Analysis of Different Techniques of Tonsillectomy: An Insight

Abstract

Tonsillectomy is one of the most commonly performed surgical procedure in otolaryngology especially in children. This is an age old procedure which has seen continuous changes in the surgical technique from guillotine method to snare technique to coblation tonsillectomy, and is still evolving day by day. But there are no consensus as to which technique is the best or most appropriate for tonsillectomy. The objective of this study is to compare three different surgical techniques of tonsillectomy namely the Cold dissection snare technique (CDST), Bipolar electro-dissection technique (BEDT) and Harmonic scalpel technique (HST) and to identify the method which is safe, with less operative time, which offers decreased intra-operative blood loss and with lowest post-operative morbidity and complications. This prospective and comparative study was conducted over a time duration of 1 year 6 months from January 2018 to July 2019 after the approval from ethical committee. Total 150 cases of tonsillectomy were done by dividing into three groups of 50 cases each. The study showed maximum cases of tonsillitis in the age group less than 10 years and the most common indication for tonsillectomy being chronic recurrent tonsillitis. Harmonic scalpel technique (HST) had least operative time, least intra-operative blood loss, took minimum time for resumption of normal diet and normal activity and also had least pain score on post-operative day 1st, 5th, 10th and 15th. STATISTICS: Kruskall-Wallis and the non-parametric Analysis of variance (ANOVA) tests were applied to determine statistically significant variances. All the differences are found to be significant P < 0.05. Harmonic Scalpel Technique (HST) is the latest technique as it is associated with quicker procedure, less intraoperative blood loss and less post-operative pain.

Introduction

Infectious and inflammatory diseases involving tonsils contributes to a significant proportion of childhood diseases often requiring tonsillectomy [1]. Tonsillectomy is not a routine procedure in adults but in pediatric population it continues to be the most common and frequently performed surgical procedures in the ear, nose and throat practice. [2, 3] Tonsillectomy is performed for recurrent or chronic pharyngotonsillitis, quinsy, adenotonsillectomy, for snoring and also as a part of ear surgery or uvulopalatopharyngoplasty [4]. It also reduces the number of infections and the symptoms of chronic tonsillitis such as persistent or recurrent sore throats, halitosis and recurrent cervical adenitis and is curative in resistant cases of cryptic tonsillitis [5].

With the advancement of technology and equipment several new techniques of tonsillectomy have evolved with the aim to make the procedure safe, easily available, with less surgical time, decreased intra-operative blood loss and with little or no morbidity and complications. Various techniques of tonsillectomy are- Cold dissection snare method, Blunt dissection method, Monopolar and bipolar diathermy dissection, Cryo tonsillectomy, Tonsillectomy by Electro cautery, Guillotine excision method, Sutter radiofrequency method, Coblation technique, Tonsillectomy by Microdebrider, Harmonic scalpel method, Plasmacision method, Laser tonsillectomy and Thermal welding. As all techniques have certain advantage and disadvantage, so there is still controversy regarding which is the optimal technique with lowest morbidity rates.

The objective of this study is to compare three different surgical techniques of tonsillectomy namely the Cold dissection snare technique (CDST), Bipolar electro-dissection technique (BEDT) and Harmonic scalpel technique (HST) and to identify the method which is safe, with less operative time, which offers decreased intra-operative blood loss and with lowest post-operative morbidity and complications.

These three techniques are chosen for comparison because these are routinely performed at this center. Moreover cold dissection snare equipment and bipolar electro dissection equipment is very basic and is almost available at all the ENT centers with operative facility. Harmonic scalpel, one of the latest emerging powered instrument with less explored role in tonsillectomy, is included to analyze and compare the conventional techniques with this new emerging technique for tonsillectomy.

Materials and Methods

This prospective and comparative study was conducted over a time duration of 1 year 6 months from January 2018 to July 2019 after the approval from ethical committee. It enrolled 150 patient of age 4 to 40 years with recurrent tonsillitis. All the patients and their guardians were explained about the procedure in detail and about the participation in this study. A voluntary informed consent was obtained for the same that mentioned the description of the technique of tonsillectomy.

Inclusion Criteria

1. Patient aged 4–40 years

2. Recurrent or chronic pharyngotonsillitis with minimum number of episodes of sore throat at least 7 episodes in the previous year, at least 5 episodes in each of the previous 2 year, or at least 3 episodes in each of the previous 3 year for children and 3–4 episode per year for 2–3 years for adults

3. As a part of ear surgery, uvulopalatopharyngoplasty and quinsy surgery

4. As part of Adenotonsillectomy

Exclusion Criteria

1. Children suffering from tonsillitis of age less than 4 years and more than 40 years

2. Neoplasms of tonsil

3. Underlying bleeding and clotting disorders

4. Submucous cleft palate

5. Chronic systemic illnesses

6. Severe anemia

Patients were first screened at the outpatient department where a detailed history was taken, they underwent a general physical examination, and a thorough local examination of throat, ears, nose and neck were done. The preoperative preparations included fitness for surgery by anesthesiologist, basic investigation for surgery under general anesthesia like complete blood count, bleeding and clotting time, blood grouping and typing, coagulation profile, renal and liver function tests, HIV, HBsAg, hepatitis C virus, urine routine, ECG (not in case of children less than 12 years old), chest radiograph, nasopharynx radiograph lateral view for adenoid enlargement if any and paranasal sinus radiograph to rule out any sinus disease.

Selection of Surgical Technique

First 50 cases (cases 1 to 50) were done using Cold dissection snare technique (n = 50). Patients no 51 to 100 were done using Bipolar electro dissection technique (n = 50) and last 101 to 150 cases were done using Harmonic scalpel technique (n = 50). All the cases were performed by same surgical team.

Surgical Technique

All cases were performed under general anesthesia after oral endotracheal intubation under all aseptic precautions. Patient was positioned at the edge of the operating table and Rose’s position was achieved by applying sand bag between the shoulders. Davis-Boyle mouth gag was inserted into the patient’s mouth and fixed into position using Draffin bipod stand and Magurens plate for adequate exposure of the oro-pharynx. In cases of adenotonsillectomy, adenoidectomy was done first and then tonsillectomy. Time and blood measurement was done separately for both the procedures.

In Cold dissection snare technique (CDST), tonsillectomy was done by palatoglossal incision using toothed Waugh forceps. Peritonsillar loose areolar plane was dissected from superior pole to inferior pole by mollison’s blunt dissector. Inferior pedicle was snared with the help of Eve’s tonsillar snare. After removal tonsillar fossa was packed with gauze for a few minutes depending on bleeding and clotting time of the patient. On removal of gauze, bleeders were ligated manually using suture material till hemostasis is achieved.

In Bipolar electro-dissection technique (BEDT), dissection and coagulation were done with the same bipolar forceps. Using the bipolar forceps, a palatoglossal incision was given, the peritonsillar loose areolar plane was dissected from superior to inferior pole. Minimum voltage current was used to allow coagulation. Fibro vascular bundles were coagulated and dissected. Low energy bipolar cautery technique of 25 watts was used to reduce heat trauma to the tonsillar bed and post-op pain. Tonsillar pericapsular plane dissection was also bluntly performed. Vascular bundles of tonsillar capsule and bed were coagulated to achieve hemostasis.

In harmonic scalpel technique (HST), ultrasonic cut ‘N seal device which is a handheld device, is used which utilizes ultrasonic energy at the blade tip to cut and coagulate the vessels or tissues simultaneously at low temperature heat (50–100 degrees Celsius). This technology controls bleeding by coaptive coagulation at low temperature. Coagulation occurs by means of protein denaturation when the blade vibrates at 55.5 kHz. This consists of a generator, a hand piece with a connecting cable, a blade system and a foot pedal. Tonsil retracted medially using Dennis Brown tonsil holding forceps. Using the harmonic hand piece, a palatoglossal incision was given, the peritonsillar loose areolar plane was dissected from superior to inferior pole and tonsillectomy performed using ultrasonic dissection. Hemostasis achieved simultaneously. The scalpel has lower temperature heat (50–100 degrees Celsius) as compared to standard electro cautery (400 to 6,000 degrees Celsius).

Operative time was recorded from the time of 1st incision to complete hemostasis of tonsillar bed. Intraoperative blood loss was measured by calorimetric method. In this the numbered plain soaked cotton balls and gauze balls used for pressure hemostasis were weighed pre and post operatively with the help of weighing balance and then adding the total so obtained (1gm = 1 ml). [8] Blood collected in the suction bottle post operatively was also measured by total amount minus the amount of normal saline in the bottle. Both these amount of blood were added together to know the total intraoperative blood loss. The incidence and severity of any postoperative bleeding in the tonsillar fossa was recorded. Bleeding was classified as primary within first 24 h and secondary after 24 h during the phase of healing of the tonsil bed. The primary and secondary hemorrhage was estimated in hospital or by the help of the patient or their relatives. Secondary hemorrhage was subdivided as those requiring evaluation in the emergency department only, requiring readmission for observation but no surgical intervention, and requiring readmission for surgical control of the bleeding.

Post-operative pain was analyzed for all the patients using Wong Bakers FACES [14] pain rating scale on day 1st, 5th, 10th and 15th (1 = No pain, 10 = Suffering). This is a visual analogue scale from 1 to 10 that uses faces to identify the level of pain and discomfort experienced by the patient.

The duration of stay of the operated patients in the hospital extended from 1 to 3 days under the observation and then the patients were checked by operating surgeon before discharging postoperatively. They were advised to return back if there is any bleeding or any other complication and were called for follow up on day 7th, day 14th and 1 month after the operation. Same surgical team performed each tonsillectomy and its follow up. All the patients received prophylactic antibiotic therapy in the postoperative period for 5 days.

The first cold liquid diet (water, milk, ice-cream) was given 4–6 h after the operation. The patients were allowed to return to their normal diet gradually till the post-operative 5th day; if unable, the soft diet was continued until they were able to receive the normal diet.

The patients were reminded about the standard postoperative care. The patient was advised about routine mouth care and betadine mouth gargle after meals. Furthermore they were instructed to report to hospital if patient is not feeding well, if there is an episode of bleeding, increasing pain, dysphagia, vomiting and infection.

Statistics

Data was analyzed using SPSS software. Age was reported as mean ± standard deviation. Test was applied after checking the condition of normality of the data. Parameters were graded into ascending and descending order after calculating the mean rank. The relationship and the scores of parameters were analyzed with non-parametric statistics (Kruskal–Wallis test). Kruskal–Wallis and Analysis of variance (ANOVA) tests were applied. Statistical significance was set as 0.05 using two-sided test (Figs. 1, 2, 3, 4).

Fig. 1.

1a Bipolar Cautery handle 1b Electro cautery system used for tonsillectomy 1c Tonsillectomy surgery set with bipolar electro cautery blade 1d Intraoperative use of bipolar cautery handle for tonsillectomy

Fig. 2.

2a Harmonic Scalpel straight handle 2b Harmonic Scalpel system used for tonsillectomy 2c Tonsillectomy surgery set with harmonic scalpel blade 2d Intraoperative use of Harmonic Scalpel straight handle for tonsillectomy

Fig. 3.

3a Eves Tonsil snare 3b Tonsillectomy surgery set with Eves Tonsil snare 3c Intraoperative use of Eves Tonsil snare for tonsillectomy

Fig. 4.

Bipolar Cautery handle, Harmonic Scalpel straight handle and Eves Tonsil snare used in this study

Results

Age Group Wise Distribution of Indications of Tonsillectomy

The age group included in our study ranged between 4 to 40 years. The study showed maximum cases of tonsillitis in the age group less than 10 years and least number of cases in the age group 30–40 years. (Table 1, Fig. 5) Incidence of tonsillitis gradually reduces as the age progresses and it is of major concern in younger age group. Most common indication of tonsillectomy was chronic recurrent tonsillitis and least common indication was quinsy. (Table 1, Fig. 5).

Table 1.

Correlation between causes of tonsillectomy and age of the patients

Age	Chronic recurrent tonsillitis	Adeno-tonsillectomy	Part of ear surgery	Hypertrophic tonsillitis with snoring	Part of uvulopalatopharyngoplasty	Quinsy
< 10 years	29 (40.3%)	20 (27.8%)	9 (12.5%)	20 (27.8%)	0	0
10–20 year	17 (37.0%)	1 (2.2%)	9 (19.6%)	12 (26.1%)	2 (4.3%)	5 (10.9%)
20–30 year	5 (35.7%)	0	1 (7.1%)	0	5 (35.7%)	3 (21.4%)
30–40 year	1 (5.6%)	0	0	0	12 (66.7%)	5 (27.8%)

Fig. 5.

Graphical representation of Correlation between causes of tonsillectomy and age of the patients

Subject Demographics

In this study 62% were male and 38% were female. 56.67% belong to urban dwelling area whereas 43.33% were from rural area. (Table 2). When we compared different techniques of tonsillectomy, we found that mean age in CDST group was 16.66 ± 11.51 year, in BEDT it was 14.48 ± 9.64 year and in HST group it was 12.46 ± 8.28 year. (Table 3).

Table 2.

Subject Demographics: age, gender and area wise

	CDST	BEDT	HST
1. Age (Mean ± SD)	16.662 ± 11.5077	14.484 ± 9.6378	12.460 ± 8.2813
2. Gender (a) Male (b) Female	31 (62%) 19 (38%)	32 (64%) 18 (36%)	30 (60%) 20 (40%)
3. Dwelling area a) Urban b) Rural	34 (68%) 16 (32%)	25 (50%) 25 (50%)	26 (52%) 24 (48%)

Table 3.

Age group wise distribution of symptoms

Age	Number	Throat pain	Fever	Difficulty in swallowing	Difficulty in breathing	Halitosis	Mouth breathing	Snoring	Foreign body sensation	Difficulty in hearing
Less than 10 year	72 (48.0%)	51 (70.8%)	49 (68.0%)	46 (63.9%)	42 (58.3%)	15 (20.8%)	35 (48.6%)	30 (41.7%)	26 (36.1%)	9 (12.5%)
10–20 year	46 (30.7%)	28 (60.9%)	23 (50.0%)	30 (65.2%)	20 (43.5%)	15 (32.6%)	15 (32.6%)	14 (30.4%)	25 (54.3%)	9 (19.6%)
20–30 year	14 (9.3%)	10 (71.4%)	8 (57.1%)	10 (71.4%)	6 (42.9%)	9 (64.3%)	8 (57.1%)	3 (21.4%)	5 (35.7%)	1 (7.1%)
30–40 year	18 (12.0%)	6 (33.3%)	6 (33.3%)	6 (33.3%)	6 (33.3%)	3 (16.7%)	11 (61.1%)	12 (66.7%)	3 (16.7%)	0 (0.0%)

Age Group Wise Distribution of Symptoms

The predominant symptom was throat pain, followed by difficulty in swallowing. (Table 3).

Age Group Wise Distribution of Sign

Whereas the predominant sign was enlarged tonsils with majority (34.67%) presenting with grade 3 tonsillar enlargement or occupying 51 to 75% of the lateral dimension of the oropharynx followed by flushed anterior pillar. (Table 4).

Table 4.

Age group wise distribution of signs on examination

Age	Enlarged tonsil	Flushed anterior pillar	Enlarged jugulodigastric LN	Erwin Moore sign	Adenoid hypertrophy	Signs of ASOM
Less than 10 year	63 (87.5%)	43 (59.7%)	36 (50%)	33 (45.8%)	16 (22.2%)	7 (9.7%)
10–20 year	38 (82.6%)	28 (60.9%)	12 (26.1%)	29 (63%)	0	9 (19.6%)
20–30 year	8 (57.1%)	10 (71.4%)	2 (14.3%)	2 (14.3%)	0	1 (7.1%)
30–40 year	13 (72.2%)	6 (33.3%)	2 (11.1%)	0	0	0

Intraoperative Blood Loss (in ml) in 3 Techniques

Maximum intra-operative blood loss was in CDST group ranging upto more than 90 ml, followed by BEDT group and least in HST group. In BEDT group, maximum patient had blood loss of 30-60 ml whereas in HST group, maximum patient had less than 30 ml blood loss. (Table 5, Fig. 6).

Table 5.

Intraoperative blood loss in different techniques of tonsillectomy

	Blood loss in ml
	< 30 ml	30–60 ml	60–90 ml	> 90 ml
CDST	0	8%	48%	44%
BEDT	0	92%	8%	0
HST	76%	24%	0	0

Fig. 6.

Graphical representation of Intraoperative blood loss in different techniques of tonsillectomy

Subject Characteristics Amongst 3 Techniques

CDST group had the longest operative time of 135 min followed by BEDT group (85 min) followed by HST group (60 min) (Table 6). Post-operative pain on day 1st, 5th, 10th and 15th was found to be statistically significant (P < 0.05). Overall the pain score was more in BEDT and least in HST group in all the 4 post-operative days. On post-operative day 1st and 5th, CDST and BEDT had a maximum pain score of 10 whereas HST had maximum score of 6. On post-operative day 10th, CDST had maximum score of 6, BEDT had maximum score of 8 and HST had score of 4. When we compared pain score on day 15th, CDST had score of 6, BEDT had score of 8 whereas HST had score of 2. (Table 6) Time until resumption of normal diet and normal activity was higher for BEDT and least for HST.

Table 6.

Subject characteristics amongst different techniques of tonsillectomy

Variable	CDST	BEDT	HST	P-value
Intraoperative blood loss	Median 90	Median 45	Median 25	> 0.05
	Min 50	Min 35	Min 20
	Max 110	Max 80	Max 50
Operative time	Median 110	Median 55	Median 40	0.000
	Min 60	Min 30	Min 25
	Max 135	Max 85	Max 60
Post operative pain score Day 1	Median 8	Median 10	Median 4	0.000
	Min 4	Min 6	Min 4
	Max 10	Max 10	Max 6
Post operative pain score Day 5	Median 6	Median 10	Median 4	0.000
	Min 4	Min 4	Min 2
	Max 10	Max 10	Max 6
Post operative pain score Day 10	Median 4	Median 8	Median 0	0.000
	Min 0	Min 0	Min 0
	Max 6	Max 8	Max 4
Post operative pain score Day 15	Median 0	Median 6	Median 0	0.000
	Min 0	Min 0	Min 0
	Max 6	Max 8	Max 2
Time until resumption of normal diet	Median 6.5	Median 6	Median 6	0.000
	Min 5	Min 3	Min 5
	Max 12	Max 12	Max 12
Time until resumption of normal activity	Median 8	Median 7	Median 7	0.000
	Min 5	Min 4	Min 5
	Max 14	Max 14	Max 14

All three groups were compared with respect to the operative time, intra-operative blood loss, pain on the post-operative 1st, 5th, 10th and 15th day, time until resumption of normal diet and time until resumption of normal activity. Normality analysis showed non-parametric distribution. Therefore, Kruskall-Wallis and the non-parametric Analysis of variance (ANOVA) tests were applied to determine statistically significant variances. All the differences are found to be significant P < 0.05.

Comparison of Primary Outcome (Primary Bleeding, Secondary Bleeding, Reactionary Bleeding) Amongst Different Techniques

The rates of primary and reactionary bleeding was maximum in CDST followed by BEDT and least in HST. Secondary bleeding was maximum in BEDT followed by CDST and least in HST group (Table 7) (Fig. 7).

Table 7.

Post-operative bleeding in different techniques of tonsillectomy

	Primary bleeding	Secondary bleeding	Reactionary bleeding
CDST (61)	35 (70%)	22 (44%)	4 (8%)
BEDT (75)	33 (66%)	40 (80%)	2 (4%)
HST (16)	9 (18%)	6 (12%)	1 (2%)

Fig. 7.

Graphical representation of Post-operative bleeding in different techniques of tonsillectomy

Comparison of Complications of Tonsillectomy Amongst 3 Techniques

When we compared the complications, we found that CDST group had maximum cases of dehydration, vomiting, odynophagia and tonsillar bed infection; Change of voice was equally present in CDST and HST group; Halitosis was found only in CDST group and we did not had any case of neck abscess in either of the technique. Overall the complications were maximum in CDST group and least in HST group (Table 8) (Fig. 8).

Table 8.

Comparison of complications in different techniques of tonsillectomy

	Dehydration	Vomiting	Odynophagia	Halitosis	Infection (Tonsillar bed)	Infection (Neck abscess)	Change of voice
CDST	28 (56%)	30 (60%)	45 (90%)	2 (4%)	28 (56%)	0	11 (22.0%)
BEDT	23 (46%)	25 (50%)	32 (64%)	0	24 (48%)	0	8 (16.0%)
HST	6 (12%)	6 (12%)	21 (42%)	0	22 (44%)	0	11 (22.0%)

Fig. 8.

Graphical representation of Comparison of complications in different techniques of tonsillectomy

Comparison of Various Modes of Treatment of Complications Amongst 3 Techniques

Maximum cases of BEDT group complications were managed by evaluation in emergency department. In CDST and HST group maximum cases of complication were observed after readmission but they did not require any surgical intervention. Surgical control of bleeding was done only in 2 cases of BEDT group (Table 9) (Fig. 9).

Table 9.

Comparison of various modes of treatment of complications in different techniques of tonsillectomy

	Evaluation in emergency department	Readmission for observation but no surgical intervention	Readmission for surgical control of bleeding
CDST	3 (6%)	12 (24%)	0 (0%)
BEDT	20 (40%)	8 (16.0%)	2 (4.0%)
HST	7 (14%)	11 (22.0%)	0 (0%)

Fig. 9.

Graphical representation of Comparison of various modes of treatment of complications in different techniques of tonsillectomy

Comparison of Operative Time, Intraoperative Blood Loss, Time Until Resumption of Regular Diet and Normal Activity and Post-Operative Pain Score Amongst 3 Techniques

We calculated mean rank for the various parameters in the 3 techniques and we graded the parameters in ascending order. We found that HST had least operative time, least intra-operative blood loss, took minimum time for resumption of normal diet and normal activity and also had least pain score on post-operative day 1st, 5th, 10th and 15th. CDST had maximum operative time and intra-operative blood loss. BEDT took maximum time for resumption of normal diet and normal activity and also had maximum pain score on post-operative day 1st, 5th, 10th and 15th (Table 10).

Table 10.

Comparison of different techniques of tonsillectomy

Mean rank	CDST	BEDT	HST
Operative time in minutes	124.12	68.54	33.84
Intraoperative blood loss in ml	124.13	74.61	27.76
Time until resumption of regular diet in days	6.58	10.32	4.5
Time until resumption of normal activity in days	7.92	11.96	5.5
Post operative pain score Day 1	7.24	9.08	4.76
Post operative pain score Day 5	6.32	9.44	3.72
Post operative pain score Day 10	4.16	7.08	0.92
Post operative pain score Day 15	0.92	4.84	0.04

Discussion

Paradise criteria is used for tonsillectomy in children which depends on minimum frequency of episodes of sore throat. It includes at least 7 episodes in the previous year, at least 5 episodes in each of the previous 2 year, or at least 3 episodes in each of the previous 3 year. [4] According to the Scottish Intercollegiate Guidance Network (SIGN) [6], for tonsillectomy in children the patient should meet the following criteria- sore throat due to tonsillitis, five or more episodes of sore throat per year, symptoms for atleast a year, episodes of disabling sore throat which prevent normal functioning. However US accepts the guidelines of American Academy of Otolaryngologists/Head and Neck Surgeon (AAO HNS) [7] which says tonsillectomy should be considered in children with three or more infections of tonsils and/or adenoids per year despite adequate medical therapy. Indication for adult tonsillectomy are repeated attacks (3–4 episode per year for 2–3 years) of acute tonsillitis. [8]

Cornelius ceisus was the first to remove tonsils by enucleation with the help of his finger nails dated back to first century A.D. almost 2000 years ago. [9] In 1917 Crowe et al. first described the surgical dissection of tonsils by sharp instrumentation [10]. In the beginning of twentieth century Worthington [11] described the dissection technique of tonsillectomy. Then in 1968, Remington-Hobbs described diathermy method of tonsillectomy. [12] Ochi et al. were the first to describe the use of ultrasonic scalpel in tonsillectomy in 2000 [13].

In the present study we compared the three techniques of tonsillectomy used in our hospital setting in view of operative time, morbidity and complications. Maximum incidence of tonsillitis was in the age group less than 10 years followed by 11–20 year. Similar observation was reported by Vijayashree et al. [15, 16] for the age group 6–12 year. Incidence of tonsillitis is high in school children because of low immunity in the children, cross infection because of overcrowded class rooms and poor ventilation of the class rooms. The distribution of tonsillitis was more in male patients (62%) compared to females probably because number of male patients admitted were more than female patients. Maximum patients were from the urban dwelling area, most likely because of less awareness and improper medical care in the rural area.

Most common indication of tonsillectomy was chronic recurrent tonsillitis similar to Verma R et al. [17]. Recurrent tonsillar infection is one of the traditional indication of tonsillectomy. But with changing era, there is also a changing trend in the indications of tonsillectomy. Nowadays, apart from infective cause, obstructive causes like obstructive tonsillar hypertrophy leading to snoring are also considered as one of the major indication of tonsillectomy [17]. We observed that hypertrophic tonsillitis with snoring was the second most common indication of tonsillectomy in our study.

In clinical manifestation, throat pain was predominant symptom followed by difficulty in swallowing and tonsillar enlargement was the most predominant sign. Vithayathil AA et al. [1] also noted the similar predominant features. The likely reason for these clinical manifestations is the infection caused by Streptococcus and various viral agents (Adenoviruses, Influenza, Epstein-Barr, Parainfluenza and Entero viruses) leading to features of inflammation, swelling of the tonsils severe enough to cause obstruction [17].

There are various techniques of tonsillectomy which can be categorized into cold and hot techniques. Cold techniques are the ones where no heat is used and they include Cold dissection snare technique, Guillotine excision technique, Harmonic scalpel technique, Plasmacision technique, Cryo-tonsillectomy. Hot techniques include Bipolar and monopolar electro dissection technique, coblation technique, Sutter radiofrequency technique, Laser tonsillectomy and Thermal welding. All these techniques have advantages and disadvantages. Surgeons prefer those techniques which can remove the tissue with greater accuracy, less damage to adjacent tissue, in less operative time, with less intraoperative bleeding, less post-operative pain and less morbidity.

We adopted 3 techniques in our study namely CDST, BEDT and HST. Amongst these CDST is the oldest one but it is still the most practiced one. In this whole tonsil tissue is dissected from its capsule and underlying constrictor muscles is exposed and hence it causes pain and there is increased chance of hemorrhage per operative and post operatively. BEDT causes more lateral thermal damage and hence more pain and discomfort in the postoperative period. HST utilizes hydro-dissection for hemostasis and cause less pain and morbidity [17].

In this study, HST has shown significantly less intra operative blood loss when compared to CDST. Similar finding was reported by Obasikene G et al. [18]. When we compared the intra-operative blood loss amongst BEDT and CDST, we found that BEDT had less blood loss as compared to CDST. This was similar to the observation of Dadgarnia MH et al. [19] Ali NS et al. [20] compared intra operative blood loss amongst HST and electro cautery group and found that it was less in HS group (EC 3.43 ± 3.42 ml Vs HS 2.40 ± 2.74 ml; P = 0.10). We also observed the similar finding in our study. In our study, the median of intraoperative blood loss in CDST group was 90, in BEDT it was 45 and in HST it was 25. Conventional technique (CDST) has more intraoperative bleeding than the newer method as it utilizes arterial ligation and gauze packing for hemostasis purpose. Whereas HST utilizes ultrasonic energy to vibrate the dissecting blade at a harmonic frequency, creating intracellular pressure waves further leading to intracellular cavities which leads to minimal intra-operative blood loss.

In this study, the operative time was found to be longest for CDST followed by BEDT and least for HST. Shinhar S et al. [21] also observed the similar finding that the operating time was 23.6 min for harmonic scalpel method, 30.2 min for electro cautery method and 35.3 min for cold dissection. Vithayathil AA et al. [1] compared two techniques and found that operative time was less for BEDT when compared with CDST. The reason behind this less operative time is attributed to the ability of diathermy to dissect the tonsils and coagulate the blood vessels simultaneously. Even with our relative inexperience with the harmonic scalpel, we are still able to perform tonsillectomies faster with it than with more established and conventional methods. As we gain experience with the harmonic scalpel, we hope to get even faster. The benefits of faster surgery, of course, include a reduced risk of patient exposure to surgery and anesthesia, more efficient use of surgical time and reduced variable costs.

Post-operative pain after tonsillectomy is one of the toughest response to study, as it is a highly subjective symptom with significant individual variability. Pain is usually caused by heat exposure or mechanical trauma to adjacent tissues, which is ultimately accompanied by edema, spasm of the pharyngeal muscles and irritation of the nerve endings of the tonsil bed. It is one of the most unpleasant side effects of tonsillectomy, and reportedly the most common reason for referral of patients in the first two weeks of surgery. Our study design allowed an effective comparative pain assessment using a visual analogue scale.

We observed that the pain score was maximum in BEDT followed by CDST and least in HST group in all the 4 post-operative days. Higher pain score were reported with BEDT in our study. This was similar to Vithayathil AA et al [1]. Obasikene G et al. [18] compared the pain scores amongst laser technique, blunt dissection technique and ultrasonic technique and found significantly more pain in laser technique followed by blunt dissection tonsillectomy and least in scalpel technique. Increased incidence of pain following electro cautery tonsillectomy [17] could be due to excessive lateral thermal damage to the tonsil bed because of excessive heat of cautery (300–400ºC) which is needed to induce the hemostasis. This kinetic energy heats the intracellular and extracellular fluids and ruptures localized tissue cells. The use of the harmonic scalpel could be advantageous regarding postoperative pain, as it utilizes the high frequency vibration of the blades and rendering less energy (60–100ºC) to the surrounding tissues leading to hydro-dissection [17].

Pain and dysphagia are common in early post-operative period. In our study we observed that most patients require atleast a week to resume normal functioning and average return to normal activity is one to two weeks. This is mainly due to pain preventing a return to normal diet. In HST the pain score start decreasing from 5th post-operative day, so patient resume their normal diet and normal activity early. As BEDT was associated with high pain score in post-operative period, so the patient undergoing BEDT tonsillectomy related prolongation of time of resumption of normal diet and normal activity. Atallah N et al. [22] also noted the similar finding in their study.

The most commonly encountered complication of tonsillectomy is bleeding, during or after surgery. Despite the surgeon’s most sophisticated efforts to prevent it, hemorrhage remains the most serious complication after tonsillectomy. In our study, overall the hemorrhage was more in BEDT group and least in HST group. This finding was consistent with Al-Mahbashi MY et al. [15]. The reason for higher post‐tonsillectomy bleeding after electro-dissection techniques could be the greater thermal damage as the result of excessively high power settings or excessively frequent or prolonged application of cautery. Amongst the three techniques, primary hemorrhage was found to be maximum in CDST and minimum in HST. The reason behind this could be the blunt dissection which is performed for removing the tonsils. This was contrary to the finding of Al-Mahbashi MY et al. [15] who observed more cases of primary hemorrhage in bipolar group.

In our study secondary hemorrhage was maximum in BEDT followed by CDST and least in HST group. This was supposed to be due to the greater amount of tissue damage within the tonsillar bed using the bipolar electro-dissection which leads to delayed healing and predispose to delayed secondary hemorrhage. Al-Mahbashi MY et al. [15] and Watson MG et al. [23] compared only BEDT and CDST and had similar finding as our study. There was very less incidence of reactionary hemorrhage. It was maximum in CDST as multiple ligatures are used in it and minimum in HST. This finding was consistent with Watson MG et al. [23]. Wiatrak BJ et al. [24] compared HST with dissection and electro cautery and found that episodes of postoperative hemorrhages were minimal in Harmonic scalpel tonsillectomy. We also observed the minimal cases of post-operative bleeding after HST.

Morbidity after tonsillectomy is significant. Both the individual and combined complication rates among the HST patients were lower than the rates seen with BEDT and CDST patients. The highest complication rates were seen with CDST, the one which is widely used and the oldest of the three techniques followed by BEDT. This was similar to the observation of Shinhar S et al. [21]. Vomiting usually occurs in early post-operative period due to either after-effects of the anaesthesia or due to the effect of swallowed blood. Excessive vomiting, decreased oral intake due to post-operative pain, odynophagia due to pharyngeal muscle trauma and blood loss lands up the patient in dehydration. As the intraoperative blood loss was maximum in CDST, so this may be the reason of maximum cases of dehydration in CDST and least in HST patients.

Postoperative infection is also encountered after tonsillectomy. Amongst which tonsillar bed infection and halitosis are the prominent feature. Halitosis is probably the result of tonsillar plaque and tonsillar fluid that linger in the excised tonsillar area. Also, the patient avoids eating, cleaning the oral cavity and brushing the teeth normally for several days after the tonsillectomy, which inevitably leads to collection of particles in the excised area further leading to tonsillar bed infection and halitosis.

After tonsillectomy, patients may have change in voice. The reason behind this could be the transient tissue changes such as pain and edema in the soft palate and tongue. But this usually temporary and improves within 2–3 weeks. However, when bilateral tonsillar tissue is removed, there occurs change in volume leading to permanent change of upper airway diameter and further leading to permanent voice change.

For the management of these morbidity, when we assessed the re-evaluation and readmission rates after tonsillectomy, we found that it was highest for BEDT patients. Although majority patients were just evaluated in the emergency or they were readmitted for observation and were managed by adequate hydration, analgesics and continued with antibiotic therapy. Only 2 cases were readmitted for surgical intervention. Apart from Verma R et al. [17] who found that readmission rate was higher in cases of cold dissection, we could not find any comparative study regarding the same.

In our study, it was evident that tonsillectomy using HST was significantly quicker method of tonsillectomy that CDST and BEDT. Average intraoperative blood loss and post-operative pain score was remarkably less while using HST. Patients undergoing HST tonsillectomy resumed their normal diet and normal activity faster whereas BEDT patients took longer time for the same. The incidence of post-operative hemorrhage and other complications were also less in HST.

With course of time, the techniques of tonsillectomy are also evolving, objective being reducing the morbidity, operative time and complications associated with the same. Ideally tonsillectomy should be quick, with minimal blood loss, minimal post-operative pain, minimal hemorrhage, patient should return to normal diet and normal activity as early as possible and should not have any morbidity. However, considering the practical point of view, the morbidity related to tonsillectomy may be significant and the surgeons should choose the technique in which they offer minimum or negligible morbidity.

Conclusion

Harmonic Scalpel Technique (HST) is the latest technique as it is associated with quicker procedure, less intraoperative blood loss and less post-operative pain. Morbidity in terms of post-operative hemorrhage and other complications (vomiting, dehydration, halitosis, odynophagia, infection of tonsillar bed) were also minimal with HST. So, to conclude our experience with HST thus far has been positive, and we will continue to use it for tonsillectomy. We recommend that any institution involved with significant number tonsillectomies consider using it, as well.

Funding

There are no financial interests the authors may have in companies or other entities that have an interest in the information in the Contribution (e.g., grants, advisory boards, employment, consultancies, contracts, honoraria, royalties, expert testimony, partnerships, or stock ownership in medically related fields). The authors have no financial interest.

Declarations

Conflict of Interest

The authors declare that they have no conflict of interest.