Abstract
Inflammatory and infectious diseases of tonsils are common in paediatric and adult otolaryngological practice and ensue in tonsillectomy which is a common surgical procedure. Dissection and snare method is being performed for ages and has evolved over a period of time while coblation is a newer technique started in 1997. It combines radiofrequency energy and normal saline, resulting in a plasma field of highly ionized particles which dissociates intercellular bonds and thus melts tissue at low temperatures (40–70 °C) thereby reducing tissue damage. To compare the intraoperative time, intraoperative blood loss, post operative pain and post operative blood loss between dissection tonsillectomy and coblation tonsillectomy. This study was carried out at the outpatient Department of Otorhinolaryngology and Head and Neck Surgery in Meenakshi Medical College, Hospital and Research Institute, Tamil Nadu. Patients with chronic and recurrent tonsillitis who were planned electively for tonsillectomy were included in this study. Study was based on the analysis of 60 patients aged between 5 and 40 years. All these 60 patients were thoroughly investigated by doing a complete surgical workup. They all were subjected to 2 different tonsillectomy procedures—dissection and snare method and coblation technique. Patients were assigned into two groups of 30 each by simple random sampling. Among these 60 patients, blood loss and post operative pain was less in Group 2 (coblation) and the duration of surgery was less in Group 1 (dissection and snare). In this study, patients who underwent surgery in Group 2 (coblation) showed better outcome when compared to Group 1 (dissection and snare method).
Keywords: Tonsillectomy, Dissection and snare, Coblation, Tonsillitis
Introduction
Infectious diseases of tonsils are common in otolaryngological practice, be it in paediatric age group or adults. Tonsillectomy is the most common surgical procedure in the practice of an Otorhinolaryngologist [1].
Tonsillectomy despite being the commonest and simplest surgery the surgeon is always keen about its high risk of complications i.e. intra and post operative haemorrhage which may even lead to shock and death. Since oropharynx and tonsils are rich in blood supply the risk of hemorrhage is very high in tonsillectomy.
Morbidity following tonsillectomy is significant. It incorporates perioperative and postoperative haemorrhage and postoperative pain. Postoperative pain and difficulty in swallowing prevent the child to return to regular diet resulting in dehydration and prolonged hospital stay.
Various methods to perform tonsillectomy [2].
Cold dissection and snare.
Bipolar radiofrequency ablation (coblation).
Bipolar electro dissection.
Microdebrider assisted partial tonsillectomy.
Diathermy.
LASER.
Cryosurgery.
Among these, dissection and snare method is the commonest procedure done by Otorhinolaryngologist. With the arrival of coblator, results of this procedure has been promising. Coblation is a newer technique started in 1997, and combines radiofrequency energy and normal saline, resulting in a plasma field of highly ionized particles, which dissociates intercellular bonds and thus melt tissue at low temp (40–70 °C) and reduces tissue damage. The surgical technique of coblation tonsillectomy is based on dissection of tonsil in the relatively bloodless tonsillar muscular plane, using an Arthrocare Evac 70 plasma wand.
There are two different techniques for coblation tonsillectomy:
Subtotal, intracapsular ablation—some tonsil tissue may be left behind.
Total, subcapsular dissection of tonsils—the entire tonsil is removed.
In similarity with other studies [3] which state that leaving a small tonsillar tissue may cause recurrent infections, a subtotal tonsillectomy may not be the best technique to use in adults with chronic tonsillitis [4]. We used total Subcapsular Tonsillectomy in our institute for all the cases.
The American Academy of Otolaryngology-Head and Neck Surgery (AAOHNS) suggested the following clinical indications [5].
Absolute Indications
Enlarged tonsils that cause upper airway obstruction, severe dysphagia, sleep disorders or cardiopulmonary complications.
Peritonsillar abscess that is unresponsive to medical management and drainage documented by surgeon, unless surgery is performed during acute stage.
Tonsillitis resulting in febrile convulsions.
Tonsils requiring biopsy to define tissue pathology.
Relative Indications
Three or more tonsil infections per year despite adequate medical therapy.
Persistent foul taste or breath due to chronic tonsillitis that is not responsive to medical therapy
Chronic or recurrent tonsillitis in a streptococcal carrier not responding to beta—lactamase resistant antibiotics.
Unilateral tonsil hypertrophy that is presumed to be neoplastic.
Materials and Methods
This present study entitled “A prospective study of comparison of tonsillectomy by dissection and snare method and coblation technique” was conducted in Meenakshi Medical College, Hospital and Research Institute from January 2016 to September 2017.
Source of Data
Study was based on the analysis of 60 patients aged 5–40 years undergoing tonsillectomy. Each case after being screened from the outpatient department underwent a general physical examination, local ENT examination, laboratory and radiological examination.
Sample size 60.
Type of study Prospective study.
Statistical analysis Paired Student T test.
Inclusion Criteria
Patients aged between 5 and 40 years.
Hemoglobin of more than 10 g%.
Recurrent attacks of acute tonsillitis—7 or more episodes in the preceding year OR 5 or more episodes in each of the preceding 2 years OR 3 or more episodes in each of the preceding 3 years.
Chronic tonsillitis.
Enlarged tonsil causing snoring and obstructive sleep apnoea.
Exclusion Criteria
Bleeding and clotting disorders.
Peritonsillar abscess.
Pregnancy and lactation.
Chronic systemic illness.
Method of collection of data
60 Patients were randomly divided into two groups. In Group one tonsillectomy performed by dissection method and Group two by coblation method. Patients were randomized to either dissection or coblation.
All the patients were explained in detail about the procedure and involvement in this study and a voluntary consent was obtained.
After obtaining history, a thorough clinical and general examination was done and they were subjected to basic investigation for fitness of surgery under general anaesthesia.
Procedure
Tonsillectomy procedure was performed by same surgeon using both dissection and snare method and coblation method under general anaesthesia by a standard anaesthetic protocol.
Intraoperative blood loss was measured by calorimetric method (swab weighing technique) [6] by calculating the difference in weights of soaked cotton ball and gauze used for hemostasis before and after use, using a weighing scale, and then adding the total obtained (1 g = 1 ml) to the volume of blood collected in the suction bottles minus saline taken for suction. In coblation method blood loss was calculated after deducting the amount of saline used from total collection.
Postoperative pain was assessed on day zero, first, second and third postoperative day. The pain was assessed using visual analog scale (VAS) [7] (0–10) and categorized as mild (0–3), moderate (4–6), severe (7–10). The ends are labelled as the extremes (‘no pain’ and ‘pain as bad as it could be’) and the rest of the line is blank. The patient is asked to put a mark on the line indicating their pain.
Postoperative bleeding from the tonsillar fossa is also assessed including the type of procedure underwent and day on which it occurred and the measures taken to stop it (Figs. 1, 2).
Fig. 1.
Tonsillectomy by dissection and snare
Fig. 2.
Tonsillectomy by coblation
Results
The study showed maximum incidence of tonsillitis in the age group of 6-10 (40%), next majority age group was 11–15 (33.3%) (Fig. 3).
Fig. 3.
Age distribution
The study showed females (23 or 39%) had higher incidence of tonsillitis compared to males (37 or 61%) (Fig. 4).
Fig. 4.
Sex distribution
The mean duration is measured from giving incision over the tonsil up to complete hemostasis, for dissection and snare method the mean duration was 26.67 min and for coblation the mean duration was 32.883 min, thus it took more time to perform coblation procedure when compared to dissection method (Tables 1, 2, 3).
Table 1.
Group statistics with respect to time (in minutes)
| Procedure | Number | Mean | SD | Standard error mean | T value | p value | |
|---|---|---|---|---|---|---|---|
| Time | Dissection and snare | 30 | 26.67 | 6.65 | 1.21 | 3.401 | < 0.05 |
| Coblation | 30 | 32.83 | 7.37 | 1.35 |
Table 2.
Group statistics with respect to blood loss (in ml)
| Procedure | Number | Mean | SD | Standard error mean | T value | p value | |
|---|---|---|---|---|---|---|---|
| Time | Dissection and snare | 30 | 49.40 | 9.34 | 1.70 | 13.604 | 0.001 |
| Coblation | 30 | 21.63 | 6.13 | 1.12 |
Table 3.
Group statistics with respect to post operative pain
| Post operative day pain scale | Dissection and snare | Coblation | T value | p value |
|---|---|---|---|---|
| 0 | 6.9 | 4.3 | 8.37 | < 0.0001 |
| 1 | 5.3 | 3.2 | 7.29 | < 0.0001 |
| 2 | 3.2 | 2.2 | 4.61 | < 0.0001 |
| 3 | 1.6 | 0.97 | 2.81 | < 0.0007 |
The amount of intra operative blood loss on an average in dissection and snare method is approximately 49 ml and the amount of blood loss in coblation is 21 ml. The difference was statistically significant p value (0.001).
There is a significant difference between pain scores in both methods during the post operative period. All patients were asked about postoperative pain at day 0, 1, 2, 3.
Postoperative Bleeding
There was no postoperative bleeding noted in both groups.
Discussion
Tonsillectomy is one of the common surgeries done worldwide. Among various techniques, dissection and snare method is still preferred. The main aim of this study is to compare the intra and post operative recovery by coblation and dissection and snare method.
Age
In our study it is found that 40% of patients in age group 6–10 were the predominant one.
Gender
The study showed higher incidence of tonsillitis in females when compared to males.
Duration of Surgery
In our study the mean duration of surgery for dissection and snare method is 26.67 min, the mean duration of surgery for coblation is 32.83 min. In our study coblation method took longer duration. The p value is < 0.05 and it is statistically significant.
Omrani et al. [8] described the duration of surgery in their studies showed evidence that coblation method had less duration compared to conventional method.
Rakesh et al. [9] described similar studies and found coblation has longer duration.
Intra Operative Blood Loss
The mean intraoperative blood loss in dissection and snare method was 49 ml and for coblation was 21 ml. The difference was statistically significant p value (0.001). In our study we found that dissection and snare method had more amount of blood loss compared to coblation. p value < 0.001 statistically significant.
Paramasivam et al. [10] described dissection method associated with greater blood loss.
Vangelin et al. [11] report showed less bleeding in coblation.
Hong et al. [12] conducted a study and demonstrated less blood loss in coblation method.
Post Operative Pain
In our study we found pain was significantly less in coblation when compared to dissection and snare method. All patients were asked about postoperative pain at day zero, one, two, three. There was significant difference between pain scores in both methods during the post operative period but the rate of pain reduction seems to be same in both methods.
Initial studies on coblation showed significant difference in post operative pain when compared with dissection and snare method.
Timms et al. [13] suggested significant benefit in post operative pain in coblation method.
Post Operative Blood Loss
In our study there was no reactionary or secondary hemorrhage in both methods.
Noon et al. [14] described significantly higher hemorrhage rate in coblation when compared with diathermy.
Divi et al. [15] found no difference between hemorrhage rates for cobaltion versus non coblation methods.
Conclusion
This study comprised of 60 patients with chronic tonsillitis who were above 4 years without adenoid hypertrophy. In half of the patients, tonsil was removed by coblation method and in the other half tonsil was removed by dissection and snare method. The patients were examined regularly on first, second and seventh post operative days.
From our prospective study we reach the following conclusions:
Coblation method is relatively easy technique to perform providing bloodless field and minimal tissue damage.
The operative time required to perform coblation method was more than the dissection method. The longer time did not cause more intra operative blood loss or increased post operative pain.
The intra operative blood loss was significantly less in cobaltion method than the dissection and snare method.
The post operative pain scores were significantly lower on the cobaltion method which helps the patient to resume their normal activities early.
To conclude, coblation tonsillectomy is easy to perform and it is safer in terms of intra operative blood loss and post operative pain. The only disadvantage of coblation tonsillectomy is the cost factor.
References
- 1.Wiatrak BJ, Woolley AL. Pharyngitis and adenotonsillar disease. In: Cummings CW, Flint PW, Harker LA, Haughey BH, Richardson MA, Robbins KT, editors. Cummings otolaryngology; head and neck surgery. 4. Baltimore: Elsevier, Mosby; 2005. pp. 4135–4165. [Google Scholar]
- 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.Friedman M, LoSavio P, Ibrahim H, Ramakrishnan V. Radiofrequency tonsil reduction: safety, morbidity and efficacy. Laryngoscope. 2003;113:882–887. doi: 10.1097/00005537-200305000-00020. [DOI] [PubMed] [Google Scholar]
- 4.Black I, Paloheimo M, Ylikoski J. Traditional tonsillectomy compared with bipolar radiofrequency thermal ablation tonsillectomy in adults: a pilot study. Arch Otolaryngol Head Neck Surg. 2001;127:1106–1112. doi: 10.1001/archotol.127.9.1106. [DOI] [PubMed] [Google Scholar]
- 5.AAO-HNSF Clinical practice guidelines: tonsillectomy in children. January 3, 2011
- 6.Prasad KC, Prasad SC. Assessment of operative blood loss and the factors affecting it in tonsillectomy and adenoidectomy. Indian J Otolaryngol Head Neck Surg. 2011;63(4):343–348. doi: 10.1007/s12070-011-0268-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Polites N, Joniau S, Wabnitz D, Fassina R, Smythe C, Varley P, Carney AS. Postoperative pain following coblation tonsillectomy: randomized clinical trial. ANZ J Surg. 2006;76(4):226–229. doi: 10.1111/j.1445-2197.2006.03700.x. [DOI] [PubMed] [Google Scholar]
- 8.Omrani M, et al. Coblation versus traditional tonsillectomy: a double blind randomized controlled trial. J Res Med Sci. 2012;17(1):45–50. [PMC free article] [PubMed] [Google Scholar]
- 9.Rakesh S, Anand TS, Payal G, Pranjal K. A prospective, randomized, double-blind study of coblation versus dissection tonsillectomy in adult patients. Indian J Otolaryngol Head Neck Surg. 2012;64(3):290–294. doi: 10.1007/s12070-011-0355-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Paramasivam VK, et al. Randomised comparative study of adenotonsillectomy by conventional and coblation method for children with obstructive sleep apnoea. Int J Pediatr Otorhinolaryngol. 2012;76(6):816–821. doi: 10.1016/j.ijporl.2012.02.049. [DOI] [PubMed] [Google Scholar]
- 11.Vangelis G, et al. Modern technology—assisted vs conventional tonsillectomy: meta analysis of randomized control trials. Arch Otolaryngol Head Neck Surg. 2011;137(6):558–570. doi: 10.1001/archoto.2011.93. [DOI] [PubMed] [Google Scholar]
- 12.Hong SM, et al. Coblation vs. 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]
- 13.Timms MS, et al. Coblation tonsillectomy: a double blind randomized controlled study. J Laryngol Otol. 2002;116(6):450–452. doi: 10.1258/0022215021911031. [DOI] [PubMed] [Google Scholar]
- 14.Noon AP, Hargreaves S. Increased post-operative haemorrhage seen in adult coblation tonsillectomy. J Laryngol Otol. 2003;117(9):704–706. doi: 10.1258/002221503322334521. [DOI] [PubMed] [Google Scholar]
- 15.Divi V, Benninger M. Postoperative tonsillectomy bleed: coblation versus noncoblation. Laryngoscope. 2005;115(1):31–33. doi: 10.1097/01.mlg.0000150682.62517.0e. [DOI] [PubMed] [Google Scholar]