Entgr Tonsillectomy

Tonsillectomy: A Review Tonsillectomy: A Review of Methods and Adjunctive of Methods and Adjunctive

Therapy in 2005Therapy in 2005

David Kluge, MDDavid Kluge, MD

Division of Division of Otolaryngology-Head Otolaryngology-Head and Neck Surgeryand Neck Surgery

November 3, November 3, 20052005

ObjectivesObjectives

Examine the various methods of tonsillectomy.

Assess the role and mechanism of action of post-operative antibiotics in tonsillectomy.

Examine the role of peri-operative steroids in tonsillectomy as currently accepted in the literature.

Doctor, I want the Doctor, I want the newest, best newest, best and most pain-freeand most pain-free

tonsillectomy for my child or I tonsillectomy for my child or I will go somewhere else…will go somewhere else…

What is “new”?What is “new”? The newer methods of tonsillectomy The newer methods of tonsillectomy

include:include: CoblationCoblation Harmonic scapelHarmonic scapel Ligasure (Thermal Welding)Ligasure (Thermal Welding) LaserLaser Intra-capsular methodsIntra-capsular methods

““Old Methods”Old Methods”

ElectrocauteryElectrocautery

Cold KnifeCold Knife

What is the “best”What is the “best” One of the main objectives for this One of the main objectives for this

lecturelecture Must integrate all the information Must integrate all the information

and studies to make the right decision and studies to make the right decision for the patientfor the patient

May vary based on patient populationMay vary based on patient population

““Pain-free” Pain-free” tonsillectomytonsillectomy

Certain methods are associated Certain methods are associated with less post-operative painwith less post-operative pain

But are these methods also But are these methods also associated with increased associated with increased bleeding or other risks?bleeding or other risks?

OverviewOverview Review of methodsReview of methods

Review of adjunctive therapiesReview of adjunctive therapies

ConclusionConclusion

DisclaimerDisclaimer

The information presented is a brief overview The information presented is a brief overview of the vast information available on methods of the vast information available on methods and adjunctive therapies for tonsillectomy and adjunctive therapies for tonsillectomy

My conclusions are based on the overall My conclusions are based on the overall consensus of the most recent studies available consensus of the most recent studies available

New information is being published weekly in New information is being published weekly in this area this area

Please review the bibliography for more Please review the bibliography for more informationinformation

Cold KnifeCold Knife Involves a combination of Involves a combination of

sharp and blunt dissection sharp and blunt dissection +/- snare to complete the +/- snare to complete the inferior amputationinferior amputation

Guillotine method-now out Guillotine method-now out of favor-but studies show of favor-but studies show very low post tonsillar very low post tonsillar hemmhorage rates as well hemmhorage rates as well as low post operative pain as low post operative pain levelslevels

Cold Knife-AdvantagesCold Knife-Advantages Overwhelming Overwhelming

evidence to indicate evidence to indicate less post-operative less post-operative painpain

Conflicting evidence Conflicting evidence for post tonsillectomy for post tonsillectomy hemorrhage (PTH) but hemorrhage (PTH) but probably less common probably less common than electrocauterythan electrocautery

Least expensive Least expensive methodmethod

Cold Knife-DisadvantagesCold Knife-Disadvantages Overwhelming evidence Overwhelming evidence

to indicate more intra-to indicate more intra-operative blood lossoperative blood loss

Variable data on PTH, if it Variable data on PTH, if it does occur it will occur does occur it will occur earlier than cautery and is earlier than cautery and is not usually as severenot usually as severe

Will cause bacteremia, Will cause bacteremia, unlike other methods unlike other methods

Usually takes longer than Usually takes longer than cautery especially if cautery especially if bleeding occursbleeding occurs

Cold Knife-ConclusionsCold Knife-Conclusions

Still the “Gold Standard”Still the “Gold Standard” Trade high intraoperative Trade high intraoperative

blood loss for less post-blood loss for less post-operative painoperative pain

InexpensiveInexpensive

A great method for A great method for most children and most children and adults. Low pain, adults. Low pain, hospital costs and PTH hospital costs and PTH ratesrates

Electrocautery: Monopolar and Electrocautery: Monopolar and BipolarBipolar

Monopolar cautery is Monopolar cautery is currently the most common currently the most common method of tonsillectomy in method of tonsillectomy in the United Statesthe United States

Bipolar cautery has received Bipolar cautery has received more attention in the last few more attention in the last few years and is commonly used years and is commonly used internationallyinternationally

Suction cautery has also Suction cautery has also been described but is not been described but is not extensively usedextensively used

Electrocautery: Monopolar and Electrocautery: Monopolar and BipolarBipolar

Electrocautery is Electrocautery is based on tissue based on tissue dessication to dessication to achieve dissection achieve dissection and hemostasisand hemostasis

There is very high There is very high local energy transfer local energy transfer that heats tissue to that heats tissue to high temperatureshigh temperatures

Electrocautery PrinciplesElectrocautery Principles The post-operative pain The post-operative pain

associated with cautery is associated with cautery is attributed to the spread of attributed to the spread of thermal injurythermal injury

The “newer” methods of The “newer” methods of tonsillectomy attempt to tonsillectomy attempt to minimize this ‘colateral minimize this ‘colateral damage’damage’

Using cut or blend instead Using cut or blend instead of coag may decrease of coag may decrease post-operative pain (good post-operative pain (good study needed here)study needed here)

Electrocautery: Monopolar and Electrocautery: Monopolar and Bipolar-AdvantagesBipolar-Advantages

Minimal Minimal intraoperative intraoperative bleedingbleeding

Probably the Probably the quickest methodquickest method

Small handpieceSmall handpiece InexpensiveInexpensive ““Tried and True” Tried and True”

method method

Electrocautery: Monopolar and Electrocautery: Monopolar and Bipolar-DisadvantagesBipolar-Disadvantages

Highest post-Highest post-operative painoperative pain

May have a higher May have a higher PTH rate than cold PTH rate than cold knifeknife

SMOKE!SMOKE! Possibility for Possibility for

endotracheal tube endotracheal tube firefire

Electrocautery: Monopolar and Electrocautery: Monopolar and Bipolar-A Word about BipolarBipolar-A Word about Bipolar

Seems to offer lower Seems to offer lower post-operative pain post-operative pain levels with the same levels with the same PTH rate as PTH rate as monopolar cauterymonopolar cautery

Minimal increase in Minimal increase in operative time over operative time over monopolarmonopolar

Electrocautery: Monopolar and Electrocautery: Monopolar and Bipolar-A Word about SmokeBipolar-A Word about Smoke

Not usually an issue in Not usually an issue in tonsillectomy as it is tonsillectomy as it is suctioned by the suctioned by the surgical assistantsurgical assistant

However it should be However it should be treated like laser smoke treated like laser smoke and aggressively and aggressively removed from all removed from all surgical fields especially surgical fields especially those known to contain those known to contain virus or cancer cellsvirus or cancer cells

No SmokingNo Smoking

NIOSH (the National Institute of Occupational NIOSH (the National Institute of Occupational Safety and Health) and the CDC (Center for Safety and Health) and the CDC (Center for Disease Control) have studied electrosurgical Disease Control) have studied electrosurgical smoke at length. They state:smoke at length. They state: ““Research studies have confirmed that this smoke Research studies have confirmed that this smoke

plume can contain toxic gases and vapors such as plume can contain toxic gases and vapors such as benzene, hydrogen cyanide, and formaldehyde, benzene, hydrogen cyanide, and formaldehyde, bioaerosols, dead and live cellular material (including bioaerosols, dead and live cellular material (including blood fragments), and viruses.”blood fragments), and viruses.”

Electrocautery: Monopolar and Electrocautery: Monopolar and Bipolar-ConclusionsBipolar-Conclusions

Low intraoperative Low intraoperative blood lossblood loss

Possibly higher PTH Possibly higher PTH rates than cold kniferates than cold knife

Highest painHighest pain

A good method for A good method for immediate immediate hemostasis and hemostasis and speed but at the cost speed but at the cost of higher painof higher pain

CoblationCoblation Uses radiofrequency (RF) Uses radiofrequency (RF)

energy to ionize NaCl in a energy to ionize NaCl in a saline medium, then the energy saline medium, then the energy of these ions (plasma) is used of these ions (plasma) is used to break molecular tissue bondsto break molecular tissue bonds

May also be used for direct May also be used for direct hemostasishemostasis

RF energy is supposed to stay RF energy is supposed to stay in the irrigation to minimize in the irrigation to minimize collateral heatingcollateral heating

Temperatue is not supposed to Temperatue is not supposed to exceed 70 C (cautery is exceed 70 C (cautery is routinely 200-400 C)routinely 200-400 C)

Coblation Tonsillectomy Coblation Tonsillectomy DemonstrationDemonstration

Coblation-AdvantagesCoblation-Advantages Most studies indicate less Most studies indicate less

pain than electrocautery, pain than electrocautery, some cite equivalent pain some cite equivalent pain to cold knifeto cold knife

Intraoperative blood loss Intraoperative blood loss comparable to comparable to electrocauteryelectrocautery

No electrical connection No electrical connection to patientto patient

Coblation Physician ContactsCoblation Physician Contacts

Stoker et al, Otolaryngol Head Neck Surg 204; 130: 666-75

Coblation-Post Op PainCoblation-Post Op Pain

Stoker et al, Otolaryngol Head Neck Surg 204; 130: 666-75

Coblation-DisadvantagesCoblation-Disadvantages Very high cost compared to Very high cost compared to

electrocautery or cold knife electrocautery or cold knife ($150-200/piece)($150-200/piece)

Current studies are highly Current studies are highly variable, but rates of PTH seem variable, but rates of PTH seem to be equivalent to to be equivalent to electrocautery or may even be electrocautery or may even be higherhigher

Operative times up to twice as Operative times up to twice as long than electrocauterylong than electrocautery

Aggressive marketing Aggressive marketing campaign targeted to lay publiccampaign targeted to lay public

Coblation-ConclusionsCoblation-Conclusions Still a new and relatively Still a new and relatively

untested methoduntested method High level of conflicting High level of conflicting

data especially on rate of data especially on rate of PTHPTH

Very expensiveVery expensive

An expensive alternative An expensive alternative to cold knife for pain to cold knife for pain with higher PTH rateswith higher PTH rates

Harmonic ScalpelHarmonic Scalpel

Blade vibrates at 55,500 Blade vibrates at 55,500 hertzhertz

This vibration is in the RF This vibration is in the RF range and causes proteins to range and causes proteins to denature and form a denature and form a coagulum which seals small coagulum which seals small vessels and divides tissuevessels and divides tissue

Larger vessels can be sealed Larger vessels can be sealed by continuous contact and by continuous contact and secondary heatingsecondary heating

Harmonic ScalpelHarmonic Scalpel

Recurrent theme in Recurrent theme in post operative pain is post operative pain is spread of thermal spread of thermal injuryinjury

Coblation, harmonic Coblation, harmonic scalpel and thermal scalpel and thermal welding were welding were designed to minimize designed to minimize this spreadthis spread

Harmonic Scalpel-AdvantagesHarmonic Scalpel-Advantages

Lower post-operative pain Lower post-operative pain than electrocauterythan electrocautery

Intraoperative blood loss Intraoperative blood loss comparable to electrocauterycomparable to electrocautery

Possibly lower PTH rates Possibly lower PTH rates than electrocauterythan electrocautery

No electrical connection to No electrical connection to patientpatient

Harmonic Scalpel-DisadvantagesHarmonic Scalpel-Disadvantages

ExpensiveExpensive Longer operative time than Longer operative time than

electrocautery or cold knifeelectrocautery or cold knife

Harmonic Scalpel-ConclusionsHarmonic Scalpel-Conclusions

Higher cost with longer Higher cost with longer operating timesoperating times

PTH rates about the same as PTH rates about the same as electrocauteryelectrocautery

Less post operative painLess post operative pain

Probably a better choice Probably a better choice than coblation among the than coblation among the ‘new’ methods based on ‘new’ methods based on a lower PTH ratea lower PTH rate

Thermal WeldingThermal Welding Variation of bipolar cautery and Variation of bipolar cautery and

bipolar scissorsbipolar scissors Feedback system to automatically Feedback system to automatically

control ‘seal cycle’control ‘seal cycle’ Minimizes thermal spreadMinimizes thermal spread Rated for up to 7 mm vessels at Rated for up to 7 mm vessels at

3x normal SBP3x normal SBP ‘‘Melts’ collagen and elastin to Melts’ collagen and elastin to

form a coagulum similar to form a coagulum similar to plasma and harmonic scalpelplasma and harmonic scalpel

Does not rely of proximal Does not rely of proximal thrombus like standard thrombus like standard electrocauteryelectrocautery

Also used for neck surgery and Also used for neck surgery and thyroid surgerythyroid surgery

May eventually replace standard May eventually replace standard bipolarbipolar

Thermal Welding-AdvantagesThermal Welding-Advantages

Would seem to have Would seem to have less post operative pain less post operative pain than monopolar than monopolar electrocauteryelectrocautery

Cost is less than Cost is less than Coblation and Harmonic Coblation and Harmonic scalpelscalpel

Thermal Welding-DisadvantagesThermal Welding-Disadvantages

Very newVery new PTH rates unknownPTH rates unknown Still more costly that Still more costly that

monopolar and cold monopolar and cold knifeknife

Only studies available Only studies available are subsidized by are subsidized by ValleyLabValleyLab

Thermal Welding-ConclusionsThermal Welding-Conclusions

Too new-many unknownsToo new-many unknowns Cost will probably be mid Cost will probably be mid

range among the ‘new’ range among the ‘new’ methodsmethods

Lower pain, unknown PTH Lower pain, unknown PTH ratesrates

A risky choice at this A risky choice at this time, however time, however technology seems solidtechnology seems solid

Intracapsular Excision Intracapsular Excision (Tonsillotomy)(Tonsillotomy)

AdvantagesAdvantages Less post operative painLess post operative pain Probably lower PTH rateProbably lower PTH rate

DisadvantagesDisadvantages Opportunity for tonsillar regrowthOpportunity for tonsillar regrowth Still serves as a nidus for infectionStill serves as a nidus for infection May require formal tonsillectomy in futureMay require formal tonsillectomy in future

Intracapsular MethodsIntracapsular Methods

Powered microdebriderPowered microdebrider

CoblationCoblation

Bipolar ScissorsBipolar Scissors

LaserLaser

MicrodebriderMicrodebrider

Same instrument as used in adenoidectomiesSame instrument as used in adenoidectomies

Requires cauterization for hemostasisRequires cauterization for hemostasis

Coblation Intracapsular Coblation Intracapsular Tonsillotomy Tonsillotomy

DemonstrationDemonstration

Bipolar ScissorsBipolar Scissors Newer method utilizing Newer method utilizing

older technologyolder technology By far, the quickest By far, the quickest

method of intracapsular method of intracapsular tonsillotomytonsillotomy

Also used for Also used for tonsillectomy:tonsillectomy: Post operative pain for total Post operative pain for total

tonsillectomy is actually tonsillectomy is actually similar to cold knife in at similar to cold knife in at least two studiesleast two studies

PTH rates similar to PTH rates similar to monopolar cauterymonopolar cautery

LaserLaser

Used for debridement of Used for debridement of hypertrophied tonsils hypertrophied tonsils

Several laser types usedSeveral laser types used Typically leaves 10-Typically leaves 10-

25% of tonsil tissue 25% of tonsil tissue behindbehind

Associated with lower Associated with lower post-operative pain than post-operative pain than electrocauteryelectrocautery

Best Among Intracapsular Best Among Intracapsular TechniquesTechniques

Pain level amongst all techniques are likely to Pain level amongst all techniques are likely to be similar as none penetrate the capsulebe similar as none penetrate the capsule

Bipolar scissors seem to offer great immediate Bipolar scissors seem to offer great immediate hemostasis and quick operative timeshemostasis and quick operative times

Coblation is slower and more expensiveCoblation is slower and more expensive Microdebrider requires cautery for hemostasisMicrodebrider requires cautery for hemostasis Laser is probably a good technique, however Laser is probably a good technique, however

dissection may be more difficult to controldissection may be more difficult to control

Best Among Intracapsular Best Among Intracapsular TechniquesTechniques

Overall, the bipolar scissors are probably Overall, the bipolar scissors are probably the best method when taking operative the best method when taking operative time and cost into account; assuming the time and cost into account; assuming the rate of PTH and post operative pain levels rate of PTH and post operative pain levels are the same.are the same.

Doctor, I want the Doctor, I want the newest, best newest, best and most pain-freeand most pain-free

tonsillectomy for my child or I tonsillectomy for my child or I will go somewhere else…will go somewhere else…

Which is ‘Best’ choice now?Which is ‘Best’ choice now?

It DependsIt Depends What is important?What is important?

PTH ratesPTH rates Post operative painPost operative pain Intraoperative bleedingIntraoperative bleeding Operative timeOperative time CostCost Possible tonsillar regrowthPossible tonsillar regrowth Chance for bacteremiaChance for bacteremia

Adjunctive TherapyAdjunctive Therapy

Basic catagoriesBasic catagories Perioperative steroidsPerioperative steroids Operative hemostasis (bismuth/afrin)Operative hemostasis (bismuth/afrin) Post operative antibioticsPost operative antibiotics Local AnestheticLocal Anesthetic Post operative pain controlPost operative pain control

Perioperative SteroidsPerioperative Steroids Numerous studies over Numerous studies over

decades have repeatedly decades have repeatedly shown no adverse effects shown no adverse effects with one dose of with one dose of perioperative steroids.perioperative steroids.

Multiple studies have also Multiple studies have also shown reduction in post shown reduction in post operative pain levels and 24 operative pain levels and 24 hr emesis rateshr emesis rates

Study dosages range from Study dosages range from 0.1-1.0 mg/kg up to a total 0.1-1.0 mg/kg up to a total dose of 50 mgdose of 50 mg

Emesis ReductionEmesis Reduction

Steward et al, Laryngoscope 111: October 2001

Return of DietReturn of Diet

Steward et al, Laryngoscope 111: October 2001

Cochrane Database of Systematic Cochrane Database of Systematic Reviews. 4, 2005Reviews. 4, 2005

The evidence suggests that a single intravenous dose The evidence suggests that a single intravenous dose of dexamethasone is an effective, relatively safe and of dexamethasone is an effective, relatively safe and inexpensive treatment for reducing morbidity from inexpensive treatment for reducing morbidity from pediatric tonsillectomy. No adverse events pediatric tonsillectomy. No adverse events attributable to dexamethasone were reported in these attributable to dexamethasone were reported in these trials. Additionally, in our 10-year experience of trials. Additionally, in our 10-year experience of routine use of a single intravenous dose of routine use of a single intravenous dose of dexamethasone during pediatric tonsillectomy, there dexamethasone during pediatric tonsillectomy, there have been no attributable, adverse events. Lastly, we have been no attributable, adverse events. Lastly, we found no reports in the literature of complications found no reports in the literature of complications from use of a single intravenous dose of from use of a single intravenous dose of corticosteroid during pediatric tonsillectomy. corticosteroid during pediatric tonsillectomy.

Bismuth/AfrinBismuth/Afrin

Bismuth is an activator of factor XII Bismuth is an activator of factor XII (Hageman Factor) in vitro(Hageman Factor) in vitro

Studies are mixed and most do not separate the Studies are mixed and most do not separate the Afrin effect from the bismuthAfrin effect from the bismuth

Hemostatic effect (if any) maybe due entirely Hemostatic effect (if any) maybe due entirely to the Afrin and not bismuthto the Afrin and not bismuth

Bismuth aspiration has been associated with Bismuth aspiration has been associated with post operative morbidity including deathpost operative morbidity including death

Bismuth/AfrinBismuth/Afrin

Overall, there is no consensus in the literature Overall, there is no consensus in the literature as to the effectivenessas to the effectiveness

The combination may be harmful if aspiratedThe combination may be harmful if aspirated Prudent, not routine, usage is probably Prudent, not routine, usage is probably

justifiablejustifiable Afrin soaked sponges may work just as well (a Afrin soaked sponges may work just as well (a

straightforward study idea)straightforward study idea)

Post Operative AntibioticsPost Operative Antibiotics

Now generally accepted in the literature Now generally accepted in the literature as routineas routine

Some disagreement on type and durationSome disagreement on type and duration Most studies recommend a 5-7 day Most studies recommend a 5-7 day

course of narrow spectum (amoxicillin) course of narrow spectum (amoxicillin) antibioticsantibiotics

Thought to decrease post operative pain Thought to decrease post operative pain and post operative healing time by and post operative healing time by decreasing the bacterial oral floradecreasing the bacterial oral flora

Local AnestheticsLocal Anesthetics

Three major catagoriesThree major catagories

Pre-surgical injectionPre-surgical injection

Post-surgical injectionPost-surgical injection

Topical administration post operativelyTopical administration post operatively

Cochrane Database of Systematic Cochrane Database of Systematic Reviews. 4, 2005 Reviews. 4, 2005

There is no evidence that the use of There is no evidence that the use of perioperative local anaesthetic in patients perioperative local anaesthetic in patients undergoing tonsillectomy improves post-undergoing tonsillectomy improves post-operative pain control. The trials identified operative pain control. The trials identified were of small size and several involved the were of small size and several involved the perioperative co-administration of intravenous perioperative co-administration of intravenous opiates which may have masked any beneficial opiates which may have masked any beneficial effect of the local anaesthetic. Further effect of the local anaesthetic. Further randomised controlled trials are necessary. randomised controlled trials are necessary.

Post Operative Pain ControlPost Operative Pain Control

TylenolTylenol

Narcotics (and tylenol/narcotic Narcotics (and tylenol/narcotic combonations) combonations)

NSAIDSNSAIDS

Narcotics and NSAIDSNarcotics and NSAIDS

Children are routinely given Tylenol #3Children are routinely given Tylenol #3 The literature is mixed but it is a generally The literature is mixed but it is a generally

accepted practiceaccepted practice Codeine can cause constipation, vomiting, and sedationCodeine can cause constipation, vomiting, and sedation

NSAIDS are controversialNSAIDS are controversial Ibuprofen, ketorolac and ketoprofen are the most Ibuprofen, ketorolac and ketoprofen are the most

commonly usedcommonly used Some studies used the NSAIDS in the immediate Some studies used the NSAIDS in the immediate

perioperative periodperioperative period

Cochrane Database of Systematic Cochrane Database of Systematic Reviews. 3, 2004Reviews. 3, 2004

Nonsteroidal anti-inflammatory drugs (NSAIDs) are Nonsteroidal anti-inflammatory drugs (NSAIDs) are used to relieve pain immediately after an operation. used to relieve pain immediately after an operation. Because these drugs can interfere with blood clotting Because these drugs can interfere with blood clotting there has been concern that these drugs will increase there has been concern that these drugs will increase bleeding in children having their tonsils out. This bleeding in children having their tonsils out. This could be a problem because children have relatively could be a problem because children have relatively small breathing airways and lower blood volume small breathing airways and lower blood volume compared to adults. The present review found that, compared to adults. The present review found that, with present evidence, NSAIDs did not significantly with present evidence, NSAIDs did not significantly increase the need to treat bleeding. There was less increase the need to treat bleeding. There was less nausea and vomiting when NSAIDs were used as part nausea and vomiting when NSAIDs were used as part of the analgesic regime, compared to when NSAIDs of the analgesic regime, compared to when NSAIDs were not used. were not used.

Conclusions-Adjunctive TherapyConclusions-Adjunctive Therapy

SteroidsSteroids Fully supported for 1 mg/kg up to 25-50 mgFully supported for 1 mg/kg up to 25-50 mg

Bismuth/AfrinBismuth/Afrin Good evidence for Afrin but very weak evidence Good evidence for Afrin but very weak evidence

for bismuth-recommend Afrin only packsfor bismuth-recommend Afrin only packs AntibioticsAntibiotics

Fully supported. Type and duration controversial-Fully supported. Type and duration controversial-recommend 5-7 days of limited spectrum abxrecommend 5-7 days of limited spectrum abx

Conclusions-Adjunctive TherapyConclusions-Adjunctive Therapy

Local AnestheticsLocal Anesthetics Mixed data-Physician’s choiceMixed data-Physician’s choice

Post Operative Pain ControlPost Operative Pain Control Plain Tylenol may be sufficient in young pts. Plain Tylenol may be sufficient in young pts.

NSAIDS are shown to be safe and effective and NSAIDS are shown to be safe and effective and reduce narcotic complications without increasing reduce narcotic complications without increasing bleeding. bleeding.

Overall ConclusionsOverall Conclusions

METHOD: Varies on what the physician METHOD: Varies on what the physician considers important. However, for rates of considers important. However, for rates of post operative pain and PTH cold knife is post operative pain and PTH cold knife is clearly superiorclearly superior

OverviewOverviewPainPain PTHPTH EBLEBL CostCost OR TimeOR Time

Cold KnifeCold Knife LowestLowest LowestLowest HighestHighest LowestLowest Mid-longMid-long

MonopolarMonopolar HighestHighest Mid-highMid-high LowerLower LowLow LowestLowest

BipolarBipolar MidMid Mid-highMid-high LowerLower LowLow MidMid

CoblationCoblation LowerLower UnknownUnknown-HIGH?-HIGH?

LowerLower HighHigh Mid-longMid-long

Harmonic Harmonic ScalpelScalpel

LowerLower LowerLower Lowest?Lowest? HighHigh Mid-longMid-long

Thermal Thermal Welding Welding (Ligasure)(Ligasure)

LowerLower LowerLower Lowest?Lowest? HighHigh MidMid

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Steward D., Welge J., Myer C. Do Steroids Reduce Morbidity Steward D., Welge J., Myer C. Do Steroids Reduce Morbidity of Tonsillectomy? Meta-Analysis of Randomized Trials. of Tonsillectomy? Meta-Analysis of Randomized Trials. Laryngoscope 2001; 111: 1712–1718.Laryngoscope 2001; 111: 1712–1718.

Stoker, K.,Don, D., Kang, R., Haupert, M., Magit, A. and Stoker, K.,Don, D., Kang, R., Haupert, M., Magit, A. and Madgy, D. Pediatric Total Tonsillectomy Using Coblation Madgy, D. Pediatric Total Tonsillectomy Using Coblation Compared to Conventional Electrosurgery: A Prospective, Compared to Conventional Electrosurgery: A Prospective, Controlled Single-Blind Study. Otolaryngol Head Neck Surg. Controlled Single-Blind Study. Otolaryngol Head Neck Surg. 2004; 130: 666-75.2004; 130: 666-75.

Sorensen, W. T.,Henrichsen J., and Bonding P. Does Bismuth Sorensen, W. T.,Henrichsen J., and Bonding P. Does Bismuth Subgallate Havw Haemostatic Effects in Tonsillectomy? Clin. Subgallate Havw Haemostatic Effects in Tonsillectomy? Clin. Otolaryngol. 1999; 24: 72-74.Otolaryngol. 1999; 24: 72-74.

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Sorin, A., Bent, J., April, M., Ward, R. Complications of Sorin, A., Bent, J., April, M., Ward, R. Complications of Microdebrider-Assisted Powered Intracapsular Tonsillectomy Microdebrider-Assisted Powered Intracapsular Tonsillectomy and Adenoidectomy. Laryngoscope 2004; 114: 297–300.and Adenoidectomy. Laryngoscope 2004; 114: 297–300.

Thomsen J., Gower V. Adjuvant Therapies in Children Thomsen J., Gower V. Adjuvant Therapies in Children Undergoing Adenotonsillectomy. Laryngoscope 2002; 112: Undergoing Adenotonsillectomy. Laryngoscope 2002; 112: 32–34.32–34.

Wiatrak, B., Willging, P. Harmonic Scalpel for Tonsillectomy. Wiatrak, B., Willging, P. Harmonic Scalpel for Tonsillectomy. Laryngoscope 2002; 112: 14–16.Laryngoscope 2002; 112: 14–16.

Windfuhr, J., Deck J., Remmert, S. Hemorrhage Following Windfuhr, J., Deck J., Remmert, S. Hemorrhage Following Coblation Tonsillectomy. Ann Otol Rhinol Laryngol 2005; Coblation Tonsillectomy. Ann Otol Rhinol Laryngol 2005; 114: 749-56.114: 749-56.

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