Tonsillectomy technique shows lower complication rate

NEW YORK (Reuters Health) - A newer surgical technique for removing tonsil tissue may have a lower rate of complications than two other commonly used approaches, a new study suggests.

In a study of nearly 3,400 children and teenagers who had tonsil tissue removed, researchers found that surgery using a microdebrider -- a device that shaves tonsil tissue down -- had a lower rate of post-surgery bleeding or dehydration than the other two techniques studied.

However, the researchers stress that complication rates were low with all three surgical approaches -- the microdebrider, electrocautery (where tissue is burned away with an electrically heated metal probe) and coblation (where radiofrequency energy is used to remove the tissue).

Overall, 2 percent of children and teens in the study had a major complication -- defined as bleeding or dehydration that required a trip to the emergency room or hospitalization.

The bottom line for parents is that they should talk with their child's surgeon about the type of tonsillectomy technique he or she is using, and why, according to Dr. Craig S. Derkay, the senior researcher on the study and director of pediatric otolaryngology at Children's Hospital of the King's Daughters in Norfolk, Virginia.

Because surgeon experience is so important, "you want your surgeon to utilize the technique that they are most comfortable with and that gets the best results in their hands," Derkay told Reuters Health in an email.

Tonsillectomies were once commonly performed in children with recurrent cases of sore throat, with more than 1 million done in the U.S. every year from the late 1950s to early 1970s. The practice declined, though, both due to a lack of evidence that it worked and because tonsil infections can often be treated with antibiotics.

Currently, about 500,000 children have the surgery each year, often as an adenotonsillectomy, where both the tonsil and adenoid tissue are removed. The tonsils and adenoids are masses of tissue that help catch incoming germs; the tonsils sit in the back of the throat, while the adenoids dwell behind the nose.

These days, adenotonsillectomy is still sometimes used for recurrent sore throats that do not respond to medication. But more often, it is used to treat obstructive sleep apnea, a disorder in which breathing repeatedly stops and restarts during the night. In children, enlarged tonsils and adenoids are often a cause of sleep apnea.

Traditionally, adenotonsillectomy has been performed with a scalpel or electrocautery. In the last decade, newer techniques have emerged, but it has not been clear how the various approaches compare when it comes to complications.

One of the new approaches is to use a microdebrider, a powered rotary shaving device that reduces, but does not remove, the tonsils and adenoids. Coblation is also a newer method, in which radiofrequency energy, rather than heat, is used to remove the tissue; it can be used for partial or complete removal of the tonsils and adenoids.

For the current study, Derkay's team reviewed the records of 3,362 patients age 18 or younger who underwent tonsillectomy or adenotonsillectomy at their hospital between 2005 and 2008.

Of those who had surgery with the microdebrider, 0.7 percent had serious post-surgery bleeding or dehydration, versus 2.8 percent of coblation patients, and 3.1 percent of electrocautery patients.

According to Derkay, the microdebrider likely has few complications because it does not injure the connective-tissue "capsule" that protects the muscle underlying the tonsils.

In a previous clinical trial, the researchers found that children randomly assigned to undergo the microdebrider procedure healed faster and returned to a normal diet more quickly than those who had electrocautery. That quicker recover, Derkay said, may be why kids in this study had less bleeding and dehydration following surgery.

Still, the choice of tonsillectomy techniques depends largely on the surgeon.

The microdebrider technique is technically more difficult than electrocautery, Derkay noted, and most surgeons today were predominately trained in the latter.

The underlying reason for the tonsillectomy also matters. Derkay said that at his center, they typically use the microdebrider for treating sleep apnea, but opt for electrocautery when treating repeated tonsil infections -- since that technique does not leave tonsil tissue behind.

As far as coblation, Derkay said there is so far little science to show that the relatively new technique is better than electrocautery.

Using a microdebrider is more costly, as the disposable blades are $100 apiece, while the electrocautery device is about $15, according to Derkay. But, he said, insurers generally pay the same for the surgery regardless of the technique, and families' out-of-pocket expenses would be similar with all three.

Some other newer tonsillectomy techniques not evaluated in this study include laser surgery and the Harmonic scalpel, where ultrasound energy is used to vibrate the blade and simultaneously cut and coagulate tissue, with the goal of limiting bleeding and tissue damage.

SOURCE: here(10)00197-X/abstract

Otolaryngology - Head and Neck Surgery, June 2010.