The tonsillectomy, with or without adenoid removal, is a commonly performed operation. The surgical procedure is recommended for recurrent infected tonsils as well as enlarged tonsils, which can lead to pediatric sleep apnea and other breathing disorders. The pain can be severe, and patients are often unable to perform in work or school or eat regular food for a number of days after surgery.

The first reported tonsillectomy was performed by the Roman surgeon Celsus in 30 AD. He described scraping the tonsils and tearing them out or picking them up with a hook and excising them with a scalpel. Today, the scalpel or “cold steel” is still the preferred surgical instrument of many ear, nose, and throat specialists. In the 21st century, the surgeon now uses stainless steel scissors or a scalpel to remove the tonsil tissue from between two muscles in the back of the throat.

However, advances in technology have ushered in new instruments for use in this surgical procedure. In the United States, the most common instrument used for tonsillectomy currently is the electrocautery device. Two devices introduced more recently are the Harmonic Ultrasonic Scalpel (Ethicon Endo-Surgery, Cincinnati, OH) and the Coblator® (ArthroCare Corp, Sunnyvale, CA); these instruments are now commonly used for tonsillectomy procedures.

Electrocautery burns the tonsillar tissue and assists in reducing blood loss through cauterization. Research has shown that the heat of electrocautery (400 degrees Celsius) results in thermal injury to surrounding tissue. This may result in more discomfort during the postoperative period. The Harmonic scalpel uses ultrasonic energy to vibrate its blade at 55,000 cycles per second. Invisible to the naked eye, the vibration transfers energy to the tissue, providing simultaneous cutting and coagulation. The temperature of the surrounding tissue reaches 80 degrees Celsius. Coblation, or radiofrequency ablation, works by passing a bipolar radiofrequency current through a medium of normal saline. This creates a plasma field of sodium ions. As the energy is transferred to the tissue, ionic dissociation occurs, which results in vaporization of tissue and coagulation of vessels at low temperatures (60°C).

Past research has revealed that post-operative pain rates for tonsillectomies using electrocautery, Harmonic Scalpel, and Coblation have been similar. A new research study, “Comparison of Post-tonsillectomy Pain Using the Ultrasonic Scalpel, Coblator, and Electrocautery,” seeks to quantitatively measure the post-operative pain rates of the three surgical instruments. The authors of this research are Stephen P. Parsons MD, and Susan R. Cordes, MD and Brett Comer, from the Indiana University School of Medicine, Indianapolis, IN. This research article appears in the January, 2006, edition, Otolaryngology Head and Neck Surgery, the medical and scientific journal of the American Academy of Otolaryngology—Head and Neck Surgery.

Methodology: This prospective, randomized trial was conducted at Indiana University School of Medicine. All adult and pediatric patients undergoing tonsillectomy or adenotonsillectomy between December 2002 and December 2004 were invited to participate. One hundred thirty-four patients agreed to participate in the study. Sixty-one patients returned a completed diary. There were 43 patients in the electrocautery group, 44 patients in the Harmonic Scalpel group, and 47 patients in the Coblation group. The three groups did not differ statistically with regards to age, gender, indication for surgery, and return rate of the pain diary. Of the 134 patients, 127 underwent adenotonsillectomy and seven underwent tonsillectomy alone. Statistical analysis was performed on pain rating, food intake status, and activity level.

All study participants were asked to fill out a daily pain diary for 10 consecutive days postoperatively. The daily diary included a commonly used, standardized pain scale (Wong-Baker FACES pain rating scale), which is a 0 to 10 numerical rating scale with correlating faces (from happy to sad) to allow both children and adults to reliably record their pain.

Results: Key findings from this research study are:

• Surgery time was found to be significantly different among the three groups. Although there was no difference between radiofrequency ablation and the Harmonic Scalpel, surgery time for electrocautery seemed to be significantly less.
• Some 52.6 percent of the patients in the electrocautery group, 24 percent in the Coblation group, and 17.7 percent in the ultrasonic group called their physician’s office within 10 days after their surgeries. The odds of a patient in the electrocautery group calling his/her physician after surgery increases 5.19 times (95 percent confidence interval, 1.11-24.14) compared with a patient in the ultrasonic group.
• Among the three methods, Coblation was associated with the lowest mean pain level. Pair-wise comparisons were made among these three groups, and significant differences in pain scores were revealed between the Coblation and electrocautery methods and between the Coblation and Ultrasonic Scalpel methods. Electrocautery and Ultrasonic Scalpel methods did not differ significantly from each other.
• Within 10 days after the surgery, 80.3 percent of the patients were able to achieve normal food intake. Visual examination suggests that Coblation might be associated with fewer recovery days in terms of food intake compared with electrocautery and the ultrasonic scalpel.
• Within 10 days after the surgery, 91.8 percent of the patients were able to reach a normal activity level. The findings suggest that there were no differences among the 3 methods in terms of the time to resume normal activity level. The large P value from the log-rank test (P = 0.96) confirmed this finding.

Conclusion: As expected, the researchers found that none of the three surgical methods in this study resulted in a pain-free recovery. There are certainly other factors that alter pain aside from the surgical instrument used. Meticulous, gentle surgical technique is universally accepted as a significant factor in postoperative pain and healing. But when surgeons use equivalent surgical technique, the instrument used may result in additional benefit to the patient.

This study revealed that Coblation tonsillectomy results in decreased postoperative pain compared with electrocautery and Harmonic ultrasonic tonsillectomy. This is based on pain scores analysis and on faster return to normal diet, as well as fewer postoperative telephone calls and visits to the physician.