International Journal of Pediatric Otorhinolaryngology 73 (2009) 793–795

Bipolar diathermy versus cold dissection in paediatric tonsillectomy

Ahmed Hesham *

Department of Otorhinolaryngology, Faculty of Medicine, Cairo University, Affliated to Magrabi Eye and Ear Hospital, P.O.Box: 513, Postal Code 112, Muscat, Oman

A R T I C L E I N F O

Article history:

Received 4 May 2008

Received in revised form 20 September 2008

Accepted 28 September 2008

Available online 28 November 2008

Keywords:

Tonsillectomy

Bipolar diathermy

Postoperative pain

Cold dissection

S U M M A R Y

Objectives: To compare bipolar diathermy with cold dissection in paediatric tonsillectomy.

Methods: One hundred and fifty children were randomized equally into bipolar diathermy tonsillectomy

(BDT) and cold dissection tonsillectomy (CDT). Operative time, operative blood loss, postoperative pain,

diet intake, activity level and complications were compared in the 2 groups.

Results: The 2 groups were comparable in age and sex distribution. Operative time and blood loss was

significantly less in the diathermy group. No significant difference in the postoperative pain except on

the 3rd day in which the cold dissection group showed significantly lower pain score. Mean percentage

of diet was significantly higher in the diathermy group on the 1st day. No significant difference between

the 2 groups in terms of postoperative activity and complications.

Conclusion: BDT is a safe technique of tonsillectomy. There is significant less operative time and blood

loss with similar morbidity compared to CDT, so it can be used safely in children.

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1. Introduction

Tonsillectomy and adenoidectomy are commonly performedotolaryngological operations, accounting for up to 20% of alloperations performed by otolaryngologists [1].

The first known tonsillectomy was performed by CorneliusCelsus using his fingernails 2000 years ago [2]. It was not until thebeginning of the twentieth century that Worthington [3] andWaugh [4,5] described the modern technique of tonsillectomy bydissection. In 1968, Remington-Hobbs described the use ofdiathermy for removal of tonsils [6].

Despite a range of different techniques, including bluntdissection, guillotine [7], diathermy [8], or laser [9], postoperativepain remains the major side effect of the operation.

Pain is the result of disruption of mucosa and glossopharyngealand/or vagal nerve fibres followed by spasm of the pharyngealmuscles that leads to ischemia and protracted cycle of pain. Thisdoes not completely subside until the muscle becomes coveredwith mucosa 14–21 days after surgery [10].

This aim of this study was to compare bipolar diathermy withcold dissection tonsillectomy in children in terms of operativetime, operative blood loss, postoperative pain and postoperativecomplications.

* Tel.: +968 9254 4027; fax: +968 2456 8874.

E-mail address: ahesham73@yahoo.com.

0165-5876/$ – see front matter � 2008 Elsevier Ireland Ltd. All rights reserved.

doi:10.1016/j.ijporl.2008.09.026

2. Methods

One hundred and fifty children (age 3–14 years) scheduled fortonsillectomy with or without adenoidectomy were enrolled inthis prospective randomized controlled study after approval ofthe ethical committee, and taking informed consent from theparents. This study was done in Magrabi Eye and Ear Hospital,Sultanate of Oman, during the period from January 2006 toMay 2007.

Children were randomized into 2 equal groups: bipolardiathermy tonsillectomy (BDT) and cold dissection tonsillectomy(CDT).

Exclusion criteria included patients with bleeding disorders anddifficult contact or communication with the parents.

3. Operative technique

All cases were done under general anesthesia. BDT was doneusing the electrosurgical unit model Erbotom ICC 80 (ERBEElektromedizin GmbH, Tubingen, Germany) set at power 18 watts.Using the bipolar forceps, a palatoglossal incision was done, theperitonsillar plane was identified and dissected from superior toinferior pole. Haemostasis was achieved by the same bipolarforceps.

CDT was done by making a palatoglossal incision using curvedblunt scissors then the peritonsillar plane was identified anddissected from superior to inferior pole by blunt dissector.Haemostasis was achieved by ties and ligatures.

Fig. 1. The Wong–Baker FACES pain rating scale.

Table 2Postoperative pain scores.

Day 1 Day 3 Day 5 Day 7

Cold dissection 3.2 � 1.61 1.59 � 1.59a 1.7 � 1.77 1.19 � 1.89

Bipolar diathermy 3.22 � 1.61 2.27 � 1.25 1.32 � 0.95 0.78 � 1.62

a Means statistical significance (P < 0.05).

Table 3The mean percentage of normal diet taken by the children.

Day 1 Day 3 Day 5 Day 7

Cold dissection 48.53 � 21.54 69.6 � 16.06 82.67 � 11.3 91.3 � 14.17

Bipolar diathermy 54.67 � 13.69a 68 � 14.33 83.3 � 6 84 � 19a

a Means statistical significance (P < 0.05).

Table 4The mean percentage of normal activity demonstrated by the children.

Day 1 Day 3 Day 5 Day 7

Cold dissection 78.13 � 16.9 84.93 � 13.39 92.8 � 6.89 96 � 7.17

Bipolar diathermy 73.33 � 19.68 82.67 � 12.98 91.33 � 5 92.67 � 14.92

A. Hesham / International Journal of Pediatric Otorhinolaryngology 73 (2009) 793–795794

Adenoidectomy was done using adenoid curette. Anesthesiaand recovery protocols were standardized for all patients.

4. Intraoperative measures

Operative time was measured by the anesthesia nurse from thestart of tonsillectomy to the completion of haemostasis (time foradenoidectomy was not included).

Operative blood loss was measured by weighing the cottonbefore and after tonsillectomy.

All patients were given intraoperative steroids in the form ofdexamethasone 0.5 mg/kg body weight up to maximum of 8 mg.

5. Postoperative measures

All patients were discharged on the same day with 1 weekcourse of weight calculated amoxycillin clavulanate and para-cetamol. Parents were given phone call on postoperative days 1, 3and 5 and were given simple questionnaire to assess the following:

(1) Perception of pain using the Wong–Baker FACES pain ratingscale [11] (Fig. 1).

(2) Presence of nausea or vomiting.(3) Amount of diet eaten by the child (% of normal).(4) Level of child activity (% of normal).(5) Presence of complications especially bleeding and dehydration.

Patients were checked on the 7th day and the samequestionnaire was filled.

Parametric data were expressed as mean � standard deviation(SD), while categorical variables were presented as number (%). Thedata were analyzed using ANOVA single factor, Student’s t-test, chisquare analysis and Fisher exact test. Statistical significance wasaccepted for P values of <0.05.

6. Results

All patients underwent adenotonsillectomy apart from fourpatients in the dissection group and six patients in the diathermygroup who underwent tonsillectomy only.

The 2 groups were comparable in age and sex. The colddissection group had 60% males, whereas the diathermy group had66% males. Demographic and operative data of the patients wereshown in Table 1.

Table 1Demographic and operative data of the patients.

Cold dissection Bipolar diathermy

Age (years) 4.6 � 2.07 4.3 � 1.26

Gender M/F 66/34 60/40

Operative time (min) 11.4 � 2.84a 16.95 � 5.89

Operative blood loss (ml) 14.53 � 12.7a 27.67 � 11.98

a Means statistical significance (P < 0.05).

Pain recorded on the 1st, 3rd, 5th and 7th postoperative daysshowed no significant difference between the 2 groups except onthe 3rd day where the cold dissection group showed lower painscore (Table 2).

The incidence of vomiting was the same (6.6%) for both groups,which occurred on the 1st postoperative day.

The mean percentage of normal diet taken by children in thediathermy group was significantly higher on day 1 and signifi-cantly lower on day 7 while on days 3 and 5, the difference was notstatistically significant (Table 3).

Activity level was better in the cold dissection group all over thestudy but the difference was not statistically significant (Table 4).

No patients in either group were readmitted for dehydration ordeveloped reactionary hemorrhage. 4 patients (5.33%) in thediathermy group versus 1 patient (1.33%) in the dissection groupdeveloped secondary hemorrhage, this was not statisticallysignificant (P > 0.05). Bleeding was controlled conservatively inall patients except 1 patient in the diathermy group (1.33%)required surgical intervention, none of them required bloodtransfusion.

7. Discussion

Various techniques of tonsillectomy have been described in theliterature, among which cold dissection tonsillectomy is consid-ered the gold standard.

Historically diathermy was not used during tonsillectomybecause flammable gases were used for induction. With the advent

A. Hesham / International Journal of Pediatric Otorhinolaryngology 73 (2009) 793–795 795

of nonflammable agents, monopolar and subsequently bipolardiathermy was introduced as a means of securing haemostasis andlater on in performing surgery itself.

This study was conducted in a prospective manner to comparebipolar diathermy and cold dissection tonsillectomy in children.

In this study, the operative time and operative blood loss werefound to be significantly less in the diathermy group. Similarresults were reported in many studies [12–15]. These findings maybe attributed to the ability of diathermy to dissect the tonsils andcoagulate the blood vessels at the same time, so no extra time isrequired for haemostasis.

Contacting the parents in this study through telephone callsafter clarification of the questionnaire before discharge, was 100%successful in obtaining outcome measures.

Pain recorded on the 1st, 3rd, 5th and 7th postoperative daysdid not show significant difference between the 2 groups except onthe 3rd day where lower pain score was recorded in the colddissection group.

Silveira et al. [13] and Raut et al. [14,15] reported no statisticallysignificant difference in pain scores between the bipolar diathermyand the cold dissection groups.

On the other hand, Nunez et al. [16] using number ofpostoperative analgesic doses as a measure of pain, showed thatchildren who underwent tonsillectomy with electrocauetry took7.5 more doses of analgesics than those undergoing colddissection. The low pain score reported in this study may beattributed to the use of steroids [17].

The mean percentage of normal diet taken by children in thediathermy group was significantly higher on day 1 and signifi-cantly lower on day 7 while on days 3 and 5, the difference was notstatistically significant.

Pang [18] reported that children in the bipolar diathermy groupwere able to drink and eat significantly earlier than those in thedissection/snare group, on the other hand, Nunez et al. [16]reported that children in the bipolar diathermy group took 2.5 daysmore to return to normal diet.

In this study, though the incidence of haemorrhage was higherin the diathermy group, yet the difference was not statisticallysignificant, this was in agreement with many studies [15,18,19].

Lee et al. [20], reported significantly higher incidence ofsecondary haemorrhage in diathermy tonsillectomy comparedto dissection tonsillectomy only in adults with no difference inchildren. They attributed the difference between children andadults to the overall slower wound healing in adults which is morenegatively influenced by techniques associated with more tissuetrauma like the bipolar diathermy.

The cause of the higher rate of haemorrhage with bipolardiathermy is unclear but could be due to more extensive tissuedamage.

8. Conclusion

BDT is a safe technique of tonsillectomy. There is significant lessoperative time and blood loss with similar morbidity compared toCDT, so it can be used safely in children.

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