Coblation tonsillectomy versus dissection tonsillectomy: postoperative hemorrhage.

OBJECTIVES/HYPOTHESIS: Coblation tonsillectomy is a recently introduced surgical technique. To measure its benefits against traditional tonsillectomy techniques, it is necessary to compare their complication rates. The study aims to identify differences in reactionary and secondary hemorrhage proportions, comparing coblation with dissection tonsillectomy. STUDY DESIGN: Prospective observational cohort study. METHODS: Rates of reactionary and delayed postoperative hemorrhage were measured, comparing 844 coblation tonsillectomies with a control group of 743 tonsillectomies performed by blunt dissection with bipolar diathermy hemostasis. RESULTS: The secondary hemorrhage rate with coblation-assisted tonsillectomy was 2.25% compared with 6.19% in the control group (P <.05). The rate of secondary hemorrhage in children following coblation tonsillectomy was 0.95% compared with 4.77% in the control group (P <.05). The difference was also significant (P <.05) in the adult population (4.40% vs. 8.81%, respectively). No difference was found in the reactionary hemorrhage proportions. CONCLUSION: In the study, coblation tonsillectomy was associated with a lesser incidence of delayed hemorrhage, more significantly in the pediatric population. The new technique using tissue coblation for tonsil dissection offers significant advantages in the postoperative period compared with dissection tonsillectomy with bipolar diathermy hemostasis. Coblation is associated with less postoperative pain and early return to daily activities. Also, there are fewer secondary infections of the tonsil bed and significantly lower rates of secondary hemorrhage with coblation. These results and the disposable nature of the coblation equipment promote coblation tonsillectomy as the authors' preferred dissection method.

Paediatric coblation tonsillectomy.

OBJECTIVE: Tonsillectomy has been described using a number of techniques. Recently Coblation Technology has been used to remove tonsils with anecdotal evidence of a reduction in post-operative morbidity. In this study we aim to see if there is any difference in post-operative pain, tonsillar fossae healing and return to a normal diet performing tonsillectomy, using tissue coblation compared with standard bipolar dissection. METHODS: A double blind randomised control trial to compare the technique of tissue coblation with standard bipolar dissection to remove tonsils in 38 children on the waiting list for tonsillectomy, with a history of chronic tonsillitis or obstructive tonsils. RESULTS: A significant reduction in post-operative pain was found in the children whose tonsils were removed by tissue coblation (P<0.0001). More rapid healing of the tonsillar fossae was found in the coblation group. Children who had their tonsils removed by coblation were found to return to their normal diet far sooner than those who underwent bipolar dissection. There were no episodes of primary or secondary haemorrhage in either group. CONCLUSIONS: This new technique using tissue coblation for tonsil removal offers significant advantages in the post-operative period, with rapid return to a normal diet and a drastic reduction in analgesic requirements following the surgery.

Blood loss reduction during laser turbinectomy.

The use of a combination of topical and injected anaesthetic and vasoconstrictive agents is widely applied in rhinological practice. To prepare the nose prior to a laser inferior turbinectomy under combined general and local anaesthetic, we routinely spray the nose with 1:1000 epinephrine and inject 2% xylocaine with 1:80.000 epinephrine into each inferior turbinate. With the current climate tending towards evidence based medicine, we were keen to show that our technique of pre-operative nasal preparation was effective. A randomised, double blind, prospective study was carried out, with patients acting as their own control. We found that the injection of 2% xylocaine with 1:80.000 epinephrine did not confer any additional benefit, in terms of blood loss or post-operative pain, in the treatment of these patients. The inferior turbinate that was injected bled more during the procedure than the non-injected side; there was no difference in post-operative discomfort between the 2 sides.

Partial laser turbinectomy: two year outcomes in patients with allergic and non-allergic rhinitis.

OBJECTIVE: The aim was to compare two year outcomes of partial laser turbinectomy in patients with allergic and non-allergic rhinitis with respect to nasal obstruction symptom scores and nasal peak inspiratory flow rates (nPIFR). This has not been reported previously. METHOD: Fifty-four patients underwent partial laser turbinectomy (28 with allergic rhinitis, 26 with non-allergic rhinitis). NPIFR was measured preoperatively, at 3 months and two years postoperatively. A symptom score questionnaire was also completed. RESULTS: Both allergic and non-allergic patients showed a significant improvement in symptom scores and nPIER at three months (n = 54). The improvement in allergic patients was greater. In the 31 patients seen at two years, there was still a significant improvement in median symptom scores but no such improvement in median nPIFR. In allergic patients (n = 18) at two years, there was no significant improvement in symptom and nPIFR scores. Non-allergic patients (n = 13), however, did show sustained significant improvement in these scores (p < 0.05). Eighty-seven percent (26/31) considered the operation successful and would recommend it to others. CONCLUSIONS: Non-allergic patients derive a more sustained improvement in the medium term compared to allergic individuals when undergoing partial laser turbinectomy. The improvement in symptom scores in the group as a whole was still significant.

Incidence and prevention of conjunctival contamination with blood during hazardous surgical procedures.

The incidence and risks of conjunctival contamination with patients' blood during a range of otolaryngological surgical procedures was assessed. Risks were found to be highest in three groups of procedures; tracheostomy, operations preceded by local anaesthetic injections and procedures involving the use of the air drill. A simple and effective method of protection using spectacles with large plain lenses is presented.

Winer's dilated pore, rare presentation in the external ear canal.

A 51-year-old female patient was admitted to our outpatient department with a discharging right ear of six months duration and not responding to aural toilet and topical antibiotics. Microscopic examination showed a collection of soggy keratin in the floor of the ear canal. Suction cleaning showed a skin defect of about 7 mm in diameter. A CT scan showed rarefaction in the bony canal. Histological diagnosis following an excision biopsy under general anaesthetic showed Winer's dilated pore. Winer's dilated pore is a hair follicle tumour arising from the pilosebaceous apparatus. Hair follicle tumours are relatively rare and their clinical appearance is commonly non-specific. In spite of their non-specific features, they show a keratotic plug grossly which when removed reveals a skin defect and may show bone erosion occasionally if the underlying structure is bone. These features can be misinterpreted for more serious lesions such as squamous cell carcinoma or basal cell carcinoma of the ear canal that can lead to pursuing a more aggressive line of management for a benign lesion. We present this rare lesion illustrating the pathological features, differential diagnosis and management.

Incidence of abnormality in routine 'vocal cord checks'.

Where elective surgery carries a risk of damage to the recurrent laryngeal nerve, pre-operative examination of the larynx is routine. The incidence of positive findings at such examination has been determined by retrospective review of 1,947 clinic records. Only 31 vocal cord palsies were found. The possible causes and relevance of such findings are discussed.

Promontory stimulation following labyrinthectomy.

Promontory stimulation testing was carried out on a series of ten patients who had undergone osseous labyrinthectomy. The thresholds, discomfort levels and dynamic ranges were found to be comparable with a series of ten patients who have subsequently been successfully implanted with the Nucleus 22 channel cochlear implant. These findings suggest that cochlear implantation might be possible in a labyrinthectomized ear.

Coblation tonsillectomy: a double blind randomized controlled study.

Tonsillectomy has been performed by a number of techniques. This double blind randomized controlled study compares the technique of tissue coblation with bipolar dissection for the removal of tonsils in 10 adult patients with a history of chronic tonsillitis. A significant reduction in post-operative pain and more rapid healing of the tonsillar fossae were found in the side removed by tissue coblation. There were no episodes of primary or secondary haemorrhage on either side. This new technique for tonsil removal warrants further study.

Basal cell carcinoma of the external auditory canal and Gorlin-Goltz syndrome: a case report.

A case of nevoid basal cell carcinoma syndrome (Gorlin-Goltz syndrome) with basal cell carcinoma of the external auditory canal is reported. Thus is only the second such case.

Nasopharyngeal Corynebacterium ulcerans: a different diphtheria.

A case of toxigenic Corynebacterium ulcerans infection is presented. The diagnosis was delayed and no anti-toxin administered. A nasopharyngeal biopsy was complicated by severe haemorrhage necessitating a post nasal pack. A brief review of the pathology and treatment of Corynebacterium ulcerans is given.

An unusual cause of facial pain.

A case of chronic facial pain and headache is presented. This was found to be due to two pieces of windscreen-glass lodged in the superior meatus of the patient's nose since a road-traffic-accident 14 years earlier. Despite being reported as normal, review of previous X-rays of her sinuses showed that the glass was visible. The importance of carefully assessing the intranasal area on sinus-views is illustrated.

Is a head bandage useful after otoplasty? A quasi-randomized controlled study of complications and patient satisfaction.

We conducted a prospective, quasi-randomized, controlled study to evaluate the incidence of postoperative complications and the degree of long-term patient satisfaction associated with the use or nonuse of a head bandage following otoplasty (pinnaplasty). Our study population was made up of 84 consecutively presenting patients who had undergone bilateral otoplasty (either an antihelical or conchaplasty procedure) for the correction of prominent ears under general anesthesia from January 2000 through March 2005. Patients ranged in age from 5 to 56 years (median: 13); 69 patients (82%) were aged 19 years and younger. Of the 84 patients, 61 (73%) received a postoperative head bandage and 23 (27%) did not. Data on complications were collected prospectively from case notes. Data on long-term satisfaction were obtained prospectively on the basis of answers to a questionnaire survey (90% response rate) in which patients rated their satisfaction on a visual analog scale from 0 (not at all satisfied) to 10 (completely satisfied). We found no significant difference between the head-bandage group and the no-head-bandage group with respect to complication rates (36 and 26%, respectively; p = 0.3) or long-term patient satisfaction scores (6.56 and 8.46; p = 0.09). According to multiple regression analysis, the performance of conchaplasty (as opposed to antihelical procedures) appeared to be the only independent variable that influenced both of the outcomes measures (i.e., fewer complications and greater long-term patient satisfaction). Two independent variables were found to influence long-term patient satisfaction only: the presence/absence of any complication and the individual surgeon who performed the procedure. There was no correlation between individual surgeons and complications. We conclude that the use of a head bandage is not necessary or advantageous following otoplasty for the correction of prominent ears, particularly in patients who have undergone cartilage plication.

Radiofrequency ablation (coblation): a promising new technique for laryngeal papillomata.

This paper describes a new application for radiofrequency ablation in head and neck surgery. Two patients with extensive laryngeal papillomata were successfully treated using this technology. The technique is described in detail, highlighting the main benefits of this approach as compared with existing techniques. These advantages include limited damage to underlying tissues and a bloodless field.

How we do it: Switching from mechanical perforation to the CO2 laser; audit results of primary small-fenestra stapedotomy in a district general hospital.

The use of laser for stapedotomy was introduced in our department in the year 2002, and since then has taken over the mechanical technique. A total of 85 patients who had undergone primary stapedotomy with either technique are reported with regards to effectiveness and rate of side effects. Although footplate complications were reduced with the laser, short-term hearing outcomes were similar between the two techniques. In four occasions, the surgeon had to switch back to the mechanical technique unexpectedly. Stapedotomy will continue to be performed with the laser in our department, bearing in mind the occasional need for the older technique.

Randomized-controlled study comparing post-operative pain between coblation palatoplasty and laser palatoplasty.

OBJECTIVES: This study aimed to evaluate differences in post-operative pain comparing KTP laser-assisted uvulopalatoplasty without tonsillectomy (LAUP) with a new described surgical method: coblation uvulopalatoplasty with tonsillectomy (CP). We also evaluate the impact of each surgical technique in reduction of snoring loudness. MATERIAL AND METHODS: Single blind randomized-controlled trial. From a population of 41 consecutive patients on the waiting list for uvulopalatoplasty for simple snoring, the study group was reduced to 17 CP and 13 LAUP. Post-operative pain and reduction of snoring loudness were recorded using visual analogue scales (VAS) during the first 15 post-operative days. Post-operative snoring loudness was documented for 1-year period. RESULTS: Both groups had similar post-operative pain during the first seven post-operative days. A statistically significant reduction in post-operative pain was observed in the CP group after day 8, and maintained until the end of the study. Reduction of snoring loudness was significant in both groups, but no differences were observed between them. DISCUSSION: Coblation uvulopalatoplasty compared with LAUP demonstrates a reduction in post-operative pain, significant after the first post-operative week. The collateral thermal injury caused by laser is responsible for the slow-healing rate and maintained post-operative pain. Coblation dissociates tissue at lower temperatures with minimal collateral thermal injury and consequently faster and less painful recovery. Both surgical procedures have significant and similar reduction in snoring loudness. CONCLUSIONS: Both methods are adequate treatment options for snoring. The less painful recovery in CP promotes this surgical technique as our preferred choice for palate surgery.