2. īŽ History
īŽ Indications
īŽ Innovative Techniques and Comorbidites
ī¨ Intracapsular tonsillectomy
ī¨ Harmonic scalpel
ī¨ Laser
ī¨ Coblation
īŽ Adjuvant Therapy
ī¨ Local Anesthesia: Bupivacaine
ī¨ Perioperative Dexamethasone
ī¨ Postoperative Antibiotics
īŽ Current Practice Patterns
3. History
īŽ Aulus Cornelius Celsus
ī¨ 1st
Century AD
ī¨ âthe tonsils are loosened by scraping around them and
then torn outâ with a finger
ī¨ Used vinegar and medication for postoperative hemostasis
īŽ Aetius of Amida
ī¨ 6th
Century AD
ī¨ Hook and knife method
īŽ Philip Syng Physick (âFather of American surgeryâ)
ī¨ First to develop the tonsillotome
īŽ Mackenzie
ī¨ Late 1800s
ī¨ Made tonsillotome use common
4. īŽ Partial versus complete tonsil removal
ī¨ 1906 William Lincoln Ballenger recommended
complete removal of tonsil with the capsule intact
ī¨ 1909 George Ernest Waugh credited as first to
describe complete tonsillectomy
īŽ 1911-1917 Crowe reviewed 1000 tonsillectomies
ī¨ Use of Crowe-Davis mouth gag
ī¨ Sharp dissection
History
5. īŽ In U.S.
ī¨ 1959: 1.4 million tonsillectomies performed
ī¨ 1979: 500,000
ī¨ 1985: 340,000
ī¨ 1996: 287,000
īŽ In 1950s and 1960s chronic infection primary
surgical indication
īŽ Now, airway obstruction and obstructive sleep
apnea more common indications
ī¨ Improvement in medical management with Abx
History
6. Indications
īŽ AAO-HNS
published
guidelines in 1995
Clinical Indicators
Compendium
īŽ Tonsillar disease
refractory to
medical therapy
īŽ 3/+ infections/year
īŽ Hypertrophy
ī¨ Dental malocclusion
ī¨ Orofacial growth affected
ī¨ Upper airway obstruction
ī¨ Dysphagia
ī¨ Sleep disorders
ī¨ Cardiopulmonary complications
īŽ Peritonsillar abscess
īŽ Halitosis due to chronic tonsillitis
īŽ Chronic/recurrent tonsillitis with Strep
carrier state
īŽ Unilateral hypertrophy, presumed
neoplasm
American Academy of Otolaryngology-Head and Neck Surgery: 1995 Clinical indicators
compendium, Alexandria, Virginia, 1995, American Academy of Otolaryngology-Head and Neck
Surgery
7. Indications
īŽ Paradise et al, 1984
ī¨Parallel randomized and
non-randomized clinical
trials to evaluate the
efficacy of tonsillectomy in
the pediatric population
with recurrent pharyngitis
8. īŽ Criteria
ī¨ 7/+ episodes in last 1 year
ī¨ 5/+ episodes in last 2 years
ī¨ 3/+ episodes in last 3 years
īŽ Clinical features of each episode
ī¨ Fever
ī¨ Lymphadenopathy
ī¨ Tonsillar/pharyngeal exudate
ī¨ Positive Ã-hemolytic streptococcus test
ī¨ Medically treated
Paradise et al
9. īŽ Paradise conclusions
ī¨Tonsillectomy was efficacious for 2 years and
possibly a third in reducing frequency and
severity of subsequent episodes
īŽ Paradise criteria adopted by many
otolaryngologists
Paradise et al
10. īŽ Paradise et al, 2002
ī¨ 2 parallel randomized controlled trials to evaluate
efficacy of tonsillectomy in moderately affected
children
ī¨ Surgical criteria not as stringent as those in previous
study
ī¨ Results
īŽ Incidence of subsequent pharyngitis in surgical groups
significantly lower than control group for 3 years
postoperatively
īŽ However, overall incidence of recurrence was low
ī¨ Concluded that surgical criteria must remain stringent
14. īŽ Statistically significant results
ī¨ Intracapsular group had lower pain scores at each postoperative
time interval: POD 1-3, 4-6,7-9, after 9
ī¨ Intracapsular group had earlier return to normal activity
ī¨ Intracapsular group had less analgesic use
īŽ Conclusions
ī¨ Tonsil capsule is not violated thereby avoiding pharyngeal muscle
exposure to secretions, injury, and inflammation
ī¨ As a result, postoperative pain and recovery time reduced
īŽ Weaknesses
ī¨ Retrospective study: Recall bias
ī¨ Tonsillar regrowth
ī¨ Surgical experience
Koltai et al.
15. īŽ Sorin et al., 2004
ī¨Retrospective review with follow up (278)
ī¨11 Complications (3.9%)
īŽ 9 with tonsillar regrowth with snoring
ī¨ 2 required completion tonsillectomy
īŽ 1 with immediate self-limited bleeding
īŽ 1 with delayed bleeding
Complications of Intracapsular
Tonsillectomy
16. Sorin A et al: Complications of microdebrider-assisted powered intracapsular tonsillectomy
and adenoidectomy. Laryngoscope 114:297-300, 2004.
Sorin et al.
17. Intracapsular Tonsillectomy in
Children Under 3 Years
īŽ Bent et al., 2004
ī¨ Retrospective cohort
study (226)
ī¨ 36 patients < 36 mo
ī¨ 186 patients > 36
mo
Bent et al: Ambulatory powered intracapsular tonsillectomy and adenoidectomy in children
younger than 3 years. Arch Otolaryngol Head Neck Surg 130:1197-1200, 2004.
18. īŽ Conclusions
ī¨Intracapsular tonsillectomy is safe and
efficacious in children under 3 years for
tonsillar hypertrophy and sleep disordered
breathing without need for admission
īŽ Limitations
ī¨Retrospective study
ī¨Uneven distribution
ī¨Long term results of tonsillar regrowth
unknown
Bent et al.
19. Harmonic Scalpel Tonsillectomy
īŽ Ultrasonic dissector and coagulator
īŽ Vibratory energy
ī¨Cutting: sharp blade with frequency of 55.5
kHz over distance of 80 Îŧm
ī¨Coagulating: vibration breaks H-bonds,
thermal energy
īŽ 50° â 100° C
īŽ Electrocautery 150° â 400° C
20. īŽ Willging et al., 2003
ī¨ Single-blind, randomized prospective study (117)
īŽ Harmonic scalpel versus electrocautery
ī¨ Indications: recurrent infection and hypertrophy with
airway obstruction
ī¨ Outcomes measured: intraoperative bleeding,
operative time, postoperative hemorrhage
ī¨ Questionnaire used for assessment of postop pain,
ability to eat and drink, and level of activity
Harmonic Scalpel Tonsillectomy
21. īŽ Operative time statistically significant
ī¨ Harmonic scalpel 8 min 42 sec
ī¨ Electrocautery 4 min 33 sec
īŽ No significant difference in intraoperative blood
loss and postoperative ability to eat and drink
īŽ Level of activity for the first postop day
significantly lower in harmonic scalpel group
īŽ Postoperative pain scores tended to be lower in
harmonic scalpel group
īŽ Postoperative bleeding
ī¨ Harmonic scalpel: 6
ī¨ Electrocautery: 3
ī¨ Not statistically significant
Willging et al
22. Laser Tonsillectomy
īŽ Kothari et al, 2002
ī¨ Prospective double-blind randomized controlled trial
(151)
īŽ Compare the use of KTP laser tonsillectomy versus cold
dissection and snare
ī¨ KTP 532 laser at 10W, continuous beam
ī¨ Outcomes measured
īŽ Operative time
īŽ Operative bleeding
īŽ Postoperative pain
īŽ Postoperative advancement to diet
23. īŽ Results
ī¨ Operative time:
īŽ Laser 12 min
īŽ Dissection 10 min
īŽ Not statistically significant
ī¨ Intraoperative blood loss
īŽ Laser 20 mL
īŽ Dissection 95 mL
īŽ Statistically significant
ī¨ Laser group with higher postop pain scores
ī¨ Laser group with greater difficulty resuming postoperative diet
ī¨ Readmission for delayed hemorrhage was 8% in the laser group
and 4% in the dissection group
īŽ Not statistically significant
Kothari et al
24. Kothari et al
Kolthari P et al: A prospective double-blind randomized controlled trial comparing the
suitability of KTP laser tonsillectomy with conventional dissection tonsillectomy for day
case surgery. Clin. Otolaryngol. 27:369â373, 2002.
25. īŽ Conclusion
ī¨KTP laser provides little benefit over
dissection tonsillectomy except to minimize
intraoperative bleeding
īŽ Limitations
ī¨Technical expertise
ī¨Electrocautery not included
Kothari et al
26. Coblation Tonsillectomy
īŽ Bipolar radiofrequency energy transferred to
sodium molecules to create an ion or plasma
field
īŽ This thin layer of plasma is utilized to ablate
tissues at molecular level
īŽ No need for electrocautery for hemostasis
īŽ Temperature from 40° to 85° C
īŽ Electrocautery at 20W: above 400° C
27. īŽ Chang et al, 2005
ī¨Prospective randomized double-blinded
controlled study (101)
ī¨Compared intracapsular tonsillectomy using
coblation versus traditional subcapsular
tonsillectomy in children
īŽ OSA
īŽ Sleep disordered breathing
Coblation Tonsillectomy
28. īŽ Coblation
ī¨ From surface out laterally
ī¨ Coblate 9 setting to ablate tissues
ī¨ Coblate 5 setting to coagulate
ī¨ Capsule not penetrated
īŽ Electrocautery
ī¨ Bovie set to 20 W
īŽ Outcomes measured
ī¨ Questionnaire
īŽ Pain
īŽ Analgesics
īŽ Nausea/vomiting
īŽ Diet
īŽ Activity
ī¨ Complications
Chang et al
29. Chang et al
Chang KW: Randomized controlled trial of coblation versus electrocautery tonsillectomy.
Otolaryngol Head Neck Surg 132:273-280, 2005.
30. Chang et al
Chang KW: Randomized controlled trial of coblation versus electrocautery tonsillectomy.
Otolaryngol Head Neck Surg 132:273-280, 2005.
31. Chang et al
Chang KW: Randomized controlled trial of coblation versus electrocautery tonsillectomy.
Otolaryngol Head Neck Surg 132:273-280, 2005.
32. Chang et al
Chang KW: Randomized controlled trial of coblation versus electrocautery tonsillectomy.
Otolaryngol Head Neck Surg 132:273-280, 2005.
33. īŽ Weaknesses
ī¨ Study compares intracapsular technique with
subcapsular technique
īŽ Capsule and therefore underlying pharyngeal tissues not
violated
ī¨ Does not account for possible long term possibility of
tonsillar regrowth
īŽ Similar study performed by Chan et al, 2004
īŽ Stoker et al, 2004 performed similar study but
used coblation for blunt dissection to perform
total tonsillectomy
īŽ Chan and Stoker had similar results in reduction
of postoperative morbidity
Chang et al
34. Coblation Tonsillectomy
īŽ Future considerations
ī¨To evaluate coblation for
intracapsular tonsillectomy,
a fair study would use
another intracapsular
technique such as power-
assisted tonsillectomy with
a microdebrider
35. Adjuvant Therapies
īŽ Aims are to reduce comorbidities of
tonsillectomy
ī¨ Reduce pain
ī¨ Reduce nausea
ī¨ Resume diet
ī¨ Resume activity
ī¨ Reduce overall postoperative cost
īŽ Local Anesthetic: Bupivacaine
īŽ Steroids: Dexamethasone
īŽ Postoperative Antibiotics
36. Local Anesthetic
īŽ Tonsils innervated by:
ī¨Tonsillar branches of glossopharyngeal nerve
ī¨Palatine nerves of V2
ī¨Lingual branches of V3
īŽ Bupivacaine: amide anesthetic
ī¨High lipid solubility and protein binding
ī¨Rapid onset with effect lasting 6-9 hours
37. īŽ Violaris and Tuffin, 1989
ī¨Prospective double-blind controlled trial to
evaluate the application of topical bupivacaine
versus saline following tonsillectomy in the
same patient
ī¨The side treated with bupivacaine had higher
pain scores than saline
Local Anesthetic
38. īŽ Nordahl et al, 1999
ī¨ Prospective double-blind randomized trial with three
treatment arms, intraoperative injections
īŽ 42 with saline (9mg/ml)
īŽ 41 with saline (9mg/ml) and epinephrine (5Îŧg/ml)
īŽ 43 with bupivacaine (2.5mg/ml) and epinephrine (5Îŧg/ml)
īŽ Injections in tonsillar pillars and uvula
ī¨ Postoperative pain scores recorded at varying
intervals
ī¨ Varying experience of otolaryngologist performing
injection and tonsillectomy
Local Anesthetic
39. Nordahl et al
Nordahl SHG, Albrektsen G, Guttormsen AB, Pedersen IL, Breidablikk H-J. Effect of bupivacaine on
pain after tonsillectomy: a randomized clinical trial. Acta Otolaryngol (Stockh) 119:369â376, 1999.
40. īŽ Results
ī¨ Only statistically significant pain score was with
swallowing (without food) in the bupivacaine and epi
group
ī¨ Patients treated by experienced otolaryngologist in
the bupivacaine and epi group had lowest pain scores
ī¨ Patients treated by less experienced otolaryngologists
in the bupivacaine and epi group had highest pain
scores
ī¨ No difference in analgesic consumption among
groups
īŽ Limitations
ī¨ Technique not specified for tonsillectomy
ī¨ Number of patients treated by experienced or less
experienced otolaryngologists not specified
Nordahl et al
41. īŽ Kountakis et al, 2002
ī¨Prospective randomized blinded and
controlled study in adults (34)
ī¨10 mL 0.5% bupivacaine vs 10 mL NS
ī¨Electrocautery tonsillectomy
ī¨Daily questionnaires for 10 days
īŽ Pain score
īŽ Analgesic required
īŽ Oral intake
Local Anesthetic
42. Kountakis SE: Effectiveness of Perioperative Bupivacaine
Infiltration in Tonsillectomy Patients. Am J Otolaryngol 23:76-80,
2002.
Kountakis et al
43. īŽ No significant difference in pain, analgesic
use and oral intake among groups
īŽ Bupivacaine group more comfortable in
initial period following tonsillectomy
ī¨Significant variation in pain score when
bupivacaine wore off
Kountakis et al
44. Intraoperative Steroids
īŽ Systemic corticosteroids known
for mood elevation, appetite
stimulation, anti-inflammatory and
antiemetic effect
ī¨Used during chemotherapy to treat
nausea
ī¨Exact antiemetic mechanism
unknown
īŽ Dexamethasone
ī¨Half-Life 36 â 72 hours
ī¨Low cost $0.25/4mg
45. īŽ Steward et al, 2001
ī¨Meta-analysis of 8 double-blinded randomized
controlled trials using dexamethasone for
children undergoing tonsillectomy
ī¨Outcomes measured
īŽ Postoperative emesis
īŽ Return to soft or solid diet
īŽ Postoperative pain
ī¨Single dose 0.15 â 1.0 mg/kg
ī¨Sensitivity analyses performed
Intraoperative Dexamethasone
46. Steward et al
Steward et al: Do steroids reduce morbidity of tonsillectomy? Meta-analysis of randomized
trials. Laryngoscope 111:1712-1718, 2001.
47. īŽ Postoperative pain was not analyzed
ī¨Missing data and different measurements
īŽ No adverse events from Dexamethasone
īŽ Strength
ī¨Sensitivity analyses
ī¨Dose recommended 1 mg/kg
īŽ Weakness
ī¨Cannot be generalized to adult population
Steward et al
48. īŽ Carr et al, 1999
ī¨Double-blind randomized controlled trial (34)
ī¨Adults undergoing electrocautery
tonsillectomy
ī¨Dexamethasone (20mg) vs. saline
ī¨Outcomes measured
īŽ Postoperative pain
īŽ Analgesic use
Intraoperative Dexamethasone
49. Carr et al
Carr MM et al: Effect of steroids on posttonsillectomy pain in adults. Arch
Otolaryngol Head Neck Surg 125:1361-1364, 1999.
A
M
P
M
C
o
d
e
i
n
e
A
c
e
t
a
m
50. īŽ Although the dexamethasone group had
lower pain scores this was not statistically
significant
īŽ No difference in groups for number of
days off of work or to return to normal diet
īŽ Dexamethasone group tended to require
less analgesia but not statistically
significant for 10 days postoperatively
Carr et al
52. īŽ Telian et al, 1986
ī¨Randomized controlled trial to evaluate the
effect of ampicillin on recovery from
tonsillectomy in children
ī¨Ampicillin group had significantly fewer fevers,
improved oral intake, and had fewer days to
return to normal activity
Postoperative Antibiotics
53. īŽ Colreavy et al, 1999
ī¨Randomized controlled trial in children(78)
ī¨Amoxicillin/clavunanic acid
ī¨Outcomes measured:
īŽ Bacterial profiles
īŽ Postoperative pain scores
īŽ Days to normal diet
īŽ Analgesic use
Postoperative Antibiotics
54. Colreavy et al
Colreavy MP et al: Antibiotic prophylaxis post-tonsillectomy: is it of benefit? Int J Ped Otorhino
50:15-22, 1999.
55. īŽ OâReilly et al, 2003
ī¨ Randomized double-blinded controlled trial of the
effect of antibiotics in adults following tonsillectomy
ī¨ Study group given intraoperative and postoperative
antibiotics while control group did not receive any
ī¨ Outcomes measured
īŽ Postoperative bleeding
īŽ Postoperative pain
īŽ If PCP was contacted following surgery for pain/antibiotics
Postoperative Antibiotics
56. īŽ Results
ī¨ Antibiotic administration had no influence on
postoperative pain and bleeding in adults
īŽ Weaknesses
ī¨ Tonsillectomy technique not standardized
ī¨ Recall bias
īŽ Patients questioned at follow-up or by mailed questionnaire
ī¨ High drop out rate
ī¨ High delayed hemorrhage in both groups (24%)
OâReilly et al
57. Current Practice Patterns
īŽ In 2004, Krishna et al. conducted a 13
question survey of AAO-HNS members
regarding tonsillectomy (418)
ī¨Experience
ī¨Technique, and why
ī¨Local anesthetic
ī¨Perioperative steroids, and why
ī¨Postoperative antibiotics, and why
58. Krishna P et al: Current practice patterns in tonsillectomy and perioperative care. Int J of Ped
Otorhinolaryngology 68:779-784, 2004.
Krishna et al.
59. īŽ Technique
ī¨Monopolar electrocautery used most often
īŽ Greatest for otolaryngologists in practice < 20 years
īŽ Hemostasis
ī¨Sharp dissection most common for group in
practice > 20 years
īŽ Decreased pain
īŽ Method of hemostasis not mentioned
īŽ Local Anesthetic evenly distributed
Krishna et al.
60. īŽ Steroids
ī¨Most respondents used steroids
īŽ Decreased pain
īŽ Decreased nausea
īŽ Decreased swelling
ī¨Those in practice > 20 years less likely
īŽ Postoperative Antibiotics
ī¨Decreased pain
ī¨Decreased infection/inflammation
ī¨Faster Healing
Krishna et al.
61. Conclusions
īŽ Tonsillectomy is a surgical procedure that
carries significant postoperative morbidity
īŽ To minimize postoperative morbidity
various techniques and adjuvant therapies
have been studied
īŽ There are many options available and it
behooves an otolaryngologist to stay as
up to date as possible
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