Med. J. Cairo Univ., Vol. 80, No. 1, September: 491-494, 2012
www.medicaljournalofcairouniversity.com
Coblation Versus Bipolar Diathermy for Adult Tonsillectomy
AHMED H. FAWZY, M.D.; AYMAN HUSSIEN, M.D.; AHMED HUSSEIN, M.D. and
BAHER ASHOUR, M.D.
The Department of Otorhinolaryngology, Faculty of Medicine, Cairo University
Abstract
leads to ischemia and protracted cycle of pain.
This does not completely subside until the muscle
becomes covered with mucosa 14-21 days after
surgery [5] .
Objective: To compare coblation and bipolar diathermy
tonsillectomy in adults in terms of operative time, operative
blood loss, post operative pain and post operative complications.
Patients and Methods: Thirty patients (aged 18-40 years)
scheduled for tonsillectomy were enrolled in this study, the
patients were randomized using sealed envelopes to have one
tonsil removed by coblation and the other tonsil removed with
bipolar diathermy. Operative time and operative blood loss
were recorded for each side separately and compared. The
patients were given a pain diary to record the level of pain
on each side using a visual analog score for 7 days. They
were asked also to report any complications.
Results: Operative time and operative blood loss were
significantly less in the coblation sides ( p<0.001). The mean
pain score on the coblation sides was significantly
lower
2nd
compared to the diathermy sides on the 1 st and
post
operative days.
Conclusion: This study can be added to the studies recommending the use of coblation for tonsillectomy in adults
based on the minimal post-operative pain and similar morbidity
compared to bipolar diathermy.
Key Words: Tonsillectomy – Coblation -– Bipolar diathermy
– Post operative pain.
The operating principle of coblation or electrodissociation is similar to bipolar diathermy or
electrosurgery. In both methods, an alternating
current passing between the active electrodes in
the tip of the device produces destruction on the
target tissue adjacent to the electrodes. In bipolar
diathermy, direct contact between electrodes and
tissue produces local temperatures of 400°C -600°C
resulting in heating of intracellular contents and
subsequent vaporization of the cell [6] . In contrast,
in coblation, a sodium rich medium must fill the
physical space between the electrodes. The coblator
causes dissociation of the medium into free sodium
ions, which are responsible for the destruction of
intercellular bonds, resulting in tissue dissociation.
This reaction is achieved at temperatures between
60°C and 70°C with minimal collateral thermal
tissue damage [7] .
This aim of this study was to compare coblation
to bipolar diathermy tonsillectomy in adults in
terms of operative time, operative blood loss, post
operative pain and post operative complications.
Introduction
TONSILLECTOMY and adenoidectomy are commonly performed otolaryngological operations,
accounting for up to 20% of all operations performed by otolaryngologists [1] .
Material and Methods
This prospective, randomised, controlled study
was conducted from June 2010 to July 2011. The
study was approved by the local ethical committee.
Informed consent was obtained from all patients.
This study was done in accordance with the ethical
standards laid down in 1964 Declaration of Helsinki.
Despite a range of different techniques, including blunt dissection, guillotine, [2] diathermy, [3]
and laser, [4] post operative pain remains the major
side effect of the operation .
Pain is the result of disruption of mucosa and
glossopharyngeal and/or vagal nerve fibres followed by spasm of the pharyngeal muscles that
Thirty patients (aged 18-40 years) scheduled
for tonsillectomy were enrolled in the study. We
excluded patients with bleeding disorders and those
with history of quinzy.
Correspondence to: Dr. Ahmed Hesham Fawzy,
The Department of Otorhinolaryngology, Faculty of Medicine,
Cairo University, E-Mail: ahesham73@yahoo.com
491
492
Coblation Versus Bipolar Diathermy for Adult Tonsillectomy
The patients were randomized using sealed
envelopes to have one tonsil removed by coblation
and the other tonsil removed with bipolar diathermy.
The patients were blinded to the technique used.
Operative technique:
All cases were done under general anesthesia.
Coblation tonsillectomy was done using the ArthroCare ENT Coblator II Surgery System with the
EVac 70 plasma wands (ArthroCare Corporation,
Sunnyvale, CA). Settings were standardized at 7
for ablation and 3 for coagulation.
The technique of bipolar dissection tonsillectomy was described in details in our previous work
[8 ] .
Anesthesia and recovery protocols were standardized for all patients.
Operative time and operative blood loss were
significantly less in the coblation sides (p<0.001)
(Table 1).
Table (1): Operative data of the patients.
Operative time (min)
Blood loss (ml)
Coblation sides
Diathermy sides
7.97±5.31
29.77±22.45
11.67±6.23
44.23±21.92
The mean pain score in the coblation sides was
significantly lower compared to the diathermy
sides on the 1 st and 2 nd post operative days (Table
2 and Fig. 1).
Table (2): Postoperative pain score.
Post op days
Coblation sides
Diathermy sides
p-value
1 st
2 nd
3 rd
4 th
5 th
6 th
7 th
4.73±1.74
4.4±1.71
4.57±2.21
4.17±1.51
3.93±1.51
3.6±1.77
3.57±2.86
5.97±1.63
5.77±1.55
5.3±2.32
4.83±2.32
4.4±2.19
4.13±1.91
3.10±1.99
0.002
< 0.001
0.128
0.169
0.215
0.103
0.323
Intraoperative measures:
Operative time (from the start of tonsillectomy
to the completion of haemostasis) and operative
blood loss were recorded for each side separately
and compared.
7
Postoperative measures:
The patients were discharged on the same day
with 1 week course of amoxycillin clavulanate and
paracetamol. They were instructed to return to the
hospital in the event of haemorrhage.
The patients were given a pain diary to record
the level of pain on each side using a visual analog
score for 7 days, the pain charts consisted of a
10cm linear scale with 10 gradations, ranging from
1 (no pain) to 10 (severe pain). They were asked
also to report any complications.
Coblation sides
Diathermy sides
6
5
4
3
2
1
0
Pain-1 Pain-2 Pain-3 Pain-4 Pain-5 Pain-6 Pain-7
The data was statistically described in terms of
mean ± standard deviation (± SD), and range, or
frequencies (number of cases) and percentages
when appropriate. Comparison of pain scores between the study groups was done using Wilcoxon
signed rank test for paired (matched) samples. For
comparing categorical data, McNemar test was
performed. p-values less than 0.05 were considered
statistically significant. All statistical calculations
were done using computer programs SPSS (Statistical Package for the Social Science; SPSS Inc.,
Chicago, IL, USA) version 15 for Microsoft Windows.
Results
30 patients were included in this study with a
mean age of 27.03±9 years (range from 13-47
years), males constituted 70% of the patients.
Fig. (1): Pain score by day in the 2 groups.
The number of patients reporting pain score >5
on either side was compared (Table 3).
Table (3): The number of patients reporting pain score >5.
Post op days
Coblation sides
(number)
Diathermy sides
(number)
p-value
1 st
2 nd
3 rd
4 th
5 th
6th
7th
9
10
8
5
3
5
7
16
12
15
13
11
7
7
0.092
0.687
0.016
0.021
0.021
0.727
1.000
None of our patients reported any bleeding
episode or any other complication.
Ahmed H. Fawzy, et al.
Discussion
A new technique for tonsillectomy should be:
Comparable to or better than existing techniques;
safe to use; have a short learning curve; and be
cost effective. In particular, such a new technique
would preferably be associated with less postoperative pain, less intra-operative blood loss, a
quicker return to normal diet and activity, and a
lower risk of both reactive and secondary haemorrhage [9] .
This study was conducted in a prospective
randomized manner to compare coblation with
bipolar diathermy tonsillectomy. Only adults were
enrolled to ensure the efficiency and adequacy of
pain assessment, one tonsil was removed with the
coblator and the other one with the bipolar diathermy, so each patient served as his or her own control
to eliminate any personal variations in pain assessment. The patients were blinded to the technique
used.
Similar study design have been adopted by
many authors, [10-13] on the other hand, Tan et al.,
[14] randomized the patients not the tonsils into 2
groups; coblation and electrocautery, and Parsons
et al. [15] randomized the patients into 3 groups;
coblation, electrocautery and harmonic scalpel.
The operative time and operative blood loss
were significantly less in the coblation sides. On
the other hand, other authors reported either no
difference [12,13] or even more time with the coblato
[11,15] . This could be attributed to the fact that we
started this study after mastering the technique of
coblation by doing large number of tonsillectomies
in children and adults to eliminate the effect of the
learning curve, other authors may have started
their studies after performing smaller number of
cases.
In our study, a statistically significant difference
in the mean pain score in favour of coblation was
reported on the 1 st and 2 nd post operative days.
We focused on post-operative pain from another
perspective by reporting on the frequency of the
sides with a pain score >5, results were again
in
4th
favour of coblation especially on the 3 rd ,
and
5 th post-operative days (p<0.05).
Similar results were reported by other studies,
on the other hand, Tan et al. [14] reported
no differences in daily visual analog score for pain
attributing this to the masking of any pain benefits
from coblation tonsillectomy by the severity of
pain in adult tonsillectomy in general, yet they
reported a faster recovery for the coblation group.
[10-13,15]
493
There are certainly other factors which alter
pain, aside from the surgical instrument used. A
meticulous, gentle surgical technique is universally
accepted as a significant factor in post-operative
pain and healing. However, when surgeons use
equivalent surgical technique, the instrument used
may result in an additional benefit to the patients
[15] .
None of our patients experienced any reactionary or secondary haemorrhage, thus excluding our
study from the debate of whether coblation causes
higher incidence of bleeding or not. The answer
for this debate could be achieved by conducting
further studies on a larger number of patients.
Conclusion:
We recommend the use of coblation over bipolar
diathermy for tonsillectomy in adults based on the
lower levels of post-operative pain and similar
morbidity.
Conflict of interest:
The authors declare that they have no conflict
of interest.
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