RSS Channels IndexFor Tonsil Removal, the Microdebrider Fares Better than Electrocautery
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Source: American Academy of Otolaryngology Head and Neck Surgery (AAOHNS)
Newswise — A tonsillectomy is one of the oldest and most commonly performed operations in the pediatric population. Though down from its peak in 1959, when some 1.4 million operations were carried out, approximately 300-400,000 tonsillectomies in the US are still performed each year in hospitals and ambulatory surgical centers. It is estimated that more than $500 million are spent yearly on adults and children undergoing surgical removal of tonsils and adenoids.
Chronic tonsillitis or recurrent strep tonsillitis used to be the primary indication for tonsil removal. However, in the past 20 years, obstructive sleep disorders have surpassed infected tonsils as the primary reason for tonsillectomy in children. Consequently, young children with upper airway obstruction have become more frequent candidates for adenotonsillar surgery. Although removing tonsils and adenoids may be performed safely in young children on an outpatient basis, the risks of bleeding, dehydration, and poor oral intake are more critical in smaller patients. This makes the requirement that postoperative pain and bleeding risk are minimized.
Past clinical research has focused on relieving postoperative distress to the patient and his or her family. Pain, oral intake, and hemorrhage are the most common measures observed. Published data have suggested that electrocautery tonsillectomy, -(removal of the tonsils through cauterizing the plane of tissue between the tonsillar capsule and the underlying muscles), results in a slight delay in recovery in children when compared to the use of a scalpel, though there is far less bleeding during the procedure.
A technique that has been recently been reintroduced is the intracapsular or "partial" tonsillectomy, performed with a microdebrider. The microdebrider is a powered instrument connected to suction and irrigation that has a very small rotating tip. Previously it has most commonly been used in surgery of the sinuses. The surgeon uses the microdebrider to precisely remove greater than 95 percent of the tonsils, leaving a thin layer of connective tissue intact to protect the throat muscles, which helps reduce postoperative pain and recovery time. In other studies, instruments such as the harmonic scalpel, radiofrequency alablation, coblation, and the carbon dioxide laser have been used for the tonsillectomy but have not been shown to be significantly more efficient or cost-effective when compared to electrocautery or cold-dissection techniques.
In a new study, researchers compared intra-operative and postoperative outcomes among children with obstructive sleep disorders caused by enlarged tonsils who were randomized to undergo either traditional electrocautery tonsillectomy or powered intracapsular tonsillectomy. The authors of "Post-Tonsillectomy Morbidity and Quality Of Life In Pediatric Patients With Obstructive Tonsils And Adenoid: Microdebrider vs Electrocautery" are Craig S Derkay MD, David H Darrow MD DDS, Camille Welch MPH and John Sinacori MD, from the Departments of Otolaryngology Head Neck Surgery and Biostatistics, at the Eastern Virginia Medical School in Norfolk, VA. Their findings are to be presented at the 109th Annual Meeting & OTO EXPO of the American Academy of Otolaryngology—Head and Neck Surgery Foundation, being held September 25-28, 2005, at the Los Angeles Convention Center, Los Angeles, CA.
Methodology: Children over the age of two undergoing tonsillectomy primarily for enlarged tonsils were in the study. The test subjects were randomized into two groups, one to have a traditional tonsillectomy performed by low-wattage electrocautery and the other an intracapsular tonsillectomy using the microdebrider. After induction, all patients in both groups were administered intraoperative antibiotics , corticosteroids and pre-and post-incisional bupivicaine and had their pain managed utilizing a standardized protocol.
Operative time, total surgical time, and total times in operating room were recorded as were the intra-operative blood loss. Postoperative morbidity was assessed by the child's caretaker every 12 hours for 14 days after surgery and recorded in a take-home diary that documented the following: the child's pain level, dosing of pain medication, time of return to normal activity, and time of return to normal diet. A validated quality of life survey was also administered preoperatively and one month postoperatively.
Results: Three hundred children and their families completed the study, 150 in the microdebrider group and 150 in the electrocautery group.
The researchers found a statistically and clinically significant advantage in the use of the microdebrider in comparison to low wattage electrocautery in children with obstructive enlarged tonsils. With equivalent demographics, children who underwent microdebrider tonsillectomy experienced less pain in the peri-operative period. Microdebrider patients took 2.5 fewer days to need no further pain medication, and were nearly three times more likely to no longer need pain medication 3 days after surgery and 2.5 times less likely to be still taking pain medication seven days post-operatively compared to those having electrocautery tonsillectomy. Microdebrider patients also required less time (2.5 days versus four days) to resume their normal activities and were nearly twice as likely to be at a normal activity level three days after surgery than their electrocautery counterparts.
Using a previously validated quality of life instrument, they found that the children who underwent microdebrider tonsillectomy experienced less emotional distress and fewer limitations on their activities in the first four weeks post-op when compared to the electrocautery patients. Both groups demonstrated equivalent and very significant improvements in physical suffering, sleep disturbance, speech and swallowing problems and caregiver concerns. Parents were satisfied at four weeks post-op regardless of the tonsillectomy procedure but were more satisfied in the microdebrider group.
Surgical times differed by only two minutes favoring the electrocautery procedure and there was no significant difference in operative blood loss. Re-bleed rates and rates of dehydration requiring a return to the hospital were equivalent.
Conclusions: This is the largest, prospective, blinded, randomized, controlled, clinical trial demonstrating improved outcomes with intra-capsular microdebrider tonsillectomy compared to low-wattage electrocautery for the treatment of obstructive enlarged tonsils and adenoids.
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