Hot and Cold Tonsillectomies Have Different Advantages

The decision to perform a tonsillectomy remains one of contention among physicians treating children. Some believe that the surgery is unnecessary and can be traumatic, relying on antibiotics to reduce infectious swelling of the tonsils. However, this position is being undermined by the rise in antibiotic resistance and the new awareness of obstructive sleep apnea in children. This disorder in children, caused by enlarged tonsils, can lead to sleep disorders and a decline in academic performance in school.

Parents are again seeking surgical treatment for tonsillitis and pediatric obstructive sleep apnea. However, the choice of a surgeon is accompanied by the specialist's preferred choice of procedure. The two most common surgical treatments are cold knife dissection, i.e. use of a scalpel, and monopolar cautery dissection, cauterization with a medical device applied to remove tissue with an application of heat to prevent hemorrhage.

This study examined the existing medical literature comparing the two procedures. The criteria included resulting pain, morbidity, operative time, and intraoperative time from the two different methods. The review of the literature revealed that previous studies exploring the two procedures utilized small sample sizes and had not accounted for confounding variables, such as whether patients received the same post-operative pain medication or if some had received pain medicines that potentially increase bleeding rates, suggesting that an optimum future study would increase sample size and eliminate the confounding factors.

The authors of the study, "Hot vs. Cold Knife Tonsillectomy: A Review of the Literature" are Sandra Lin MD, Robert Leinbach MD, Jerry A. Colliver PhD, and Stephen Markwell, all from the Division of Otolaryngology, Southern Illinois University School of Medicine, Springfield, IL. Their findings were presented at the Annual Meeting and OTO EXPO of the American Academy of Otolaryngology--Head and Neck Surgery Foundation, held September 22-25, 2002, at the San Diego Convention Center, San Diego, CA.

Methodology: The Medline database was searched using the keywords tonsillectomy, hot, cold, sharp, bleeding, and cautery in combinations. Six of the 815 articles identified met selection criteria. Selected studies were prospective trials comparing electrodissection versus cold knife dissection on post-tonsillectomy pain and hemorrhage. Four studies used a paired design in which patients were their own control (one tonsil removed by each method). Two other studies used an unpaired design in which patients had both tonsils removed by one method.

Results: Pooled data for the paired studies showed significantly more patients with pain worse with electrodissection (148 of 293, 51 percent) than cold-knife (33 of 293, 11 percent) on post-operative day seven. On post-operative day 14, two of the paired studies reported more patients with worse pain, electrodissection, but this was not significantly different (15 percent vs. seven percent). For the two unpaired design studies, one showed significantly more analgesic doses following surgery with electrodissection; the other revealed higher pain scores for adults undergoing electrodissection, but no difference for children. Across all studies, very few patients had post-operative bleeding, and there were no meaningful differences between methods.

Conclusions: The study found patients undergoing cold steel tonsillectomy have less pain than patients undergoing electrocautery when followed up to two weeks. However, intraoperative blood loss and operative time (and for the patient, this means the time they are under anesthesia) are decreased cautery tonsillectomy. Electrodissection increases pain in comparison to cold knife dissection for tonsillectomy. Post-operative hemorrhage rates are not significantly different when comparing the two methods.