Coblation tonsillectomy, is it superior to cold steel method

Coblation tonsillectomy is a new technique that was started in 1975, it involves passing a radiofrequency bipolar electrical current through a medium of normal saline, resulting in a plasma field of highly ionized particles which in turn break down intercellular bonds and thus melt tissue at around 40o to 70oC (in comparison with electrocautery which cuts tissues at 400oC) The aim of this study is to evaluate the benefit of coblation tonsillectomy over conventional (cold steel) tonsillectomy, comparing tonsillectomy duration, blood loss during the surgery, and the postoperative pain. This prospective randomised single-blinded clinical trial was done on 90 patients. Patients were divided into 2 equal groups; Group A: Underwent coblation tonsillectomy, and Group B who underwent cold steel tonsillectomy. The study was performed in Al-Musawy Private Hospital, Basrah Teaching Hospital, and Al-shifaa hospital, Basrah, Iraq. All surgeries were done by the three authors in the period between February 2018 to August 2020. The intraoperative bleeding, duration of surgery, and postoperative pain were evaluated and compared for both groups. The age range of the studied patients was 4–32 years, 52 were males and 38 were females. The average duration of tonsillectomy procedure was 31.8 minutes in coblation tonsillectomy (Group A), while the average duration in the cold steel tonsillectomy (Group B) was 25.8 minutes. The average operative blood loss in cold steel tonsillectomy was 31.5 ml while that in coblation was 3.2 ml. Average postoperative pain in coblation group was (20.7± 6.15), while in cold steel group was (27.5±7.27). In conclusion, coblation tonsillectomy is effective and beneficial in decreasing the volume of intraoperative blood loss but not for postoperative pain in comparison with conventional method, in addition that it take more time to be completed.


Introduction:
elsus was the first person to recognize tonsillar disease and its relationship to infection performing the first tonsillectomy in 40 A.D 1 . The tide turned in the 1980s, when Paradise et al demonstrated that surgery significantly improved patient outcome compared with medical therapy 2 . Chronic tonsillitis is one of the most common and frequent illness within otolaryngology. Tonsillectomy is also one of the most frequently performed surgical procedure 3 .
Improvements in the procedure of tonsillectomy which are many should have the advantage of decreasing the operating time, reduction in the intraoperative and postoperative blood loss, and reduction in postoperative morbidity namely pain. Coblation is a new technique that was started in 1975. It involves passing a radiofrequency bipolar electrical current through a medium of normal saline resulting in a plasma field of highly C ionized particles, which in turn break down intercellular bonds and thus melt tissue at around 40º to 70ºC (in comparison with electrocautery which cuts tissues at 400º C) 4 . This study was carried out to evaluate the benefit of coblation tonsillectomy over conventional (cold steel) tonsillectomy, comparing tonsillectomy duration, blood loss during surgery, and the postoperative pain.

Patients and methods
This is prospective, randomized, singleblinded clinical trial included 90 patients. Forty five randomly selected patients underwent coblation tonsillectomy (Group A), the later 45 patients underwent cold steel tonsillectomy (Group B). The study was carried out in Al-Musawy Private Hospital, Basrah Teaching Hospital and Al-Shifaa Hospital, Basra, Iraq in the period between February 2018 to August 2020. The risk was mentioned to all the patients. Some of them refused to take part in the study, but all those who were included accepted the possibility of risk and gave their permission. All of the included patients have recurrent acute tonsillitis above 3 years of age. All patients with unilateral or asymmetrically enlarged tonsils, those who need adenoidectomy, or additional procedure like myringotomy, and those with bleeding tendency, were excluded. All adult patients have paracetamol tab. 500mg thrice daily and 20mg/kg for children for 7 days. Tonsillectomy operation duration was calculated as the time interval between the first application of coblator probe ( Figure 1) or first incision, to the time when all bleeding and oozing was secured completely. The operative blood loss was calculated by weighing the blood impregnated gauze packs against an equal number of unused packs as well by measuring the volume of blood for each group separately. The volume of blood in the packs was calculated by dividing the weight of blood on the pack by the specific gravity of blood (1.055) 5 . Patient's follow-up was performed at operative day (after recovery), 1st, 3rd, 7th postoperative days in regard to pain.
Pain assessment was done using the numeric pain rating scale for adult and Wong baker faces scale for children (age 3 years and older), both scores from 0-10 (record from day 0, 3,7,14), until returned to normal diet and activity. The "Wong baker faces" pain scale is a visual analogue scale that uses faces rather a line to identify the level of pain or discomfort that the child is experiencing. The children were asked by themselves or by the assistance of parents to point the "face" that best expresses the way that they feel. The results of the study were statistically analyzed by using paired t-test for significance.

Results
The age range of the studied patients was 4-32 years, 52 were males and 38 were females. The average duration of tonsillectomy procedure was 31.8 minutes in coblation tonsillectomy (Group A), while the average duration in the cold steel tonsillectomy (Group B) was 25.8 minutes, which meant increment in tonsillectomy duration in coblation method. This is statistically not  One of randomized double blind study performed in 2012, described the duration of surgery of both coblation and cold steel methods, it found less duration of coblation compared to conventional method 6 . While Singh Rakesh etal found coblation has longer duration 7 . In the present study, coblation method takes longer duration (31.8 minutes) in comparison with conventional method (25.8 minutes), which is not statistically significant( p-value >0.05). Taking long duration of coblation method in comparison with other studies is to decrease the manipulation as well as to secure all bleeding in time. Izny Hafiz Zainon et al 8 showed in his study that coblation tonsillectomy is superior in improving intraoperative efficiency in term of intraoperative time and bleeding compared to cold dissection tonsillectomy. The mean Intraoperative blood loss in the present study for conventional method was 31.5 ml and for coblation method was 3.2 ml. which is statistically significant.
Paramasivam et al 9 , concluded that conventional tonsillectomy associated with greater blood loss. Vangelin et al 10 , illustrated intraoperative bleeding was significantly less in coblation. Hong etal 11 , performed a study for children underwent tonsillectomy and verified that coblation tonsillectomy has lesser blood loss. Zaki  and postoperative complications and less postoperative pain were observed with coblation In the present study the average postoperative pain in coblation group was (20.7±6.15), while in cold steel group was (27.5±7.27) which is statistically not significant (p-value >0.05), we suggested that the slight decrement of postoperative pain probably due to less manipulation during coblation procedure. Conclusion: Coblation tonsillectomy is effective and beneficial in decreasing the volume of intraoperative blood loss but not for postoperative pain in comparison with conventional method, additionally, it takes more time to be completed.