Diathermy tonsillectomy: comparisons of morbidity following bipolar and monopolar microdissection needle excision

Tonsillectomy is frequently associated with a considerable post-operative morbidity. In some cases reactionary or secondary haemorrhage occurs and all patients suffer a degree of post-operative pain. The use of bipolar diathermy excision has become popular because it reduces intra-operative blood loss, but all diathermy inevitably produces a degree of damage to adjacent normal soft tissues. In turn this inadvertent injury must act to increase the post-operative pain. Monopolar dissection using a fine tungsten diathermy needle (the Colorado needle) allows sharp dissection at low power levels and in previous studies has been shown to produce a reduction in collateral tissue damage. In this prospective study the morbidity associated with tonsillectomy using this needle was compared to that following a standard bipolar dissection. Using the monopolar needle produced no enhanced risk of reactionary or secondary haemorrhage while causing significantly less post-operative pain and a reduction in eschar. We believe that excision using this needle preserves the advantages associated with bipolar dissection while reducing local soft tissue damage.     

Electrocautery versus epinephrine-injection tonsillectomy

This prospective, single-blinded study on tonsillectomy was done to compare the Bovie electrocautery dissection technique with the epinephrine-and-lidocaine injection technique and to document which technique is safer, faster, and less morbid. Twenty-nine patients who were scheduled for tonsillectomy at two Northern California Region Kaiser Permanente Medical Centers were enrolled in the study. Each patient served as his or her own control, and tonsillectomy technique was randomized on the basis of even or odd numbers of the last digit of the medical record number. The time of injection of epinephrine and time of dissection for each tonsil was recorded. Blood loss was quantified for each dissection, and pain was assessed by asking the patient which side hurt more. I found no statistically significant difference in operating time, intraoperative blood loss, or postoperative hemorrhage between these two methods. The electrocautery, or Bovie, technique produced more clinically significant eschar and delayed healing than the epinephrine-injection technique did. The Bovie technique produced more inadvertent burns to surrounding tissue than the epinephrine-injection technique did, but the epinephrine caused transient tachycardia in 14% of the study participants. The present study showed no difference between the two techniques in postoperative pain experienced by study participants, but other recent studies have shown that patients experience more pain when the Bovie technique is used. Study data do not support the superiority of Bovie tonsillectomy. I recommend epinephrine-injection tonsillectomy as a safe and expedient operation.     

A new fine probe for electric cautery during endoscopic surgery

The present paper introduces a new fine probe for electric cautery (1.65 mm in diameter, 22 cm long) that can be connected to a conventional cylindrical hand-controlled cautery holder, which is monopolar and widely used in general surgery. When cautery was required, a 14-gauge intravenous catheter was inserted at an appropriate site under the guidance of a videoscope. After removing the steel inner needle, the extra tube was used as the fine surgical port for the cautery probe. The position of insertion could be altered according to the operating field. Cautery was performed by conventional methods. There was no bleeding or air leakage at the site of puncture during or after surgery. The puncture wound was closed without any sutures. Based on these results, the new fine probe for cautery can reduce the number of surgical ports required for instruments during video-assisted surgery, thus improving the ease and safety of endoscopic surgery.     

Acute pharyngitis, tonsillitis and tonsillectomy

Respiratory infections are the most common group of diseases experienced in the community and treated by doctors. Tonsillitis and pharyngitis, sometimes referred to together as acute sore throat, are among the most common of the individual respiratory infections.     

The encircling Silastic 3 mm band without cautery in retinal detachment surgery

Retinal detachment with tears can be cured by scleral buckling by synthetic material pressure retino-choroidopathy without cautery (diathermy, cryo- or photocoagulation) to tear edges on conditions: (1) To use the encircling Silastic 3-mm band (equatorial or oblique according to tear site) giving a permanent buckle. The segmental buckle may recede reopening the tear and its retino-choroidopathy effect may not be sufficient to seal the tear. (2) Not to evacuate the subretinal fluid leaving the ocular tension at end of operation a bit high [about 25 mm Hg in the first operation and 5 mm Hg (Sch?tz) in the recent reoperation above the preoperative level]. The synthetic material pressure retino-choroidopathy seals the tear and lowers the ocular tension in subsequent days with beter buckling. (3) As these conditions may not be attained, it is wiser to use minimal diathermy or cryo-therapy to seal the tear.     

Microsurgical treatment of cavernous sinus tumor

We studied 25 cases of cavernous sinus tumors who underwent microsurgical operation. The tumors were mainly composed of neurinomas and meningiomas. The tumors of 8 of 9 cases of the former, and 4 of 6 cases of the latter were totally removed. None of the patients died. We discussed the operative, method, preoperative preparation and postoperative complication.     

Subcutaneous emphysema as a complication of tonsillectomy

Subcutaneous emphysema occurs when air is introduced into the tissues. This can happen as a complication during, or immediately after surgery. It has rarely been described after tonsillectomy. Definitive treatment will depend on the cause. We report two cases of subcutaneous emphysema following tonsillectomy.     

Corneal neovascularization induced by xenografts or chemical cautery. Inhibition by cyclosporin A

PURPOSE: Neovascularization of the cornea occurs in numerous pathologic states causing decreased visual acuity and blindness and is a major complication of corneal allotransplantation. The purpose of this study was to investigate the effect of topical and systemic cyclosporin A (CsA) on corneal angiogenesis induced by xenotransplantation or by chemical cauterization. The subcutaneous disc angiogenesis system (DAS) also was used to study the effects of CsA on angiogenesis in a nonocular site. METHODS: Corneal angiogenesis was provoked by either xenotransplantation or chemical cautery. Rats from experiments using both of these models were subdivided into four treatment groups. Topical treatment was administered by using 4% CsA eye drops or vehicle (castor oil) four times daily for 10 days. Systemic therapy consisted of daily (5 mg/kg per day) subcutaneous injections of CsA or vehicle. In the DAS experiments, rats received CsA or vehicle systemically or intradisc. The amount of neovascularization was quantitated by digital image analysis in corneal flat preparations and sections of discs. RESULTS: Rats that received xenografts or cautery manifested less corneal neovascularization than did control animals after topical of subcutaneous CsA treatment. CsA also enhanced the survival of corneal xenografts. A difference between CsA and vehicle-treated animals in the DAS experiments was not detected. CONCLUSIONS: CsA effectively retards the growth of new vessels in the cornea after xenotransplantation or chemical cauterization and prolongs xenograft survival. However, CsA does not suppress angiogenesis in all systems, because it was ineffective in blocking vessel growth in the subcutaneous DAS.     

Microsurgical treatment of intramedullary spinal cord tumors

Eighty patients with intramedullary spinal cord tumors were treated by microsurgical methods between 1988 and 1996. Twenty-nine patients were diagnosed with astrocytoma, 36 with ependymoma, five with metastasis, four with lipoma, three with dermoid or epidermoid tumor, two with neurofibroma, and one with neuroma. Vascular and infectious lesions (such as abscesses and hemangioblastomas) were excluded. After laminectomy, total removal of the lesion was achieved in 68 of 80 patients and subtotal removal in 12. Postoperative radiation therapy was performed in 13 of 80 patients. The follow-up period ranged from 12 to 92 months (mean 42.2 months). All patients underwent preoperative and postoperative magnetic resonance imaging at intervals ranging from 3 months to 5 years postoperatively. Four patients showed clinical and radiological evidence of local tumor recurrence during the follow-up period. Four patients died 5 months to 15 months postoperatively from the re-expansion of their primary metastatic disease. The operative results at long term (after the 6th postoperative month) were better than the results at short term (before the 6th postoperative month) and revealed clinical improvement in 63, no change in 10, and deterioration in seven patients. We recommend early radical surgery, whenever possible, to be performed when the patient's neurological status is still good. Subtotal removal and irradiation are better for malignant or metastatic tumors. Partial decompressive removal is best for large intramedullary lipomas. Plastic laminotomy with preservation of the intervertebral joints is especially recommended in young or middle-aged patients.     

Microsurgical management of craniopharyngiomas--outcomes in 56 patients

PURPOSE: The tight junctions in the intestinal epithelium represent highly specialized intercellular junctions. Ranitidine, an H2-antagonist, causes a tightening of the tight junctions. Hence, we have investigated the effect of ranitidine and other H2-antagonists on the function of the intestinal tight junctions. METHODS: Effect of the H2-antagonists on the tight junctions has been investigated using the transepithelial electrical resistance (TEER) and the transport of mannitol across the Caco-2 cell monolayers. RESULTS: Four different H2-antagonists caused an increase in the TEER across the Caco-2 cell monolayers, accompanied by a decrease in the permeability for mannitol. The effect was concentration-dependent and saturable. Ranitidine and famotidine, caused a decrease in their own transport rate across the Caco-2 cells. Ranitidine competitively inhibited the increase in TEER caused by famotidine, whereas compounds which represent molecular fragments of ranitidine had no effect. The relative potency of the four H2-antagonists in causing an increase in the TEER correlated inversely with the oral bioavailability of these compounds in humans. CONCLUSIONS: We hypothesize that the H2-antagonists exert their effect on the tight junctions of Caco-2 cells by modulation of interactions among proteins associated with the tight junctional complex.     

Long-term prognosis for tonsillectomy patients with IgA nephropathy

A retrospective study of 85 patients with IgA nephropathy was undertaken to determine the long-term effect of tonsillectomy. Forty-three patients (24 males and 19 females) had received tonsillectomies (Group A) and 42 patients (17 males and 25 females) had not (Group B). These patients had been followed up for more than 5 years after renal biopsy. The average age at the initial renal biopsy was 25.72 years in Group A, and 33.16 years old in Group B. The average period of renal biopsy to tonsillectomy in Group A was 10.47 months. The average follow-up period was 8 years and 9 months in both groups. At the beginning of treatment, the two groups were well matched in terms of creatinine clearance, urinalysis, and blood pressure. Six patients in Group A and eight patients in Group B were treated with steroids. The glomerular injury detected at the renal biopsy was more extensive in Group A than in Group B. Renal function in the two groups was compared. The clinical remission rate in Group A was significantly higher than in group B (P<0.05). The stable renal function rate in Group A was significantly higher than in Group B (P<0.05). The renal survival rate was 97.7% in Group A and 83.3% in Group B, but there was no significant difference between the two groups. Histologically, the rate of remission of the minor lesion in Group A was significantly higher than in Group B (P < 0.05). Our results showed that tonsillectomy for IgA nephropathy was clinically of great value.     

The effect of tonsillectomy on eustachian tube function

A two-part study was designed to investigate the effect of tonsillectomy on eustachian tube function and to identify if any change is related to postoperative pain. Middle ear pressure was measured by tympanometry and results were classified as type A (+50 daPa to -99 daPa), type B (flat) or type C (-100 daPa to -350 daPa). Thirty-one patients with type A tympanograms, undergoing tonsillectomy enrolled in study A. Patients had tympanometry the next day and filled in a questionnaire incorporating visual analogue pain scores. In study B, 30 patients underwent a similar protocol and were followed up at 1 week tympanometry and a questionnaire. A control group of 26 patients undergoing appendicectomy was recruited. Follow-up was available on 23 patients from study B. Combining A and B, on the first postoperative day 39% of patients developed type C tympanograms. No member of the control group developed any change in middle ear pressure. There was no significant relationship between pain scores for throat pain or otalgia and the development of negative middle ear pressure. By day 7 all patients had type A tympanograms. Otalgia was a delayed symptom significantly associated with increased throat pain. Transient negative middle ear pressure commonly occurs following tonsillectomy.     

A review of tonsillectomy for recurrent throat infection

Tonsillectomy is most frequently carried out for recurrent throat infection, but there is uncertainty about its effectiveness. This paper reviews the evidence of its effectiveness obtained from a search of the Cochrane database and MEDLINE for randomized controlled trials comparing tonsillectomy with non-surgical management of recurrent throat infection. The results show that the effectiveness of a procedure such as tonsillectomy, needs to be considered in the light of its adverse effects. Attempts should be made to inform patients about the uncertainty surrounding the procedure.     

Local infiltration of epinephrine and bupivacaine before tonsillectomy

The effects of peritonsillar injections of epinephrine and local anesthetics before tonsillectomy on blood loss and postoperative pain were evaluated in a prospective, randomized double-blind trial on 103 children. Patients were randomly assigned into one of three groups: controls given injections of 0.9% NaCl (n = 34), patients injected with 0.4 ml/kg (1:200,000) epinephrine combined with 0.25% bupivacaine (n = 33) and patients given only 1:200,000 epinephrine (n = 36). All injections and operations were performed by the same surgeon (KS). Blood loss was calculated by weighing all blood aspirated perioperatively and swabs used during surgery. Postoperative pain was assessed at regular intervals by using three methods: (1) use of a visual analogue scale by parents and nurses to estimate pain; (2) postoperative need for nalbuphine as analgesic; (3) the Hannallah-Broadman semi-objective pain score (including crying, anxiety, restlessness, and changes in blood pressure). The mean blood loss in the control group (given NaCl) was 132 g, which was significantly increased when compared with the epinephrine/bupivacaine group (85 g) and the group treated with only epinephrine (90 g). However, analysis of the postoperative pain scores did not reveal any significant differences among groups. These findings indicate that the peritonsillar injection of bupivacaine does not decrease postoperative pain, but peritonsillar injections of epinephrine will significantly reduce blood loss during tonsillectomy.