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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 4  |  Issue : 2  |  Page : 35-38

Microscope-Assisted coblation tonsillectomy: Our experiences at a tertiary care teaching hospital of eastern India


1 Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha “O” Anusandhan University (Deemed to be), Bhubaneswar, Odisha, India
2 Ghosh ENT Foundation, Kolkata, West Bengal, India

Date of Submission25-May-2019
Date of Decision13-Jan-2021
Date of Acceptance14-Jan-2021
Date of Web Publication19-Feb-2021

Correspondence Address:
Dr. Santosh Kumar Swain
Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha “O” Anusandhan University (Deemed to be), Bhubaneswar, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aiao.aiao_10_19

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  Abstract 

Objective: A retrospective study was done for comparing surgical parameters such as intraoperative bleeding, duration of surgery, postoperative bleeding, postoperative pain, and hospital stay in patients undergoing coblation tonsillectomy with or without assistance of operating microscope. Materials and Methods: Data regarding intraoperative bleeding, postoperative pain, postoperative bleeding, and hospital stay were collected from the medical records of the patients undergoing with or without microscope-assisted coblation tonsillectomy during the past 5 years from December 2014 to March 2019. Results: There was no significant difference between two groups in terms of duration of surgery among coblation tonsillectomy with or without microscope. The incidence of primary hemorrhage, reactionary hemorrhage, and secondary hemorrhage was significantly reduced in case of microscope-assisted coblation tonsillectomy than direct tonsillectomy with help of headlight. Pain scores and hospital stay are significantly less in microscope assisted coblation tonsillectomy. Conclusions: Microscope-assisted coblation tonsillectomy reduces the intraoperative and postoperative hemorrhage, postoperative pain and decrease the hospital stay, so that help in an early improvement of the patient.

Keywords: Coblation, microscopy, postoperative pain, secondary hemorrhage, tonsillectomy


How to cite this article:
Swain SK, Ghosh TK, Das A. Microscope-Assisted coblation tonsillectomy: Our experiences at a tertiary care teaching hospital of eastern India. Ann Indian Acad Otorhinolaryngol Head Neck Surg 2020;4:35-8

How to cite this URL:
Swain SK, Ghosh TK, Das A. Microscope-Assisted coblation tonsillectomy: Our experiences at a tertiary care teaching hospital of eastern India. Ann Indian Acad Otorhinolaryngol Head Neck Surg [serial online] 2020 [cited 2021 Mar 8];4:35-8. Available from: https://www.aiaohns.in/text.asp?2020/4/2/35/309781


  Introduction Top


Palatine tonsils are lymphoid tissues located at the oropharynx within the tonsillar fossa. In pediatric age, palatine tonsils have role in defense mechanism and immunology. Secretions of antibody-like IgA plays an important role in the mucosal defense mechanism. In case of repeated infections of tonsils, the protective mechanisms of tonsils fail and cause sore throat, fever, and other complications for which it needs tonsillectomy.[1] Tonsillectomy is a common surgical procedure in otolaryngological practice. Tonsillectomy is a surgical procedure where postoperative pain, hemorrhage, and other complications are seen. There are different surgical technique for tonsillectomy have been successfully attempted since long back such as guillotine method, diathermy, dissection method to more recent method such as laser, ultrasonic and coblation. The postoperative complications such as pain in the throat, hemorrhage, otalgia, and fever.[2] Coblation is an advanced technology used for tonsillectomy in present days. This technology combines gentle radiofrequency energy with a natural salt solution too quickly. Coblation never removes tissue by heating or burning.[3] Here, we study the details of microscope-assisted coblation tonsillectomy including complications such as intraoperative hemorrhage and pain. The primary advantage of microscope-assisted coblation tonsillectomy is the ability to observe the detailed anatomy of the extracapsular loose tissues in the tonsillar bed. In addition to magnified view of the surgical field, the surgical assistants and students can directly see the surgical steps by external monitor or secondary mirror. Microscope-assisted tonsillectomy could be an effective tool for educating students and young surgeons and to minimize the complications. This study analyzes the intraoperative hemorrhage, surgical duration, postoperative pain, reactionary hemorrhage, secondary hemorrhage, and hospital stay after surgery in patients undergoing microscope-assisted coblation tonsillectomy.


  Materials and Methods Top


This is an observational, descriptive, and retrospective study carried out at a tertiary care teaching hospital in Eastern India. There were 594 patients participated in this study. Out of the 594 patients, 312 patients underwent coblation tonsillectomy under microscope over the period of 5 years between December 2014 and March 2019. This study was approved by the Institutional ethics committee. There were 282 patients underwent coblation tonsillectomy under headlight. All selected patients for tonsillectomy had recurrent throat infections and diagnosed as chronic tonsillitis. Patients with bleeding disorders, anemia, acute infections (History of tonsillitis within 3 weeks prior to surgery), poor anesthetic risk, and uncontrolled medical illness were excluded from this study. General anesthesia was preferred in the patients. Boyle's Davis mouth gag was used in all cases in extended neck position [Figure 1]. Total 312 patients underwent tonsillectomy by coblation under operating microscope. All the surgery was performed by senior authors. The coblation tonsillectomy was done using the Smith and Nephew ENT Coblator II surgery system with EVac 70 plasma wands (Arthro Care Corporation, Sunnyvale, CA, USA). Settings were standardized at seven for ablation and three for coagulation. Microscope was utilized during surgery. The operative field was better visualized under microscopic view [Figure 2]. Blood loss during surgery was documented. Duration of surgery in each case was also documented. A telephonic record sheet was maintained for documenting the data corresponding to pain, reactionary and secondary hemorrhage on the 3rd, 7th, and 14th day. All patients were advised for maintaining the pain diary and records details on a daily basis for 2 weeks after surgery: 1-Visual analog score for pain of 0–10 where 0 being no pain and ten being extreme pain, 1–3 represents mild pain, 4–7 represents moderate pain, and ten indicates extreme pain; 2-number of analgesic tablet taken for that day; 3-ability to take normal food; 4-ability to return to perform normal activities; 5-experiencing pain during swallowing. Pain score of ≤3 was set for cut-off value as which considered as level of pain which did not affect quality of life. The pain score was calculated at rest and during swallowing daily at the same time for the first 7 postoperative days by face-to-face or telephonic enquiry. Data were calculated as mean ± standard deviation intraoperative blood loss, duration of surgery, secondary hemorrhage, postoperative pain, and postoperative hospital stay were analyzed using student's independent two-sample t-test. P < 0.05 was considered statistically significant. All the statistical calculations were carried out with SPSS software (version 15, SPSS Inc., Chicago, IL, USA).
Figure 1: Position of the patient during microscope assisted coblation tonsillectomy

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Figure 2: Intraoperative view of the microscope-assisted coblation tonsillectomy

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  Results Top


This is a retrospective study where 594 patients participated. Out of the 595, 312 patients undergone coblation tonsillectomy under operating microscope, whereas 282 undergone coblation tonsillectomy under headlight. Out of the 312 patients those undergone microscope-assisted coblation tonsillectomy, 176 were male and 136 females with mean age was 17.45 years and the age range 3 years to 36 years. Patients were divided into two groups according to the use of an operating microscope and headlight using group. Tonsillectomy done using headlight were among 282 with 156 male and 126 females with mean age 18.24 years. Microscope-assisted coblation tonsillectomy was done using operating microscope among 176 male patients and 136 female patients in two tertiary care hospital of Eastern India. Patient data were carefully recorded such as intraoperative blood loss, postoperative pain, and duration of the postoperative hospital stay. The intraoperative blood loss was recorded by a staff nurse as the volume of fluid coming through suction tube minus the volume of saline flush. Clinical data are shown in [Table 1] and [Table 2]. There were no significant between group differences in terms of duration of surgery, but there was significant between two groups in primary and postoperative haemorrhage [Table 3]. There was also significance lower postoperative pain and hospital stay in patients undergone tonsillectomy under operating microscope (P < 0.05).In this study, we performed microscope-assisted coblation tonsillectomy and on the basis of our experiences, it revealed that this technique allows minimally invasive tonsillectomy with less or no damage to surrounding soft tissue, minimal or no blood loss, and minimal postoperative complications.
Table 1: Clinical profile of the patients those undergone microscopic coblation tonsillectomy

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Table 2: Clinical profile of patients those undergone coblation tonsillectomy under headlight

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Table 3: Clinical parameters of patients those undergone coblation tonsillectomy without or with microscope

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  Discussion Top


Tonsillectomy is one of the common surgical procedures performed by otolaryngologists during their practice period. Despite different range of techniques for tonsillectomy including guillotine, blunt dissection, diathermy, or laser and the use of several analgesics, postoperative pain and hemorrhage are the major side effects of this operation.[4] In addition to above techniques, there are several newer methods such as CO2 lasers, harmonic scalpel using ultrasonic energy, microdebriders, and coblation using bipolar radiofrequency ablation.[5] Very few surgeons perform tonsillectomy under microscope vision.[6] Tonsillectomy often regarded as simple surgery and surgeons often are not bothered for further optimization and development in this field. The use of the coblation technique in tonsillectomy has added several advantages in comparison to alternative form of surgery. Coblation tonsillectomy has the important advantage by giving limited thermal injury in comparison to other techniques used for tonsillectomy. The term coblation is derived from the word “controlled ablation” which means nonheat driven process for soft-tissue dissociation by the use of bipolar radiofrequency energy to excite electrolytes in conductive medium as in saline solution.[7]

Coblation technique uses bipolar radiofrequency energy which generate a field of ionized sodium molecules which ablates and coagulates soft tissue without any thermal injury. Conductive saline solution kept in the gap between the device tip and the soft tissue and converted into an ionized plasma layer. When this plasma layer touch with tissue, there is enough energy to break the molecular bonds, leading to molecular dissociation. This effect is resulted at temperatures of about 40°C–70°C so reducing thermal damage to the tissues.[4]

Postoperative pain is an important factor which limits the recover from the surgical procedure. Inadequate pain relief can delay and prevent hospital discharge.[8] Telephonic follow-up for postoperative pain is usually done on the 4th, 7th, and 15th day as it often coincides with the key stages in the evolution of the posttonsillectomy inflammatory process. The maximum inflammation of the tonsillectomy wound produced in the 3rd and 5th days of the postoperative period whereas the separation of the fibrin clot formed around the 7th day after the surgery.[9] Similarly, the appearance of the hemorrhagic process at the 14th days of the postoperative period in some cases made the patient follow-up during the 2nd week appropriately.

The important advantages of tonsillectomy under operating microscope over direct vision are ability to visualize the detailed anatomy of the extracapsular loose soft tissues of the tonsil. In addition to good visualization, students and trainees can directly see the surgical steps through monitor or observer eyepiece. Although many surgeons have microscope, majority do tonsillectomies under direct vision. Many surgeons do tonsillectomies under headlamp or surgical loupe although the lighting and magnifications of the surgical field are inferior to those seen under a operating microscope. In comparison to headlight and loupe, the magnification of the operating microscope can be adjusted any point during surgery. The microscope is adjusted to 3X at the initial part of the surgery and it can be increased to 6–8X for precise separation of the tonsil from the tonsillar bed and blood vessels. The visualization and axes of the light are usually parallel; provide deep illumination and visualization of the operating or surgical site. Moreover, the operative microscope prevents the field of view from moving as it has a mechanical arm bracket. These features of the operative microscope enhance the visualization of the tonsillar bed. Operative microscope provides better quality of brightness, color, and clarity of the light than headlight and loupes. It can also be connected to an image display system for providing better quality of teaching to the trainees.

During intraoperative time, the ablation mode with a plasma wand is performed only for loose soft tissue between pharyngeal muscles and capsule of the tonsil so that it will avoid direct damage to the pharyngeal muscles during microscope assisted coblation tonsillectomy. In comparison to coblation tonsillectomy without assistance of microscope, the capsule of the tonsils can be easily distinguished along with fine blood vessels over it. The nourishing blood vessels entering the tonsils are only occluded during this surgery. Injury to the paratonsillar veins and tonsillar arteries is effectively avoided by the use of the operating microscope. In our cases, injury to the paratonsillar vein (external palatine vein) is an important and major cause for bleeding during surgery by conventional method. Taking the help of operating microscope help to distinguish and occlude these veins over the capsule of the tonsils, so easily limit the blood loss. Microscope-assisted coblation tonsillectomy is an improvement overall techniques used for tonsillectomy since past with respect to damage to the soft tissue at the surgical field including blood vessels.[10]

The use of the operating microscope allows not only better visualization of the surgical field but also lower pole of the tonsils, so there will be no residual lower pole tissue and cause again infection and hypertrophy in future.[11]

The use of the operating microscope provide better representation of the brightness, color, and clarity of the operative field than headlight or loupes and which can be connected to the image display system for facilitating the teaching to students.[12]


  Conclusions Top


Microscope-assisted coblation tonsillectomy allows minimal invasive intervention, reduced intraoperative blood loss, short duration of surgery, less postoperative pain, reduced hospital stay, and less chance of reactionary and secondary hemorrhage in comparison to conventional tonsillectomy. The use of operating microscope does not only simply enhance the field of vision, but also offers an innovative change to the surgical approach.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Sasindran V, Mathew N, Shabna AK, Harikrishan B. Comparison of coblation tonsil-lectomy vs dissection tonsillectomy. Int J Otolaryngol Head Neck Surg 2019;8:49-60.  Back to cited text no. 1
    
2.
Meybodian M, Dadgarnia M, Baradaranfar M, Vaziribozorg S, Mansourimanesh M, Mandegari M, et al. Effect of cold diet and diet at room temperature on post-tonsillectomy pain in children. Iran J Otorhinolaryngol 2019;31:81-6.  Back to cited text no. 2
    
3.
Lin C, Thung AK, Jatana KR, Cooper JN, Barron LC, Elmaraghy CA. Impact of coblation versus electrocautery on acute post-operative outcomes in pediatric tonsillectomy. Laryngoscope Investig Otolaryngol 2019;4:154-9.  Back to cited text no. 3
    
4.
Temple RH, Timms MS. Paediatric coblation tonsillectomy. Int J Pediatr Otorhinolaryngol 2001;61:195-8.  Back to cited text no. 4
    
5.
Noordzij JP, Affleck BD. Coblation versus unipolar electrocautery tonsillectomy: A prospective, randomized, single-blind study in adult patients. Laryngoscope 2006;116:1303-9.  Back to cited text no. 5
    
6.
Belloso A, Chidambaram A, Morar P, Timms MS. Coblation tonsillectomy versus dissection tonsillectomy: Postoperative hemorrhage. Laryngoscope 2003;113:2010-3.  Back to cited text no. 6
    
7.
Leong AT, Ganhasan S, Sun PL, Wai YH, Yuan IL, Poh HP, et al. PEAK plasma blade versus monopolar electrocautery tonsillectomy in adults: A prospective double blinded randomized controlled trial. Am J Otolaryngol 2019;40:478-81.  Back to cited text no. 7
    
8.
Thung AK, Elmaraghy CA, Barry N, Tumin D, Jatana KR, Rice J, et al. Double-blind randomized placebo-controlled trial of single-dose intravenous acetaminophen for pain associated with adenotonsillectomy in pediatric patients with sleep-disordered breathing. J Pediatr Pharmacol Ther 2017;22:344-51.  Back to cited text no. 8
    
9.
Isaacson G. Tonsillectomy healing. Ann Otol Rhinol Laryngol 2012;121:645-9.  Back to cited text no. 9
    
10.
Magdy EA, Elwany S, el-Daly AS, Abdel-Hadi M, Morshedy MA. Coblation tonsillectomy: A prospective, double-blind, randomised, clinical and histopathological comparison with dissection-ligation, monopolar electrocautery and laser tonsillectomies. J Laryngol Otol 2008;122:282-90.  Back to cited text no. 10
    
11.
Pang Y, Gong J, Huang J, He S, Zhou H. Coblation tonsillectomy under surgical microscopy: A retrospective study. J Int Med Res 2016;44:923-30.  Back to cited text no. 11
    
12.
Yi Wong DJ, Paddle P. Harmonic scalpel versus other techniques for tonsillectomy: A systematic review and meta-analysis. Aust J Otolaryngol 2019;2:3.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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