8212019 265105pdf

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Hindawi Publishing CorporationInternational Journal o Otolaryngology Volume 983090983088983089983091 Article ID 983090983094983093983089983088983093 983092 pageshttpdxdoiorg983089983088983089983089983093983093983090983088983089983091983090983094983093983089983088983093

Clinical Study Comparison of Pediatric and Adult TonsillectomiesPerformed by Thermal Welding System

Tolga Ersoumlzluuml1 Yavuz Selim Y JldJrJm2 and Selman Sarica 3

983089 Department of Otorhinolaryngology Head and Neck Surgery Elbistan State Hospital 983092983094983091983088983088 Kahramanmaras urkey 983090 Department of Otorhinolaryngology and Head and Neck Surgery Faculty of Medicine Bezmialem Vakif University Adnan Menderes Bulvarı Vatan Caddesi Fatih 983091983092983088983097983091 Istanbul urkey

983091 Department of Otorhinolaryngology Head and Neck Surgery Afsin State Hospital 983092983094983091983088983088 Kahramanmaras urkey

Correspondence should be addressed to Yavuz Selim Yıldırım dryavuzselimyahoocom

Received 983093 May 983090983088983089983091 Revised 983095 October 983090983088983089983091 Accepted 983095 October 983090983088983089983091

Academic Editor Charles Monroe Myer

Copyright copy 983090983088983089983091 olga Ersozlu et al Tis is an open access article distributed under the Creative Commons Attribution Licensewhich permits unrestricted use distribution and reproduction in any medium provided the original work is properly cited

Objective o comparepediatric andadult agegroups in termso postoperative bleeding andpain ollowing tonsillectomy perormedby thermal welding system (WS) Method Te study consisted o 983090983089983091 patients o whom 983089983095983096 were children and 983091983093 were adults Temean age o the pediatric patients (983096983089 girls and 983097983095 emales) was 67 plusmn 24 years (range 983091ndash983089983091 years) and the mean age o the adults (983090983088males and983089983093 emales) was 218plusmn 707 years (range 983089983093ndash983092983089 years) All o the patients were evaluatedin terms o postoperative bleedingand pain ollowing tonsillectomy perormed by WS Results Bleeding was detected in the late postoperative period in 983089983089 pediatricand 983095 adult patients and o them 983090 pediatric and 983091 adult patients controlled under general Postoperative bleeding was signi1047297cantly less prevalent in the pediatric age group compared to the adult age group ( = 004) Likewise postoperative pain was signi1047297cantly less prevalent in the pediatric age group as compared to the adult age group ( lt 0001) Conclusion Both postoperative bleedingand pain ollowing tonsillectomy perormed by WS were more prevalent in the adult age group compared to the pediatric agegroup

1 Introduction

onsillectomy is the most common surgical procedure per-ormed in the ear nose and throat practice It is mostrequently perormed via cold dissection both in the pediatricandadult agegroup worldwide Many hotdissection methods

have been de1047297ned as an alternative to the cold dissectionHot dissection methods include bipolar andor monopolarelectrocautery radiorequency harmonic scalpel coblatorand thermal welding system (WS) [983089] Previous studieshave reported and compared the outcomes o radiorequencyWS cold knie or monopolar electrocautery in terms o posttonsillectomy bleeding and pain [983090] Termal welding isthe technique that simultaneously uses heat and pressure toprovide coagulation In a study conducted on adults ton-sillectomies perormed by WS and bipolar electrocautery werecompared in terms o intraoperative bleeding operationduration postoperative pain time to regain normal dietand postoperative bleeding [983091 983092] Multiparametric studies

comparing a ew methods have been conducted also in thepediatric age group [983093] However studies comparing adultand pediatric patients in terms o postoperative bleeding andpain ollowing tonsillectomy perormed by WS are limitedTe aim o the present study was to investigate and compare

the postoperative bleeding and pain ollowing tonsillectomy perormed by WS in the pediatric and adult patients

2 Materials and Method

Te present prospective study included 983090983089983091 pediatric andadult patients that underwent only tonsillectomy andoradenotonsillectomy under general anesthesia by thermalwelding device in Elbistan State Hospital Ear-Nose-Troatclinic between February 983090983088983088983096 and June 983090983088983089983090 O the patients983089983095983096 were children aged between 983091 and 983089983091 years and 983091983093were adults aged between 983089983093 and 983092983089 years Te indicationsor tonsillectomy were recurrent tonsillitis andor tonsillar

8212019 265105pdf

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983090 International Journal o Otolaryngology

F983145983143983157983154983141 983089 Termal welding system (WS) device

hypertrophy in the pediatric patients and chronic tonsillitisin the adult patients

Patients with history or penicillin allergy coagulationdisorder andor abnormal elevated prothrombin time andactivated partial thromboplastin time wereexcluded rom thestudy All o the patients were operated by the same surgeon

(ogla Ersozlu) under general anesthesia with endotrachealintubation One hour prior to the surgical procedure thepediatric patients were given 983093983088983088 mg ampicillinsulbactamintravenously whereas the adult patients were given 983089983088983088983088 mgampicillinsulbactam intravenously Both pediatric and adultpatients received 983088983093 mgkg methylprednisolone intraopera-tively Afer the surgery patients in the pediatric age groupreceived amoxicillinclavulanateand paracetamol suspensiontwo times a day or ten days and the patients in the adultage group received amoxicillinclavulanate and paracetamoltablets two times a day with ten days

983090983089 Surgical echnique WS consists o a single-use probe(ENceps) double-controlled oot switch and a univer-sal power supply (UPS) Te energy rom the universalpower supply turns into thermal energy in the heating wire(nichrome) at the distal end o the thermal welding probeand causes coagulation by simultaneous pressure that occursas the probe is closed by the silicone boot at the otherdistal end [983094 983095] Nichrome wire at the ends o the probecannot be activated via lef oot switch unless completely squeezed by hands issue-cutting is perormed by clampingthe coagulated tissue between the ends o the probe andactivating via the right side o the oot switch (Figure 983089)

In the present study we perormed extracapsular ton-sillectomy with WS using a probe with a power setting

o ldquo983091rdquo afer placing the mouth gag While the tonsil wasretracted medially using allis clamp dissection was made

via tonsil probe at the upper pole o the tonsil by clampingthe anterior pillar mucosal tissue Te tissue was activatedwith the oot switch and clamped between the ends o thetonsil probe orapproximately 983094 seconds and coagulation wasperormed Tereafer cutting procedure was perormed by activating with the right oot switch or approximately twoseconds Dissection was extended rom the upper pole to thelower pole by exposing the tonsil capsule onsil tissue wascoagulated or the last time at the lower pole and removedrom the surgical area Tis technique was perormed orboth tonsils onsil bed was postoperatively monitored or

983137983138983148983141 983089 Te ages and visual analogue scale scores o the patients

Mean plusmn SD 983097983093 CI RSD Median MinndashMax

Pediatric patients(1038389 = 178)

Age 983094983095 plusmn 983090983092983088 983094983091ndash983095983088 983088983091983093 983094 983090ndash983089983091

VAS score 983095983091 plusmn 983089983089983093 983095983090ndash983095983093 983088983089983093 983096 983094ndash983089983088Adult patients(1038389 = 35)

Age 983090983089983096 plusmn 983095983088983095 983089983097983092ndash983090983092983091 983088983091983090 983090983089 983089983093ndash983092983089

VAS score 983096983093983094 plusmn 983093983096983088 983096983091983094ndash983096983095983094 983088983088983094983095 983096983093 983095983088ndash983097983093

VAS visual analogue scale SD standard deviation CI con1047297dence intervalRSD relative standard deviation MinndashMax minimumndashmaximum

bleeding Surgical area was washed with normal saline Colddiet was initiated both to the pediatric group and adult group983091 hours afer the surgery All o the patients were dischargedon the postoperative 983090nd day

Pain was questioned by nurse on the 983089st 983091rd 983095th and 983089983088thpostoperative days via aces pain scale under the assistance o the amilies o the children younger than 983096 years [983096] whereasit wasevaluatedvia visual analogue scale (VAS)in the patientsolder than 983096 years [983089] Postoperative bleeding was monitoredand recorded i any

983090983090 Statistical Analysis Data were evaluated using the Med-Calc statistics program version 983089983089983093983089 (MedCalc SofwareMariakerke Belgium) Te Chi-square test was used to com-pare the categorical variables whereas Mann-Whitney U -testand independent samples 1103925-test were used to determine inter-group differences Te data were expressed as mean plusmn stan-dard deviation A value lt983088983088983093 was considered signi1047297cantComparison o two groups proportions minimally requiredsample size per group 983089983091

3 Results

Te present study included 983090983089983091 patients o whom 983089983095983096 werepediatric and 983091983093 were adult Te pediatric age group com-prised 983096983088 girls and 983097983096 boys with a mean age o 67 plusmn 24

years (range 983091ndash983089983091 years) Te adult age group comprised 983090983088

male and 983089983093 emale patients with a mean age o 218 plusmn 707

years (range 983089983093ndash983092983089 years) O the pediatric patients 983089983089 devel-oped postoperative bleeding in the late term (983089ndash983089983088 days)bleeding was controlled under general anesthesia in twopatients Postoperative bleeding was developed in 983095 o 983091983093adult patients in thelate term andthe bleeding wascontrolledunder general anesthesiain 983091 patients Postoperative bleedingwas signi1047297cantly less prevalent in the pediatric age groupcompared to the adult age group ( = 004) Moreoverpostoperative pain was signi1047297cantly less prevalent in thepediatric age group as compared to the adult age group( lt 0001) Ages and postoperative pain in the pediatric andadult age groups are presented in able 983089

8212019 265105pdf

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International Journal o Otolaryngology 983091

4 Discussion

onsillectomy techniques have been compared through var-ious parameters in the previous studies Tese comparisonshave been perormed only among pediatric andor adultage groups [983091ndash983093] Tere have also been studies comparing

various techniques in both age groups [983090 983097] However limitednumber o studies in the literature has compared adult andpediatric patients in terms o the same technique In thepresent study we compared the adult and pediatric patientsin terms o postoperative bleeding and pain ollowing tonsil-lectomy perormed WS

Karatzias et al [983097] reported no postoperative bleedingafer tonsillectomy perormed by WS in the adult andpediatric patients Moreover operation duration was shorterin the pediatric patients than in the adults In that particularstudy 983091 adult patients developed intraoperative bleedingrom the tonsillar artery in the inerior pole region andthe bleeding was controlled by bipolar electrocautery Inthe present study postoperative bleeding was developed in

both groups being signi1047297cantly more prevalent in the adultage group Karatzias et al [983097] mentioned that intraoperativebleeding requires additional coagulation o the large vesselsand additional suture techniques particularly in the adultpatients Tis result was consistent with the result o thepresent study which revealed more prevalent postoperativebleeding among adult patients

Stavroulaki et al [983089] compared cold dissection and WSin the adult patients and showed signi1047297cantly lower painscores in the WS group particularly within the 1047297rst ourpostoperative days In the present study pain scores wereound higher in the adult age group as compared to thepediatric age group Stavroulaki et al [983089] attributed this result

to the act that WS was simple and aster and producedmuch lower collateral thermal damage as compared to themonopolar or bipolar electrocautery Tey ound no signi-icant difference between these two techniques in terms o postoperative bleeding Postoperative bleeding was observedonly in 983091 patients in the cold dissection group o whom 983090 hada history o peritonsillar abscess

Karatzanis et al [983089983088] perormed a comparative study inthe adultsusing WS andLigaSuremethod andoundno di-erence between the techniques in terms o the intraoperativebleeding and mean operation duration On the other handthe mean pain score was signi1047297cantly lower in the WS groupon each postoperative day as compared to that in the LigaSure

group Moreover they noted late postoperative bleeding in 983089patient in the WS group and in 983090 patients in the LigaSuregroup Tus they concluded that both techniques provideadequate homeostasis in the adult patients Te present study showed higher incidence o postoperative bleeding amongadult patients as compared to that in the WS group o Karatzanis et al [983089983088]

In their comparative study conducted on adult patientsusing WS and bipolar electrocautery Karatzias et al [983091]reported that 983097 patients presented with late postoperativebleeding o whom 983092 were in the WS group and 983093 were inthe bipolar electrocautery group Tey noted no bleeding inthe mouths or pharynxes o 983090 patients in the WS group and

983091 patients in the bipolar electrocautery group andthe patientswere discharged Te remaining 983089 (983089983090) patient in the WSgroup and 983091 (983092983091) patients in the bipolar electrocautery group were hospitalized because o bleeding in the oral cavityBleeding was controlled under general anesthesia in 983089 patientin the bipolar electrocautery group In the present study

postoperative bleeding was observed in 983095 adult patients o whom 983092 (983089983089983092) were hospitalized due to bleeding in theoral cavity and were discharged without any interventionBleeding was controlled under general anesthesia in theremaining 983091 (983096983093) patients

In their multiparametric study Chimona et al [983093] com-pared cold knie radiorequency and WS in the childrenundergoing tonsillectomy and they reported that postopera-tive pain was signi1047297cantly lower in the cold knie procedureTey ound no signi1047297cant difference between these threemethods in terms o late postoperative bleeding In thatparticular study the incidence o postoperative bleeding was983090983090983091 whereas it was 983094983089983096 among pediatric age group inthe present study O the pediatric patients withpostoperativebleeding 983090 (983089983089983090) required bleeding control under generalanesthesia Chimona et al [983093] indicated that the incidence o posttonsillectomy bleeding was low in their study and they attributed this result to the experience o the surgeons whomperormed the procedure as well as to the time that they recommended to the children to start their normal diet andactivity

Michel et al [983090] conducted a study on 983089983088983088 patientsand divided them into two subgroups according to theirages patients between 983090 and 983089983090 years o age constitutedyounger group and patients between 983089983091 and 983092983095 years o ageconstituted older group Tis study which is the only study in the literature similar to the present study introduced thepreliminary results about saety efficacy and morbidity o WS used or tonsillectomy and compared the results withthose o other total tonsillectomy techniques in the literatureIn that particular study the mean pain score during healingwas 983090983088 in the younger group and 983091983089 in the older groupTeseresults were consistent with the results o the present studythe postoperative pain score was signi1047297cantly lower in thepediatric patients compared to that in the adults Moreoverin that particular study the incidence o late postoperativebleeding was the same both in the younger and older groups(983090) Te incidence o late postoperative bleeding in thepresent study was 983094983089983096 in the pediatric age group and 983090983088in the adult age group

In the literature Lee et al [983089983089] reported that there wasno difference between cold and hot dissections in termso the incidence o secondary bleeding in the pediatricage group Nevertheless in their study Michel et al [983090]perormed a literature review and reported the incidences o latepostoperative bleeding or different techniques as ollows983096983094 (1038389 = 1455) or electrodissection 983091983097 (1038389 = 1829) orcoblation 983090983096 (1038389 = 468) or harmonic scalpel and 983089983093(1038389 = 1610) or cold knie In the present study the incidenceo late postoperative bleeding was 983094983089983096 in the pediatric agegroup and 983090983088 in the adult age group

Te present study evaluated postoperative bleedingand pain ollowing tonsillectomy perormed by WS in

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983092 International Journal o Otolaryngology

the pediatric and adult age groups and revealed higherincidences o postoperative bleeding and pain in the late termin the adult age group compared to those in the pediatric agegroup Large-scale studies comparing different tonsillectomy techniques in adult and pediatric age groups are needed

Conflict of Interests

Te authors declare that they have no con1047298ict o interests

References

[983089] P Stavroulaki C Skoulakis E Teos N Kokalis and D Vala-gianis ldquoTermalwelding versus colddissectiontonsillectomy aprospective randomized single-blind study in adults patientsrdquo Annals of Otology Rhinology and Laryngology vol 983089983089983094 no 983096 pp983093983094983093ndash983093983095983088 983090983088983088983095

[983090] R G Michel B I Weinstock and K sau ldquoSaety and efficacy o pressure-assisted tissue-weldingtonsillectomy a preliminary evaluationrdquo Ear Nose and Troat Journal vol 983096983095 no 983090 pp 983089983088983088ndash983089983088983093 983090983088983088983096

[983091] G Karatzias V A Lachanas and V G Sandris ldquoTermalwelding versus bipolar tonsillectomy a comparative studyrdquoOtolaryngologymdashHead and Neck Surgery vol 983089983091983092 no 983094 pp983097983095983093ndash983097983095983096 983090983088983088983094

[983092] J Silvola A Salonen J Nieminen and H Kokki ldquoissue weld-ing tonsillectomy provides an enhanced recovery comparedto that afer monopolar electrocautery technique in adults aprospective randomized clinical trialrdquo European Archives of Oto-Rhino-Laryngology vol 983090983094983096 no 983090 pp 983090983093983093ndash983090983094983088 983090983088983089983089

[983093] Chimona E Proimos C Mamoulakis M zanakakis C ESkoulakis and C E Papadakis ldquoMultiparametric comparisono cold knie tonsillectomy radiorequency excision and ther-

mal welding tonsillectomy in childrenrdquo International Journal of Pediatric Otorhinolaryngology vol 983095983090 no 983097 pp 983089983092983091983089ndash983089983092983091983094983090983088983088983096

[983094] B I Weinstock ldquoAn improved method or tonsillectomy usingthermal welding technologyrdquo httpwwwhakermedikalcomdocAdvances983090983088in983090983088Otolaryngologyhs onsillectomypd

[983095] H Yasar H Ozkul and A Verim ldquoComparison o the thermalwelding technique and cold dissection or pediatric tonsillec-tomyrdquo rakya Universitesi ıp Fakultesi Dergisi vol 983090983094 no 983092pp 983091983090983094ndash983091983091983088 983090983088983088983097

[983096] D Bieri R A Reeve G D Champion L Addicoat and JB Ziegler ldquoTe aces pain scale or the sel-assessment o the severity o pain experienced by children developmentinitial validation and preliminary investigation or ratio scale

propertiesrdquo Pain vol 983092983089 no 983090 pp 983089983091983097ndash983089983093983088 983089983097983097983088[983097] G Karatzias V A Lachanas S M Papouliakos and V

G Sandris ldquoonsillectomy using the thermal welding systemrdquoORL Journal of Oto-Rhino-Laryngology and Its Related Special-ties vol 983094983095 no 983092 pp 983090983090983093ndash983090983090983097 983090983088983088983093

[983089983088] A Karatzanis C Bourolias E Prokopakis I Panagiotakiand G Velegrakis ldquoTermal welding technology vs ligasuretonsillectomy a comparative studyrdquo Te American Journal of Otolaryngology vol 983090983097 no 983092 pp 983090983091983096ndash983090983092983089 983090983088983088983096

[983089983089] M S W Lee M-L Montague and S S M HussainldquoPost-tonsillectomy hemorrhage cold versus hot dissectionrdquoOtolaryngologymdashHead and Neck Surgery vol983089983091983089no 983094pp983096983091983091ndash983096983091983094 983090983088983088983092

8212019 265105pdf

httpslidepdfcomreaderfull265105pdf 55

Submit your manuscripts at

httpwwwhindawicom

8212019 265105pdf

httpslidepdfcomreaderfull265105pdf 25

983090 International Journal o Otolaryngology

F983145983143983157983154983141 983089 Termal welding system (WS) device

hypertrophy in the pediatric patients and chronic tonsillitisin the adult patients

Patients with history or penicillin allergy coagulationdisorder andor abnormal elevated prothrombin time andactivated partial thromboplastin time wereexcluded rom thestudy All o the patients were operated by the same surgeon

(ogla Ersozlu) under general anesthesia with endotrachealintubation One hour prior to the surgical procedure thepediatric patients were given 983093983088983088 mg ampicillinsulbactamintravenously whereas the adult patients were given 983089983088983088983088 mgampicillinsulbactam intravenously Both pediatric and adultpatients received 983088983093 mgkg methylprednisolone intraopera-tively Afer the surgery patients in the pediatric age groupreceived amoxicillinclavulanateand paracetamol suspensiontwo times a day or ten days and the patients in the adultage group received amoxicillinclavulanate and paracetamoltablets two times a day with ten days

983090983089 Surgical echnique WS consists o a single-use probe(ENceps) double-controlled oot switch and a univer-sal power supply (UPS) Te energy rom the universalpower supply turns into thermal energy in the heating wire(nichrome) at the distal end o the thermal welding probeand causes coagulation by simultaneous pressure that occursas the probe is closed by the silicone boot at the otherdistal end [983094 983095] Nichrome wire at the ends o the probecannot be activated via lef oot switch unless completely squeezed by hands issue-cutting is perormed by clampingthe coagulated tissue between the ends o the probe andactivating via the right side o the oot switch (Figure 983089)

In the present study we perormed extracapsular ton-sillectomy with WS using a probe with a power setting

o ldquo983091rdquo afer placing the mouth gag While the tonsil wasretracted medially using allis clamp dissection was made

via tonsil probe at the upper pole o the tonsil by clampingthe anterior pillar mucosal tissue Te tissue was activatedwith the oot switch and clamped between the ends o thetonsil probe orapproximately 983094 seconds and coagulation wasperormed Tereafer cutting procedure was perormed by activating with the right oot switch or approximately twoseconds Dissection was extended rom the upper pole to thelower pole by exposing the tonsil capsule onsil tissue wascoagulated or the last time at the lower pole and removedrom the surgical area Tis technique was perormed orboth tonsils onsil bed was postoperatively monitored or

983137983138983148983141 983089 Te ages and visual analogue scale scores o the patients

Mean plusmn SD 983097983093 CI RSD Median MinndashMax

Pediatric patients(1038389 = 178)

Age 983094983095 plusmn 983090983092983088 983094983091ndash983095983088 983088983091983093 983094 983090ndash983089983091

VAS score 983095983091 plusmn 983089983089983093 983095983090ndash983095983093 983088983089983093 983096 983094ndash983089983088Adult patients(1038389 = 35)

Age 983090983089983096 plusmn 983095983088983095 983089983097983092ndash983090983092983091 983088983091983090 983090983089 983089983093ndash983092983089

VAS score 983096983093983094 plusmn 983093983096983088 983096983091983094ndash983096983095983094 983088983088983094983095 983096983093 983095983088ndash983097983093

VAS visual analogue scale SD standard deviation CI con1047297dence intervalRSD relative standard deviation MinndashMax minimumndashmaximum

bleeding Surgical area was washed with normal saline Colddiet was initiated both to the pediatric group and adult group983091 hours afer the surgery All o the patients were dischargedon the postoperative 983090nd day

Pain was questioned by nurse on the 983089st 983091rd 983095th and 983089983088thpostoperative days via aces pain scale under the assistance o the amilies o the children younger than 983096 years [983096] whereasit wasevaluatedvia visual analogue scale (VAS)in the patientsolder than 983096 years [983089] Postoperative bleeding was monitoredand recorded i any

983090983090 Statistical Analysis Data were evaluated using the Med-Calc statistics program version 983089983089983093983089 (MedCalc SofwareMariakerke Belgium) Te Chi-square test was used to com-pare the categorical variables whereas Mann-Whitney U -testand independent samples 1103925-test were used to determine inter-group differences Te data were expressed as mean plusmn stan-dard deviation A value lt983088983088983093 was considered signi1047297cantComparison o two groups proportions minimally requiredsample size per group 983089983091

3 Results

Te present study included 983090983089983091 patients o whom 983089983095983096 werepediatric and 983091983093 were adult Te pediatric age group com-prised 983096983088 girls and 983097983096 boys with a mean age o 67 plusmn 24

years (range 983091ndash983089983091 years) Te adult age group comprised 983090983088

male and 983089983093 emale patients with a mean age o 218 plusmn 707

years (range 983089983093ndash983092983089 years) O the pediatric patients 983089983089 devel-oped postoperative bleeding in the late term (983089ndash983089983088 days)bleeding was controlled under general anesthesia in twopatients Postoperative bleeding was developed in 983095 o 983091983093adult patients in thelate term andthe bleeding wascontrolledunder general anesthesiain 983091 patients Postoperative bleedingwas signi1047297cantly less prevalent in the pediatric age groupcompared to the adult age group ( = 004) Moreoverpostoperative pain was signi1047297cantly less prevalent in thepediatric age group as compared to the adult age group( lt 0001) Ages and postoperative pain in the pediatric andadult age groups are presented in able 983089

8212019 265105pdf

httpslidepdfcomreaderfull265105pdf 35

International Journal o Otolaryngology 983091

4 Discussion

onsillectomy techniques have been compared through var-ious parameters in the previous studies Tese comparisonshave been perormed only among pediatric andor adultage groups [983091ndash983093] Tere have also been studies comparing

various techniques in both age groups [983090 983097] However limitednumber o studies in the literature has compared adult andpediatric patients in terms o the same technique In thepresent study we compared the adult and pediatric patientsin terms o postoperative bleeding and pain ollowing tonsil-lectomy perormed WS

Karatzias et al [983097] reported no postoperative bleedingafer tonsillectomy perormed by WS in the adult andpediatric patients Moreover operation duration was shorterin the pediatric patients than in the adults In that particularstudy 983091 adult patients developed intraoperative bleedingrom the tonsillar artery in the inerior pole region andthe bleeding was controlled by bipolar electrocautery Inthe present study postoperative bleeding was developed in

both groups being signi1047297cantly more prevalent in the adultage group Karatzias et al [983097] mentioned that intraoperativebleeding requires additional coagulation o the large vesselsand additional suture techniques particularly in the adultpatients Tis result was consistent with the result o thepresent study which revealed more prevalent postoperativebleeding among adult patients

Stavroulaki et al [983089] compared cold dissection and WSin the adult patients and showed signi1047297cantly lower painscores in the WS group particularly within the 1047297rst ourpostoperative days In the present study pain scores wereound higher in the adult age group as compared to thepediatric age group Stavroulaki et al [983089] attributed this result

to the act that WS was simple and aster and producedmuch lower collateral thermal damage as compared to themonopolar or bipolar electrocautery Tey ound no signi-icant difference between these two techniques in terms o postoperative bleeding Postoperative bleeding was observedonly in 983091 patients in the cold dissection group o whom 983090 hada history o peritonsillar abscess

Karatzanis et al [983089983088] perormed a comparative study inthe adultsusing WS andLigaSuremethod andoundno di-erence between the techniques in terms o the intraoperativebleeding and mean operation duration On the other handthe mean pain score was signi1047297cantly lower in the WS groupon each postoperative day as compared to that in the LigaSure

group Moreover they noted late postoperative bleeding in 983089patient in the WS group and in 983090 patients in the LigaSuregroup Tus they concluded that both techniques provideadequate homeostasis in the adult patients Te present study showed higher incidence o postoperative bleeding amongadult patients as compared to that in the WS group o Karatzanis et al [983089983088]

In their comparative study conducted on adult patientsusing WS and bipolar electrocautery Karatzias et al [983091]reported that 983097 patients presented with late postoperativebleeding o whom 983092 were in the WS group and 983093 were inthe bipolar electrocautery group Tey noted no bleeding inthe mouths or pharynxes o 983090 patients in the WS group and

983091 patients in the bipolar electrocautery group andthe patientswere discharged Te remaining 983089 (983089983090) patient in the WSgroup and 983091 (983092983091) patients in the bipolar electrocautery group were hospitalized because o bleeding in the oral cavityBleeding was controlled under general anesthesia in 983089 patientin the bipolar electrocautery group In the present study

postoperative bleeding was observed in 983095 adult patients o whom 983092 (983089983089983092) were hospitalized due to bleeding in theoral cavity and were discharged without any interventionBleeding was controlled under general anesthesia in theremaining 983091 (983096983093) patients

In their multiparametric study Chimona et al [983093] com-pared cold knie radiorequency and WS in the childrenundergoing tonsillectomy and they reported that postopera-tive pain was signi1047297cantly lower in the cold knie procedureTey ound no signi1047297cant difference between these threemethods in terms o late postoperative bleeding In thatparticular study the incidence o postoperative bleeding was983090983090983091 whereas it was 983094983089983096 among pediatric age group inthe present study O the pediatric patients withpostoperativebleeding 983090 (983089983089983090) required bleeding control under generalanesthesia Chimona et al [983093] indicated that the incidence o posttonsillectomy bleeding was low in their study and they attributed this result to the experience o the surgeons whomperormed the procedure as well as to the time that they recommended to the children to start their normal diet andactivity

Michel et al [983090] conducted a study on 983089983088983088 patientsand divided them into two subgroups according to theirages patients between 983090 and 983089983090 years o age constitutedyounger group and patients between 983089983091 and 983092983095 years o ageconstituted older group Tis study which is the only study in the literature similar to the present study introduced thepreliminary results about saety efficacy and morbidity o WS used or tonsillectomy and compared the results withthose o other total tonsillectomy techniques in the literatureIn that particular study the mean pain score during healingwas 983090983088 in the younger group and 983091983089 in the older groupTeseresults were consistent with the results o the present studythe postoperative pain score was signi1047297cantly lower in thepediatric patients compared to that in the adults Moreoverin that particular study the incidence o late postoperativebleeding was the same both in the younger and older groups(983090) Te incidence o late postoperative bleeding in thepresent study was 983094983089983096 in the pediatric age group and 983090983088in the adult age group

In the literature Lee et al [983089983089] reported that there wasno difference between cold and hot dissections in termso the incidence o secondary bleeding in the pediatricage group Nevertheless in their study Michel et al [983090]perormed a literature review and reported the incidences o latepostoperative bleeding or different techniques as ollows983096983094 (1038389 = 1455) or electrodissection 983091983097 (1038389 = 1829) orcoblation 983090983096 (1038389 = 468) or harmonic scalpel and 983089983093(1038389 = 1610) or cold knie In the present study the incidenceo late postoperative bleeding was 983094983089983096 in the pediatric agegroup and 983090983088 in the adult age group

Te present study evaluated postoperative bleedingand pain ollowing tonsillectomy perormed by WS in

8212019 265105pdf

httpslidepdfcomreaderfull265105pdf 45

983092 International Journal o Otolaryngology

the pediatric and adult age groups and revealed higherincidences o postoperative bleeding and pain in the late termin the adult age group compared to those in the pediatric agegroup Large-scale studies comparing different tonsillectomy techniques in adult and pediatric age groups are needed

Conflict of Interests

Te authors declare that they have no con1047298ict o interests

References

[983089] P Stavroulaki C Skoulakis E Teos N Kokalis and D Vala-gianis ldquoTermalwelding versus colddissectiontonsillectomy aprospective randomized single-blind study in adults patientsrdquo Annals of Otology Rhinology and Laryngology vol 983089983089983094 no 983096 pp983093983094983093ndash983093983095983088 983090983088983088983095

[983090] R G Michel B I Weinstock and K sau ldquoSaety and efficacy o pressure-assisted tissue-weldingtonsillectomy a preliminary evaluationrdquo Ear Nose and Troat Journal vol 983096983095 no 983090 pp 983089983088983088ndash983089983088983093 983090983088983088983096

[983091] G Karatzias V A Lachanas and V G Sandris ldquoTermalwelding versus bipolar tonsillectomy a comparative studyrdquoOtolaryngologymdashHead and Neck Surgery vol 983089983091983092 no 983094 pp983097983095983093ndash983097983095983096 983090983088983088983094

[983092] J Silvola A Salonen J Nieminen and H Kokki ldquoissue weld-ing tonsillectomy provides an enhanced recovery comparedto that afer monopolar electrocautery technique in adults aprospective randomized clinical trialrdquo European Archives of Oto-Rhino-Laryngology vol 983090983094983096 no 983090 pp 983090983093983093ndash983090983094983088 983090983088983089983089

[983093] Chimona E Proimos C Mamoulakis M zanakakis C ESkoulakis and C E Papadakis ldquoMultiparametric comparisono cold knie tonsillectomy radiorequency excision and ther-

mal welding tonsillectomy in childrenrdquo International Journal of Pediatric Otorhinolaryngology vol 983095983090 no 983097 pp 983089983092983091983089ndash983089983092983091983094983090983088983088983096

[983094] B I Weinstock ldquoAn improved method or tonsillectomy usingthermal welding technologyrdquo httpwwwhakermedikalcomdocAdvances983090983088in983090983088Otolaryngologyhs onsillectomypd

[983095] H Yasar H Ozkul and A Verim ldquoComparison o the thermalwelding technique and cold dissection or pediatric tonsillec-tomyrdquo rakya Universitesi ıp Fakultesi Dergisi vol 983090983094 no 983092pp 983091983090983094ndash983091983091983088 983090983088983088983097

[983096] D Bieri R A Reeve G D Champion L Addicoat and JB Ziegler ldquoTe aces pain scale or the sel-assessment o the severity o pain experienced by children developmentinitial validation and preliminary investigation or ratio scale

propertiesrdquo Pain vol 983092983089 no 983090 pp 983089983091983097ndash983089983093983088 983089983097983097983088[983097] G Karatzias V A Lachanas S M Papouliakos and V

G Sandris ldquoonsillectomy using the thermal welding systemrdquoORL Journal of Oto-Rhino-Laryngology and Its Related Special-ties vol 983094983095 no 983092 pp 983090983090983093ndash983090983090983097 983090983088983088983093

[983089983088] A Karatzanis C Bourolias E Prokopakis I Panagiotakiand G Velegrakis ldquoTermal welding technology vs ligasuretonsillectomy a comparative studyrdquo Te American Journal of Otolaryngology vol 983090983097 no 983092 pp 983090983091983096ndash983090983092983089 983090983088983088983096

[983089983089] M S W Lee M-L Montague and S S M HussainldquoPost-tonsillectomy hemorrhage cold versus hot dissectionrdquoOtolaryngologymdashHead and Neck Surgery vol983089983091983089no 983094pp983096983091983091ndash983096983091983094 983090983088983088983092

8212019 265105pdf

httpslidepdfcomreaderfull265105pdf 55

Submit your manuscripts at

httpwwwhindawicom

8212019 265105pdf

httpslidepdfcomreaderfull265105pdf 35

International Journal o Otolaryngology 983091

4 Discussion

onsillectomy techniques have been compared through var-ious parameters in the previous studies Tese comparisonshave been perormed only among pediatric andor adultage groups [983091ndash983093] Tere have also been studies comparing

various techniques in both age groups [983090 983097] However limitednumber o studies in the literature has compared adult andpediatric patients in terms o the same technique In thepresent study we compared the adult and pediatric patientsin terms o postoperative bleeding and pain ollowing tonsil-lectomy perormed WS

Karatzias et al [983097] reported no postoperative bleedingafer tonsillectomy perormed by WS in the adult andpediatric patients Moreover operation duration was shorterin the pediatric patients than in the adults In that particularstudy 983091 adult patients developed intraoperative bleedingrom the tonsillar artery in the inerior pole region andthe bleeding was controlled by bipolar electrocautery Inthe present study postoperative bleeding was developed in

both groups being signi1047297cantly more prevalent in the adultage group Karatzias et al [983097] mentioned that intraoperativebleeding requires additional coagulation o the large vesselsand additional suture techniques particularly in the adultpatients Tis result was consistent with the result o thepresent study which revealed more prevalent postoperativebleeding among adult patients

Stavroulaki et al [983089] compared cold dissection and WSin the adult patients and showed signi1047297cantly lower painscores in the WS group particularly within the 1047297rst ourpostoperative days In the present study pain scores wereound higher in the adult age group as compared to thepediatric age group Stavroulaki et al [983089] attributed this result

to the act that WS was simple and aster and producedmuch lower collateral thermal damage as compared to themonopolar or bipolar electrocautery Tey ound no signi-icant difference between these two techniques in terms o postoperative bleeding Postoperative bleeding was observedonly in 983091 patients in the cold dissection group o whom 983090 hada history o peritonsillar abscess

Karatzanis et al [983089983088] perormed a comparative study inthe adultsusing WS andLigaSuremethod andoundno di-erence between the techniques in terms o the intraoperativebleeding and mean operation duration On the other handthe mean pain score was signi1047297cantly lower in the WS groupon each postoperative day as compared to that in the LigaSure

group Moreover they noted late postoperative bleeding in 983089patient in the WS group and in 983090 patients in the LigaSuregroup Tus they concluded that both techniques provideadequate homeostasis in the adult patients Te present study showed higher incidence o postoperative bleeding amongadult patients as compared to that in the WS group o Karatzanis et al [983089983088]

In their comparative study conducted on adult patientsusing WS and bipolar electrocautery Karatzias et al [983091]reported that 983097 patients presented with late postoperativebleeding o whom 983092 were in the WS group and 983093 were inthe bipolar electrocautery group Tey noted no bleeding inthe mouths or pharynxes o 983090 patients in the WS group and

983091 patients in the bipolar electrocautery group andthe patientswere discharged Te remaining 983089 (983089983090) patient in the WSgroup and 983091 (983092983091) patients in the bipolar electrocautery group were hospitalized because o bleeding in the oral cavityBleeding was controlled under general anesthesia in 983089 patientin the bipolar electrocautery group In the present study

postoperative bleeding was observed in 983095 adult patients o whom 983092 (983089983089983092) were hospitalized due to bleeding in theoral cavity and were discharged without any interventionBleeding was controlled under general anesthesia in theremaining 983091 (983096983093) patients

In their multiparametric study Chimona et al [983093] com-pared cold knie radiorequency and WS in the childrenundergoing tonsillectomy and they reported that postopera-tive pain was signi1047297cantly lower in the cold knie procedureTey ound no signi1047297cant difference between these threemethods in terms o late postoperative bleeding In thatparticular study the incidence o postoperative bleeding was983090983090983091 whereas it was 983094983089983096 among pediatric age group inthe present study O the pediatric patients withpostoperativebleeding 983090 (983089983089983090) required bleeding control under generalanesthesia Chimona et al [983093] indicated that the incidence o posttonsillectomy bleeding was low in their study and they attributed this result to the experience o the surgeons whomperormed the procedure as well as to the time that they recommended to the children to start their normal diet andactivity

Michel et al [983090] conducted a study on 983089983088983088 patientsand divided them into two subgroups according to theirages patients between 983090 and 983089983090 years o age constitutedyounger group and patients between 983089983091 and 983092983095 years o ageconstituted older group Tis study which is the only study in the literature similar to the present study introduced thepreliminary results about saety efficacy and morbidity o WS used or tonsillectomy and compared the results withthose o other total tonsillectomy techniques in the literatureIn that particular study the mean pain score during healingwas 983090983088 in the younger group and 983091983089 in the older groupTeseresults were consistent with the results o the present studythe postoperative pain score was signi1047297cantly lower in thepediatric patients compared to that in the adults Moreoverin that particular study the incidence o late postoperativebleeding was the same both in the younger and older groups(983090) Te incidence o late postoperative bleeding in thepresent study was 983094983089983096 in the pediatric age group and 983090983088in the adult age group

In the literature Lee et al [983089983089] reported that there wasno difference between cold and hot dissections in termso the incidence o secondary bleeding in the pediatricage group Nevertheless in their study Michel et al [983090]perormed a literature review and reported the incidences o latepostoperative bleeding or different techniques as ollows983096983094 (1038389 = 1455) or electrodissection 983091983097 (1038389 = 1829) orcoblation 983090983096 (1038389 = 468) or harmonic scalpel and 983089983093(1038389 = 1610) or cold knie In the present study the incidenceo late postoperative bleeding was 983094983089983096 in the pediatric agegroup and 983090983088 in the adult age group

Te present study evaluated postoperative bleedingand pain ollowing tonsillectomy perormed by WS in

8212019 265105pdf

httpslidepdfcomreaderfull265105pdf 45

983092 International Journal o Otolaryngology

the pediatric and adult age groups and revealed higherincidences o postoperative bleeding and pain in the late termin the adult age group compared to those in the pediatric agegroup Large-scale studies comparing different tonsillectomy techniques in adult and pediatric age groups are needed

Conflict of Interests

Te authors declare that they have no con1047298ict o interests

References

[983089] P Stavroulaki C Skoulakis E Teos N Kokalis and D Vala-gianis ldquoTermalwelding versus colddissectiontonsillectomy aprospective randomized single-blind study in adults patientsrdquo Annals of Otology Rhinology and Laryngology vol 983089983089983094 no 983096 pp983093983094983093ndash983093983095983088 983090983088983088983095

[983090] R G Michel B I Weinstock and K sau ldquoSaety and efficacy o pressure-assisted tissue-weldingtonsillectomy a preliminary evaluationrdquo Ear Nose and Troat Journal vol 983096983095 no 983090 pp 983089983088983088ndash983089983088983093 983090983088983088983096

[983091] G Karatzias V A Lachanas and V G Sandris ldquoTermalwelding versus bipolar tonsillectomy a comparative studyrdquoOtolaryngologymdashHead and Neck Surgery vol 983089983091983092 no 983094 pp983097983095983093ndash983097983095983096 983090983088983088983094

[983092] J Silvola A Salonen J Nieminen and H Kokki ldquoissue weld-ing tonsillectomy provides an enhanced recovery comparedto that afer monopolar electrocautery technique in adults aprospective randomized clinical trialrdquo European Archives of Oto-Rhino-Laryngology vol 983090983094983096 no 983090 pp 983090983093983093ndash983090983094983088 983090983088983089983089

[983093] Chimona E Proimos C Mamoulakis M zanakakis C ESkoulakis and C E Papadakis ldquoMultiparametric comparisono cold knie tonsillectomy radiorequency excision and ther-

mal welding tonsillectomy in childrenrdquo International Journal of Pediatric Otorhinolaryngology vol 983095983090 no 983097 pp 983089983092983091983089ndash983089983092983091983094983090983088983088983096

[983094] B I Weinstock ldquoAn improved method or tonsillectomy usingthermal welding technologyrdquo httpwwwhakermedikalcomdocAdvances983090983088in983090983088Otolaryngologyhs onsillectomypd

[983095] H Yasar H Ozkul and A Verim ldquoComparison o the thermalwelding technique and cold dissection or pediatric tonsillec-tomyrdquo rakya Universitesi ıp Fakultesi Dergisi vol 983090983094 no 983092pp 983091983090983094ndash983091983091983088 983090983088983088983097

[983096] D Bieri R A Reeve G D Champion L Addicoat and JB Ziegler ldquoTe aces pain scale or the sel-assessment o the severity o pain experienced by children developmentinitial validation and preliminary investigation or ratio scale

propertiesrdquo Pain vol 983092983089 no 983090 pp 983089983091983097ndash983089983093983088 983089983097983097983088[983097] G Karatzias V A Lachanas S M Papouliakos and V

G Sandris ldquoonsillectomy using the thermal welding systemrdquoORL Journal of Oto-Rhino-Laryngology and Its Related Special-ties vol 983094983095 no 983092 pp 983090983090983093ndash983090983090983097 983090983088983088983093

[983089983088] A Karatzanis C Bourolias E Prokopakis I Panagiotakiand G Velegrakis ldquoTermal welding technology vs ligasuretonsillectomy a comparative studyrdquo Te American Journal of Otolaryngology vol 983090983097 no 983092 pp 983090983091983096ndash983090983092983089 983090983088983088983096

[983089983089] M S W Lee M-L Montague and S S M HussainldquoPost-tonsillectomy hemorrhage cold versus hot dissectionrdquoOtolaryngologymdashHead and Neck Surgery vol983089983091983089no 983094pp983096983091983091ndash983096983091983094 983090983088983088983092

8212019 265105pdf

httpslidepdfcomreaderfull265105pdf 55

Submit your manuscripts at

httpwwwhindawicom

8212019 265105pdf

httpslidepdfcomreaderfull265105pdf 45

983092 International Journal o Otolaryngology

the pediatric and adult age groups and revealed higherincidences o postoperative bleeding and pain in the late termin the adult age group compared to those in the pediatric agegroup Large-scale studies comparing different tonsillectomy techniques in adult and pediatric age groups are needed

Conflict of Interests

Te authors declare that they have no con1047298ict o interests

References

[983089] P Stavroulaki C Skoulakis E Teos N Kokalis and D Vala-gianis ldquoTermalwelding versus colddissectiontonsillectomy aprospective randomized single-blind study in adults patientsrdquo Annals of Otology Rhinology and Laryngology vol 983089983089983094 no 983096 pp983093983094983093ndash983093983095983088 983090983088983088983095

[983090] R G Michel B I Weinstock and K sau ldquoSaety and efficacy o pressure-assisted tissue-weldingtonsillectomy a preliminary evaluationrdquo Ear Nose and Troat Journal vol 983096983095 no 983090 pp 983089983088983088ndash983089983088983093 983090983088983088983096

[983091] G Karatzias V A Lachanas and V G Sandris ldquoTermalwelding versus bipolar tonsillectomy a comparative studyrdquoOtolaryngologymdashHead and Neck Surgery vol 983089983091983092 no 983094 pp983097983095983093ndash983097983095983096 983090983088983088983094

[983092] J Silvola A Salonen J Nieminen and H Kokki ldquoissue weld-ing tonsillectomy provides an enhanced recovery comparedto that afer monopolar electrocautery technique in adults aprospective randomized clinical trialrdquo European Archives of Oto-Rhino-Laryngology vol 983090983094983096 no 983090 pp 983090983093983093ndash983090983094983088 983090983088983089983089

[983093] Chimona E Proimos C Mamoulakis M zanakakis C ESkoulakis and C E Papadakis ldquoMultiparametric comparisono cold knie tonsillectomy radiorequency excision and ther-

mal welding tonsillectomy in childrenrdquo International Journal of Pediatric Otorhinolaryngology vol 983095983090 no 983097 pp 983089983092983091983089ndash983089983092983091983094983090983088983088983096

[983094] B I Weinstock ldquoAn improved method or tonsillectomy usingthermal welding technologyrdquo httpwwwhakermedikalcomdocAdvances983090983088in983090983088Otolaryngologyhs onsillectomypd

[983095] H Yasar H Ozkul and A Verim ldquoComparison o the thermalwelding technique and cold dissection or pediatric tonsillec-tomyrdquo rakya Universitesi ıp Fakultesi Dergisi vol 983090983094 no 983092pp 983091983090983094ndash983091983091983088 983090983088983088983097

[983096] D Bieri R A Reeve G D Champion L Addicoat and JB Ziegler ldquoTe aces pain scale or the sel-assessment o the severity o pain experienced by children developmentinitial validation and preliminary investigation or ratio scale

propertiesrdquo Pain vol 983092983089 no 983090 pp 983089983091983097ndash983089983093983088 983089983097983097983088[983097] G Karatzias V A Lachanas S M Papouliakos and V

G Sandris ldquoonsillectomy using the thermal welding systemrdquoORL Journal of Oto-Rhino-Laryngology and Its Related Special-ties vol 983094983095 no 983092 pp 983090983090983093ndash983090983090983097 983090983088983088983093

[983089983088] A Karatzanis C Bourolias E Prokopakis I Panagiotakiand G Velegrakis ldquoTermal welding technology vs ligasuretonsillectomy a comparative studyrdquo Te American Journal of Otolaryngology vol 983090983097 no 983092 pp 983090983091983096ndash983090983092983089 983090983088983088983096

[983089983089] M S W Lee M-L Montague and S S M HussainldquoPost-tonsillectomy hemorrhage cold versus hot dissectionrdquoOtolaryngologymdashHead and Neck Surgery vol983089983091983089no 983094pp983096983091983091ndash983096983091983094 983090983088983088983092

8212019 265105pdf

httpslidepdfcomreaderfull265105pdf 55

Submit your manuscripts at

httpwwwhindawicom

8212019 265105pdf

httpslidepdfcomreaderfull265105pdf 55

Submit your manuscripts at

httpwwwhindawicom