Surgical advances in tonsillectomy: report of a roundtable discussion.

Tonsillar surgery dates back to antiquity, and both its indications and techniques continue to evolve. During the past 10 years, the large number of articles on tonsillar surgery published in the literature is a testament to the ongoing growth, development, and controversies involved with this procedure.

Based on observations made during a roundtable discussion, this supplement contains a review of several recent advances in the surgical management of tonsillar disease. In particular, the seven participating physicians discuss three of the newer surgical tools that are available to otolaryngologic surgeons: the harmonic scalpel, the powered tissue microdebrider, and the plasma excision (Coblation[R]) device. They also share some practical surgical pearls that will help surgeons maximize their use of these modalities.

Indications and rationale for tonsillectomy

As far as we know, Celsus was the first to recognize tonsillar disease and its relationship to infection, and he performed the first tonsillectomy in 40 A.D. (1) The popularity of tonsillectomy peaked in the 1930s, but after the use of antibiotics became widespread, enthusiasm for the procedure waned and its use had decreased dramatically by the 1960s. Concerned about the morbidity inherent in the surgical procedure, pediatricians began to question its value relative to medical management with antimicrobials. The tide turned again in the 1980s, when Paradise et al demonstrated that surgery significantly improved patient outcomes compared with medical therapy. (2) They also identified specific indications for which tonsillar surgery had proved to be beneficial.

The traditional indication for tonsillectomy is recurrent tonsillar infection. More recently, awareness of the incidence of obstructive adenotonsillar hypertrophy with associated obstructive sleep apnea has increased; in fact, in many practices, it has become the most common indication for tonsillar surgery. Other relative indications include craniofacial and dental growth abnormalities, chronic irritation, biopsy for suspicious neoplasms, and halitosis. For all these indications, most clinicians advocate the complete removal of the tonsillar tissues via standard dissection.

Another procedure--intracapsular (partial) tonsillectomy--has been shown to be as beneficial as total tonsillectomy in some cases, particularly in patients with obstructive adenotonsillar hypertrophy. By preserving the tonsillar capsule, the surgeon avoids interrupting the deeper tissue layers (e.g., the pharyngeal muscles) and leaves in place a biological dressing that keeps the muscles isolated from inflammatory secretions. (3) Compared with total tonsillectomy, tissue-sparing intracapsular tonsillectomy decreases the risk associated with exposing the larger blood vessels. It is also associated with reductions in postoperative pain, recovery time, and delayed postoperative bleeding. (3,4) The lower risk of bleeding may be attributable to the fact that the tonsil is removed from the outside in; the resection is performed distal to the arborization of the primary tonsillar vessels, exposing only the smaller branched arterioles. (3)

Even so, experience with intracapsular tonsillectomy suggests that allowing tonsillar tissue to remain after surgery may pose limited risks of recurrent infection and tonsillar regrowth. Tonsillar tissue is different from other lymphoid tissues because the tonsillar surface contains deep crypts. Some authors have suggested that accumulated debris in the tonsillar crypts can cause chronic irritation and subsequent infection. The crypts protect the bacteria from the effects of both the body's immune response and systemic antibiotics. In addition, the bacteria in these crypts have been found to produce biofilms. These biofilms may be a principal reason that tonsillar infections recur despite the aggressive use of oral antibiotics. This finding suggests that if intracapsular tonsillar procedures are to be an effective treatment, they must be designed to include the removal of the tonsillar crypt tissue.

Another significant disadvantage of intracapsular tonsillectomy is that it may take longer to perform than total tonsillectomy. Because larger tonsils have more volume, tissue removal often takes longer to perform. The advantages and disadvantages of intracapsular tonsillectomy must be discussed with patients or their parents so that they can make an informed decision.

The effectiveness of the intracapsular procedure continues to be studied, but in the meantime, total tonsillectomy remains the procedure of choice for most surgeons. During the panel discussion, Dr. Dolitsky emphasized that he prefers total tonsillectomy for patients with chronic or recurrent tonsillar infection because it obviates the risk that a patient will require additional tonsillar surgery in the future, which is a possibility associated with intracapsular tonsillectomy. He also pointed out that some parents have the misconception that the tonsils are a functioning part of the immune system. They erroneously believe that if the tonsils are removed, their child will be at increased risk of developing asthma, bronchitis, or pulmonary infection. He points out that there are no data to support this belief.

Current practice

The standard approach to tonsillectomy is dissection with an electrocautery device. For many, electrosurgery replaced the scalpel because it provides for rapid hemostasis. This helped reduce the incidence of postoperative bleeding, which was and remains today one of the most common complications of tonsillar surgery. Surgeons achieve tissue ablation with conventional electrosurgery by applying high-voltage sparking via a pair of electrodes across the gap between the electrode source and electrically conductive tissue. Air and water molecules in the gap are excited into charge-carrying ions. The kinetic energy between these ions and the tissue molecules heats intracellular and extracellular fluids and ruptures localized tissue cells. The temperatures achieved with electrocautery can reach 300[degrees]C, which is sufficient to induce hemostasis in most blood vessels encountered during tonsillectomy.

Morbidity

The most common complications of tonsillectomy are postoperative pain and delayed postoperative bleeding. Other fairly common complications include alterations in voice and nausea. Rare but serious complications include dislocation of the temporomandibular joint, pulmonary edema, hemorrhage, and death.

Postoperative pain can lead to poor oral intake, dehydration, fever, otalgia, and a difficult recovery. A slow recovery delays the patient's return to work and other daily activities, so it has societal costs, as well.

Immediate (<24 hr) postoperative bleeding is rare. Delayed (>24 hr) bleeding, when it occurs, usually does so 5 to 10 days postoperatively. Delayed bleeding is commonly attributed to the mobilization of the pharyngeal eschar. It may occur as a result of dehydration or an underlying infection. The rate of postoperative bleeding seems to vary in the nonpediatric population. Some authors have reported higher rates of postoperative bleeding in adults and adolescents, but others have noted no difference in the rates between adults and children.

A number of factors are related to the occurrence of posttonsillectomy bleeding:

* The primary variable is a particular patient's intrinsic ability to heal. Some patients experience minimal inflammation and excellent coagulation, while others do not.

* The roundtable participants suggested that another factor that might be associated with the incidence of bleeding is the surgeon's experience and technique. An important technical variable is the surgeon's attention to careful excision, including remaining in the right plane and erring on the side of rupturing the tonsillar capsule rather than penetrating too deeply into the parapharyngeal space.

* A third variable is the choice of instrument--hence the trend toward eschewing the conventional scalpel.

With these factors in mind, clinical researchers have attempted to improve outcomes by focusing on implementing new technology that can provide intraoperative hemostasis, reduce postoperative pain, and shorten recovery times.

New alternatives to conventional electrosurgery

The past decade has seen an increase in the use of the harmonic scalpel, the powered tissue microdebrider, and the plasma excision device. The harmonic scalpel is used to perform total tonsillectomy, the powered tissue microdebrider is used for intracapsular tonsillectomy, and the plasma excision device can be used for both procedures (table). Surgeons find these instruments attractive because they can remove tissue with greater accuracy and less damage to adjacent tissue and, in many cases, they can do so with more speed and ease than is possible with older methods. Because these technologies are relatively new, it is helpful to review how they work.

Harmonic scalpel. In addition to tonsillectomy, the harmonic scalpel is widely used in laparoscopic and abdominal surgery as well as for other procedures. It is equipped with vibrating titanium blades (figure 1, A) that cut at a frequency of approximately 55.5 kHz. The blades move only approximately 80 [micro]m during each cycle. The scalpel has two speed settings,full and variable, and five levels of power. The combination of the high frequency and the minimal movement provides precise cutting power. The vibration of the blades also assists in hydrodissection, and it can help define tissue dissection planes during tonsillectomy.

[FIGURE 1 OMITTED]

By generating between 60 and 100[degrees]C of heat, the harmonic scalpel promotes hemostasis by creating protein coagulum, which results in vessel coaptation and the fusion of smaller vessels. The relatively low level of heat also minimizes damage to surrounding tissues. However, traditional electrocautery is often required to control vessels larger than 1 mm in diameter.

The harmonic scalpel's cutting speed and the amount of hemostasis it achieves can be controlled by the sharpness of the blade and by adjusting the power setting. The device can be activated by a foot pedal or by a hand-controlled adapter (figure 1, B). A foot pedal is used to activate the device. In addition, the surgeon can control tissue retraction tension to change the speed of the dissection. The more tightly the tissue is retracted, the more aggressively the harmonic scalpel cuts.

Each harmonic scalpel blade has three surfaces that can be used: a sharp hook facet, which cuts most aggressively; a blunter facet, which is used for less aggressive cutting and for hydrodissection; and a back side, which is used for hemostasis. Thus, by using different power settings and blade surfaces and by varying the tissue tension, surgeons can take advantage of the versatility of this instrument to achieve optimal ablation and hemostasis.

Powered tissue microdebrider. The powered tissue microdebrider is a familiar and relatively simple device that is widely used in sinus surgery and adenoidectomy and is available in most operating rooms. In most cases, the device's adenoidectomy-style blades are used to perform intracapsular tonsillectomy. Several manufacturers have now developed blades specifically for tonsillectomy.

The handpiece is equipped with a motor, a suction device, and an attached hollow blade. A foot pedal controls the speed of the blade. As the motor spins, the debrider sucks tissue into a small aperture that contains the oscillating blade, which essentially shears off the tissue. This shearing force provides hemostasis for small vessels. The microdebrider removes the bulk of tonsillar tissue rapidly; it requires only about 5 minutes to treat each tonsil. The choice of blade design and the level of suction determine the aggressiveness of the procedure. During surgery, the only variable is the number of revolutions per minute (rpm) that the blade turns. The recommended setting for tonsillar surgery is 1,500 rpm. In all cases, after the tissue has been removed, a separate device is needed to provide complete hemostasis.

Plasma excision device. Plasma excision, formerly known as Coblation[R], can be used to perform both total tonsillectomy and intracapsular tonsillectomy. The plasma excision device is a product of radiofrequency technology. Within a plasma excision Wand, radiofrequency energy is used to excite electrolytes in a conductive medium, such as saline solution, and create a precisely focused plasma field. The excited particles in the plasma possess enough energy to break molecular bonds, and they can excise or dissolve soft tissue at relatively low temperatures (typically 40 to 70[degrees]C), which helps preserve the integrity of the surrounding healthy tissue. These relatively low temperatures are still high enough to control bleeding in smaller vessels, even in bipolar cautery mode. To achieve hemostasis in larger vessels, the surgeon can use the bipolar cautery that is built into the Wand by depressing an alternate foot pedal.

The plasma excision device has tissue ablation and cautery capabilities that are controlled by the design of the handpiece or Wand. Each device has four essential components: an active electrode(s), a return electrode, a suction port, and a saline drip port. The active electrode array is located in the tip of the Wand and is insulated from the return electrode, which is typically located in the lower shaft of the Wand (figure 2). The radiofrequency energy that enlists the plasma field is established from these two electrodes. Saline between these electrodes is vital for plasma development; otherwise, the device acts as a weak bipolar cautery device. The saline from the saline drip port is designed to drip onto the electrodes; the saline drip port is connected to a bag of normal saline. Given that the process of plasma excision of tissue produces molecular debris and gas, suction to remove this material is important to allow for visualization of the dissection process. Thus, strong suction is built into the shaft of the Wand and suction is connected to a suction canister (figure 3).

[FIGURES 2-3 OMITTED]

The overall aggressiveness of the tissue ablation compared with the amount of heat generated by a particular plasma Wand is determined primarily by the Wand's design, its electrode composition, and the design of the electrode array. When the voltage is changed, the same active and return electrodes can deliver low-power bipolar electrocautery through the Wand. The surgeon can also determine the relative aggressiveness of the dissection to a certain degree by changing the plasma power setting on the controller unit, and the cautery power setting controls the hemostatic power. The plasma power setting will increase the aggressiveness of the tissue ablation, but at the same time it will decrease the plasma field's ability to cauterize smaller blood vessels.

Placing an adequate amount of saline over the electrodes is of paramount importance in creating the plasma field. If an insufficient amount of saline is used, the device cannot perform excision, only cautery. The surgeon can ensure that sufficient saline is present for excision by using a pressure bag on the saline delivery system or a bulb to manually deliver additional saline.

The newer generation of Wands features much more aggressive electrode arrays and improved suction design to specifically speed up tonsillar surgery. In addition, the bipolar cautery has also been enhanced by the Wand's design. The suction design uses a larger portal, which makes clogging by tissue fragments rare.

Total tonsillectomy

Despite the availability of numerous perioperative medications and different surgical techniques, the postoperative course of patients who undergo total tonsillectomy is characterized by a painful tonsillar fossa, which generally limits daily activities and diet for 7 to 10 days. In addition, significant immediate and delayed postoperative bleeding has been described. Most surgeons perform total tonsillectomy via either sharp or electrocautery-assisted standard dissection and electrocautery-generated hemostasis. Of the three new devices described in this supplement, two--the harmonic scalpel and the plasma excision device--can be used to perform total tonsillectomy.

Harmonic scalpel. Total tonsillectomy with the harmonic scalpel takes somewhat longer than conventional electrodissection--approximately 10 minutes for each tonsil.

Technique. The surgeon uses a curved Allis clamp to grasp the tonsil and retract it medially, thereby exposing the triangular area between the superior aspect of the tonsil and the interior border of the anterior and posterior pillars. The scalpel is inserted into this space. To activate the scalpel, the surgeon presses a foot pedal and sets the controls at level 3 in variable mode. By gently pressing the scalpel against the area above the tonsil, the surgeon dissects the right plane and then the left plane.

During the roundtable discussion, Dr. Bent noted that although the planes pale and look like eschar, they are actually blanching. This avascular area serves as a guide for cutting. The surgeon applies pressure to the scalpel to open the avascular area and expose the tonsillar capsule. Dissection continues in the subcapsular plane as the surgeon uses both the hooked and blunt facets of the blade until the entire tonsil is removed. The flat edge of the scalpel is applied to achieve cautery during the dissection, although back-up electrocautery is required in many cases. A surgeon will need to perform approximately 10 cases to become comfortable with this procedure, which is comparable to the learning time for most other tonsillectomy modalities.

Advantages. The harmonic scalpel is considered to have several advantages over other surgical methods:

* Because its cutting and coagulation temperatures are lower than those of electrocautery devices and lasers, thermal damage is minimal. (5)

* Visibility in the surgical field is better than it is with the conventional steel scalpel and electrocautery device.

* It causes less blood loss, desiccation, and smoke than do electrocautery devices and lasers.

* Because it requires no electrical energy that can be transferred to or through the patient, there is no risk of electrical shock or burn.

* It allows precise access to the optimal dissection plane adjacent to the tonsil, thereby enabling the surgeon to leave as much fascia as possible to protect the neurovascular structures of the parapharyngeal space. Instruments that cause more eschar can make it difficult to find the optimal dissection plane.

Study data. The results of harmonic scalpel tonsillectomy studies have been mixed. In a prospective, nonrandomized study, Morgenstein et al compared harmonic scalpel tonsillectomy (n = 95) and electrocautery (n = 61) in 156 children. (6) They found no significant differences between the two groups with respect to the use of pain medication, pain resolution, time to resumption of normal activities and diet, and the number of complications. The only difference was that harmonic scalpel tonsillectomy was more expensive.

Willging and Wiatrak conducted a prospective, randomized comparison of tonsillectomy in 120 children--61 by the harmonic scalpel and 59 by electrocautery. (7) Although the harmonic scalpel procedure took slightly longer, these patients slept more soundly and had lower pain scores. No differences were observed in terms of blood loss and complications.

Clinical experience. During the roundtable discussion, Dr. White recalled that she experienced a steep learning curve with the harmonic scalpel. She noted that it requires only a light touch and works well. On the other hand, she believes that it does not provide adequate coagulation in cases of significant bleeding; these cases require the use of electrocautery, as well. She added that the need to switch instruments during the procedure to achieve hemostasis is another drawback of the harmonic scalpel.

Dr. Lee summarized the experience of surgeons at the New York University Medical Center who perform total tonsillectomy with the harmonic scalpel in children. They found that it was superior to electrocautery for dissection in that it caused less damage to adjacent tissue. However, they still needed to use intermittent electrocautery in most cases for hemostasis. Therefore, most of the surgeons there do not consider the advantages of the harmonic scalpel significant enough to warrant its use when weighed against the need to switch to another device for hemostasis and then back again throughout the procedure.

Plasma excision device. Total tonsillectomy with a plasma excision device takes approximately the same amount of time as does conventional electrocautery. A surgeon becomes fairly proficient in the procedure after approximately 10 cases.

Technique. The surgeon retracts the tonsil with an Allis clamp to identify the lateral extent of the tonsil submucosally. The tonsil is then retracted inferomedially, and the Wand is used to incise the mucosa with a low controller setting (5 or 6). Once the tonsillar capsule is identified, the surgeon dissects the tonsil in a superior-to-inferior direction, dissecting the muscle fibers from the capsule (figure 4). The tip of the Wand with the saline media creates a plasma field around the shaft end that will disintegrate any tissue that is in contact with the plasma. The flat active surface is directed toward the tonsil, and the Wand is held lightly to aid in the dissection and to decrease the risk of clogging and intraoperative bleeding.

[FIGURE 4 OMITTED]

Dissection continues under tension as the surgeon retracts the tonsil inferiorly and medially. When the device is in the correct plane, excision progresses quickly. Dissection into the tonsil tissue proceeds much more slowly. When any vessel is encountered, bipolar cautery should be administered immediately. Bipolar cautery is much more difficult when cut vessels have retracted into muscle because the energy does not penetrate muscle very deeply. After the tonsils are removed, the surgeon applies suction over the tonsil fossae to check for evidence of oozing or bleeding. Any bleeding site, especially at the inferior and superior poles, is coagulated with the Wand to ensure that it is dry.

The dissection tip of the plasma excision device is a bit bulkier than traditional tools, and it may limit visibility. Orientation of the Wand is crucial to maximizing the flow of saline over the electrodes and in directing the plasma field into the plane of dissection. Early versions of the Wand were associated with clogging, but suction with newer models has been substantially improved. It is important that the surgeon not push too heavily on the Wand to achieve mechanical blunt dissection. For best results, the Wand must be wielded with a light touch, and it must be directed toward the area of dissection at all times to avoid damage to the muscle bed. The flow rate of saline should be high at all times.

Advantages. Among the advantages of plasma excision tonsillectomy:

* It can be used for both total and intracapsular tonsillectomies.

* The instrument provides the surgeon with the ability to perform dissection, cautery, suction, and hemostasis without the need for additional instrumentation.

* The procedure is smooth and quick, and it causes only minimal damage to adjacent tissue.

Study data. The findings of the first clinical study of this device were published by Back et al in 2001. (8) They concluded that the results of plasma excision were not significantly different from those of electrocautery, although they noted that their findings might have been skewed by the extensive use of electrocautery for hemostasis.

In the same year, Temple and Timms reported a favorable experience with plasma excision for total tonsillectomy, although they suggested thai the device was limited in its ability to cauterize. (9) Using limited bipolar cautery for hemostasis, they observed that plasma excision conferred a significant benefit over traditional electrocautery in terms of recovery; patients in the former group returned to a normal diet in 2 to 4 days, compared with approximately 7 days for those in the latter group.

The following year, the same two authors published the results of a study of 10 adults with a history of chronic tonsillitis who underwent plasma excision for the removal of one tonsil and bipolar cautery dissection for the other. (10) All patients reported that the side treated with plasma excision was significantly less painful than the other side; pain resolved in a mean of 4 and 7 days, respectively. At postoperative day 9, all 10 tonsillar fossae on the plasma excision side had completely healed, whereas granulation tissue was still present on the other side.

Clinical experience. The three roundtable participants who perform plasma excision--Dr. White, Dr. Younis, and Dr. Mansfield--agreed that the procedure is easy to perform, particularly because it is not necessary to switch instruments. They suggested that this alone minimizes pull time for nurses and increases operating room efficiency.

Some physicians use a lower controller setting (e.g., level 5 versus level 9) and proceed slowly; this reduces the ablation power but increases the inherent hemostatic ability of the plasma field.

When Dr. White performed total tonsillectomy with electrocautery, she used a guarded needle tip to minimize the field effect. She recalled that her patients experienced significant postoperative pain and some postoperative bleeding, and their recuperation time ranged from 7 to 10 days. She now says that plasma excision tonsillectomy is superior to traditional electrocautery in terms of precision, speed, and control, and that bleeding is not significant. With plasma excision, she has observed a decrease in postoperative pain and recuperation time (now 5 to 7 days). She has performed an annual average of approximately 200 total tonsillectomies via plasma excision and has seen only 2 cases of hemorrhage, compared with 4 or 5 cases with traditional electrocautery.

Dr. Younis has also experienced favorable results with plasma excision for total tonsillectomy, particularly with respect to postoperative pain and return to normal activities and diet.

Dr. Mansfield conducted a study (unpublished) of 294 patients, aged 1 to 60 years, who underwent plasma excision for total tonsillectomy. He reviewed the perioperative course of patients grouped by age. As is the case with other surgical techniques, younger patients recovered more quickly than did older patients. In addition, because adult tonsils are more vascular, they are more prone to vigorous intraoperative bleeding that may be difficult to control with bipolar cautery alone. Bipolar cautery is effective, but it does not work in the same way as monopolar cautery, which is widely used in tonsil surgery, particularly with vigorously bleeding vessels. Therefore, it requires some experience before it can be used to maximum effectiveness. Precise exposure of the bleeding site and some saline in the field are helpful in achieving hemostasis with this modality. Also, adults have had a lifetime to form scar tissue and fibrosis, and this scar tissue may be more difficult to dissect with plasma excision. Because of these factors, he recommends that when surgeons are learning this technique, they perform it only on pediatric patients. Once they become familiar with the technique, they can then perform it on adults.

All three of these panel members believe that the plasma excision device allows them to perform an efficient tonsillectomy with less reliance on cautery and less morbidity.

Intracapsular tonsillectomy

In light of the risks of recurrent infection and tonsil regrowth mentioned earlier, intracapsular tonsillectomy remains a more controversial method of treating recurrent tonsillitis. Its use is generally reserved for the treatment of obstructive tonsillar hypertrophy. This procedure can be performed with either the powered tissue microdebrider or the plasma excision device.

Powered tissue microdebrider. The powered tissue microdebrider is a popular choice for intracapsular tonsillectomy because it can be used aggressively to clear tissue very rapidly. In fact, tissue removal is achieved within 1 minute. There is no hemostasis inherent in the tissue removal process, so follow-up electrocautery must be performed.

Technique. The patient i s placed in the intubated position and the adenoids are removed. The inferior rim of adenoid tissue is left in place to minimize the risk of postoperative nasopharyngeal insufficiency. Reinfection arising from adenoid remnants has not been reported. Then the nasopharynx is temporarily packed for hemostasis.

Because of the way the microdebrider blade is curved, it is usually easier for a right-handed surgeon to remove the left tonsil and vice versa, which is in direct contrast to the traditional approach to tonsillectomy.

Using a metal Herd retractor, the surgeon gently hooks the anterior edge of the tonsillar pillar and moves it to the side, taking care not to cut or tear the pillar. When the tonsil is pushed laterally, it rolls out and everts itself so that it is completely exposed.

The surgeon places the debrider into the middle of the tonsil and uses the retractor as a shield so that the debrider will not stray too close to the edge of the tonsil. The surgeon hollows out the tonsil so that the tissue assumes something of a bowl shape. Debridement is deepest in the middle and near the superior edge of the tonsil. The surgeon must be careful when working inferiorly on the anterior and posterior edges, where there are more blood vessels. As the debrider moves, the retractor should move with it to protect the adjacent mucosa from injury. The surgeon removes all tonsillar tissue that is located above the tonsillar capsule from pillar to pillar. The blade must rotate at full speed; otherwise, suction increases and debridement decreases, resulting in the extraction of unwanted tissue. As the debrider penetrates, the color of the tonsil changes. The middle will be white, and it will barely bleed. As the surgeon works closer to the edge of the capsule, a red streak will eventually appear, indicating that the procedure is almost completed.

After the tissue has been removed, monopolar cautery is used to provide hemostasis to the capsule. Then the nasal packing is removed, and electrocautery is used to achieve hemostasis in the nasopharynx.

Advantages and disadvantages. Surgeons who already use the powered microdebrider to remove adenoids do not incur any additional costs and do not require any additional setup in order to use it for intracapsular tonsillectomy. Also, the powered microdebrider rapidly removes exophytic tonsils.

On the other hand, with this procedure, it is difficult to remove deeper tissue near the tonsillar capsule and to estimate the amount of remaining tissue. Surgeons must also rely on extensive electrocautery to treat much of the remaining tonsillar tissue above the capsule. After the eschar sloughs off, the amount of remaining tissue may vary.

Another drawback of this device is that it is not always easy to determine when to stop dissection. To avoid accidentally shaving the posterior pillar of the tonsil, the posterior portion of the tonsil should be addressed last--that is, after the middle and anterior portions have been treated. The surgeon must manipulate the Herd retractor until it is placed between the tonsil and the posterior pillar, which is not visible initially. The debrider is then used to shave down to the top of the retractor. By doing this, Dr. Bent noted, the surgeon will not inadvertently suction and debride the posterior pillar.

Study data. Thus far, only retrospective studies of the microdebrider for intracapsular tonsillectomy have been published, but the results have been favorable in children with obstructive tonsillar disease. Its effectiveness in treating recurrent tonsillar infections has not yet been established.

In 2002, Koltai et al performed a retrospective comparison of 312 children who underwent either standard total tonsillectomy (n = 162) or intracapsular tonsillectomy with the microdebrider (n = 150). (3) They found that the microdebrider group fared significantly better in three areas: pain scores, use of analgesics, and time to resumption of normal activities. There were no statistically significant differences between the two groups in terms of complication rates and the length of surgical time. There was 1 case of tonsillar regrowth in the microdebrider group, but it did not require further surgery.

A year later, Koltai et al presented data from a multicenter, retrospective case series involving 1,214 children. (11) Of this group, 688 underwent intracapsular tonsillectomy with the microdebrider and 526 underwent standard total tonsillectomy. There were statistically significant differences in the number of days to resumption of normal activities and diet and in the use of analgesics in favor of the microdebrider group. Regrowth of tonsils occurred in 3 patients. There was no significant difference between the two groups in the incidence of major complications. The authors concluded that intracapsular tonsillectomy with the microdebrider was beneficial in this patient population.

In 2004, Sorin et al reported the outcomes of 278 children who had undergone intracapsular tonsillectomy with the microdebrider. (12) They noted that tonsils grew back in 9 patients, 2 of whom required total tonsillectomy because of obstructive sleep apnea. There were also 2 cases of self-limited bleeding that did not require further surgery. Despite the risk of tonsillar regrowth, the investigators considered this procedure to be worthwhile because of the relatively low morbidity.

Clinical experience. Dr. Bent uses the powered microdebrider regularly for patients with obstructive tonsillar hypertrophy. He feels that this surgical modality offers both speed and control of tissue removal, which are ideal for subtotal tonsillectomy.

Dr. White appreciates the precision of the powered microdebrider, even though it is associated with significant bleeding and an increased need to cauterize. However, she rarely performs subtotal procedures where minimizing morbidity is very important.

Dr. Lee is a strong advocate of subtotal tonsillectomy because it decreases the morbidity of tonsillar surgery and, just as important, it decreases the incidence of postoperative bleeding. However, given the potential for tonsil regrowth and recurrent infection, he advocates removing as much tissue as possible without violating the tonsillar capsule. Although the powered microdebrider is very fast and relatively precise, it is difficult to remove the deepest layer of tonsillar tissue just over the capsule. With extensive cautery, much of this likely sloughs off secondary to thermal injury by monopolar cautery, but surgeons cannot be sure what they are left with after the fossa heals.

Plasma excision device. Plasma excision has been used extensively for tonsillar surgery, and it is the only one of the three new technologies discussed here that can be used for both total and intracapsular tonsillectomy.

Technique. For treating patients with large tonsils, the Wand is set to plasma excision mode and its power level is set at 9. The plasma quickly removes tissue while fusing most of the small blood vessels encountered. When the bulk of the tonsil has been removed, the power level is lowered to 7 and then to 5 as the Wand's surface slowly passes over the remaining tissue. At a lower power level, the Wand oscillates between coagulation and excision modes, and the surgeon is therefore able to continue to remove tissue while more effectively fusing the vessels encountered.

The length of the procedure depends on the amount of tonsillar tissue that needs to be ablated. For patients with very large tonsils, especially older patients, the surgeon can expedite the process by partially debulking the tonsil before proceeding to the layer-by-layer removal. To debulk the tissue, the surgeon grasps the middle of the tonsil with an Allis forceps and retracts it medially. The Wand is then used to excise the tissue just under the forceps. Conservative debulking is recommended because the tonsillar fossa will also be retracted medially during this process, and the capsule can be easily violated in the midsection of the tonsil. The remaining tonsillar tissue is then removed as described earlier.

Tissue removal is continued until minimal tonsillar tissue is palpable in the tonsillar fossa. The tonsillar tissue remaining in the fossa is usually blanched white (figure 5). If the tonsillar capsule is penetrated, immediate bleeding will be noted in the field at the site of occurrence because of the vascularity of the muscle. Performing bipolar cautery with the alternate foot pedal usually provides adequate hemostasis. Paying careful attention to the fossa under the superior pole and along each tonsillar pillar ensures that maximal tissue is achieved. With experience, a nearcomplete tonsillectomy can be performed routinely without injury to the capsule.

[FIGURE 5 OMITTED]

Advantages. Intracapsular tonsillectomy via plasma excision has been reported to minimize postoperative pain, resulting in a more rapid return to normal activities and diet. There also appears to be a decrease in postoperative bleeding because the larger blood vessels that feed the tonsillar capsule are not exposed. (3)

Study data. In a multicenter trial, Chan et al randomized 50 pediatric patients with tonsillar hypertrophy to undergo either electrocautery dissection or intracapsular tonsillectomy via plasma excision. (4) Patients kept a pain diary for 14 days postoperatively, and their symptoms were monitored for 1 year. Findings at study's end indicated that plasma excision was significantly more beneficial in terms of time to resolution of pain and return to a normal diet. There were no postoperative complications in either group.

Lee et al conducted a retrospective study of 528 patients who had undergone intracapsular tonsillectomy via plasma excision. (13) Patients ranged in age from 1 to 62 years (mean: 15), and 55% were 12 years of age or younger. The most common primary indications for surgery were chronic tonsillitis (49%), obstructive symptoms (24%), and recurrent infection (13%). The authors found no cases of postoperative airway complications, aspiration, or immediate postoperative hemorrhage. Five patients had delayed postoperative bleeding, but only 1 of them required surgical control; the rate of bleeding (<1%) was less than that usually reported in the literature with respect to standard total tonsillectomy. No other complications related to plasma excision were noted.

Clinical experience. During the panel discussion, Dr. Lee said he is an enthusiastic proponent of intracapsular tonsillectomy. In his experience, it has resulted in a significant decrease in morbidity in terms of both pain and hemorrhage and it provides a significant benefit with respect to return to normal activities and diet. Although most cases of posttonsillectomy hemorrhage are not life-threatening, they are of concern because they can cause a great deal of anxiety. Therefore, Dr. Lee believes that any approach that can reduce the incidence of postoperative hemorrhage is worthwhile. Most of the other panel members preferred total tonsillectomy; they reserve intracapsular tonsillectomy for selected cases.

While Dr. Lee uses plasma excision for both total and intracapsular tonsillectomy, he especially prefers it for intracapsular surgery. He finds that this approach is particularly beneficial in adults, in whom tonsil regrowth is less of an issue than it is in children.

Because of the risks of reinfection and tonsillar regrowth, Dr. White considers intracapsular tonsillectomy only for cases of tonsillar hypertrophy with tonsillar irritation. She also recalled that she had performed partial tonsillectomy on several college students who had tonsillar hypertrophy with halitosis and cryptic tonsils. A speedy recovery was important to these patients. She offered them the option of intracapsular tonsillectomy and explained its risks and benefits. All of these patients accepted. They did well and were eating normally within 2 days, compared with the 7 to 10 days typically associated with total tonsillectomy. None of these students experienced any immediate or delayed postoperative bleeding. However, she noted that this experience was based on a small number of patients and that there was no follow-up beyond the first few days.

Adenoidectomy. Like the powered microdebrider, the plasma excision device can be used to perform adenoidectomy. The procedure is similar to that used for intracapsular tonsillectomy. For adenoidectomy in children, the Wand is set to power level 7 and coagulation setting 3. Saline is applied at lull force. The surgeon begins the procedure by moving the Wand lightly in a circular fashion in the center of the adenoid tissue. As the center portion is removed, the remaining adenoid tissue folds in and collapses into the cavity. The surgeon applies suction so that the eustachian tube cushions are not injured. If necessary, the surgeon can go back over any bleeding vessels lightly to achieve coagulation.

Referrals

Some of the most common reasons that pediatricians refer patients to otolaryngologists are hypertrophic tonsils, pharyngitis, pharyngotonsillitis, recurrent ([greater than or equal to] 6 cases/yr) tonsillar infections, and documented culture-positive streptococcal infection that is resistant to antibiotic treatment. Yet the primary reason for referral is chronic obstructive sleep apnea. Most pediatricians prefer to refer patients to physicians who work well with children. However, their choice of physician is often limited by the mandates of various health maintenance organizations (HMOs).

Dr. Hinchcliffe noted that overall patient comfort postoperatively is the pediatrician's most important concern. Other considerations, of course, are a rapid and uncomplicated recovery.

Most pediatricians have not been particularly concerned about which tonsillectomy procedure that an otolaryngologist chooses to use. However, public awareness of new technologies that can improve patient outcomes is focusing some attention on this matter. Because more parents are asking about the newer modalities, both otolaryngologists and pediatricians must stay abreast of new technology.

The economics of new technology

Because of the pressures that HMOs put on hospital administrators as well as surgeons, the economics of any new technology must be addressed. The cost of the technology must be justified, and justification is not always easy to provide because some cost savings are often indirect. For example, if a particular procedure will result in children returning to school more quickly, indirect savings will be realized because their parents will spend less time away from work. Such an advantage is particularly meaningful in single-parent families. Nevertheless, because the procedure would result in only indirect savings rather than in clearly quantifiable savings, HMOs will not recognize it.

Intangible savings also include those associated with reductions in equipment pull time for nurses and in lengths of stay in the ambulatory surgery area for other staff, faster patient turnover, user-friendliness, and less need for postoperative analgesics. Costs also need to be balanced against such factors as patient outcomes, quality of life, and patient care and satisfaction. The true cost-effectiveness of any medical technology cannot be accurately determined without considering the impact of noneconomic factors. Several cost-benefit investigations are under way in an attempt to determine whether the harmonic scalpel, the powered tissue microdebrider, and the plasma excision device are more cost-effective than conventional tonsillectomy techniques.

Future directions

The consensus of the roundtable participants is that each of the three new surgical approaches to tonsillectomy may have a place in the armamentarium.

* The harmonic scalpel allows for precise excision with minimal thermal damage. However, it often requires the adjunctive use of electrocautery, and it can be used to perform total tonsillectomy only.

* The microdebrider is an aggressive device that rapidly removes tonsillar tissue. It does not provide hemostasis, so electrocautery is always necessary. Also, it can be difficult for surgeons to know when to stop dissection. The microdebrider can be used to perform intracapsular tonsillectomy only.

* Plasma excision can be used to perform both total and intracapsular tonsillectomy. The device is designed to rapidly perform precise dissection or excision with an element of hemostasis via the plasma. The device is designed to enable surgeons to switch easily between tissue excision and definitive hemostasis by using an alternate foot pedal.

The choice of tonsillectomy procedure has run the gamut from cold steel and electrocautery to the innovations discussed in this supplement. The future direction of tonsillectomy technology appears to be promising. The ability to perform surgery quickly and safely while minimizing morbidity is a goal that all surgeons strive to attain. Medical technology offers a way to achieve this goal and thereby improve patient outcomes and quality of life.

Table. Comparison of selected characteristics of the three
tonsillectomy devices

                        Harmonic      Powered      Plasma excision
Uses                    scalpel    microdebrider       device

Total tonsillectomy       Yes           No               Yes

Intracapsular             No            Yes              Yes
  tonsillectomy

Adenoidectomy             No            Yes              Yes

Tonsillectomy

OR time [less than or     Yes           Yes              Yes
  equal to] 10 min
  in most cases

Provides hemostasis       Yes           No               Yes

Built-in suction          No            Yes              Yes

Optimal visibility        Yes           No               No
  of surgical field

Handpiece cost <$100      No            Yes              No

References

(1.) Curtin JM. The history of tonsil and adenoid surgery. Otolaryngol Clin North Am 1987;20:415-19.

(2.) Paradise JL, Bluestone CD, Bachman RZ, et al. Efficacy of tonsillectomy for recurrent throat infection in severely affected children. Results of parallel randomized and nonrandomized clinical trials. N Engl J Med 1984;310:674-83.

(3.) Koltai PJ, Solares CA, Mascha EJ, Xu M. Intracapsular partial tonsillectomy for tonsillar hypertrophy in children. Laryngoscope 2002;112:17-19.

(4.) Chart KH, Friedman NR, Allen GC, et al. Treatment of tonsillar hypertrophy by subtotal tonsillectomy using ionized field ablation: A randomized multicenter trial. Presented at the annual meeting of the American Society of Pediatric Otolaryngology; May 5, 2003; Nashville, Tenn.

(5.) Amaral JF. The experimental development of an ultrasonically activated scalpel for laparoscopic use. Surg Laparosc Endosc 1994; 4:92-9.

(6.) Morgenstein SA, Jacobs HK, Brusca PA, et al. A comparison of tonsillectomy with the harmonic scalpel versus electrocautery. Otolaryngol Head Neck Surg 2002;127:333-8.

(7.) Willging JP, Wiatrak BJ. Harmonic scalpel tonsillectomy in children: A randomized prospective study. Otolaryngol Head Neck Surg 2003;128:318-25.

(8.) Back L, Paloheimo M, Ylikoski J. Traditional tonsillectomy compared with bipolar radio frequency thermal ablation tonsillectomy in adults: A pilot study. Arch Otolaryngol Head Neck Surg 2001 ;127: 1106-12.

(9.) Temple RH, Timms MS. Paediatric coblation tonsillectomy, Int J Pediatr Otorhinolaryngol 2001;61 : 195-8.

(10.) Timms MS, Temple RH. Coblation tonsillectomy: A double blind randomized controlled study. J Laryngol Otol 2002; 116:450-2.

(11) Koltai PJ, Solares CA, Abelson TI, et al. The safety and efficacy of intracapsular partial tonsillectomy for pediatric obstructive sleep disordered breathing. Presented at the annual meeting of the American Society of Pediatric Otolaryngology; May 5, 2003; Nashville, Tenn.

(12.) Sorin A, Bent JP, April MM, Ward RF. Complications of microdebrider-assisted powered intracapsular tonsillectomy and adenoidectomy. Laryngoscope 2004; 114:297-300.

(13.) Lee KC, Altenau MM, Barnes DR, et al. Incidence of complications for subtotal ionized field ablation of the tonsils. Otolaryngol Head Neck Surg 2002; 127:531-8.