ORIGINAL ARTICLE Traditional Tonsillectomy Compared With Bipolar Radiofrequency Thermal Ablation Tonsillectomy in Adults A Pilot Study Leif Ba¨ck, MD; Markku Paloheimo, MD, PhD; Jukka Ylikoski, MD, PhD Objectives: To assess the morbidity and efficacy of bi- until the telephone interview 3 weeks after the operation. polar radiofrequency thermal ablation tonsillectomy and compare it with traditional cold dissection tonsillec- Main Outcome Measures: Operating time and intraop- tomy with diathermy hemostasis. erative blood loss; need for anesthetics during the operation; different recovery indicators in the recovery room (ie, du- Design: Prospective, randomized, single-blinded, con- rationandmedicationsadministered),surgicalward(ie,medi- trolled clinical study. cations administered, use of corticosteroids, general condi- tion, and status of the uvula on the first postoperative day), Setting: Helsinki University Central Hospital, Depart- and in the 2 weeks following surgery (ie, visual analog scale ment of Otorhinolaryngology–Head & Neck Surgery, scores on 6 symptoms, medications needed, the day patients Helsinki, Finland. returned to work, use of antibiotics, and retreatment accep- tance); and complications and certain laboratory parameters. Patients: Forty healthy volunteer patients aged 18 to 65 years admitted for elective tonsillectomy with recurrent or Results: There was a statistically significant but clini- chronic tonsillitis, obstructive tonsillar hypertrophy, or his- cally insignificant difference in operating time and in- tory of quinsy. Two patients were excluded from the study traoperative blood loss in favor of the traditional tonsil- and 1 patient cancelled the operation. lectomy group. The other outcome measures showed no statistically significant differences. Interventions: Nineteen patients underwent a traditional cold dissection tonsillectomy with diathermy hemostasis, Conclusion: Bipolar radiofrequency thermal ablation and and 18 patients underwent a bipolar radiofrequency ther- traditional tonsillectomy were associated with similar post- mal ablation tonsillectomy. There was no intergroup dif- operative morbidity. ference in age, sex, weight, and indications for tonsillectomy. The subjects were not informed of the type of procedure Arch Otolaryngol Head Neck Surg. 2001;127:1106-1112 ONSILLECTOMY is one of the All the techniques have certain ad- most common surgical pro- vantages and disadvantages. Any improve- cedures performed world- ment of this procedure should decrease wide. Over the years, various operating time, blood loss, postoperative techniques and instruments hemorrhage, and particularly the postop- Thave evolved to accomplish this operation erative morbidity. With the growing in- and have a long history; in fact, the first de- terest in day-case surgery, quick tech- scription of tonsillary removal as a medical niques with rapid recovery are favored. procedure is from the first century AD.1 Unlike most operative procedures, There is still controversy over which which are closed primarily, tonsillectomy is the optimal technique of tonsillectomy produces an open wound that heals by sec- with the lowest morbidity rates. The de- ondary intention. The major postopera- scribed techniques are blunt dissection, tive morbidity problems are pain and de- guillotine excision, cryosurgery, monopo- layed hemorrhage. The pain is the result of From the Departments of lar and bipolar diathermy dissection, suc- disruption of mucosa and glossopharyn- Otorhinolaryngology–Head & tion diathermy dissection, bipolar scissor geal and/or vagal nerve fibers followed by Neck Surgery (Drs Ba¨ck and dissection, microscopic bipolar diathermy inflammation and spasm of the pharyn- Ylikoski) and Anesthesiology dissection, ultrasonic removal, and laser dis- geal muscles that leads to ischemia and a and Intensive Care Medicine 2-10 (Dr Paloheimo), Helsinki section. A few centers perform guillo- protracted cycle of pain; it does not com- University Central Hospital, tine excisions, and tonsillotomies are also pletely subside until the muscle becomes 11 Helsinki, Finland. performed for certain indications. covered with mucosa 14 to 21 days after sur- (REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 127, SEP 2001 WWW.ARCHOTO.COM 1106 ©2001 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/01/2021 PATIENTS, MATERIALS, fentanyl was given, if necessary, according to autonomous nervous system signs (eg, a sudden increase in heart rate AND METHODS or blood pressure and reduction of the plethysmographic pulse amplitude). In the recovery room, 0.05 mg/kg of in- travenous oxycodone was administered to relieve imme- This study was prospective, randomized, and single blinded. diate postoperative pain, and a dose of 0.1 mg/kg of intra- The study protocol was reviewed and approved by the re- muscular oxycodone was allowed in the surgical ward for search ethical committee of the of Department of Otorhi- intractable pain. The numbers of required analgesic doses nolaryngology–Head & Neck Surgery, Helsinki Univer- were used to differentiate the patients between the groups. sity Central Hospital, Helsinki, Finland. Written informed The patients were prepared in accordance with our stan- consent was obtained from all patients. Forty patients aged dardized guidelines for tonsillectomy in both groups. Rou- 18 to 65 years admitted for elective tonsillectomy at the ENT tine prophylactic antibiotic agents were not prescribed. Tra- unit of Helsinki University Central Hospital entered the ditional tonsillectomy was initiated by an incision overlay- study. The indications for tonsillectomy were recurrent in- ing the superior pole of the tonsil. The dissection proceeded fections, chronic infection, airway obstruction, or history along the tonsillar fossa in the peritonsillar plane keeping as of quinsy. Exclusion criteria included patients with bleed- close to the tonsil capsule as possible. Hemostasis was achieved ing disorders and any significant chronic illness that would by the application of pressure with packs, and persistent bleed- interfere with expected recovery. The electrosurgery sys- ing was controlled by a bipolar diathermy coagulation of ves- tem was also contraindicated in patients with pacemakers sels. The bipolar ENTec Coblator Plasma Surgery System and or other electronic device implants. Each patient was ran- ENTec Plasma Scalpel wand (ArthroCare Corporation) were domly assigned to either the TEtrad or TErfta group by the used in the TErfta technique. The wand comprises 5 active surgeon’s (L.B.) picking a card from a pack of cards. None electrodes located at the distal end of the tip with the exposed of the nursing staff taking care of the patient was aware of portion of the shaft acting as the return electrode just proxi- the group in which the patient was randomized, and the mal to the active electrodes. Cooled saline was connected to subjects were not informed of the type of procedure until thewandandsettoaflowrateof1to3dropspersecondthrough the telephone interview 3 weeks after the operation. The the saline delivery channel. A different suction line was used. first author (L.B.) did all the procedures, and the same an- The power was set to levels 5 to 7 (192-260 Vrms) during the esthesiologist (M.P.) administered the anesthesia. ablation, and in case of bleeding the coagulation mode was A standardized anesthetic technique was used in all applied. The Coblation tonsillectomy proceeded slowly along patients. The preoperative inquiry was based on a ques- the capsular plane. If there was more bleeding or if the wand tionnaire completed by the patient. Premedication, if re- did not seal the vessel within 5 seconds, the point diathermy quested by the patient, consisted of 10 mg of oral diaz- coagulation was applied. In both groups, the tonsillar beds epam. After 2 µg/kg of intravenous fentanyl citrate was were irrigated with water to localize smaller bleeding vessels. administered, anesthesia was induced with an injection of The time taken to perform the operation was measured 10 mg/kg of propofol, and 3% isoflurane in oxygen was ad- from the first incision to the removal of the mouth gag. The ministered by endotracheal intubation without neuromus- intraoperative blood loss was measured by volume of suc- cular block. Prior to the start of the tonsillectomy, an ad- tion aspirate. The need for anesthetics during the operation, ditional dose of 1 µg/kg of fentanyl citrate was administered. the time spent in the recovery room, and the need for pain Anesthesia was maintained with 65% nitrous oxide in medications in the recovery room were recorded. oxygen and isoflurane in necessary concentrations (1-2 minimum alveolar concentration). An additional dose of Continued on next page gery. The postoperative delayed hemorrhage is due to sec- The ENTec Coblator Plasma Surgery System has a Food ondary infection of the tonsillar fossa resulting in disrup- and Drug Administration approval for “ablation and coagu- tion of vessels and bleeding.12 lation of soft tissue in ENT [ear, nose, and throat] surgery Monopolar radiofrequency thermal ablation (RFTA) including head, neck, oral and sinus surgery.”20 One of of soft tissues has been studied extensively by specialists the suggested applications is for the entire removal of the in cardiology,13 neurosurgery,14 urology,15 and oncology.16 tonsil (tonsillectomy) with the bipolar radiofrequency It has demonstrated acceptable efficacy, safety, and repro- equipment.