ORLANDO, FL-Even though tonsillectomies are a commonly performed procedure, research continues to find out more about how to best do the surgery, as well as other values of the procedure. At the recent annual Combined Otolaryngology Spring Meeting, attendees heard a comparison of different techniques for performing them, as well as a description of a novel combined tonsillectomy and sphincter pharyngoplasty procedure for treating patients with velopharyngeal insufficiency.
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July 2008
Augustine L. Moscatello, MD, Associate Professor of Otolaryngology at Westchester Medical Center in New York, described the various approaches surgeons use on tonsillectomies. There are about 263,000 tonsillectomies performed in the United States each year, making it one of the leading pediatric surgical procedures in the country. The preference for which procedure should be used has changed over the past 30 years. In the 1980s, electrocautery coagulation-dissection gained favor and is now probably the most commonly used approach. It is associated with less bleeding, but patients have more postoperative pain, he said.
Coblator and microdebrider techniques have also gained popularity. Both techniques remove about 90% of the tonsillar tissue, while leaving a thin rim laterally-this avoids disruption of the tonsillar capsule, he said. Coblation works by dissociating isotonic saline between the electrodes of the coblator. It breaks the bonds between cells, and reaches a temperature of between 45°C and 85°C. A microdebrider works by shaving tonsillar tissue from the inferior medial pole-proceeding superior laterally. It preserves the tonsillar capsule along with a thin rim.
Which Technique Is Best?
But are any of these commonly used techniques superior? A prospective, double-blind study was launched to help answer that question. It compared the three techniques and their surgical parameters, efficacy, and morbidity in a series of pediatric patients with obstructive sleep apnea (OSA).
A total of 156 patients, aged six months to 22 years, were entered into the study. Exclusions from the study included craniofacial dysmorphism, cerebral palsy, asymmetrical tonsillar hypertrophy, and other complicating conditions. The surgery was performed by one of two surgeons for uniformity in the procedures.
Patients were placed into one of three treatment groups. A total of 53 patients were treated with extracapsular electrocautery (a Teflon-coated spatula [Bovie] with a coagulation setting of 10W); 53 underwent coblation (an EVAC-70 handpiece [ENTec] probe with a standard setting of ablation at 7, and coagulation set to 3). Another 53 patients were treated with a Zomed or Gyrus microdebrider set at 1500 RPM was used.
Surgical time varied, depending on the device used: It was a mean of 21.6 minutes for the cautery group; 20.2 minutes for the coblation group, and 16.14 minutes in the microdebrider group. Patients returned to a normal diet a mean of 6.36 days, 4.85 days, and 4.59 days in the cautery, coblation, and microdebrider groups, respectively. The differences were statistically significant.
There was also a significant difference in how long it took for patients to return to normal activity levels. This ranged from a mean of 6.57 days, to 4.72 days, to 4.51 days, respectively.
Kids recover faster from coblation or the microdebrider, Dr. Moscatello said. Among the three groups, there was no significant difference in rates of postoperative complications, including problems such as fever or voice change.
Dr. Moscatello noted there are significant differences in the prices of the three devices. The Bovie electrocautery spatula costs only $5.34, whereas the coblator wand for the EVAC-70 costs $370, and the microdebrider blade costs $89.40. When it came to total costs (device and OR cost), they were a mean of $2825.10 for cautery, $3007.06 for coblation, and $2199.03 for the microdebrider.
Cost is something that doctors may want to discuss with patients, especially those who have poor or no insurance coverage, he said. Still, overall recovery time is shorter with use of a coblator or microdebrider-something else to keep in mind.
Tonsillectomy and Sphincter Pharyngoplasty
Could patients benefit from a one-size-fits-all approach to velopharyngeal insufficiency (VPI) after cleft palate repair? This is what is being proposed by a Florida-based surgeon who suggests a possible effective initial intervention, which entails performing a tonsillectomy and sphincter pharyngoplasty as a combined procedure.
VPI is a common consequence in children who were born with clefting of the soft palate, even after the anatomy appears to have been surgically normalized. Children with the problem have speech distortion due to an inability to close the nasopharyngeal airway on the production of phonemes.
It can lead to mild distortions on a few sounds to a complete lack of intelligibility, said John D. Donaldson, MD, Board Chairman at Lee Memorial Health System in Fort Myers, FL.
Children with clefts and other craniofacial abnormalities should be cared for by a multidisciplinary team. The problem is that although anatomy can be relatively well repaired, functional outcome is not always at its best. Over the years, various procedures have been developed and tried to correct VPI with varying levels of success.
However, when one of our plastic surgeons commented how much easier a sphincter pharyngoplasty was to perform after a fresh tonsillectomy, the seed was planted for our new protocol, Dr. Donaldson told ENT Today. It was also observed that the patient who had undergone tonsillectomy and sphincter palatoplasty ended up with normal speech, and a well-healed central port that was surrounded by muscle.
After that, the team undertook to perform tonsillectomy and sphincter pharyngoplasty as a combined procedure on all subsequent patients, irrespective of examination or age, he said.
At the recent annual meeting of ASPO at COSM, Dr. Donaldson presented observational findings of 22 patients with VPI who underwent the combined procedure. There was no control group for comparison. The children all had clefting of the soft palate with variations of hard palate clefting with or without lip involvement. They ranged in age from 3 to 7.5 years.
The patients all underwent tonsillectomy with a coblator, and an inferior based flap on the posterior pharyngeal wall was created. The flap was elevated to Passavant’s ridge. Two muscle pedicles were created from the posterior tonsil pillars, and these were used to make a mucosa-lined sphincter.
All the patients were discharged home the same day after demonstrating the ability to drink and breathe appropriately in the secondary recovery after removal of the nasopharyngeal airway. No child to date has been readmitted after the procedure. Every child has demonstrated some speech improvement in the recovery area, Dr. Donaldson said.
At two-year follow-up, all the children attained improvement in speech, with 20 of them having good to excellent speech with respect to decrease in hypernasaslity.
Two cases, both in children over age five, had short palates at the initial surgery, and achieved only minimal improvement. They then underwent a Furlow double Z-plasty, planned by the team. Within six months, three patients presented with increased snoring, mild sleep apnea and vocal hyponasality-all attributed to nasopharyngeal stenosis with heavy midline scarring. The cases were resolved with removing the scar tissue and injecting steroids.
This procedure has no unique elements. It combines a well-proven procedure, sphincter palatoplasty, with an adjunct tonsillectomy, which improves pharyngeal mobility. The procedure can be performed early and does not violate the palatal repair, facilitating secondary procedures of that structure, Dr. Donaldson said.
He noted that the procedure is best undertaken early after the palate is repaired and VPI is no longer improving with intensive speech therapy. Also, traditional testing beyond speech evaluation is of very limited value due to the young age, and is of dubious significance given the alterations in anatomical relationships created by this surgery, he said.
©2008 The Triological Society