compared with other hot techniques [8, 9].

This study aims to present our experience with tonsillectomy surgery. At our center, we utilize three techniques: dissection with variable degrees of bipolar use, coblation extracapsular, and coblation intracapsular. In recent years, there has been a growing preference for intracapsular tonsillectomy as opposed to total tonsillectomy or extracapsular tonsillectomy. [10, 11]

Several studies have extensively discussed the benefits of using coblation as a surgical technique in comparison to other methods. It has been found that coblation results in decreased blood loss and shorter operative time when compared to laser procedures [12] and electrocautery techniques [13]. Additionally, research has shown that patients who undergo coblation experience reduced postoperative pain compared to those treated with electrocautery [14] or dissection techniques [15].

The surgical procedure of tonsillectomy has garnered significant attention among ENT surgeons who are not only concerned with the choice of instruments but also with the extent of surgery and preservation of the capsule. The ultimate goal is to identify the most effective instrument and technique that can be utilized for this widely performed procedure while minimizing potential complications.

Two systematic reviews [16, 17] have indicated that intracapsular tonsillectomy offers better postoperative recovery compared to extracapsular tonsillectomy in pediatric patients with obstructive symptoms, regardless of the device used. Additionally, a systematic review [18] comparing intracapsular and extracapsular tonsillectomy found that the former technique results in less late but not immediate post-operative pain, although it should be noted that all included studies were small. Moreover, Sedgwick et al. [19] conducted a comprehensive review of 17 studies which concluded that intracapsular tonsillectomy is associated with lower postoperative complications while demonstrating similar efficacy to total tonsillectomy.

A study conducted on coblation technique, specifically preserving only the inferior pole capsule, showed significant improvement in postoperative pain levels on days 3 and 5. Additionally, this study reported a lower overall rate of postoperative hemorrhage [20]. Furthermore, another comparative study [21] compared total tonsillectomy with partial tonsillectomy using the coblation device. The findings indicated that total or extracapsular tonsillectomy was associated with a higher incidence of both postoperative hemorrhage and severe pain.

In a comparison of the safety between intracapsular and extracapsular tonsillectomy techniques, it was found that intracapsular tonsillectomy was both safe and effective for patients of all ages and indications. The risk of bleeding during the procedure and the need for revision surgeries were low [22]. Although we found that extracapsular coblation has the highest rate of postoperative haemorrhage, pain was not as significant as reported in this study. The rate of bleeding in our study was highest in the extracapsular coblation tonsillectomy (14.9% ) and lowest in the intracapsular technique (1.65%) while the dissection group had an intermediate rate of 8%.

Our study sought to examine the potential impact of surgeon grade on the outcomes of tonsillectomy. To our knowledge, this is the sole investigation that explores any link between surgeon grade and post-tonsillectomy complications. The incidence of bleeding was found to be 8.4% in non-training grades, 5% in consultants, and 4% in training grades. Though there appeared to be a lower rate of bleeding among the consultant group, this difference did not reach statistical significance.

In addition to evaluating the postoperative hemorrhage rate, we also assessed the incidence of infection following surgery, specifically throat pain and fever within one month. These cases were identified through visits to the emergency department or readmission to the hospital. Surprisingly, all three techniques showed similar rates of postoperative infection. Interestingly, none of the patients in the extracapsular group reported significant throat pain; however, 3.5% and 1.24% of patients who underwent dissection and intracapsular tonsillectomy respectively experienced notable pain and sought medical attention at an emergency department facility.

The selection of patients who underwent intracapsular coblation tonsillectomy at our institution was based on their primarily obstructive symptoms and/or associated comorbidities. As a result, these patients required hospitalization for post-operative monitoring, which contributed to the lower percentage of day cases observed with this technique.

Ultimately, the choice of surgical technique may depend on various factors, including the surgeon’s experience and preference, patient characteristics, and the specific indications for surgery.

This study has some limitations. It should be noted that this was a retrospective analysis of medical records conducted at a single institution, limiting its generalizability to other settings and populations. Furthermore, the study design did not allow for randomization of patients to different tonsillectomy techniques, potentially introducing selection bias.

Conclusions

Intracapsular coblation tonsillectomy has been shown to be a safe and effective procedure with fewer complications. Our findings suggest that extracapsular coblation is associated with higher post-operative bleeding rates compared to intracapsular coblation. There is a significant correlation between the technique used for tonsillectomy and the occurrence of post-tonsillectomy bleeding, both clinically and statistically. Based on our results, it is recommended to use intracapsular coblation for cases involving sleep-disordered breathing.