Tonsil

Harmonic scalpel tonsillectomy versus hot electrocautery and cold dissection: An objective comparison

September 30, 2004     Shai Shinhar, MD; Brett M. Scotch, DO; Walter Belenky, MD; David Madgy, DO; Michael Haupert, DO
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Abstract
We conducted a large-scale retrospective study to compare the surgical efficacy, practical utility, safety, and cost-effectiveness of ultrasonic harmonic scalpel tonsillectomy, hot electrocautery, and cold surgical dissection. We based our findings on the length of operating time, complication rates, the length of hospital stay for patients with complications, and relative costs. We then compared our findings with those published in earlier reports, none of which were based on a three-way comparison. Our study population was made up of 316 patients''175 males and 141 females aged 1 to 23 years (mean: 7.3)''who had undergone adenotonsillectomy or tonsillectomy alone at our tertiary care children's hospital between Sept. 1, 2000, and Aug. 31, 2001. The harmonic scalpel was used on 75 patients (23.7%), electrocautery on 109 patients (34.5%), and cold surgical dissection on 132 (41.8%). The mean length of operating time for adenotonsillectomy was 42.4 (n = 70), 43.0 (n = 103), and 49.2 (n = 95) minutes, respectively; the corresponding times for tonsillectomy alone were 23.6 (n = 5), 30.2 (n = 6), and 35.3 (n = 37) minutes. Overall complication rates were 2.7, 5.5, and 6.1%, respectively. Hospital stays for immediate (<24 hr) postoperative bleeding averaged 2.0, 1.0, and 0.7 days, respectively, and stays for dehydration averaged 1.0, 1.3, and 1.5 days. Mean per-patient institutional costs were $460.00, $310.75, and $300.00, respectively. We conclude that harmonic scalpel tonsillectomy is efficacious, practical, safe, and cost-effective, and we recommend that any institution involved with a significant number of pediatric tonsillectomies consider using it.

Harmonic scalpel versus conventional tonsillectomy: A double-blind clinical trial

September 30, 2004     Patrick J. Collison, MD, FACS; Robin Weiner, MD
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Abstract
We conducted a prospective, double-blind clinical trial to evaluate the differences in operating time, intraoperative blood loss, postoperative pain at 3 hours and 1 week, and delayed (>24 hr) bleeding associated with ultrasonic harmonic scalpel tonsillectomy and conventional tonsillectomy. The study was carried out on 28 patients with recurrent tonsillitis and/or adenotonsillar hypertrophy who underwent harmonic scalpel tonsillectomy on one side and cold dissection tonsillectomy with suction electrocautery hemostasis on the other. The harmonic scalpel was associated with significantly less intraoperative blood loss (mean: 6.2 vs. 58.8 ml; p < 0.0001) and less early (3 hr) postoperative pain as determined by scores on a 10-point visual analog scale (mean: 3.5 vs. 4.4; p = 0.0042); although the difference in early pain scores is statistically significant, it is probably not clinically significant. Pain scores at 1 week were nearly identical (mean: 2.7 vs. 2.6; p = 0.9246). The length of operating time was similar (mean: 10.9 vs. 7.7 min; p = 0.0022). An unanticipated finding was the fact that delayed bleeding, which occurred in 3 patients (10.7%), occurred only on the harmonic scalpel side. We conclude that the only clearly demonstrable advantage that the harmonic scalpel had over cold dissection was that it caused less intraoperative blood loss.

Pediatric intracapsular tonsillectomy with bipolar electrosurgical scissors

September 30, 2004     Glenn Isaacson, MD
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Abstract
This article describes the benefits of performing intracap- sular tonsillectomy with bipolar electrosurgical scissors as an alternative to the powered microdebrider. These scissors are used to excise approximately 90% of the tonsillar mass en bloc. The remaining tonsillar tissue is electrodesiccated by monopolar suction cautery, while the anterior and posterior pillars are completely preserved. The procedure leaves a smaller surgical wound than do extracapsular techniques. Surgical time averages 6 min-utes. There is typically no intraoperative blood loss. Bipolar electrosurgical scissors are an efficient and low-cost tool for performing pediatric intracapsular tonsillectomy.

August 2004 Supplement

July 31, 2004    
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Introduction

July 31, 2004    
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Grisel's syndrome: The two-hit hypothesis-A case report and literature review

July 31, 2004     Andrew P. Battiata, MS, MD, CPT, MC, USA; George Pazos, MD, LCDR, MC, USN
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Abstract
Grisel's syndrome is a rare but well-documented clinical entity. It is a nontraumatic, fixed rotary subluxation of C1 on C2 (atlantoaxial). Although first described in 1830, the exact mechanism of Grisel's syndrome remains unclear. We present a postoperative case of Grisel's syndrome and an extensive literature review, and we propose a mechanism for its pathogenesis. In addition, we propose a treatment algorithm for Grisel's syndrome.

Radiofrequency volume tissue reduction of the tonsils: Case report and histopathologic findings

July 31, 2004     Alyssa R. Terk, MD; Steven B. Levine, MD
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Abstract
Innovative new techniques to resect tonsillar tissue have been described in the recent literature. We report the case of a patient who underwent volume reduction of tonsillar tissue by radiofrequency energy under local anesthesia in an office setting. Treatment resulted in a reduction of tonsillar size with minimal pain, which can be attributed to the avoidance of mucosal interruption. The patient subsequently underwent standard tonsillectomy, which allowed us to examine the histopathology of the tissue that was treated with radiofrequency. In doing so, we noted an absence of fibrosis and preservation of normal histologic architecture. We conclude that performing volume reduction of tonsillar tissue by applying radiofrequency energy to the stroma of the tonsils without temperature control results in objective improvement in airway size with minimal effects on the histopathology of the tonsillar stroma. Mucosa-sparing tonsillar reduction may be a preferable alternative to other techniques of tonsillar reduction, especially for young children, who would experience a nearly pain-free procedure.

The roles of the anterior tonsillar pillar and previous tonsillectomy on sleep-disordered breathing

May 31, 2004     James Chan, MD; Lee M. Akst, MD; Isaac Eliachar, MD
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