Patient History

Over the past 2 years, a 4-year-old girl who underwent liver transplantation for chronic liver failure developed progressive snoring, occasional gasping for air during sleep, and continual mouth breathing during the day as well as at night.

Because of the patient’s history of progressive worsening of obstruction of the upper airway at night and the presence of enlarged tonsils, she was considered a candidate for adenotonsillectomy. Her restless sleep, irregular respiratory pattern at night, and loud snoring and gasping were becoming of increasing concern to her family and the liver transplantation specialist. This concern prompted immediate referral to a pediatric otolaryngologist for consideration for adenotonsillectomy, which would provide both diagnostic and therapeutic benefit.

Physical Examination

On physical examination, she was noted to breathe intermittently via her mouth and she had hyponasal speech. The otologic examination was normal. Examination of her oral cavity revealed 3+ bilateral tonsils. Nasal examination was notable for enlarged turbinates and inflamed mucosa. Examination of her neck showed it to be free of masses.

Treatment

The patient in this case underwent adenotonsillectomy via Coblation, a soft-tissue surgery system. Coblation-Assisted Tonsillectomy and adenoidectomy provide an alternative to conventional surgical techniques because they use low-temperature radiofrequency energy applied to a sterile solution, such as saline, to dissolve the soft tissue. The procedure took approximately 15 minutes, and the patient lost only 2 cc of blood. She was discharged from the recovery room a few hours after surgery. The patient’s tonsils and adenoids were examined microscopically, and immunohistochemistry was performed. There was no evidence of posttransplantation lymphoproliferative disorder. She was discharged from the hospital with a prescription for acetaminophen with codeine elixir for significant discomfort and regular children’s acetaminophen for mild discomfort. On follow-up 4 weeks after surgery, the snoring had resolved. There were no postoperative complications, and the tonsillectomy sites had healed completely.

Discussion

After undergoing organ transplantation, patients require immunosuppressive therapy to increase the chance of longterm survival. However, this type of therapy may predispose patients to developing tumors of the lymphoreticular system, such as posttransplantation lymphoproliferative disorder, which is characterized by an abnormal proliferation of lymphoid tissue. This disorder is a significant cause of morbidity and mortality in recipients of organ transplantation. Enlargement of adenotonsillar tissue may represent the earliest manifestation of posttransplantation lymphoproliferative disorder. Children who develop adenotonsillar enlargement after organ transplantation are monitored closely to determine whether surgical removal of the tonsils and adenoids is necessary. Prompt surgical management of enlarged adenotonsillar tissue in this patient population may result in earlier recognition and treatment of posttransplantation lymphoproliferative disorder.

Coblation was used in this case because the process minimizes damage to healthy tissue, resulting in less pain and faster recovery than noted with traditional electrocautery methods. Coblation also reduces the operating time required for the procedure, and there is a noticeable decrease in the amount of intraoperative bleeding compared with standard adenotonsillectomy techniques.

In my experience, patients tend to require a shorter stay in the recovery room and are more comfortable in the immediate postoperative period after Coblation-Assisted Tonsillectomy than after standard tonsillectomy, possibly because the shorter intraoperative time results in a decrease in exposure time to anesthesia.

Clinical Pearls

Children who have undergone organ transplantation require lifetime immunosuppressive therapy. Although this practice has led to great strides in long-term survival of this patient population, it is associated with an increased risk of developing proliferation of abnormal lymph cells. The abnormal growth of lymph nodes may first manifest as adenotonsillar enlargement. Signs and symptoms of adenotonsillar enlargement in this patient population should lead to prompt referral to an otolaryngologist to determine the need for adenotonsillectomy. Coblation allows the rapid and complete removal of tonsillar tissue with minimal time required for the procedure and recovery.