Abstract
Post tonsillectomy bleeding and pain are two main problems following traditional tonsillectomy. Coblation therapy (controlled ablation) was first used in tonsillectomy in 2001. A great amount of literature debated around its use with controversial opinions regarding its benefits, efficacy, and cost. This is a prospective double-blind randomized controlled study that compares between coblation tonsillectomy and conventional tonsillectomy as regard operative time, operative blood loss, time needed to return back to the normal activity and diet, and incidence of postoperative hemorrhage whether primary or secondary. The study included 1004 patients with mean age of 10.4 years (range from 4 to 35 years). The first group (coblation tonsillectomy group) included 507 patients, age ranging from 4 to 35 years with mean age 15.1 year. This group included 277 female (54.6%) and 230 male (45.4%). The second group (conventional tonsillectomy group) included 497 patients, age ranging from 4 to 24 years and mean age 14.7 years. This group included 274 female (55.1%) and 223 male (44.9%). Coblation tonsillectomy offers significant advantages over dissection method with less operative time, decreased intraoperative blood loss, early restoration of daily activities and normal diet. However coblation tonsillectomy is associated with a higher incidence of secondary hemorrhage.
Keywords: Coblation, Tonsillectomy, Dissection
Introduction
Although tonsillectomy is one of the most commonly performed surgical maneuvers [1]. There is still a lot of controversies about different tonsillectomy techniques. Conventional dissection technique has remained the gold standard method for more than a century [2]. Post tonsillectomy bleeding and pain are two main problems following traditional tonsillectomy; attempts to develop new techniques mainly aim to overcome these two conditions [3].
Coblation therapy (controlled ablation) was first used in tonsillectomy in 2001 [4]. Since that time a great amount of literature debated around its use with controversial opinions regarding its benefits, efficacy, and cost [5–8]. Many studies claimed a reduced postoperative bleeding and pain with quick return to normal diet [4, 5, 9] while other authors deny benefits of coblation method compared to conventional tonsillectomy [10].
Most of the fore mentioned studies are limited by the low number of cases, in this study we compare coblation and traditional tonsillectomy techniques regarding their advantages and complications in a relatively larger number of population (Figs. 1, 2, 3).
Fig. 1.
Intraoperative blood loss; comparison between coblation tonsillectomy and conventional tonsillectomy
Fig. 2.
Comparison between coblation tonsillectomy and conventional tonsillectomy as regard operative time, intraoperative blood loss and time for clinical recovery
Fig. 3.
Incidence of post-tonsillectomy hemorrhage in both groups
Materials and Methods
This is a prospective double-blind randomized controlled study that included patients who had tonsillectomy in the period between Jan 2012 and December 2015. Patients were divided into two groups according to the used technique; group one included patients subjected to coblation tonsillectomy while group two included patients subjected to conventional tonsillectomy through dissection by cold instruments. Both groups were compared as regard operative time, operative blood loss, time needed to return back to the normal activity and diet, and incidence of postoperative hemorrhage whether primary or secondary (Tables 1, 2).
Table 1.
Comparison between coblation tonsillectomy and conventional tonsillectomy as regard operative time, intraoperative blood loss, and time for clinical recovery
| Parameter | Mean ± SD | p value | |
|---|---|---|---|
| Coblation | Traditional | ||
| Operative time (min) | 10.63 ± 2.45 | 30.66 ± 8.66 | 0.000 |
| Blood loss (ml) | 65.06 ± 8.73 | 174.31 ± 43.98 | 0.000 |
| Post-operative diet intake (days) | 5.00 ± 1.41 | 9.95 ± 1.98 | 0.000 |
| Return to normal behavior (days) | 10.30 ± 2.80 | 13.59 ± 3.74 | 0.000 |
Table 2.
Comparison between coblation tonsillectomy and conventional tonsillectomy as regard incidence of postoperative hemorrhage
| Parameter | Coblation (507 patient) | Traditional (497 patient) |
|---|---|---|
| Primary hemorrhage | 0.2% | 0.8% |
| Secondary hemorrhage | 1.2% | 0.2% |
Preoperative clinical and laboratory evaluation is done and patients with active infection or bleeding tendency were excluded. All tonsillectomies were performed under general anesthesia using the same standardized anesthetic technique.
Operation time, from insertion till removal of mouth gag, was recorded for each case, intraoperative blood loss was measured through volume of blood in suction bottle after the operation. Data including volume of blood loss, operation time, time period needed to return to work and normal diet and postoperative hemorrhage if occurred, were gathered in both groups. Data were collected and analyzed using SPSS software (SPSS, Windows, version 16). Data regarding period of recovery and return to normal activity and normal diet were analyzed and student’s t test was used to compare between both groups.
Results
The study included 1004 patients with mean age of 10.4 years (range from 4 to 35 years). The first group (coblation tonsillectomy group) included 507 patients, age ranging from 4 to 35 years with mean age 15.1 year. This group included 277 female (54.6%) and 230 male (45.4%).
The second group (conventional tonsillectomy group) included 497 patients, age ranging from 4 to 24 years and mean age 14.7 years. This group included 274 female (55.1%) and 223 male (44.9%).
There was no significant difference between the mean ages of the two groups (p > 0.05). The mean intraoperative blood loss was 65.06 ± 8.73 ml for coblation technique and 174.31 ± 43.98 ml for the dissection technique (p < 0.000). Mean operative time was 10.63 ± 2.45 min in coblation group and 30.66 ± 8.66 min in conventional group. The mean operation time was thus significantly less for coblation group (p < 0.000). Mean time period till return to normal diet was significantly shorter in the coblation group (5.00 ± 1.41 vs. 9.95 ± 1.98 days) (p < 0.05). Return to normal activity was earlier in the coblation group (10.30 ± 2.80 vs. 13.59 ± 3.74 days) (p < 0.05).
Incidence of primary post tonsillectomy hemorrhage was higher in dissection group while incidence of secondary post tonsillectomy hemorrhage was higher in coblation group.
Discussion
Coblation tonsillectomy has been recently introduced among the efforts to decrease post-operative morbidity. In this study we compare coblation tonsillectomy to the traditional dissection technique. Significant argument is present in the literature regarding the outcomes of these two methods [11]. Tonsillectomy with steel forceps (conventional) is claimed to consume longer operative time than coblation tonsillectomy [12].
As regard the operative time, we found that coblation tonsillectomy is significantly time saving procedure with mean time of intervention approximately third that time needed for achieving dissection tonsillectomy. These results are matching with results obtained in a study on 50 patients in 2012; more time was spent in dissection method compared to coblation technique [7]. Another study on 34 patients conducted by Rosdan and his colleagues in 2013 stated that operative time was significantly shorter in coblation tonsillectomy when compared to cold dissection tonsillectomy [13].
A study involving 60 patients in 2012 found that the mean operative time was 11 min for dissection tonsillectomy and 15 min for coblation. Thus it took an average of 4 min longer to perform the coblation procedure compared to the conventional technique, but this difference did not reach statistical significance [14]. Another study including 94 patients and published in 2012 reported a mean operative time of 31 ± 5.4 min (range 20–45 min) for traditional tonsillectomy and 27.3 ± 4.8 min (range from 18 to 42 min) for coblation tonsillectomy [15]. We found nearly similar results as regard time needed for conventional tonsillectomy but the time we recorded for coblation tonsillectomy was significantly lesser.
Some studies reported no difference between the two methods regarding intraoperative blood loss [5, 16]. However others reported results in favor of coblation tonsillectomy. Temple and Timms [11] stated that the average blood loss is less with coblation; O’Leary and Vorrath [17] reported higher blood loss in the traditional method than that obtained with coblation method. In our study, a considerable difference between the two methods with less intraoperative blood loss reported in the coblation population.
Belloso et al. [2] claimed that coblation tonsillectomy was associated with a lesser incidence of secondary hemorrhage, more significantly in the pediatric population. Also Omrani and his colleagues in 2012 who reported that postoperative secondary hemorrhage was slightly higher in traditional group than in the coblation group.
In this study we found that coblation technique is associated with less incidence of primary tonsillectomy hemorrhage than dissection technique but higher incidence of secondary tonsillectomy hemorrhage.
Return to normal activities indicated by time needed to return to work and time till retrieving normal diet were used to assess clinical recovery. The mean time period for return to normal diet was significantly shorter in the coblation group; also return to normal activity (measured by resuming job activity) was earlier in the coblation group.
Conclusion
Coblation tonsillectomy offers significant advantages over dissection method with less operative time, decreased intraoperative blood loss, early restoration of daily activities and normal diet. However coblation tonsillectomy is associated with a higher incidence of secondary hemorrhage.
Compliance with Ethical Standards
Conflict of interest
Both authors declare that they have no conflict of interest.
Ethical Approval
All procedures performed in this study were in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki declaration and its later amendments.
Informed Consent
Informed consent was obtained from all individual participants included in the study.
Contributor Information
Mostafa El-Taher, Phone: 00201008087435, Email: mostafaent@yahoo.com.
Zaki Aref, Email: dr.aref@svu.edu.eg.
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