Abstract
Objectives
Tonsilloliths, proven to be tonsillar biofilms cause symptoms of halitosis, foreign body sensation and recurrent sore throats. Laser Tonsil Cryptolysis (LTC) performed in the office may represent an alternative to tonsillectomy in selected cases of persistent tonsilloliths with cryptic infections.
Study Design
A retrospective chart analysis using CPT codes.
Setting
Office and hospital.
Methods
A retrospective complications review consisting of bleeding, the need for an additional procedure, patient satisfaction and conversion rate to complete tonsillectomy was documented.
Results
Five hundred consecutive LTCs performed in the office under local anesthesia with a CO2 or diode laser were identified. Energy delivery was in continuous mode with power settings of 18W and 10W respectively. Bleeding occurred in 6 patients requiring unscheduled return office visit for evaluation. Eighty patients required a second procedure, comprising total of 1.16 procedures per patient. Eighteen (3.6%) patients underwent complete tonsillectomy. Patient satisfaction was high with an overall incidence of 0–2 days of work absence. Follow-up was 1–8 years.
Conclusions
With a small tonsil size, controllable gag reflex and cooperative adult patient LTC allows several advantages compared to conventional tonsillectomy. Benefits of LTC include avoidance of general anesthesia and limited ablation of cryptic pockets, resulting in reduced post-operative pain, bleeding, shorter recovery time and the convenience and cost advantage of an office procedure. With 1.16 sessions required per patient, low conversion rate to standard tonsillectomy and minimal complication rate LTC can be considered an alternative option to a patient suffering from recurrent cryptic tonsillitis with or without tonsilloliths.
1
Introduction
Tonsilloliths may contain calcium deposits, and some have suggested that they result from infection. Samant and Gupta concluded in 1975 that they represent incomplete evacuation of pus with the dead bacteria and the inflammatory cells providing the nidus for their formation. Most of the ensuing reports regarding tonsilloliths have focused on the tonsillolith size (up to 44 gram reported) and symptoms derived from it . Evidence of tonsilloliths being responsible for chronic silent infection came with Stoodley et al , confirming that tonsilloliths are similar in architecture and physiologically behaving as dental biofilms. This fact coincides with preferential formation of biofilms forming in grooves, depressions and cryptic pockets rather than on the tonsil surface. Biofilms are mixture of dormant bacteria within a matrix in a low energetic form capable of reversing their hibernation under environmental changes. Typically tonsillar biofilms are formed by anaerobic gram negative bacteria. Oxygen poor environments can be detected at the center of the tonsilloliths, with depletion of sugar at the surface. This state is reversible with the addition of fluoride in experimental models. Thus Stoodley and collaborators postulated that tonsilloliths exhibit typical behavior quite similar to dental biofilms .
Despite inadequate understanding regarding the cause of tonsilloliths, the signs and symptoms of foreign body sensation, metallic taste, throat closing or tightening, coughing, choking and halitosis are well documented. Rio et al performed halitometry in patients suffering from recurrent tonsilloliths, finding a tenfold increase in the risk of halitosis when tonsilloliths were present. Conversely, all patients without tonsilloliths had normal halitometry. Tonsilloliths form within the tonsillar crypts. The external face of the tonsil is covered by stratified squamous epithelium, which invaginates toward the inside of the tonsillar parenchyma, forming the crypts. Each adult palatine tonsil has an average of 10–20 crypts , which resemble fissure apertures on the tonsil surface and become an anaerobic environment for certain bacteria to accumulate to form biofilms. As the biofilm matures and enlarges the crypt dilates to accommodate the tonsillolith causing inflammation at crypts. According to Dal Rio et al CO2 laser ablation of the tonsil crypts opens the crypt ostium, thus avoiding bacterial retention and allows easy clearing the cryptic pocket. The stretching and tension of scar tissue around the crypt with the resultant superficial coagulation and contraction are similar to that observed in laser skin resurfacing. The tissue vaporization leading to consequent reduction of tonsillar parenchyma results in crypt’s opening directed outward thus forcing the crypt to remain widely open. Halitometry was performed before the treatment and following LTC. A histological exam following LTC showed that procedure was safe and halitometry showed reduction of volatile sulphur compounds by 30% with disappearance of halitosis . Finkelstein et al presented a series of 53 patients with the tonsils as a source of halitosis to assess the efficacy of CO2 laser for its treatment. Finkelstein’s tonsil smelling evaluation consisted of massaging the tonsils with a gloved index finger and smelling the squeezed discharge. The authors performed Laser Cryptolysis as an office procedure under topical anesthesia and concluded that LTC appeared as an effective, safe, and well-tolerated procedure. Although simple smelling of the gloved finger may not represent an objective measurement of the reduction of halitosis.
Passos et al introduced LTC as treatment for chronic tonsillitis. The CO2 laser was used with biopsies of the tonsil and histological evaluation focusing on germinal centers, lymphoid tissue, sub-epithelial fibrosis, and parenchyma fibrosis documented. The biopsies showed that the laser, used at a specific energy density, could relieve the symptoms without increase of the fibrotic content, nor decrease of the lymphoid structure. The laser action caused only epithelial coagulation, thus only weakening the tension forces in the crypt borders resulting in their marsupialization and exteriorization. The large or deeper crypts required additional vaporization creating a large furrow.
The current study is a compilation of the above mentioned indications for LTC, i.e. halitosis, tonsilloliths formation and chronic cryptic tonsillitis. The study focuses on safety, effectiveness and complications of LTC by reviewing a large series of office procedures performed. Additionally, an alternative method of examining the tonsils and tonsilloliths is suggested in indentifying imbedded tonsilloliths. Patient satisfaction and grading of halitosis were performed on some patients with the Halitosis Associated Life-quality Test (HALT) questionnaire, which was recently introduced by Kizhner et al .
2
Methods
Following IRB approval using CPT codes five hundred consecutive cases of LTC going from 2003 to 2011 were analyzed. End results included: number of total procedures, complications and number of patients that needed completion tonsillectomy under general anesthesia.
The indications for office LTC are a cooperative patient, tonsil size <+2, controllable gag reflex and the ability to adequately visualize and explore the oropharynx. The exclusion criteria are large tonsils with tonsillar tissue extending beyond the posterior pillar, hyperactive uncontrolled gag reflex and an uncooperative patient. Patients with significant tonsil hypertrophy were not considered candidates.
Patients were excluded if the tonsils expanded medial to the posterior pillar, obstructing the view of the palato-pharyngeal fold. Assessment of the gag reflex, during the initial examination consisted of palpation of the anterior pillars after spraying with Benzocaine aerosol 20% spray. Patients gagging after topical spray were excluded. Prior to the procedure, only local anesthesia is used avoiding intravenous agents. Lidocaine 2% with1:100,000 epinephrine is injected with a 27 gauge needle. Approximately 1 cc. injected in each tonsil site… Local anesthesia was infiltrated along the anterior pillar and into the posterior pillar. When tonsilloliths are suspected a two hand technique using two wooden tongue blades is used. One hand gently depresses the tongue, while the other tongue depressor will press the upper border of the anterior pillar (palato-glossal fold) vertically and laterally pushing the tonsil medially and gently squeezing its contents. The tonsilloliths are hidden from view, particularly at the upper pole behind the anterior pillar. The caseous tonsilloliths material is examined with an offensive smell confirming the source of halitosis.
Since 2010 fifty patients also completed the HALT questioner before and after LTC. Additionally, mapping of the location of the tonsilloliths was performed.
As the general technique for LTC is covered elsewhere some key points are worth mentioning. Ablation of the upper corner of the anterior pillar to expose the superior pole of the tonsil enables complete identification of new crypts filled with tonsilloliths ( Fig. 1 ).
Then the tonsil lymphoid tissue is ablated with CO2 laser with a rapidly rotating 2 mm scanning device to evaporate the tonsil surface layer by layer ( Fig. 2 ), similar to peeling the layers of an onion. The laser action with scanner causes char-free epithelial coagulation. Contraction of mucosa at the ablation site weakens the crypt borders resulting in their marsupialization. The mucosal tension and forces end up pulling the edges apart resulting in thus opening the crypts. The tissue characteristics of the tissue after ablation resemble those after laser skin resurfacing. Eventually exteriorization of the cryptic pocket with complete evacuation occurs as the laser energy reaches close to the bottom of the crypt ( Fig. 3 ). The large or deeper crypts require additional vaporization creating a large furrow. The procedure is continued until the bottom of the crypts are identified and coagulated to avoid reformation of biofilm. Post procedure patient instructions include analgesic medications, topical anesthetics in the form of a gargling solution and antibiotics.
