Avoiding oral burns during electrocautery tonsillectomy.
Electrocautery tonsillectomy is a common method of tonsil removal, and electrocautery devices are widely available. Although these devices are relatively safe, inadvertent patient injury may occur with their use, such as oral cavity burns. We describe a simple surgical technique that reduces the risk of oral burns during electrocautery tonsillectomy and review additional safety considerations.
Electrocautery tonsillectomy continues to be the most common technique used to remove hypertrophic tonsils despite the introduction of new technologies such as the laser, the microdebrider, coblation, and the harmonic scalpel. Decreased intraoperative bleeding rates, improved operative times, and overall cost savings compared to those of "cold knife" techniques have contributed to this trend.
Electrocautery devices are widely available and commonly used for many routine head and neck surgical procedures. While these devices are relatively safe, inadvertent patient injury may occur due to the malfunction or improper use of surgical devices, errors in surgical technique, carelessness of operating room personnel, or a combination of these factors. Multiple accounts of inadvertent oral cavity burns during electrocautery tonsillectomy have been documented in the medical literature. It is likely that many more such injuries occur but are not reported.
We present a simple surgical technique that greatly reduces the risk of oral burns during electrocautery tonsillectomy and review additional important considerations for safely performing this procedure.
Pitfalls to avoid
A common error in the use of electrocautery devices is the incomplete insertion of the insulated electrocautery tip into the handpiece (figure 1). This may expose the patient's oral tissues to the uninsulated portion of the electrode, thereby allowing arcing of the electrical current and causing inadvertent burns. The surgeon or assistant also may accidentally pull the tip loose from the handpiece during cleaning.
Manufacturing defects in the electrode insulation, accidental use of an unninsulated electrocautery tip, or direct contact with the patient's tissues or other conductive devices within the surgical field may also contribute to injury.
Most surgeons hold the electrocautery handpiece like a pencil, using the thumb and index finger to manipulate the tip. By simply sliding the middle finger of the operating hand between the handpiece and oral commissure or buccal mucosa, the surgeon can create a physical barrier and electrical insulator to decrease the risk of inadvertent direct contact or arcing between the handpiece and the patient's oral cavity (figure 2). This technique should likewise be employed with handling of the tonsil tenaculum, because arcing from the electrocautery tip to the tenaculum can occur and contribute to an unintentional oral burn.
There is a slight learning curve involved in employing and adjusting to this technique; however, the authors have practiced this method for years and have taught it to otolaryngology residents with consistent results. Employing this technique also serves as a psychological reminder to the surgeon to employ basic safety principles when using electrosurgical devices during head and neck surgery.
The majority of tonsillectomies carried out during the last half of the 20th century were performed with the "cold knife" technique; that is, by employing a Dean or Fisher knife and tonsil snare to remove the palatine tonsil from its fossa. Hemorrhage was then controlled with direct pressure and resorbable suture. (1) However, Krishna et al (2) and Eibling (3) report that the monopolar electrocautery technique for tonsillectomy is now being practiced by the majority of otolaryngologists in the United States. The reason for this trend, according to the results of the Krishna survey, was a decrease in intraoperative blood loss seen with the electrocautery technique.
[FIGURE 1 OMITTED]
O-Lee and Rowe performed a cost analysis comparing electrocautery with the cold knife technique for adenotonsillectomy and demonstrated overall decreased surgical times and an average variable cost savings of 19% in the electrocautery group. (4) Additionally, studies in the current literature have demonstrated comparable postoperative hemorrhage rates between electrocautery and cold steel tonsillectomy groups. (5,6)
While tonsillectomy-associated hemorrhage and pain are discussed frequently in the medical literature, little discussion exists regarding complications secondary to the use of electrocautery devices in the oral cavity. In an excellent article discussing the fundamentals of electrocautery devices, Zinder and Parker describe an incident of an inadvertent oral commissure burn from a bipolar electrocautery handpiece contacting the oral commissure during a routine tonsillectomy. (7)
In Smith and Smith's national survey of otolaryngologists regarding electrosurgery complications, 267 of 324 (82%) complications related to electrosurgical instruments were direct burns resulting from unintentional contact between the active electrode and tissue or burns resulting from the flow of electrical current through a metallic retractor or instrument? These authors noted that four of the direct burns during oral cavity surgery had required commissuroplasty.
[FIGURE 2 OMITTED]
Respondents to the Smith and Smith survey were also asked about the complications that had occurred throughout their careers. Of the burns reported, eight occurred because of a "leak of current" at the connection between the Bovie handle and the tip. (8) These findings are significant, and it is likely that many more such injuries occur but are not reported.
Noteworthy to this discussion is the practice by some surgeons of placing a cut piece of a red rubber catheter over the portion of the electrocautery tip where electrical current could leak. (9) Commercially available protective sheaths, such as the Safety Sleeve (Valleylab, a division of Tyco Healthcare Group LP; Boulder, Colo.), are also available and serve a similar protective function.
Routine use of these barriers could indeed prevent electrical injury, but the added time and expense involved may be a deterrent to their use in clinical practice. Conversely, our described technique of electrocautery handpiece operation adds no extra time or cost to the procedure and can be practiced routinely in any operative setting, regardless of the availability of electrocautery accessories.
The technique we have described is simple and straightforward. It is not difficult to learn, and continued practice makes it second nature for the operating surgeon. This technique will decrease the risk of inadvertent oral cavity burns during tonsillectomy and other surgeries of the oral cavity by creating a physical barrier and electrical insulator between the electrocautery handpiece and patient's oral tissues.
We also suggest that as an adjunct to this technique, preoperative and intraoperative inspection of the electrocautery handpiece and tip be carried out by the operating surgeon and assistant, to ensure that the tip is firmly seated in the handpiece. Additionally, using minimum power settings, activating the handpiece only while in contact with the patient, and avoiding close contact between the tip and metallic devices within the mouth will help avoid unintentional injury. (7)
Adenotonsillectomy is one of the first surgical procedures an otolaryngology resident learns. An inexperienced resident may become focused on the tonsillar tissue and lose awareness of the entire surgical field. Employing this technique helps new surgeons develop that awareness, which translates to increased safety for the patient and decreased risk of complications. We recommend the teaching of the described tonsillectomy technique to otolaryngology residents and encourage experienced otolaryngologists to employ it, as well.
(1.) Bailey BJ. Tonsillectomy. In: Bailey BJ, Calhoun KH, eds. Atlas of Head and Neck Surgery--Otolaryngology. 2nd ed. Philadelphia: Lippincott Williams and Wilkins; 2001:858-9.
(2.) Krishna P, LaPage MJ, Hughes LF, Lin SY. Current practice patterns in tonsillectomy and perioperative care. Int J Pediatr Otorhinolaryngol 2004;68(6):779-84.
(3.) Eibling DE. Tonsillectomy. In: Myers EN, ed. Operative Otolaryngology Head and Neck Surgery. Philadelphia: W.B. Saunders Company; 1997:186-98.
(4.) O-Lee TJ, Rowe M. Electrocautery versus cold knife technique adenotonsillectomy: A cost analysis. Otolaryngol Head Neck Surg 2004;131(5):723-6.
(5.) Walker P, Gillies D. Post-tonsillectomy hemorrhage rates: Are they technique-dependent? Otolaryngol Head Neck Surg 2007;136(4 Suppl):S27-31.
(6.) Wei JL, Beatty CW, Gustafson RO. Evaluation of posttonsillectomy hemorrhage and risk factors. Otolaryngol Head Neck Surg 2000;123(3):229-35.
(7.) Zinder DJ, Parker GS. Electrocauteryburns and operator ignorance. Otolaryngol Head Neck Surg 1996; 115 (1): 145-9.
(8.) Smith TL, Smith JM. Electrosurgery in otolaryngology-head and neck surgery: Principles, advances, and complications. Laryngoscope 2001;111(5):769-80.
(9.) Nichter LS, Goldstein LJ, Bush AM, et al. A simple method for preventing misplaced electrocauterization. Plast Reconstr Surg 1987;80(2):307.
Thomas R. Lowry, MD, FACS; Jonathon R. Workman, MD, FACS
From the Marshfield Clinic, Eau Clair, Wisc. (Dr. Lowry) and Eastern Carolina ENT Head and Neck Surgery, Greenville, N.C. (Dr. Workman).
Corresponding author: Thomas R. Lowry, MD, Marshfield Clinic, 3800 Craig Rd., Eau Claire, WI 54701. Phone: (715) 858-4747; fax: (715) 858-4505; e-mail: firstname.lastname@example.org
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|Title Annotation:||ORIGINAL ARTICLE|
|Author:||Lowry, Thomas R.; Workman, Jonathon R.|
|Publication:||Ear, Nose and Throat Journal|
|Date:||Feb 1, 2009|
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