**7. "Cold" knife**

A frequently used method for total tonsillectomy is the"cold"or sharp dissection technique. In this technique, the tonsil and capsule are dissected from surrounding tissue using scissors, knife, or t dissector (Figure 4) and the inferior pole is amputated with a tonsil snare.

Fig. 4. Tonsil Dissector.

A Review of Tonsillectomy Techniques and Technologies 167

This is another method for intracapsular tonsillectomy. The microdebrider is a powered rotary shaving device with continuous suction, made up of a tube, and connected to a hand piece, which, in turn, is connected to a motor with foot control and a suction device. A partial tonsillectomy is completed with the removal of approximately 90% to 95% of the

There is great debate about the relative merits of the various tonsillectomy techniques published in many studies, with many more ongoing that compare the techniques. The existing literature consistently reports that the intracapsular (partial) techniques result in less postoperative pain, however, the degree of lessened pain continues to be much debated.19,20,21In addition; there is a small risk of tonsil regrowth and the necessity for an additional procedure with the intracapsular techniques. Of the extracapsular techniques, "cold" tonsillectomy results in less postoperative pain compared with an electrocautery or "hot" tonsillectomy; however, the latter procedure is typically faster and has less intraoperative blood loss.22,23,24 Although not extensively researched thus far, a total tonsillectomy with the coblation unit may have slight advantages over electrocautery tonsillectomy.25 The studies on outcomes of surgeries completed with the harmonic scalpel do not show any denitive advantage to the scalpel.26,27 It is not clear which technique, if

Most of the data available to date suggest that there is no difference in the bleeding rates between extracapsular and intracapsular tonsillectomy.30The equipment involved with various techniques varies in price, although the largest cost factor in any tonsillectomy is the

A majority of children can safely be discharged home on the same day of surgery, regardless of the surgical technique used.10,30Children younger than 2 years or who live far from a hospital should be kept overnight for observation. Pain medication should be recommended, and most physicians prescribe either acetaminophen or acetaminophen with codeine postoperatively.31 Some physicians recommend a soft diet postoperatively, others recommend "diet as tolerated."10 In our centres we commence the child on firstly on cold ice

Studies have not shown any difference in recovery between children who have a restricted

Fig. 6. Bipolar Probe.

operating time.

**12. Postoperative care** 

cream and subsequently on liquid diet.

versus those who have non-restricted diets postoperatively.32,33

**10. Microdebrider tonsillectomy** 

tonsil, while preserving the tonsillar capsule.

**11. Advantages and disadvantages of the techniques** 

there is one, results in the lowest rate of postoperative hemorrhage.28,29

#### **8. Harmonic scalpel**

The harmonic scalpel (Figure 5) can be used to perform an extracapsular tonsillectomy (Ethicon Endo-Surgery Inc, Cincinnati, OH).It uses ultrasonic energy to vibrate its blade at 55,000 cycles per second. The vibration transfers energy to the tissue, providing simultaneous cutting and coagulation, so, typically, no additional instrument is needed for haemostasis. The components of the device include a generator, a hand piece, and a disposable blade. A high-frequency power supply provides energy to the hand piece. The blade oscillations dissect tissues by creating intra-cellular cavities as pressure waves are conducted through the tissues. The expansion and contraction of these cavities results in the lysis of cellular connections, resulting in tissue dissection.

Fig. 5. Harmonic/ultrasonic scalpel.

#### **9. Bipolar radiofrequency ablation**

Bipolar radiofrequency ablation can be used to perform an extracapsular or intracapsular tonsillectomy; however, it is most commonly used to perform a partial tonsillectomy (Figure 6). The equipment includes a radiofrequency generator, foot control, saline irrigation regulator, and the coblation wand (PlasmaCare Corp, Sunnyvale, CA). During a bipolar radiofrequency ablation tonsillectomy, conductive saline solution is converted into an ionized plasma layer, resulting in molecular dissociation with minimal thermal energy transfer. Haemostasis can usually be performed with the coblation wand alone.

Fig. 6. Bipolar Probe.

166 Otolaryngology

The harmonic scalpel (Figure 5) can be used to perform an extracapsular tonsillectomy (Ethicon Endo-Surgery Inc, Cincinnati, OH).It uses ultrasonic energy to vibrate its blade at 55,000 cycles per second. The vibration transfers energy to the tissue, providing simultaneous cutting and coagulation, so, typically, no additional instrument is needed for haemostasis. The components of the device include a generator, a hand piece, and a disposable blade. A high-frequency power supply provides energy to the hand piece. The blade oscillations dissect tissues by creating intra-cellular cavities as pressure waves are conducted through the tissues. The expansion and contraction of these cavities results in the

Bipolar radiofrequency ablation can be used to perform an extracapsular or intracapsular tonsillectomy; however, it is most commonly used to perform a partial tonsillectomy (Figure 6). The equipment includes a radiofrequency generator, foot control, saline irrigation regulator, and the coblation wand (PlasmaCare Corp, Sunnyvale, CA). During a bipolar radiofrequency ablation tonsillectomy, conductive saline solution is converted into an ionized plasma layer, resulting in molecular dissociation with minimal thermal energy

transfer. Haemostasis can usually be performed with the coblation wand alone.

lysis of cellular connections, resulting in tissue dissection.

Fig. 5. Harmonic/ultrasonic scalpel.

**9. Bipolar radiofrequency ablation** 

**8. Harmonic scalpel** 
