Patient History

A 26-year-old woman presented with a history of recurrent streptococcal tonsillitis over the past 2 years and a longstanding history of nasal obstruction and breathing via her mouth. She was otherwise in excellent health but was concerned about this problem because she was a runner. By the time she presented for evaluation, the bouts of tonsillitis would occur within a few weeks of completing treatment with antibiotics. She did not smoke, take any other medication, or undergo any previous surgery.

Physical Examination

The ENT examination revealed a marked deflection of the septum to the right side with enlargement of the inferior turbinates, which was more pronounced on the left side. Evaluation of the oropharynx demonstrated enlarged tonsils with deep follicular pockets. The adenoids had regressed, and she had bilateral, small, reactive nodes in the neck.

Treatment

Clinically, the patient met the indications for tonsillectomy. She also had significant nasal obstruction, for which septoplasty and reduction of the turbinates were recommended. During the preoperative discussion, information regarding Coblation® bipolar radiofrequency technology was provided, and it was agreed to use this equipment for the total removal of the tonsils and for the reduction of the turbinates. Subtotal removal of the tonsils using Coblation was discussed; however, because of the number of recurrent infections, it was recommended that the patient undergo total removal of the tonsils.

After the induction of general anesthesia, the nasal area was injected with a local anesthetic agent and packed with 4% cocaine. The tonsils were removed using the Coblation tonsil wand at a setting of 6. Bleeding was controlled with the radiofrequency coagulation function. After the tonsillectomy, the patient underwent septoplasty; the Coblation ReFlex Ultra 45 Wand® was used for the inferior turbinates at a setting of 6. On the left side, which had the larger turbinate, 4 passes of 10 seconds were made; on the right side, 3 sites were treated.

By the second day postoperatively, the patient developed nausea from the narcotic pain medication and was switched to only acetaminophen for discomfort. The procedure was performed 6 months earlier; since then, she has been free of tonsillar infections, is breathing well through the nose, and continues her running.

Discussion

As surgeons, we are always looking for ways to help our patients through surgery safely, with as little morbidity as possible. Electrocautery requires high temperatures (300ºC) for both cutting and coagulation functions, which causes damage to the tissue of the tonsil bed.

Coblation, a bipolar radiofrequency process, is delivered at low temperatures (40ºC to 60ºC) in a plasma field, and the bonds between cells are broken down, allowing tissue to be removed or destroyed. The Coblation Wand can be used to “shave” the tissue of the tonsils to the level of the capsule or as an instrument for total removal of the tonsils, as in this case.

The ideal instrument for the removal of the tonsils would cut with minimal damage to surrounding tissues, effectively control bleeding points, and allow suctioning in the oropharynx. The bipolar Coblation radiofrequency Wand meets these criteria and is effective technology for tonsillectomy. Clinical studies have shown a reduction in pain for patients undergoing tonsillectomy using this technique, which was helpful in this case because the patient could not tolerate narcotic pain medication.

The Coblation turbinate Wand is also a bipolar device that works at low temperatures to create tunnels of tissue destruction, with resultant fibrosis and contraction reducing the volume of the turbinate. Clinical studies have demonstrated its effectiveness in nasal surgery and have shown persistent mucociliary activity of the turbinate. Three to four channels can be made by passing the Wand into the turbinate for 10 seconds each pass, which can be performed in the operating room or in an office setting.

Clinical Pearls

Bipolar radiofrequency energy can be used effectively for a number of procedures relating to the ear, nose, and throat. The Coblation tonsil Wand removes and coagulates at low temperatures, creating less tissue damage to the tonsil bed; as a result, many patients are able to tolerate the surgery better than with traditional techniques. The same technology can be used for reducing the nasal turbinates and treating the soft palate.

Suggested Reading

1. Chinpairoj S, Feldman MD, et al: A comparison of monopolar electrosurgery to a new multipolar system in a rat model. Laryngoscope 2001;111: 213-217.
2. Rice D, Thapliyal H: Coblation: A novel method for head and neck soft tissue management. Res Outcome Otolaryngol 1999.
3. Stadler KR, Brown IG, Smith CD: Repetitive plasma discharges in saline solutions. Appl Physics 2001;97:4503-4505.
4. Temple R H, Timms MS: Paediatric coblation tonsillectomy. Int J Pediatr Otorhinolaryngol 2001;61:195-198.
5. Timms M S, Temple RH: Coblation tonsillectomy: A double blind randomized controlled study. J Laryngol Otol 2002;116:450-452.
6. Woloszko JS, Brown I G: Plasma characteristics of repetitively-pulsed electrical discharges in saline solutions used for surgical procedures. IEEE Trans Plasma Sci 2002;30:1367-1383.