Parents who elect to have their children undergo a tonsillectomy look for a procedure that is safe, painless, bloodless, atraumatic, and hopefully pain free in the post-operative period.
Years ago, the procedure most performed to remove the tonsils was "cold" sharp dissection, the use of a scalpel. Today, a great number of surgeons have adopted the monopolar cautery (MPC) tonsillectomy, which allows enhanced speed and minimal blood loss. A pediatric otolaryngologist and a research scientist have made their case that the next stage for the tonsillectomy will be the use of the contact diode laser (CDL). The CDL provides laser light from a solid state laser diode at a wavelength of 810 nm (near infrared) delivered through the tip of a flexible optical fiber. The fiber is manipulated with a hand piece used as a normal scalpel to dissect tissues.
The otolaryngologist, who had performed tonsillectomies with both the MPC and CDL techniques, set out to compare the efficacy of the two procedures and benefits to the patients in collaboration with the scientist. The authors of the study, "Contact Diode Laser Tonsillectomy in Children," are Riccardo D'Eredita MD, from the Department of Otolaryngology--Head and Neck Surgery, Vicenza Civil Hospital, Vicenza, Italy; and Roger R. Marsh PhD from the Department of Pediatric Otolaryngology, The Children's Hospital of Philadelphia, Philadelphia, PA. Their findings are to be presented at the Annual Meeting and OTO Expo of the American Academy of Otolaryngology--Head and Neck Surgery Foundation, September 22-25, 2002, at the San Diego Convention Center, San Diego, CA.
Methodology: This prospective, single blinded study was conducted between January 8, 2001, and January 9, 2002, at a tertiary care pediatric institution. Fifty-eight pediatric patients undergoing tonsillectomy only -- without adenoidectomy -- were included. The same surgeon performed all the tonsillectomies; assignment to the monopolar cautery and contact diode laser groups was random.
MPC patients had their anterior tonsillar pillar mucosa incised with a flat-tipped electrocautery blade, electrically insulated down to the tip. The dissection proceeded along the plane of the tonsillar capsule, and suction spot cautery was applied to any remaining bleeding sites. Laser tonsillectomy was performed in the same fashion, with the only difference being the use of a CDL probe. No course of antibiotics was prescribed following the surgery; all patients were treated on an inpatient basis.
The Wong-Baker FACES pain scale was provided to the families to assess pain severity after surgery. For ten days, pain was measured after waking up, before breakfast, and prior to drug administration; parents of patients were also asked to record information on medication, diet, voice and activity.
Results: Twenty-eight MPC and 30 CDL tonsillectomies were performed for obstructive tonsillar hypertrophy and/or recurrent tonsillar infections during the 12-month testing period. The median patient age was five years, ranging from two to eight. Key findings included:
* Mean pain scores were consistently lower for the CDL group than for the MPC patients. By the third day after surgery, most CDL patients had scores of no pain or "hurts a little."* The difference in pain was reflected in reduced medication requirements for the CDL group. Because analgesic medication was on a fixed regimen for both groups through day 4, days 5 -- 10 were assessed. The CDL group averaged 0.24 doses of acetaminophen compared to 1.20 doses for the MPC group.* Multiple awakenings during the evening are used as a measure of discomfort. The CDL group had an average of 0.9 nights with more than one awakening; the corresponding rate for the MPC group was 3.7 nights.* The differences in changes in voice and intraoperative blood loss between the two groups were not statistically significant.
Experimental studies with a CO2 laser suggest that when used in surgery, small blood vessels are photocoagulated along with the sealing of lymphatics and nerve endings fibers. This sealing action of laser light may play a role in the minimal pain endured by the CDL group. Additionally, the small CDL delivery fiber -- one mm fiber diameter with a 0.3 mm tip diameter -- provides little scattered radiation, with a "near field" delivery of laser light. With a wavelength of 810 nm, there is excellent absorption by hemoglobin, contributing to effective coagulation without the need for high power rates. On the other hand, standard MPC thermal energy is delivered with a more diffuse fashion, possibly causing more tissue damage and a higher level of postoperative pain.
Conclusions: The researchers believe that tonsillectomies incorporating laser technology provide significantly less pain during the postoperative recovery of children, resulting is less sleep disturbance, decreased morbidity, and less need for medications.
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