Newswise — A new study has determined that radiofrequency (RF) is an effective and safe treatment for chronic tonsillitis, producing little pain and discomfort and few side effects. Prior to this study, the procedure was primarily used for reduction of enlarged tonsils.
Background: More than 400,000 tonsillectomies are performed yearly in the United States making it one of the most commonly performed operations. This surgery historically has been performed with a diagnosis of chronic infections (defined as three months of tonsil inflammation), recurrent acute episodes of tonsillitis, and a history of peritonsillar abscess (PTA). In the last decade, a diagnosis of enlarged tonsils, with or without obstructive sleep apnea, has often resulted in removal of the tonsils.
Conventional tonsillectomy using cold knife, electrocautery, or coblation has well-known risks and complications. These conventional tonsillectomy techniques have changed little over the last fifty years, all result in prolonged postoperative pain and have significant morbidity. Consequently, a number of new modalities have been introduced recently in an effort to decrease morbidity and improve on this prolonged postoperative recovery. RF treatment for enlarged tonsils and shrinkage of other oropharyngeal tissues is now being performed with some regularity. The basic principles of RF differ from conventional excisional surgical techniques in that tissues are reduced in size by delivering low temperature (60-850C) energy to dissociate tissue bonds resulting in resorption of tissue over an 8 to 12 week period. The primary advantage is that there is less postoperative pain due to the absence of an open wound requiring mucosalization for complete healing. More importantly, there is the potential to decrease the risk of post-tonsillectomy hemorrhage and dehydration, and the amount of recovery time needed before returning to work or school. After using a dual blunt-tipped probe for temperature-controlled RF tonsil ablation (TCRF-TA) in patients with enlarged tonsils, researchers noted significant symptomatic improvement in patients incurring chronic tonsillitis. This included a decrease in sore throat symptoms and a decrease in the use of antibiotics. This particular observation led the researchers to explore an expanded scope of indications for TCFR-TA for not only tonsillar hypertrophy (enlarged tonsils) but chronic tonsillitis as well. No previous studies have addressed the role for TCRF-TA in patients with chronic tonsillitis.
This current study set out to 1) characterize the outcomes of TA using TCRF technology; 2) identify potential complications; and 3) develop treatment parameters which could be applicable to all patient populations with appropriate indications for tonsillectomy. The authors of "A Long-Term Review of Low-Temperature RF Tonsillectomies," are Marc M. Kerner, MD, FACS from the Northridge Hospital Medical Center, Northridge; Specialty Surgical Center of Encino, and the Department of Surgery, Division of Head and Neck Surgery, David Geffen School of Medicine, University of California, Los Angeles, all in California; and Kim Silva, from UCLA. Their findings will be presented September 24, 2003, at the American Academy of Otolaryngology—Head and Neck Surgery Foundation (http://www.entnet.org) Annual Meeting and OTO EXPO, September 21-24, 2003, at the Orange County Convention Center, Orlando, FL.
Methodology: This study reviewed 85 consecutive RF-TA procedures using temperature-controlled RF energy. The patients were non-randomized and all patients enrolled met criterion for tonsillectomy. Patients diagnosed with chronic tonsillitis had either three months of continuous symptomatic episodes of throat discomfort, repeated positive Streptococcal cultures, more than five recurrent acute episodes of tonsillitis in the preceding year or a history of recent peri-tonsillar or parapharyngeal abscess.
Patients with obstructive tonsillar hypertrophy or frank obstructive sleep apnea with tonsillar enlargement all had symptoms including loud snoring, witnessed gasping or apneic events, or daytime somnolence. All adults with sleep-disordered breathing underwent a sleep study; parents of pediatric patients who otherwise would have undergone conventional electrocautery tonsillectomy and adenoidectomy were offered RF tonsillectomy with standard adenoidectomy, which was performed with curettes and suction cautery.
Patients with suspected tonsil malignancies, patients less than three years of age, and those that refused to participate in the study were excluded. All patients, parents or guardians were fully informed of the risks, benefits and alternatives to conventional and TCRF tonsillectomy.
Results: In this study, the mean age of all patients was 28.3 ± 15.2 years. Mean follow-up for all patients was 17.4 months. There were 12 pediatric patients treated aged between four and 12 years old (mean 7.83 ± 2.5 years with follow-up of 18 ± 9.2 months). Adult patients had a mean age of 31.8 ± 13.7 years with a mean follow-up of 17.3 ± 12.9 months.
Overall mean energy in joules delivered per tonsil was 2603 ± 357.8 joules. This varied slightly between the adult (2635 ± 346 joules) and pediatric group (2412 ± 381 joules). Blood loss for TCRF-TA was negligible. Bleeding associated with concomitant adenoidectomy was less than 20 mls. Two adult patients experienced transient oropharyngeal blood upon coughing out some sloughed tonsil tissue around the sixth postoperative day, however, in both cases this resolved without any intervention other than salt water swishes. There were no post-treatment hemorrhages requiring re-operation or cautery in the office. Other findings included:
"¢ Tonsil size reduction was noted in all treated patients. Both the patients and physician noted initial effects beginning at approximately two weeks, and continued shrinkage was noted to occur up to nine months in some patients
"¢ All patients were given narcotic pain medication for postoperative pain control. Most patients or parents reported that narcotic pain medication use was limited to the first 24 hours and in some cases up to 72 hours, but the vast majority reported that they switched to either acetaminophen or non-steroidal anti-inflammatory medications within the first 24 to 48 hours. Patients treated for chronic infections, sore throat symptoms, and post-PTA were asked to rate their symptoms at six-month follow-up. All noted a significant reduction in the number of sore throats, use of antibiotics, and snoring.
"¢ Patients with snoring as a significant complaint pre-treatment reported that there was a significant reduction post-treatment.
"¢ Two adult patients reported severe dysguesia beginning in the first postoperative week. Both resolved completely within six months. Eleven patients were treated with local anesthesia only, including the three patients requiring re-treatment. All tolerated the procedure without any complications or significant discomfort.
Conclusions: This study set out to assess patients with a wider range of indications than hypertrophy, primarily patients with chronic infections, and secondarily, patients with sleep disordered breathing. Prior to this study there had been no published reports on patients treated for chronic infections, or whether patients could be successfully treated with TCRF-TA after a prior peritonsillar or parapharyngeal abscess.
Overall, 92 percent (77/83) improvement in tonsil symptoms was found in those treated with TCRF-TA after a single treatment session. There were no major complications such as hemorrhage, dehydration, readmission, prolonged use of narcotic pain medication (greater than seven days) or significant disability. Most patients noted that they would readily undergo this procedure again and would recommend it to others. Three adult patients requiring repeat treatment were successfully re-treated under local anesthesia. Even though there were increased costs associated with this additional procedure, the morbidity remained low and all three returned to work the following day, and none required narcotic pain medication.
The researchers believe that TCRF-TA is a treatment that has demonstrable benefits over conventional tonsillectomy methods. They suggest the time has come for a series of cogent, properly designed controlled, randomized studies to assess whether long-term outcomes differ between conventional techniques and TCRF-TA.
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