Tonsillectomy Techniques: Tradition versus Technology?

The concern about regrowth of the remnant and subsequent tonsillitis, however, is legitimate, he admitted.

We acknowledge the problem and recognize the controversy, but propose that, today, most tonsillectomies are done for hypertrophy and not for infection, and less bleeding and lower bleeding rates do have a positive value, he said. Personally, I think intracapsular tonsillectomy is best done on small children with obstructive sleep-disordered breathing. We perform with the microdebrider, but believe that coblation is just as elegant and just as efficacious.

Cooler Ablation=Coblation

A recent survey of the American Society of Pediatric Otolaryngologists found that 16 percent of ASPO members use Coblation for tonsillectomy (Shah UK. What surgeons want in a tonsillectomy instrument: Results of an ASPO member survey. Poster presentation at the Annual Meeting of ASPO, Chicago, IL, May 21, 2006). Coblation is the brand name for the application of plasma-mediated ablation to soft tissue, which results in cooler tissue ablation, therefore the moniker: Coblation.

Coblation has been a technology in evolution, with the controller and handpiece design progressively being better incorporated with integrated cables and tubing, said Udayan Shah, MD, Attending Surgeon and Director of the Otolaryngology Innovative Technologies Program at the Children’s Hospital of Philadelphia (Pa.), and Assistant Professor of Otorhinolaryngology-Head and Neck Surgery at the University of Pennsylvania School of Medicine. The first device for tonsillectomy using plasma-mediated ablation was the plasma wand, which was introduced in 1998.

He said the instrumentation has come a long way since then, and today, with better devices and more experienced surgeons, the evidence in the literature does overall support the use of Coblation for complete and partial tonsillectomy, for excision and intraoperative hemostasis.

The evidence, as it stands today, does show that there is no significant difference in primary bleeding for Coblation in both complete and partial tonsillectomy compared with monopolar and cold techniques, he said. The bulk of the evidence also finds no significant difference in delayed bleeding, and pain in general is considered to be far less with Coblation.

He said there are some questions, though, that still need to be answered.

I think the economics do need to be addressed, and the question of regrowth following partial Coblation tonsillectomy needs to be answered as well, Dr. Shah said. Continued careful refinement, application, and investigation of Coblation technique and instrumentation, most likely involving multicenter cooperation, is going to be required to generate sufficient power in clinical studies to answer the questions that surgeons care most about according to the recent survey of ASPO members: Is it safe and will it reduce post-op hemorrhage?

The Data

Answers to many of the questions surrounding both hot and cold techniques may be forthcoming. Unfortunately, those answers may not be the ones needed to lay the great tonsillectomy debate to rest once and for all, according to David Albert, MD, a pediatric otolaryngologist at Great Ormond Street Hospital for Sick Children in London, UK.