Tonsillectomy is one of the oldest and most frequent procedures performed by otolaryngologists. It was not until the beginning of the twentieth century that Worthington and Waugh described the modern tonsillectomy technique by dissection. [1]. Cautery use in tonsillectomy was first defined in 1962. Further, Andrea defined the first microsurgical bipolar cautery technique3 in 1993. A variety of techniques performs tonsillectomy. These techniques have evolved over the years, aiming to make the procedure safe and decrease surgical time, intraoperative blood loss, postoperative morbidity, and complications. [2]. Despite the developments in techniques and technology, tonsillectomy still carries a relatively high risk of morbidity. Conventional tonsillectomy and bipolar tonsillectomy are the standard techniques used in the paediatric population with different indications. [3].

But, nowadays, bipolar electrocautery is one of the most standard procedures as it is easy to perform and helps reasonable control of bleeding. Apart from that, new instruments like harmonic scalpel, light amplification by stimulated emission of radiation (LASER) have also been used to perform a tonsillectomy. [4]. The main aim of the tonsillectomy with these instruments is to reduce bleeding and pain. However, there is not any such instrument causing a total reduction of bleeding and pain. [5]. Certainly, otolaryngologists would want to investigate the feasibility of any new instrumentation that would decrease the morbidity of tonsillectomy, even if it were relatively expensive. [6]. Coblation tonsillectomy was initially introduced in 2001. A significant number of articles have been published either to confirm its efficacy or to reject that because of unsatisfactory or unproven outcomes with undesirable cost-effectiveness. [7]. However, more studies are still required to reveal a clear conclusion. [8]. Even though some former studies showed reduced postsurgical pain and no significant morbidities like postoperative bleeding, they were not considered due to their small sample size. A study observed the healing process of the tonsillar bed in 10 patients and concluded that the coblation method would be preferable to bipolar dissection. [9]. A recent study defended the use of coblation surgery because of decreased bleeding and pain, but cases in the study were only 14 patients. [10].

Method of study

Surgical technique (MES vs RFA) and its relation to time to discharge on postoperative day #1 were compared. The total number of patients who underwent tonsillectomy was 60 patients (30 of them by bipolar diathermy technique, 30 by Coblation assisted technique).

Data collection procedure: Parents and patients of assenting age were consented and enrolled, and primary demographic data were collected preoperatively. Data included age on the day of surgery, sex, indication for tonsillectomy, surgical technique, length of stay (time from surgery completion to discharge), time of discharge, and perioperative complications. The attending surgeon on the case decided upon the choice of the surgical instrument. All patients underwent a standard extracapsular tonsillectomy to standardize the analysis of the two groups.

Surgical procedure: In diathermy tonsillectomy, the upper pole of the tonsil was grasped with a tonsil holding forceps and pulled medially. Using a toothed dissecting forceps, the initial mucosal incision was made 1 mm medial to the anterior pillar in the loose areolar tissue between the tonsil capsule and the anterior pillar avoiding injury to the fibers palatoglossal muscle. During dissection, any bleeding points found were quickly cauterized for 2-3 seconds with bipolar diathermy forceps with a power setting of 20 watts and packed with cotton balls. The cautery point was carefully applied close to the tonsil. The bleeding points found in the tonsillar bed were also cauterized in the same way. To minimize thermal injury to the muscles of the tonsillar bed, cautery was selectively used only to cauterize the bleeding points and not the entire fossa. After controlling the bleeding, the fossa was packed with cotton balls, and a similar procedure was repeated on the other side. [13].

In coblation, tonsillectomy is done under general anesthesia with orotracheal intubation. The same wand achieved hemostasis in coagulation mode. Operating time was measured from the anterior pillar incision or beginning of dissection until complete haemostasis of the tonsillar fossa was achieved. Before starting the surgery, a good amount of gauze and ribbon gauze was taken, weighed, and sterilized. The weight was always kept constant at 20 g. The suction bottle, including the rubber tube, was cleaned and emptied before starting the operation.

The Visual Analogue Scale was used on the day of surgery and every 24 hours until discharge and the 14th postoperative day.

Ethical Consideration and permission: After approval from Institutional Ethics Committee for Medical Research at Adesh Medical College and Hospital, the study was initiated.

Statistical analysis: The data analysis was done using MS excel. Categorical variables were presented in number and percentage (%).

In table 1, there is a total of 60 children, 19 in the age group of <5 years, 23 children (38.3%) in the age group of 5-10 years, and at least one 30% in the age group of 10-14 years old.

Table 1: Distribution of age group

Table 2: Distribution of sex

In table 2, out of 60 patients, 7 (61.6%) were male, and 18 (38.3%) were female.

Table 3: Incidence of postoperative haemorrhage

In table 3, the incidence of postoperative bleeding is almost similar in both groups. In the Diathermy group, only one patient and the Cobalation group, only two patients had a secondary hemorrhage that was managed conservatively and did not need surgical intervention.

Table 4: Duration of surgery and blood loss between groups

Tonsillectomy remains one of the most common surgical procedures performed in the world. One of the most significant complications is postoperative hemorrhage. [15]. Episodes of post-tonsillectomy hemorrhage are unpredictable and potentially life-threatening. Post-tonsillectomy bleeding occurs in approximately 1 of 20 children independent of individual patient characteristics. However, the exact incidence of postoperative tonsillar bleeding is very difficult to determine. The statistics in the literature range from 0% to 20%. [16].

Surgical techniques and equipment have evolved tremendously over the centuries to decrease operating time and intraoperative blood loss. [17]. Excessive intraoperative blood losses are one of the significant risk factors for post-tonsillectomy hemorrhage. [18]. Cold dissection, hot knife dissection, and bipolar diathermy dissection are the most commonly used techniques worldwide, and intraoperative blood loss is far less with electrocautery than with challenging dissection techniques. [19].

A new technique for tonsillectomy should be: Comparable to or better than existing techniques; safe to use; have a short learning curve, and be cost-effective. In particular, such a new technique would preferably be associated with less postoperative pain, less intra-operative blood loss, a quicker return to regular diet and activity, and a lower risk of both reactive and secondary haemorrhage. [20]. The present study consisted of 23 (38.3%) females and 37 (61.6%) males, similar to previously reported gender distributions by Hultcrantz E et al., including paediatric cases. [21]. In the present study, patients ranged from 15 to 40 years (mean 24.4 years), and paediatric cases were excluded because pain scores and symptom records tend to be unreliable.

In our study, Diathermy group only one patient, and in the Cobalation group, only two patients were reported with secondary hemorrhage. All these patients were managed conservatively and did not need surgical intervention. The literature review revealed that bipolar diathermy tonsillectomy did not carry the risk of secondary bleeding different from other standard techniques. [22]. Koltai PJ has reported incidence of postoperative bleeding as 1.7% with bipolar diathermy tonsillectomy compared to 3.4% with cold dissection, carrying no statistical significance. [23].

In our study, the postoperative Secondary hemorrhage rate for the Diathermy group was one compared with the Cobalation group was 2. There were few cases of Primary postoperative bleeding in both the study. Timms MS et al. [31]. Reported a primary hemorrhage rate of 1.7% (1 child) in the Cobalation group requiring hemostasis in the theatre while both groups secondary hemorrhage due to infection, which was treated conservatively with intravenous antibiotics. In our study, postoperative pain scores averaged around 3–6 on a 1–10 points scale in children. In a study reported by Businco LR et al., pediatric patients experienced pain for a mean period of 1.7 days following ablation and 7.1 following conventional tonsillectomy. In pediatric patients undergoing ablation, virtually all patients (27 of 28 children) were pain-free by the 3rd postoperative day.

However, patients who underwent conventional tonsillectomy experienced pain beyond the 6th postoperative day in all adults and 30 out of 40 children undergoing tonsillectomy. [32]. In a study reported by Mitic S et al., patients who underwent the Cobalation group had less pain from the 1st day of surgery, needed fewer analgesics, and were pain-free earlier than the conventional tonsillectomy group. [33]. According to Maddern BR et al., there is no correlation between the number of analgesics consumed and the pain experienced by the child, as dispensing analgesics by the parents rather corresponds to the doctor's prescription than the child's pain. [34]. Younis RT et al. concluded coblation technique offers significant advantages in the postoperative period, with rapid return to a normal diet and a drastic reduction in analgesic requirements following the surgery. [35].

Diathermy dissection tonsillectomy is less expensive but is associated with more postoperative pain in several studies. The postoperative pain after electrocautery dissection of tonsillectomy using bipolar cautery could be due to the higher power setting, duration, and frequency of the cautery application, as explained by Young JR et al. [36]. The use of electro dissection needles or forceps for the complete dissection could result in more thermal injury and tissue damage delaying the healing and increased pain after surgery. This was shown in the studies by Solares CA et al. [37].

Limitations of the current study include the small study size, randomization of instrument choice, and quantification of postoperative oral intake as a metric for safe discharge from the hospital.