1

Introduction

In 2011, Silvola et al. reported a documented 300,000 tonsillectomies performed in the United States. Despite the volume of patients who undergo this procedure, we have yet to perfect it. Furthermore, in the age of reduced reimbursement and payment bundling, physicians must consider cost effective management decisions that do not compromise patient care lending the procedure to continual scrutiny.

Tonsillectomies have been performed in a multitude of ways evolving from blunt dissection and guillotine excision, to the more recent electrocautery (EC), cryosurgery, coblation, ultrasonic removal, laser removal, monopolar and bipolar dissection . With the newer technologies, we see less intraoperative bleeding with shorter operative times in exchange for more postoperative pain . We attribute both to the tissue destruction associated with sealing blood vessels in the fossa. With this tissue destruction we have seen increased rates of secondary bleeds when the fossa “scabs” slough, in addition to dehydration, increased use of narcotic pain medication, and time away from work or school.

Without great success, multiple studies have published comparisons of the above methods with the goal of finding a superior instrument for the procedure . More recently, Silvola et al. published a comparison between the tissue welder (TW) and electrocautery (EC) tonsillectomy. The EC is used extensively for tonsillectomies and is the instrument of greatest use at our institution. With the reported benefits of shorter pain duration, less affected activities of daily living, decreased need for hospital contact after surgery, and decreased post-operative bleeding , we sought to duplicate the findings and further evaluate the instrument by including an analysis on operative times, intraoperative blood loss, and cost.

2

Materials and methods

This prospective, randomized, single-blinded clinically controlled study was approved by the institutional review board at the Wexner Medical Center at Ohio State University. All patients were informed and provided written consent according to the principles approved by the IRB committee prior to enrollment in the study. Standard HIPAA protocols were used, and database information was stored on password encrypted files.

We recruited 48 patients between the ages of 18 and 50 years, undergoing tonsillectomy for recurrent or chronic tonsillitis, or adenotonsillar hypertrophy associated with airway obstruction. Patients were excluded for decisional impairment, non-English speaking, pregnancy or lactation, immunocompromised status, or malignancy.

Each subject had a thorough history and physical exam, including demographic information obtained prior to consideration for tonsillectomy. Once enrolled, the subject was randomized to the TW group or EC group which was blinded to the study participant. All tonsillectomies were performed by the senior author under general endotracheal anesthesia at one of our two surgical sites, Wexner Medical Center main operating room or the Eye and Ear Institute Outpatient Surgery Center. All patients were positioned with a shoulder roll, draped in the usual sterile fashion, and suspended with a Crowe-Davis taking appropriate cautions with positioning. All patients were injected with half percent bupivacaine in the posterior soft palate for postoperative analgesia. Intraoperative blood loss was recorded as well as duration of the procedure. Procedure time was started when the Crowe-Davis was placed and stopped with removal from the patient’s oral cavity.

All EC tonsillectomies were performed on a setting of 20 W with a red rubber catheter in place. The anterior pillar was divided in a plane parallel to the length of the tonsil limiting palatoglossus muscle resection. Dissection continued around the tonsillar capsule allowing for identification and control of vessels. The palatopharyngeus muscle was preserved and the uvula mucosa was left unharmed. The second tonsil was then removed in the same fashion. The patient was taken down out of suspension after removing the red rubber catheter, and placed back in suspension after 30 seconds to inspect for bleeding. This was controlled as needed with suction cautery on a setting of 20 W. A second look was performed when there was concern for bleeding.

The TW tonsillectomies were managed in a similar fashion. No red rubber catheter was needed. The tonsil was first grasped with a curved Allis hemostat and rotated medially. The tonsil was dissected away from the tonsillar fossa using a TW at a setting of 3 in the peritonsillar plane. Hemostasis was achieved using the coagulation mode. The Crowe-Davis was closed for approximately 30 seconds and reopened to inspect for bleeding.

Patients were managed in the post anesthesia care unit by the anesthesiology team and discharged when they met PACU specific criteria. They were discharged home with prescriptions for oxycodone/acetaminophen elixir or hydrocodone/acetaminophen elixir and magic mouthwash (a 1:1:1 mixture of lidocaine, diphenhydramine, and an antacid [magnesium hydroxide, aluminum hydroxide, simethicone]). Given that some patients were prescribed hydrocodone/acetaminophen and some oxycodone/acetaminophen, we used an opioid equivalent adjustment such that 5 ml of oxycodone/acetaminophen was equivalent to 7.5 ml of hydrocodone/acetaminophen. The post-operative log which was explained pre-operatively, was given to the patient to take home.

The post-operative log consisted of three pages, one for each week after surgery. The log required documentation of pain score, medication use, bleeding, return to normal diet and return to work. The pain rating was to be completed based on a scale of 0–10 where ten represented the worse pain ever felt and zero represented no pain. Oxycodone/acetaminophen elixir was reported in teaspoons or 5 ml doses. The patients were directed to follow up in our clinic 3–4 weeks after the procedure. Those who did not return were contacted by phone and mailed a self-addressed stamped envelope to return their postoperative log.

Additional measures were recorded separately in our electronic medical record. We documented intraoperative blood loss which was estimated by the surgeon and anesthesiologist at the end of the case and operative time which was recorded by the circulator according to cues by the attending surgeon.

Finally, we evaluated how the differences between the two groups would lead to greater or decreased cost for the tonsillectomy procedure by looking at the charges for instrumentation, operating room (OR) time for each of the two groups. We calculated the cost of OR time based on the method of charges for by our surgery center for staff, use of the OR, in addition to charges for anesthesia. For the intended purposes of total cost analysis, these charges are presented together as one number.