Coblation Adenotonsillar surgery: a game changer in decreasing postoperative complications while maintaining efficacy – an audit of 345 cases

doi:10.21203/rs.3.rs-1325007/v1

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Coblation Adenotonsillar surgery: a game changer in decreasing postoperative complications while maintaining efficacy – an audit of 345 cases

https://doi.org/10.21203/rs.3.rs-1325007/v1

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Purpose: To assess the safety and efficacy of coblation adenotonsillar surgery with emphasis on intra-capsular tonsillectomy (ICT) in children with both obstructive and infective indications.

Methods: Children, 6 months to 18y of age, who underwent coblation adenotonsillar surgery by the senior author between Feb 2017 and Sep 2020, were included. We reviewed the demographic data, preoperative and postoperative symptoms and degree of obstruction, postoperative complications, the need for revision surgery.

Results: We reviewed 345 patients; median age 4.5y (11 months – 16.3y, mean 5.2y). Most patients had snoring (94.2%), mouth breathing (92.8%), restless sleep (62.6%), and sleep disorder breathing (52.8%), 12.5% had recurrent tonsillitis. Median initial total symptoms score (TSS) was 4.5 (1-8; mean 4.1); 87.5% having 3 or more symptoms; this decreased postoperatively to a median of 0.0 (range 0 – 7; mean 0.2). Most patients underwent ICT (86.7%). Postoperative course was uneventful in most patients with median hospital stay of 1 day (0-3, mean1). Secondary bleeding was 1.7% [66.7% in extracapsular tonsillectomy (ECT)], none required admission or intervention. There was no tonsillar regrowth resulting in upper airway obstructive symptoms. None needed tonsillar revision surgery (only one patient needed revision adenoidectomy), at a median follow up of 27 months (range 9-47, mean 26.6).

Conclusions: Coblation adenotonsillar surgery is a safe and effective procedure; ICT reduced the risk for postoperative bleeding to 0.7% and was self-limiting. The need for another tonsillar surgery was nil. We adopted ICT for both obstructive and infective indications based on our results and those of other published data.

tonsils

tonsillectomy

intracapsular tonsillectomy

extracapsular tonsillectomy

coblation

tonsillar reduction

tonsillotomy

Adenotonsillar surgery is one of the most common performed surgeries in children. Many tools have been used to perform this surgery with variable outcomes. The concept of intra-capsular tonsillectomy (ICT) remerged after the work of Koltai using the microdebrider [1].

The National Prospective Tonsillectomy Audit (NPTA) assessed 33,921 extracapsular tonsillectomies (ECT), both adults and children between 2003 and 2004. These constituted 70% of the total number of tonsillectomies in the United Kingdom during the same period [2]. They reported a readmission rate of 3.9%, a haemorrhage rate of 3.5% with 0.9% return to theatre rate.

Though the risk of mortality post tonsillectomy is quite low and estimated at 1/7132 to 1/170 000 [3], more concern was raised after the deaths of five young children who underwent ECT in Austria between 2006 and 2007. That resulted in a progressive switch to ICT in many places [4].

The use of microdebrider for ICT became popular at some point due to decrease in the degree of postoperative pain, quicker recovery and lower rate of postoperative bleeding [5]. The only concern was intraoperative bleeding; Stansifer KJ et al (2012) showed that there was approximately twice as much blood loss with the microdebrider, but the absolute increase was insignificant from a hemodynamic perspective [6]. Despite that, a shift towards using the coblator has been noticed mainly to avoid excessive intraoperative blood loss.

After having a long experience with the microdebrider in ICT [5], the senior author started shifting to the coblator for all tonsillar surgeries whether ECT or ICT with a progressive shift to ICT for all cases whether for obstructive or infective indications. For that an audit was performed to evaluate the efficacy and safety of this change in practice.

The study was approved by the Institutional Review Board of Mohammed bin Rashid University of Medicine and Heath Sciences in Dubai, UAE. The research was performed in accordance with the relevant guidelines and regulations. Informed consent was obtained from the participants’ legal guardians, during the clinic visit prior to performing the surgery. Confidentiality was maintained all through the study. Consecutive patients undergoing tonsillar surgery using the coblator, between February 2017 and September 2020 were included in the study. Inclusion criteria included: children aged 6 months to 18 years, surgery done using the coblator, ECT or ICT, surgery performed by the senior author (single surgeon series to avoid the confounding effect of variation in technique and skills). Exclusion criteria included patients with craniofacial abnormalities, previous tonsillar surgery.

The indications for surgery included upper airway obstruction, obstructive sleep apnea (OSA) and recurrent tonsillitis (defined as 7 episodes/year over 1 year, or 5 episodes/year for 2 years or 3 episodes/year over 3 years).

The demographic data was reviewed. The preoperative and postoperative symptoms were noted and the total number of symptoms was used for comparison and was labelled as total symptoms score (TSS). The degree of obstruction by the tonsils were reviewed and graded according to the known grading scales [7]. The grade of the tonsils at the postoperative follow up visits was also noted. Any complication, like postoperative bleeding (primary or secondary), dehydration, severe pain, respiratory distress was documented, as well as the need for readmission or control of bleeding. We looked for any persistent symptoms postoperatively and the need for revision surgery.

Statistical analyses were performed using the SPSS software version 22.0 (SPSS Inc., Chicago, IL, USA). Descriptive data were expressed as mean ± SD for continuous measures, or as a percentage for discrete measures. McNemar's test of agreement was performed to evaluate pre-operative and post-operative tonsillar and adenoid grades. Spearman's rank correlation tests and bivariate analyses were performed to measure the degree of association between variables. The level of significance was set at p < 0.05.

Operation

Coblation is a well-known technology, and its mechanism has been well described by its company (Smith & Nephew) in their product’s documents and website [8]. The setup that we use for all our cases will be described below as well as the selection of the wands depending on the preference and the experience of the senior author (MAB).

Under general anesthesia and the patient in Rose position, the mouth is opened using McIvor mouth gag. Two suction catheters are introduced through the nasal cavities to retract the palate. A laryngeal mirror is used to visualize the adenoids pad. This is sometimes coupled with 30-degree telescope when the patient is very young with limited transoral access or the adenoids extends inside the posterior choanae.

The ablation of the adenoids is performed from inferior to superior, ensuring keeping the inferior edge of the adenoids intact to provide an adequate ridge in Passavant sphincter area to avoid creating velopharyngeal insufficiency. Care is taken to remove all obstructive tissues and ensuring clearance of both the posterior choanae and the eustachian tubes. Hemostasis is achieved using the coagulation mode of the Coblator. The wand’s type used for the adenoids depends on the choice made for the tonsillar surgery. We usually use the default setting of the Coblator but occasionally increase the ablation power to 8 or 9 in case the adenoids tissue is dense (usually in older children). Both adenoids and tonsillar surgeries are done under magnification. That was initially provided by a surgical loop; However, with the emergence of covid pandemic we shifted to the microscope that provided a mean to keep the surgeon away from the oral cavity. This practice became the norm till the present time.

Intracapsular tonsillectomy

The senior surgeon (MAB) chooses the type of wands as follows: PROCISE^◊ EZ View wand for children younger than 2y of age; EVAC^◊ 70 HP for children 2-5y of age and PROCISE^◊ MAX for children older than 5y of age. This choice is not rigid and is sometimes influenced by the size of the tonsils, the size of the oral cavity and the ability to manoeuvre the wand inside the mouth. The coblation is carried on from the most protruding part of the tonsil and progressing along the length of the tonsil and from anterior to posterior, avoiding working in blind deep craters. The scrub nurse helps aspirating the resulting vapor using a Yanker sucker.

The Hurd dissector is used to protect the surrounding soft tissues (uvula, soft palate, posterior pillar, base of tongue, posterior pharyngeal wall) and to expose tonsillar tissue in different parts of the tonsillar bed. Care is taken to adequately address the superior pole where the tissue can be easily missed in this approach. Visualization of this area is made using the laryngeal mirror if it is deep.

Coblation is carried on till all the crypts are flattened. If the indication is purely obstructive, then coblating all tonsillar tissues is not carried on, especially if the tonsil is quite embedded or the child is younger than 2y of age (parents are often concerned about immunity and ask to leave tonsillar tissues in place). Otherwise, the tonsillar tissue is coblated till the capsule is identified by its greyish color and care is taken to coblate and sometimes coagulate (denature) the islands of tonsillar tissue left behind. Hemostasis is achieved using the coagulation mode of the Coblator. We usually use the default setting of the Coblator (7 ablation, 4 coagulation), however a higher ablation setting is used (8 or 9) in case the tonsillar tissue is dense and the tonsil size is massive.

Extracapsular tonsillectomy

The preferred wand is PROCISE EZ wand as its flat surface makes it ideal for a clean dissection between the tonsillar capsule and the bed muscles. It is the preference of the senior author to use a lower ablation power of 4. Any encountered vessel or a bleeder is addressed using the coagulation mode.

We reviewed 345 patients, 208 M/137 F (1.5/1 = M/F), with a median age of 4.5y (range 11 months – 16.3y; mean 5.2y); 79.7% of them were younger than 7 years (Fig. 1). The patients presented mostly with upper airway obstructive symptoms; the various symptoms are summarized in Fig. 2. Only 39 patients had a formal sleep study done; with 33.3% having severe, 43.6% moderate and 23.1% mild OSA.

The patients had a median TSS of 4.5 (range 1–8; mean 4.1), with 87.5% having 3 or more symptoms at the time of presentation (Fig. 3). There was a significant negative correlation between the age of the patient and the degree of preoperative symptoms (p < 0.01).

Most patients had a diagnosis of adenotonsillar hypertrophy (89.9%), while only 12.5% had recurrent tonsillitis; in addition, 40.6% had middle ear effusion with 93.6% of them bilateral. Fifty-nine patients (17.1%) had comorbidities, such as having a syndromes (e.g. Down, Turner), hypotonia, reactive airway disease, cleft palate, cardiac problem, diabetes type 1, receiving growth hormone, autism, thalassemia, Familial Mediterranean Fever (FMF) and Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS).

Intracapsular tonsillectomy was performed in 86.7% of the studied children (299 patients), 9 did not have concomitant adenoidectomy. Of these children, 51 had an infective indication for tonsillar surgery. Only 13.3% (46 patients) had ECT (35 of them had an infectious indication) and 34.2% (118 patients) had grommets insertion at the same time. The comparison of preoperative and postoperative assessment of tonsils and adenoids is summarized in Table 1.

Table 1

Preoperative, intraoperative and postoperative assessment results, presented as percentage of patients
	G0 (%)	G1 (%)	G2 (%)	G3 (%)	G4 (%)
Tonsillar size
Preoperative assessment	0	0.9	7.5	40.3	51.3
Intraoperative assessment	0	0	1.8	43.6	54.6
Postoperative assessment (routine 1st follow up)	12.1	86.4	1.1	0.4	0
Postoperative assessment (extended follow up)	6.8	91.3	1.9	0	0
Adenoids’ degree of obstruction
Preoperative assessment	0	8.4	22	44	25.6
Intraoperative assessment	0	2.4	45.2	28.2	24.2
27.5% of the patients did not have an x-ray done

The postoperative course was smooth and uneventful in most of the patients with a median stay in hospital of 1 day (range 0–3, mean 1), (Fig. 4). No correlation was found between the age of the patient (p 0.221), the preoperative TTS (p 0.546), or the type of surgery (p 0.156) and the length of stay in the hospital.

Postoperative complications included secondary bleeding that occurred in 1.7% (0.7% in the ICT group) and respiratory distress (0.3%); 66.7% of the postoperative bleeding occurred in the patients who underwent ECT. No correlation was found between the age group and the occurrence of postoperative bleeding (p 0.097). None of the patients who had postoperative bleeding required admission to the hospital or control of bleeding in the operating room.

Routine postoperative follow-up (usually instructed to be in one month) occurred at a median of 35 days (range 5-1077, mean 65.6). The patients had a median persistent TSS score of 0.0 (range 0–7; mean 0.2); 88.2% had no symptoms, 7.6% had one symptom, 2.1% had 2 symptoms and 2.1% had 3 or more symptoms. The persistent symptoms were present in 33 patients (11.8%) at a median follow up of 37 days (Fig. 5).

As the coblation adenotonsillar surgery was a newly adopted technique at our division, we made sure to check for recurrence of symptoms at an extended follow-up and for any revision surgery that might have been performed at another facility. None of our patients needed revision tonsillar surgery, only one patient needed revision adenoidal surgery at a median follow up of 27 months (range 9–47, mean 26.6).

There was no correlation found between age and persistence of postoperative symptoms whether at first follow-up (p 0.951) or extended follow-up (p 0.978). The postoperative grading of the tonsils is summarized in Table 1. No patient had recurrent tonsillitis postoperatively both at short and long term follow up.

Coblation adenotonsillar surgery has been gaining its place as an alternative to conventional techniques among surgeons. In a prospective, randomized study by Babademez MA et al (2011), the coblation was compared to radiofrequency and laser in terms of postoperative recovery and recurrence rate [9]. Seventy-nine children aged 4–13 years with symptoms of tonsillar hypertrophy were included and randomized into 3 groups according to the treatment option. Pain was found to be the highest among the laser group with analgesic usage, return to normal diet and normal activity noted to be the lowest in the coblator group (p 0.0001). In addition, none of the coblator cases needed reoperation (vs. 21.4% in the radiofrequency, and 8.3% in the laser groups). This highlights the advantages of the coblator among the tools that avoid intraoperative blood loss (compared to the microdebrider).

Though the coblator is used for both ECT and ICT, the ICT is getting more attention in terms of its association with marked decrease in the rate of postoperative complications in both adults and children; namely postoperative bleeding and pain. In a series by Hoey AW et al (2017), 500 patients, (aged 6 months to 18 years, mean 5.1 years) undergoing ICT were analysed [10]. Most patients had upper airway obstruction symptoms (96%), but half of them had an infectious indication as well. Though a small group (3.6%) underwent ICT for a purely infective indication, the total number of patients who had a history of sore throat was large (246 patients), which challenged the concept of avoiding ICT in patients with history of recurrent tonsillitis. We had a much small group with tonsillitis but our positive results were similar. However, it is not clear if these patients that had a history of tonsilitis had simply viral infections or documented strep infections.

Our data showed marked improvement in the preoperative symptoms. Postoperatively, 33 patients had persistent symptoms with a median score of 0.0 (range 0–7; mean 0.2) at the initial routine follow up (median 37 days). All these patients had ICT with a mean preoperative TSS of 4.2; 21.2% of them had preoperative documented OSA and 15% had comorbidities. However, these symptoms faded away with time and only 8 patients had some symptoms at a median follow up of 27 months. One of these patients needed revision adenoidectomy.

The rate of postoperative bleeding reported by Hoey AW et al was 0.4% which is dramatically lesser than what is known for tonsillectomy; it was described as a small secondary hemorrhage occurring 6–7 days postoperatively and treated by conservative management only. This rate has been previously reported by Duarte VM et al (2014) who noticed a 0.48% prevalence of postoperative bleeding the ICT group compared to 3.61% in the ECT group, with 1.2% (5 patients) of them requiring management in the operating room (4 ECT patients) [11]. We have encountered a similar low rate among the ICT group (0.7%) and all the affected patients were managed conservatively.

The rate of recurrence has been reported to be 2.4% in Hoey AW et al series, mostly for obstructive indication (10/12 patients); majority in very young children. We did not encounter the need for revision tonsillar surgery in our series.

We perform our surgeries under magnification. The use of magnification (namely the microscope) was evaluated by Pang Y et al (2016) who concluded that it decreases the duration of hospital stay and the incidence of postoperative secondary haemorrhage, and results in an early improvement in postoperative pain scores. It is also useful for medical teaching [12].

The use of Coblation in intracapsular tonsillectomy is a very promising technique. It seems to alleviate the fear of post tonsillectomy bleeding, which has always been a nightmare for the patient, the parents and the surgeon. In addition, it provides an effective method to resolve the preoperative symptoms. Its role in patients with documented recurrent bacterial tonsillitis (not just the viral sore throat) needs further investigation to strongly support its promising use for such an indication.

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The National Prospective Tonsillectomy Audit. Final Report. (2005) Royal College of Surgeons of England.
Windfuhr JP (2013) Serious complications following tonsillectomy: how frequent are they really? ORL 75:166–173.
Sarny S, Habermann W, Ossimitz G, et al (2013) What lessons can be learned from the Austrian events? ORL 75:175–181.
Bitar MA, Rameh C (2008) Microdebrider-assisted partial tonsillectomy: short- and long-term outcomes. Eur Arch Otorhinolaryngol 265:459–463.
Stansifer KJ, Szramowski MG, Barazsu L, Buchinsky FJ (2012) Microdebrider tonsillectomy associated with more intraoperative blood loss than electrocautery. Int J Pediatr Otorhinolaryngol 76:1437–1441.
Friedman M, Tanyeri H, La Rosa M, Lansberg R, Vaidyanathan K, Pieri S, et al (1999) Clinical predictors of obstructive sleep apnea. Laryngoscope 109:1901–1907.
https://www.smith-nephew.com/professional/products/ear-nose-and-throat/tonsils--adenoids/
Babademez MA, Yurekli MF, Car BA, Gunbey E (2011) Comparison of radiofrequency ablation, laser and coblator techniques in reduction of tonsil size. Acta Otolaryngol 750:750–756.
Hoey AW, Foden NM, Hadjisymeou Andreou S, Noonan F, Chowdhury AK, Greig SR, Sproson EL, Allin D, Amin N, Wouters KM, Jonas NE, Tweedie DJ (2017) Coblation intracapsular tonsillectomy (tonsillotomy) in children: A prospective study of 500 consecutive cases with long-term follow-up. Clinical Otolaryngology 42:1211–1217.
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No competing interests reported.

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You are reading this latest preprint version

Coblation Adenotonsillar surgery: a game changer in decreasing postoperative complications while maintaining efficacy – an audit of 345 cases

Status:

Version 1

Abstract

Figures

Introduction

Materials And Methods

Operation

Intracapsular tonsillectomy

Extracapsular tonsillectomy

Results

Discussion

Conclusion

References

Additional Declarations

Status:

Version 1