Tonsillectomy is one of the most common operative procedures in childhood. According to the Croatian national guidelines
for the treatment of sore throat (ISKRA guidelines), apsolute indications for tonsillectomy are recurrent tonsillitis (>4 per
year) and sleep disordered breathing (including snoring and obstructive sleep apnea). Most children in Croatia undergo
conventional cold steel tonsillectomy with bipolar diathermy coagulation using reusable surgical accessories. Estimated
blood loss during this type of surgery is about 10% of complete blood volume. That is why, tonsillectomy is performed
mostly in children 3 years of age and above because their weight and blood volume. Coblation tonsillectomy results in
less postoperative blood loss and less postoperative morbidity and is therefore the method of choice for operating on very
small children.
We present the case of a 3-year-old girl with somatic retardation (height 92 cm, weight 9,280 kg) who underwent coblation
tonsilloadenoidectomy. As far as we now, this procedure has never been performed in a child of lower weight

SANDA STOJANOVIĆ STIPIĆ

VESELIN ŠKRABIĆ

Željka Roje

English

Hrčak - Portal of scientific journals of Croatia

 1www.signavitae.comCoblation tonsilloadenoidectomy - treatment of choice for very small childrenABSTRACTTonsillectomy is one of the most common operative procedures in childhood. According to the Croatian national guidelines for the treatment of sore throat (ISKRA guidelines), apsolute indications for tonsillectomy are recurrent tonsillitis (>4 per year) and sleep disordered breathing (including snoring and obstructive sleep apnea). Most children in Croatia undergo conventional cold steel tonsillectomy with bipolar diathermy coagulation using reusable surgical accessories. Estimated blood loss during this type of surgery is about 10% of complete blood volume. That is why, tonsillectomy is performed mostly in children 3 years of age and above because their weight and blood volume. Coblation tonsillectomy results in less postoperative blood loss and less postoperative morbidity and is therefore the method of choice for operating on very small children.We present the case of a 3-year-old girl with somatic retardation (height 92 cm, weight 9,280 kg) who underwent coblation tonsilloadenoidectomy. As far as we now, this procedure has never been performed in a child of lower weight. ŽELJKA ROJE (  ) •School of Medicine, University of SplitŠoltanska 12 21 000 SplitCroatiaPhone: +385 21 462 871E-mail: zroje@kbsplit.hrVESELIN ŠKRABIĆDepartment of Pediatrics University Hospital, Split, CroatiaSANDA STOJANOVIĆ STIPIĆDepartment of Anesthesiology University Hospital Split, Split, CroatiaŽELJKA ROJE • VESELIN ŠKRABIĆ • SANDA STOJANOVIĆ STIPIĆ CASE REPORTS   SIGNA VITAE 2014; 9(1)Key words: tonsillectomy, body wei-ght, obstructive sleep apnea, weight gain IntroductionTonsillectomy is one of the most com-mon operative procedures in childhood. (1) At the Ear Nose and Throat (ENT) Department, Mayo Clinic, Rochester, Minnesota, USA, 4662 tonsillectomies were performed during a 12-year peri-od; at the Department of ENT, Head and Neck Surgery, University Hospital of Split, Split, Croatia, 3619 tonsillec-tomies were performed during a four-year period. (2) Tonsillectomy has been practiced for more than 2000 years (Celsus, 30 B.C.). (1,3)Although indications for tonsillectomy have included a large number of condi-tions over the years, most procedures have traditionally been performed to address infection, either recurrent or chronic. More recently, a trend towar-ds airway obstruction as a common indication for tonsillectomy has emer-ged because of increasing informati-on about the causes and sequelae of obstructive sleep apnea (OSA). That is why there are more and more very small children  undergoing tonsilloa-denoidectomy in the first 3 years of life. Frequently, patients under 3 years of age are considered higher risk pati-ents.  This higher risk status is generally based on one of two premises: 1. that young children are at increased risk of having postoperative problems; or 2. that these young children have such little hemodynamic reserve that compli-cations become more dangerous. (4)A number of operative methods have been investigated in terms of less intra-operative bleeding, less postoperative pain, infection or postoperative hemor-rhage, however, none yielding satisfac-tory results in all respects. (2,5-8)Coblation surgery, one of several types of radiofrequency surgery, is a novel sur-gical technique that was first introduced in ENT practice in the late 1990s for the operation of head and neck soft tissues. (6) The operative technique of coblation tonsillectomy is based on the standard technique of dissecting in the relatively bloodless tonsil-muscular plane, with the tonsillectomy hand piece tip direct-ed toward the tonsil in order to avoid damage to tonsillar arches and tonsillar fossa. (2,6)  A previous study conduct-ed by Roje et al. proved that coblation tonsillectomy results in lower intraop-erative blood loss, which is a particular advantage in children, especially those with homeostasis disorders, anemia and children under 3 years of age. (2)2 www.signavitae.comThanks to much better antenatal, intra-partal and neonatal monitoring and therapy, a large number of children with chronic diseases, become candidates for tonsilloadenoidectomy at a very early age. This trend implicates more efforts from otorhinolaryngologists and anesthesiologists in order to achieve the best possible result for the operated child and his parents. (9) One of these children is the child in this case report.Case reportA 3.3-year-old Caucasian girl was referred to an ENT specialist because of recurrent tonsillitis, otitis media and sleep breathing disorders (snoring and obstructive sleep apnea).On arrival, was 82 cm tall (height-stan-dard deviation score or H-SDS - 2,67; ct <1 ) and weighed 9280 g, with a body mass index of 12,78 kg/m2 (BMI-SDS - 3,08; ct <1). The girl was born prematurely by C-section in 35th ges-tational week because of intrauterine growth retardation. The mother suffered from gestational diabetes. At birth, the girl weighed 1770 g (birth weight or BW-SDS – 1.7; ct 4.35) and was 42 cm long (birth length or BL-SDS – 1.8; ct 3.63). Apgar score after the 1st minute was eight. She was treated in the neo-natal intensive care unit for 42 days. During that time she developed sepsis (Klebsiella pneumoniae). An atrial sep-tal defect was detected by ultrasound. After discharge from hospital she showed additional somatic retardation with very poor weight and height gain. DNA analysis for celiac disease and cystic fibrosis was undertaken, but no pathology was found. Due to her short stature she was referred to a pediatric endocrinologist at the chronological age 1.48 years, height was 71.5 cm (H-SDS – 2.92; ct <1 ), midparental target height 169 cm (TH-SDS -1.16, ct 87.7), weight 7.1 kg, BMI 1.89 kg/m2 (BMI-SDS – 3.08 ct <1), predicted target height comparing with the midparental height fell significantly below the target height range. On regular follow-up ses-sions anthropological parameters were measured and notified. Throughout this period she was below the 1st centile for both investigated parameters. Skel-etal age was similar to chronological. Growth hormone deficiency was not proven by the stimulation test. No neu-rological or intellectual problems were noted. Atrial septal defect closed at one year of age. After starting kindergarten, upper respi-ratory infections occurred monthly. She had five courses of antibiotics in less than four months. At the same time, sleep disorders became more seri-ous with significant obstructive sleep apnea. All this time she was not able to swallow hard textured food.ENT examination revealed enlarged tonsils (Friedman gradus IV), angular lymphadenopathy bilaterally, slightly retracted eardrums and hypertrophic mucosa in the nasal cavities with a great amount of mucous-purulent discharge.Polisomnography recorded apnea/hypopnea index (AHI) =11.Because of all these problems she had very poor quality of life and was physi-cally backward compared with other children of her age.That is why we decided to perform ade-notonsillectomy even through we were aware that she was a high risk patient due to  her small weight (<10 kg) and potential intraoperative blood loss of more than 10% of her blood volume. Thanks to our study from 2008 when we compared intraoperative blood loss during so called “classic” tonsil-lectomy and coblation tonsillectomy we knew that intraoperative blood loss during coblation is less then 10 ml and concluded that this was the method of choice for our patient.The operation was done under general anesthesia with the ArthroCare ProCize wand (ArthroCare, Sunnyvalle, Califor-nia, USA). Surgery lasted 10 minutes with no intraoperative complications.After EMLA (Eutectic Mixture of Local Anesthetics) application, intravenous access was established on the ward. Anesthesia was induced with mida-zolam 1mg, fentanyl 2μg/kg, propofol 3 mg/kg and vecuronium 0,1 mg/kg. Paracetamol 15 mg/kg was given as a slow intravenous infusion immediately after induction and dexamethasone 2 mg. Anesthesia was maintained with continuous infusion of propofol (150-200 μg/kg/min). The child was ven-tilated with a mixture of oxygen and air (40%:60%) in the pressure-contro-lled mode of ventilation to keep end-tidal CO2 between 30 and 35 mmHg. During  anesthesia the child was stable. Reversal of neuromuscular blokade was performed with atropin/neostigmin (0,02/0,07 mg/kg). Extubation was une-ventful and the child was transferred to the post-anesthesia care unit (PACU). After 2 hours in PACU, the child was transferred to the ward. No postoperat ive compl icat ions occurred and she was discharged on day three.Her night breathing became normal (no snoring, no apnea) and she started to eat hard textured food for the first time in her life. Seven months after surgery at age 4.01 years her height was 92.3 cm (H-SDS - 1,89;  ct 2,95), weight 12 kg, BMI 14,09 kg/m2 (BMI-SDS - 1,38, ct 8,48) and height velocity was excellent -11,42 cm/year (HV-SDS + 3,46, interval 0,63 year). We confirmed  great progress in linear growth (H-SDS from -2,67 to -1,89, ∆ H-SDS 0,78)   and body com-position (BMI-SDS from - 3,08  to - 1,38, ∆ BMI-SDS 1,7).DiscussionEven though there are some data about tonsilloadenoidectomy in very small chil-dren (< 2 years old) we could not find data showing that any of those children weighed less than 10 kg. (9)  Berkowitz et al. published their study of 190 chil-dren with an average age of 2 years and 4 months and average weight of 12.8 kg. (10) That is why we believe that this is a unique case of tonsilloadenoidectomy in such a small weight child. Perform-ing surgery on such small children is a challenge for every ENT specialist and anesthesiologist: in choosing the best operative technique and pre- and post-operative care. The surgeon is not only concerned about the very small opera-tive field (small mouth), intraoperative blood loss, but also about postoperative morbidity including pain, postoperative  3www.signavitae.comprimary or secondary hemorrhage and infection in order to prevent more weight loss after surgery. According to Berkowitz et al. tonsil-loadenoidectomy in very small children has to be done as an inpatient pro-cedure with intensive postoperative monitoring including pulse oxymetry because those children are prone to postoperative airway obstruction and oxygen desaturation. (10) Other post-operative complications (postoperative hemorrhage and dehydration) have similar rates like in older children. On the contrary, Shapiro et al., Helmus and Wiatrak et al. found that small children more often have delayed oral fluid intake and bleeding. They  have emphasized that younger children have less ’reserve’ when considering these important hemodynamic variables. As such, they are more likely to have poor outcomes from complications which would be less serious in older children and adults. (4,11,12)Apart from the paper by Werle et al., published in 2003, all data on tonsil-loadenoidectomy in small children are more than fifteen years old. (9) During that time only two tonsillectomy tech-niques were introduced: electrocautery and cold-steel technique. Neither of them is very friendly for small children: electrocautery because of intensive postoperative pain and cold-steel tech-nique because of more intraoperative blood loss. In the last decade, several new techniques have been introduced which offer better intraoperative blood loss control and less postoperative pain (radiofrequency, harmonic scal-pel) which can be crucial for very small children. (5-8,13,14) Less postopera-tive pain means better postoperative fluid-intake, less dehydration and read-missions to hospital. (12) That is why every ENT surgeon has to be informed and trained for various ton-sillectomy techniques, their advantages and disadvantages in every specific situation. Here are a few reasons why we advocate coblation as the method of choice for tonsilloadenoidectomy in very small children:1. less intraoperative blood loss2. less postoperative pain3. no increased risk for postoperative hemorrhage.It allows operated children faster post-operative recovery and a quicker return to normal dietary habits and activities of daily living. (2,6,13)All of this was confirmed in our case: improved weight and height gain and better quality of life for this little girl. (2,6,13,15)REFERENCES1. Belloso A, Chidambaram A, Morar P, Timms AS. Coblation tonsillectomy versus dissection tonsillectomy: postoperative haemorrhage. Laryngoscope 2003;113:2010-13.2. Roje Ž, Račić G, Pešutić Pisac V, Ðogaš Z, Timms M. Postoperative morbidity and histopathologic characteristics of tonsillar tissue follo-wing coblation tonsillectomy in children: prospective randomised single-blind study. Coll Antropol 2009;33(1):293-8.3. Wiatrak BJ, Woolley AL. Pharingitis and Adenotonsillar Disease. In: Cummings CW, editor. Otolaryngology, Head & Neck Surgery. St. Luis: Mosby; 1998. p. 188-215.4. Shapiro NL, Seid AB, Pransky SM, Kearns DB, Magit AE, Silva P. Adenotonsillectomy in the very young patient: cost analysis of two methods of postoperative care. Int J Pediatr Otorhinolaryngol 1999;48:109-15.5. D'Eredita R, Marsh RR. Contact diode laser tonsillectomy in children. Otolaryngol Head Neck Surg 2004;131:732-5.6. Timms MS, Temple RH. Coblation tonsillectomy: a double blind randomized controlled study. J Laryngol Otol 2002;116:450-2.7. Oko MO, Ganly I, Loughran S, Clement WA, Young D, Geddes NK. A Prospective Randomized Single-Blind Trial Comparing Ultrasonic Scalpel Tonsillectomy With Tonsillectomy by Blunt Dissection in a Pediatric Age Group. Otolaryngol Head Neck Surg 2005;133:579-84.8. Derkay CS, Darrow DH, Welch C, Sinacori JT. Post-Tonsillectomy Morbidity and Quality of Life in Pediatric Patients with Obstructive Tonsils and Adenoid: Microdebrider vs Electrocautery. Otolaryngol Head Neck Surg 2006;134:114-20.9. Werle AH, Nicklaus PJ, Kirse DJ, Bruegger DE. A retrospective study of tonsillectomy in the under 2-year-old child: indications, perioperative management, and complications. Int J Pediatr Otorhinolaryngol 2003;67(5):453-60.10. Berkowitz RG, G.H. Zalzal GH. Tonsillectomy in children under 3 years of age. Arch Otolaryngol Head Neck Surg 1990;116:685-/6.11. Helmus C. Tonsillectomy and adenoidectomy in the one and two-year-old child. Laryngoscope 1979;89:1764-71.12. Wiatrak BJ, Myer CM, Andrews TM. Complications of adenotonsillectomy in children under 3 years of age. Am JOtolaryngol 1991;12:170-2.13. Temple RH, Timms MS. Pediatric coblation tonsillectomy. Int J Pediatr Otorhinolaryngol 2001;61:195-8.14. Schmidt R, Herzog A, Cook S, O'reilly R, Deutsch E, Reilly J. Complications of tonsillectomy: a comparison of techniques. Arch Otolaryngol Head Neck Surg 2007;133(9):925-8.15. Mitchell RB, Kelly J.Outcomes and quality of life following adenotonsillectomy for sleep-disordered breathing in children. ORL J Otorhino-laryngol Relat Spec 2007;69(6):345-8. 

Coblation tonsilloadenoidectomy - treatment of choice for very small children

Abstract

Similar works

Full text

Available Versions

Hrčak - Portal of scientific journals of Croatia