If you’ve had your tonsils or adenoids removed, you know this type of procedure isn’t always a walk in the medical park.
Among the most often reported complications that plague patients following tonsillectomy and adenoidectomy (T&A) — about 600,000 such procedures each year in the U.S. — are post-operative pain and a significant delay in return to normal diet. Frequently, there is no quick recovery.
But a recent study, entitled “Complications of Tonsillectomy: A Comparison of Techniques” published in the September 2007 issue of the Archives of Otolaryngology-Head and Neck Surgery, conducted by the Division of Pediatric Otolaryngology at the Alfred I. DuPont Hospital for Children (Wilmington; Delaware), says that powered intracapsular tonsillectomies and adenoidectomy (PITA) procedures had lower incidences of delayed postoperative hemorrhage and return visits to the hospital and boasted quicker recovery times.
PITA can be performed using devices such as Medtronic’s (Minneapolis) StraightShot M4 microdebrider to remove at least 90% of tonsil tissue.
The device, fitting in one hand, resembles a large fountain pen, with a six inch metal rod extending from its body, with a tiny rotating tip attached to the rod.
Medtronic says that the rotating tip feature gives it more precision and control than traditional and tonsil/adenoid surgery tools.
The StraightShot, which received FDA approval in 2001, is also used for sinus, nasal and laryngeal surgery. It can be used to treat chronic sinusitis, reduce nasal obstructions and remove benign and malignant tumors in the airway around the vocal cords, according to a Medtronic spokesperson.
The company won 2006 Medical Device Excellence Silver Award for the device.
The DuPont Hospital study reviewed post-operative outcomes for 2,944 patients undergoing tonsillectomy with or without adenoidectomy between Jan. 1, 2002, and May 31, 2005. The powered intracapsular tonsillectomy group comprised 1,731 patients; an additional 1,212 patients were treated with electrodissection tonsillectomy.
“The incidence of delayed hemorrhage (bleeding more than 24 hours after surgery) was 1.1 % in the powered intracapsular group, as compared to 3.4 % in the electrodissection group. Delayed hemorrhage requiring treatment in the operating room was 0.5 % and 2.1 % for the intracapsular and electrodissection groups, respectively,” the report says.
It also states that treatment in the emergency department or hospital for postoperative pain or dehydration occurred for 3% of the intracapsular group and 5.4% of the electrodissection group. Eleven, or 0.64%, of the intracapsular tonsillectomy patients required revision surgery. Including revision cases and hospital visits for pain, dehydration, and bleeding, complications were 8.8% in the total tonsillectomy group and 4.7 % in the intracapsular group — a 47% reduction in complications.
According to the report, devices used for PITA procedures like the Straightshot allow the surgeon to remove the maximum amount of obstructive or disease-causing adenoid tissue to treat the problem, while leaving a very small amount of tonsil tissue intact to protect the delicate throat muscles, decrease postoperative pain, and shorten the convalescent period.
Microdebriders in general are powered rotary shaving devices with continuous suction often used during sinus surgery. A microbrider is made up of a cannula or tube, connected to a hand piece, which in turn is connected to a motor with foot control and a suction device.
The endoscopic microdebrider is used in performing a partial tonsillectomy, by partially shaving the tonsils. This procedure entails eliminating the obstructive portion of the tonsil while preserving the tonsillar capsule. A natural biologic dressing is left in place over the pharyngeal muscles, preventing injury, inflammation, and infection.
Traditionally, a combined tonsillectomy and adenoidectomy procedure consists of a radio frequency tonsillectomy and a curette adenoidectomy. This is typically effective and relatively safe, but it is less precise and involves considerable postoperative pain.
These techniques are “extracapsular,” meaning all of the tonsils are removed, including the capsule that encloses the tonsils and attaches to the throat. Removing the capsule exposes the throat muscles, large blood vessels and sensitive nerves to bacterial toxins that increase pain and swelling.
The surgeon also has to cauterize the throat muscles directly to stop bleeding. The severe pain after a conventional T&A prolongs recuperation and can cause dehydration. The lack of precision can lead to a hypernasal voice.
The complete removal of the tonsils can also contribute to delayed postoperative bleeding following a traditional T&A procedure.
The DuPont Hospital study comes as no surprise to some and offers confirmation of what was long believed.
“We are pleased but not surprised by the results of this study,” said Richard Schmidt, MD, of the DuPont Hospital for Children, Division of Pediatric Otolaryngology. “Prior to conducting the study we had noted that after powered intracapsular tonsillectomy and adenoidectomy, our patients had a more pleasant post-operative experience than after traditional tonsillectomy and adenoidectomy.
“However, the most significant value of PITA is in the decrease in postoperative bleeding. These bleeding events are extremely stressful to both the child and parents when they occur. PITA decreases such events and must be strongly considered.”