Plasma Dissection Versus Tissue Dissection in Adenoid Surgery

Abstract

Aim is to compare coblation versus conventional adenoidectomy, to evaluate whether this approach is adequate, safer and could be a coblation a good alternative of conventional adenoidectomy? It is a prospective randomized controlled study done at Civil Hospital Ahmedabad from January 2016 to January 2017 with 70 patients. The study includes children between age groups 5–11 years divided into Group A (38 children underwent coblation adenoidectomy) and Group B (32 children underwent conventional adenoidectomy) with an average follow-up period of 10 days, 1 month and 3 months. Information on average time of operation, intra-operative blood loss, post-operative pain, and time required regaining normal breathing pattern, presence of residual adenoid tissue 4 weeks after surgery and postoperative hemorrhage were gathered and compared. We found statistically significant differences in average operation time (p < 0.001), intra-operative blood loss (p < 0.001), post-operative pain (p < 0.0001) and time required regaining normal nasal breathing pattern (p < 0.001) presence of residual adenoid tissue 4 weeks after surgery (p < 0.0001) However, post operative hemorrhage (p > 0.5) was not significantly different between two groups. This study suggested a significantly less intra-operative or postoperative complications and morbidity in coblation adenoidectomy in comparison with conventional method. Coblation was associated with less pain and quick return to normal nasal breathing pattern. These findings indicate that coblation adenoidectomy is a safer, method and can be a better alternative of conventional method.

Introduction

It has been in the last three decades that the ENT specialty has developed rapidly. Coblation is a low thermal technology that creates controlled, stable plasma for effective dissection and removal of tissue like adenoid, tonsil, larynx with minimal damage to surrounding tissue. Adenoid is the lymphoid aggregation seen in the nasopharynx. This tissue is a component of inner waldeyer’s ring. This tissue undergoes hypertrophy till the child reaches the age of 4 after which the proportional increase of the size of nasopharynx makes it appear reduced in size which is followed by a reduction of symptoms. Adenoidectomy is the commonly performed surgery in children with rare complication [1]. Various methods of performing adenoidectomy include [2]:

1. Conventional with curettage

2. Bipolar coagulation under endoscopic vision

3. Adenoidectomy using microdebrider [3]

4. Coblation adenoidectomy [4–7]

For purposes of classification and management adenoid hypertrophy has been graded according to the size of the tissue taking into consideration the relationship of the hypertrophied tissue with vomer, soft palate and torus tubaris [8].

Grade I None, Grade II Torus tubaris, Grade III Torus tubaris, Vomer Grade IV Torus tubaris, Vomer and soft palate at rest.

Materials and Methods

Children of age group between 5 and 11 years were included in the study. Parents of the children were not aware of the procedure followed during surgery. Patients were chosen randomly for the procedure. These patients had symptoms of nasal obstruction, mouth breathing and snoring. This random choice averted surgeon bias [9, 10]. Children with co morbid conditions like anemia, upper and lower respiratory infections were excluded from the study. Size of adenoid is assessed by X-ray nasopharynx lateral view and in some by performing diagnostic nasal endoscopic examination under topical anesthesia.

Procedure

Conventional Method (Group B)

The patient lies in the supine position. The mouth is held open with a mouth gag. The curette is held at the handle like a dagger. The curette is then introduced into the oral cavity, all the way above and behind the soft palate. The adenoid tissue is caught in the curette and removed with a smooth, shaving movement. Blood loss is calculated by weighing the gauze pre operatively and post operatively.

Coblation Adenoidectomy (Group A)

Patients were given general anesthesia with orotracheal intubation. The nasal cavities were decongested by using cotton wick soaked in 4% lignocaine with 1:10 000 adrenalines. It was performed by putting the patient in head up position. Soft palate is retracted by passing an infant feeding tube via the nasal cavity. Cut mode kept at 7 and coagulation mode at 3. Adenoid tissue is visualized by passing a 0° 4 mm nasal endoscope from nasal cavity and in some patient by 45° endoscope from oral cavity (Fig. 1). Oral cavity is kept open by using a Boyles Davis mouth gag. Tonsillectomy wand is bent in such a way that it could be passed under the soft palate. Coblation of adenoid tissue is performed under visualization. Adenoid is ablated till the prevertebral fascia becomes visible (Figs. 2, 3, 4) Adenoid tissue behind the tubal orifice can also be ablated.

Fig. 1.

Adenoid by 0° endoscope

Fig. 2.

Evac-70 extra HP coblator wand

Fig. 3.

Ablation with minimal damage

Fig. 4.

Prevertebral fascia with complete removal of adenoid

Result

1. Operating time of coblation adenoidectomy was significantly higher than that of conventional adenoidectomy. For coblation adenoidectomy it took 29 min while it took just 11 min to perform conventional adenoidectomy.

2. Bleeding after conventional adenoidectomy was higher than that of bleeding after coblation adenoidectomy. On an average blood loss following conventional adenoidectomy was 51 ml while it was 23 ml for coblation adenoidectomy.

3. Post operative pain of score 0–4 is more common in group A than B and score of 5–7 is higher in group B compared to group A.

4. Average time required to regain normal nasal breathing pattern is 1.5 days in coblation operated patient and 5 days in patient treated conventionally.

5. Amount of residual adenoid tissue was assessed in both categories of patients by performing nasal endoscopy using 4 mm 0° nasal endoscope in all these patients. The amount of residual adenoid tissue was significantly higher in conventional adenoidectomy when compared to that of coblation method.

6. Post operative hemorrhage was not significantly different between two groups.

Conclusion

Coblation technique ensures complete removal of adenoid tissue with minimal bleeding. Coblation creates a controlled, stable plasma field to precisely remove in tissue at a low temperature resulting in minimal damage to surrounding tissue. It generate around 40°–70° heat. This helps in early resolution of secretary otitis media. Adenoid tissue present behind the tubal tonsil can also be removed safely using coblation technique. Coblation technique does not exert undue pressure over atlanto-occipital joint because the patient is not put in Rose position and the wand also does not exert pressure over the area.

The operation was performed in the standard way using either the ArthroCare 2 assisted Evac-70 extra HP coblator wands or St. clair Thomsan curette. Our surgeon had performed more than a hundred coblation assisted tonsillectomies and adenoidectomy prior to trial to eliminate a learning curve related disturbance. Postoperative analgesic was only acetaminophen in suppository, tablet or elixir form. Operation time, from insertion till removal of Boyle–Davis mouth gag with blade, was recorded for each case. Operation scrub evaluated and recorded intra-operative blood loss by checking volume of blood in suction bottle after the operation. Postoperative cares were the same in both groups.

Data including age, volume of blood loss, operation time, postoperative pain score, postoperative hemorrhage, days required to regain normal breathing pattern were gathered. Respiratory outcomes after endoscopic coblator adenoidectomy are within the normal range and stable, with no risk of recurrence of adenoid tissue [11]. Patients were examined for the following postoperative complications during post surgical visits: primary hemorrhage, secondary hemorrhage and postoperative pain. On discharge, the patients were advised to call the medical group for any complications especially bleeding. Follow up of all patients was performed by a second colleague to make the surgeon blind. On the other hand, none of patients were aware of type of procedure.

The primary hemorrhage was defined as bleeding occurring within 24 h after surgery and secondary hemorrhage as bleeding after 24 h postoperatively. Visual analog scale was used for the pain severity, ranging from 0 to 10. Zero indicated no pain and 10 revealed an extreme pain.

Data were entered into a database and analyzed using SPSS software (SPSS, Windows, version 16). Chi squared tests were used to compare graded scores for pain and time required to regain normal breathing pattern. All other parameters were analyzed using student’s t test.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Approval

All procedures performed in this study involving human participant were in accordance with the ethical standard.