Authors: Rebecca Sinard Arch (Department of Otolaryngology–Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA; Department of Otolaryngology–Head and Neck Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA), Sanjeet Rangarajan (Department of Otolaryngology–Head and Neck Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA), Kris Jatana (Department of Otolaryngology–Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA; Department of Otolaryngology–Head and Neck Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA), Evan Tobin (Department of Otolaryngology–Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA; Ohio ENT and Allergy Physicians, Columbus, Ohio, USA)
Categories: Original Research, intracapsular, monopolar, posttonsillectomy bleed, tonsillectomy
Source: OTO Open
Doi: 10.1002/oto2.70119
Intracapsular Tonsillectomy With Monopolar Cautery—A Cost‐Effective Surgical Technique
Authors: Rebecca Sinard Arch, Sanjeet Rangarajan, Kris Jatana, Evan Tobin
Abstract
Objective
To illustrate improved posttonsillectomy hemorrhage rates with a novel cost‐effective monopolar intracapsular tonsillectomy (ICT) technique.
Study Design
Retrospective cohort.
Setting
Single physician's experience at a Midwest private practice.
Methods
A single surgeon's chart review of 576 pediatric patients who underwent a tonsillectomy in the last 20 years was completed. In total, 331 cases were treated with ICT performed with a novel monopolar bovie electrocautery technique, as opposed to the more widely used microdebrider or coblator techniques. In total, 246 were treated with the traditional extracapsular tonsillectomy (ECT) technique using monopolar electrocautery.
Results
Of the 331 ICTs performed, one postoperative hemorrhage requiring intervention was identified, resulting in an ICT postoperative bleed rate of 0.3%. Of the 246 ECTs performed, 9 postoperative bleeds requiring intervention were identified, resulting in an ECT postoperative bleed rate of 3.7%. In this cohort, the relative risk of developing a bleed with ECT was 12 times higher than the bleed risk with ICT (P = .018). Every 30 cases of ICT prevented one tonsil bleed (number needed to treat [NNT] = 29.8). Potential savings of ICT with monopolar cautery is 1.6 million for every 10,000 cases that transition to ICT with electrocautery from a microdebrider or coblator technique.
Conclusion
ICT with monopolar electrocautery resulted in a significantly decreased bleed rate compared to the ECT technique in this single surgeon experience and at a much lower cost compared to the more widely used microdebrider or coblator techniques.
Tonsillectomy is one of the most commonly performed pediatric surgeries in the United States with more than 500,000 performed annually. ^1^ The majority of procedures are performed for pediatric obstructive symptoms and obstructive sleep apnea (OSA), and a lesser percentage for recurrent tonsillitis. ^2^ , ^3^ , ^4^ , ^5^ The procedure typically improves symptoms and quality of life in patients in both groups with acceptable postoperative complication rates. ^6^ , ^7^ , ^8^ , ^9^ Risks associated with tonsillectomy include bleeding, pain, dehydration, and very rarely, mortality.
Historically, total tonsillectomy with an extracapsular dissection was the favored method for the most complete removal of tonsil tissue. Recently, there has been a growing popularity of intracapsular tonsillectomies (ICTs), where the capsule overlying pharyngeal muscles is preserved. The technique has gained greater acceptance with reports describing anywhere from 20% to 60% of tonsillectomies performed using intracapsular techniques. ^10^ , ^11^ , ^12^ Previously described ICT techniques utilize a microdebrider or coblator and have been shown to result in significantly lower posttonsillectomy hemorrhage rates and reduced post‐op pain compared to the total or extracapsular tonsillectomy (ECT) technique. ^13^ , ^14^ , ^15^ , ^16^ , ^17^ Despite contemporary utilization of ICT, there is a paucity of literature examining the medical decision‐making, physician preference, and relative cost.
Our study demonstrates a cost‐effective ICT technique with instruments familiar to all otolaryngologists—monopolar electrocautery and monopolar suction cautery and examines posttonsillectomy hemorrhage rates compared to ECT using a single surgeon's experience.
Materials and Methods
This study was approved by the Institutional Review Board of Nationwide Children's Hospital. A single surgeon, retrospective study design was utilized to enroll patient cases into the study. Two cohorts were combined and analyzed. Children younger than 12 years undergoing either ECT or ICT between 2018 and 2023 comprised the first cohort. ECT and ICT patients within this first cohort were considered separate subcohorts for the purposes of analysis. Episodes of posttonsillectomy hemorrhage requiring operative intervention were identified and reported. The ICT data collected from this 5‐year period were combined with available previously described summary data from the same surgeon's post‐ICT bleed rates in the years 2004 to 2014. These data, which comprised the second cohort, were previously presented at the 2014 Combined Otolaryngology Spring Meeting and summarized postoperative bleed rates and cost benefits of the ICT technique among 220 patients. No ECT data were collected for the 2014 presentation.
Student's t test of means was used to evaluate the difference in postoperative hemorrhage between all available ICT cases and the same surgeon's subcohort of ECT cases from 2018 to 2023. A number needed to treat (NNT) was calculated to determine the number of ICT cases needed to avoid one post‐op ECT bleed. A query was completed to compare disposable instrument costs of the monopolar ICT technique versus ICT using microdebrider or coblator. These cost estimates were derived from discussions with both a local product representative and a purchasing center officer in addition to an internet query of publicly available instrument cost information.
ICT Technique
ICT is performed with a monopolar bovie electrocautery scalpel. Intraoperative antibiotics are not used, and patients are routinely given 0.1 to 0.5 mg/kg of dexamethasone per anesthesia. The patient is anesthetized, and the oropharynx is carefully exposed. A suction catheter is passed transnasally through the oropharynx and secured to gently retract the soft palate and uvula. The tonsil is grasped and medialized. Although maintaining FiO2 less than 30%, the majority of the tonsil is amputated with the monopolar cautery on 15 to 20 W with a combination of cut and coagulation mode, taking care to clean debris from the tip with a moistened sponge when necessary. This is similar to the ECT technique, where 15‐W settings are used for all monopolar and suction cautery. To assist with dissection, the guarded bovie tip is bent slightly medially to keep the dissection within the tonsillar parenchyma and away from the capsule. The tonsillar remnant is then cauterized and curetted with the suction cautery to gradually remove the residual tonsillar tissue, approaching, but not violating the tonsillar capsule laterally (Figure 1). The capsule becomes thin and attenuated inferiorly, and care is taken to avoid inadvertent exposure of the pharyngeal musculature here. Hemostasis is maintained and completed with the suction cautery on 15‐ to 20‐W settings. Palpation and visual inspection are used to confirm >95% tissue removal from the tonsillar fossa. The bleeding is typically minimal with estimated blood loss less than 10 mL.
This technique follows similar steps to ICT with a microdebrider. The majority of tonsil tissue is removed with monopolar bovie cautery rather than a microdebrider, and the remaining tonsil tissue is treated with suction bovie. Following the procedure, patients are prescribed acetaminophen as needed. Initially, patients were additionally prescribed ibuprofen for pain control, but over the last 3 years, patients have been instead prescribed celecoxib twice daily for 10 days.
Cost Analysis
Disposable instrument cost for the monopolar cautery ICT technique ranged from 44, averaging 128 to 189. Available pricing data for disposable supplies for the microdebrider technique range from 200, averaging $179.
Results
Of the 331 ICTs performed with monopolar and suction cautery in the last 20 years, one postoperative hemorrhage requiring operative intervention was identified. This resulted in a postoperative bleed rate of 0.3%. Of the 246 ECTs performed and analyzed in the last 5 years, 9 postoperative bleeds requiring operative control were identified (Table 1). This resulted in an ECT postoperative bleed rate of 3.7%. The relative risk of developing a bleed with ECT is 12 times higher than the bleed risk with ICT (P = .018). Every 30 cases of ICT prevents one tonsil bleed (NNT = 29.8). The distribution of ECT and ICT in the last 5 years is illustrated in Figure 2.
Secondary adverse outcomes including revision tonsillectomies, poor oral intake or pain control leading to emergency department (ED) presentation, and tonsil bleeds not requiring return to the operating room (OR) were recorded. Among all 331 ICT cases, there are two known patients who required return to the OR for completion of ECT. In the 2018 to 2023 ICT group, there were three cases who presented to the ED the day after surgery for pain control and poor oral intake. In the 2018 to 2023 ECT group, there was one case who presented to the ED for poor pain control and oral intake on postoperative day 5. In the 2018 to 2023 ECT group, there were five cases with concern for postoperative tonsil bleeds. One of these cases left the ED before further evaluation, and the other four underwent a period of observation before being discharged without return to the OR. There were no cases of tonsil bleeds requiring observation in the 2018 to 2023 ICT group.
With respect to cost, estimated disposable cost savings for ICT with monopolar cautery averaged 151 per case compared with the microdebrider. On a broader scale, the potential savings of ICT with monopolar cautery is about 160,000 for every 1000 tonsillectomy cases or 16 million for every 100,000 cases that transition to this ICT technique from a microdebrider or coblator technique.
Discussion
There is no consensus that one surgical tonsillectomy technique is “best,” as indications, patient factors, and surgeon preferences can vary widely. Multiple reports have demonstrated decreased pain, bleeding, and symptom reduction or resolution with the microdebrider or coblator intracapsular technique. ^17^ , ^18^ The data reported here demonstrate that ICT with monopolar cautery is similarly safe and effective, and compares favorably with regard to postoperative bleeding. Although ICT with electrocautery has been described, there are few large reported series. ^19^ In our series, ICT with monopolar cautery resulted in significantly reduced incidence of postoperative hemorrhage compared to our internal control group and to published ECT bleed rates. ^11^ , ^20^ , ^21^ , ^22^ ICT reduced disposable supply expenses compared with the other two techniques by 161 per case. To our knowledge, there have been only two cases in the ICT group requiring subsequent total tonsillectomies. This leads to a known revision rate of 0.60%, which is lower than published revision rates of 1.18% to 1.39% with coblator and microdebrider ICT techniques. ^23^ , ^24^ Of note, our true ICT revision rate is potentially higher if patients have left our center and sought revision tonsillectomies elsewhere. Given defined risk reduction for return to OR, a patient in our study was 5.6x more likely to come back bleeding and emergently go to the OR than come back for an elective revision procedure in the future.
ICT has been shown to reduce postoperative hemorrhage, pain, and reoperation rates. Preservation of the tonsillar capsule is thought to be the main explanation for reduced pain and bleeding. Despite these conclusions, there remains a lack of consensus regarding the role of ICT. Clinical practice guidelines (CPGs) have been released to help clinicians and patients engage in shared decision‐making regarding the procedure. The most recent published CPG comments on indications, management of postoperative pain, and recording of episodes of postoperative hemorrhage. Recommendations on surgical technique (and which indications merit a particular one) and strategies for reducing cost are not discussed, however. ^25^ Complicating decision‐making is the significant public discourse, including on social media, where reports of catastrophic tonsillectomy complications abound. These complex, “mixed signals” can make parents understandably struggle with decisions about their children's care, particularly if a choice between ICT and ECT is offered.
Surgeon preference continues to drive tonsillectomy instrumentation and technique, with the goal of eliminating patients' symptoms in the safest and most effective way based on each surgeon's personal clinical experience and judgment. Literature suggests that ICT is primarily indicated for sleep disordered breathing or OSA. ^10^ Many children, however, have components of both obstruction and recurrent infection, and some have only infection‐related issues (chronic or recurrent acute tonsillitis). ICT has been described for recurrent tonsillitis with data showing results similarly as effective as ECT, as nearly all of the potentially infected lymphoid tissue is removed. ^20^ , ^26^ , ^27^ ICT for tonsillitis will likely be an ongoing topic of investigation and discussion.
Although cost should not be the sole determining factor, there are savings with monopolar ICT compared with other ICT techniques. The disposable cost for monopolar ICT (for both pencil handpiece and suction cautery unit) averages 189 per case. The disposable cost for a microdebrider is $179 per case. On principle, reduction of disposable costs is appealing, especially for ambulatory surgery centers with a typically fixed reimbursement and no opportunity to bill and collect for additional disposable material costs. In addition to instrumentation, there are potential cost savings associated with ICT will all techniques. Reducing the incidence of postoperative bleeding requiring reoperation results in obvious institutional cost savings. ^28^ These hospital expenses, including costs of readmission, observation, return to the OR, and workup of possible underlying bleeding disorder, could far exceed the expense of the outpatient tonsillectomy itself. The estimate of these savings would need to be offset by later resource utilization for completion tonsillectomy patients who require it later on. Of note, these completion tonsillectomies would likely be performed in an outpatient setting and would not require emergent hospital resource utilization and those associated higher expenses. In addition, emergency management of an acute tonsillar hemorrhage is not without increased anesthesia risk as patients are not nothing by mouth. Determining the long‐term financial impact of ICT can be addressed in future studies.
Even after numerous published studies demonstrating safety, efficacy, reduced pain, and reduced postoperative bleed rates with ICT, widespread adoption is not clear. Reasons that may prevent adoption of ICT include acceptance that the outcomes with complete tonsillectomy are satisfactory, reluctance to adopt a new technique, and uncertainty of long‐term outcomes with ICT that might require completion tonsillectomy—for example, regrowth and reinfection rates.
Ultimately, the decision of when to offer intracapsular technique and then what instrument to use is made based on the clinician's experience and familiarity with a particular instrument, as well as the availability of the instrument. This paper supports the use of electrocautery for ICT, especially for those surgeons who are comfortable with that instrument and do not want to adopt coblation or microdebrider. Electrocautery is readily accessible with several available handpieces and relatively inexpensive. Even for those surgeons who prefer coblation or microdebrider, electrocautery could serve as a useful backup if the primary instrument is not available.
Weaknesses of this study include potential selection bias since ICT is currently offered more often for obstructive symptoms and in younger children who may constitute a lower‐risk group for postoperative bleeding compared to those who received complete tonsillectomy, mostly for recurrent infection. Underreporting of bleeding episodes may also have occurred if patients who experienced postoperative hemorrhage were treated at facilities other than where this single surgeon performed surgery. An additional limitation of this study is the lack of a detailed analysis of operative times to assess for statistically significant differences in case duration by technique. However, by routine, the ambulatory surgery center where all cases were performed tracks and analyzes operative times for all cases so the scheduled times can be adjusted when necessary. No significant difference in operative time has been noted between ICT and ECT with the surgeon performing the cases.
Although this study examined the difference in postoperative hemorrhage between ICT and ECT for a single surgeon, future evaluation of ICT's potential to reduce postoperative pain and provide long‐term alleviation of symptoms for both recurrent tonsillitis and sleep disordered breathing without reoperation will hopefully improve acceptance of this important technique.
Conclusion
ICT with monopolar electrocautery is effective and compares well with other reported techniques for ICT with regard to postoperative bleed rates and cost. In this single‐surgeon experience, ICT demonstrates superior rates of postoperative hemorrhage when compared with ECT. Although currently published practice guidelines do not specify indications and techniques for ICT, we hope that with future attention and inquiry, the technique will enjoy broader acceptance and representation in the literature and in the public zeitgeist.
Author Contributions
Rebecca Sinard Arch, led data analysis and assisted in manuscript development; Sanjeet Rangarajan, assisted in data analysis and manuscript development; Kris Jatana, assisted in manuscript development and editing; Evan Tobin, led research study design and manuscript development.
Disclosures
Competing interests
No authors have any conflicts of interest to disclose.
Funding source
None.